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One Stop Shop on REFLUX!

The effects on your voice and why its so important to manage it!



Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are two manifestations of the same underlying condition, characterized by the backward flow of stomach contents into the oesophagus and upper airway. The primary distinction lies in the predominant symptoms and the affected anatomical areas.

 

GERD primarily manifests with symptoms related to the lower oesophagus, such as heartburn, regurgitation, and chest pain. These symptoms arise due to the reflux of stomach acid into the lower oesophagus, potentially leading to oesophageal irritation and damage over time.


On the other hand, LPR primarily affects the upper respiratory tract, including the larynx and pharynx, and is often referred to as "silent reflux" because it may not present with typical GERD symptoms. LPR symptoms include hoarseness, chronic cough, throat clearing, and a sensation of a lump in the throat.

The key difference is the anatomical site predominantly affected by the reflux. While GERD primarily impacts the lower oesophagus, LPR extends its influence on the upper airway, larynx and pharynx. It's important to recognize these distinctions for accurate diagnosis and tailored treatment approaches.

 

The Impact of Laryngopharyngeal Reflux on Vocal Function

Laryngopharyngeal reflux (LPR) is characterized by the backflow of gastric contents into the larynx and pharynx. LPR can significantly compromise vocal function, affecting both amateur vocalists and professionals alike.

 

LPR Mechanisms and Vocal Tissue Vulnerability:

LPR is distinguished by the regurgitation of stomach acid and digestive enzymes into the larynx and pharynx, regions critical for vocal production. The delicate tissues of the larynx, including the vocal cords, are particularly vulnerable to the corrosive effects of these refluxed contents. Unlike typical GERD symptoms, LPR may not always present with overt heartburn, making its diagnosis and management challenging.


Research suggests that pepsin, a digestive enzyme found in gastric juices, plays a pivotal role in LPR-induced vocal damage. The chronic exposure to acidic gastric materials due to LPR contributes to a spectrum of mucosal alterations, from oedema and erythema to more severe pathologies like vocal fold nodules and polyps.


The enzymatic activity of pepsin, identified in laryngeal tissues of LPR patients, emerges as a key player in mucosal damage, adhering to the vocal fold surfaces and triggering inflammatory responses. Pepsin can adhere to the mucosal surfaces of the larynx, leading to cellular damage and triggering an inflammatory response. A study published in the Journal of Voice highlighted the presence of pepsin in laryngeal tissues, underscoring the direct link between refluxed contents and cellular injury within the vocal folds. The acidic environment further disrupts the protective mucosal barrier, rendering the vocal folds susceptible to injury. These mucosal changes not only impair voice quality but may lead to persistent symptoms like hoarseness and difficulty in vocal fold vibration.


Clinical Manifestations of LPR-Related Vocal Dysfunction:

LPR-related vocal dysfunction encompasses a range of symptoms, with hoarseness, chronic cough, throat clearing, and a sensation of a lump in the throat being common manifestations. These symptoms can significantly impact vocal quality and endurance, posing challenges for individuals who rely on their voices professionally or recreationally.


Studies have demonstrated a strong association between LPR and various vocal pathologies. In a study published in the Journal of Voice, researchers found that individuals with LPR exhibited higher rates of vocal fold nodules, vocal fold polyps, and laryngeal hyperplasia compared to those without reflux.


What are the common symptoms associated with LPR?:

(Sara Harris, SLT guidelines written for the British Voice Association)

  • A sensation of food sticking or a feeling of a lump in the throat

  • A hoarse, tight or 'croaky' voice

  • Frequent throat clearing

  • Difficulty swallowing (especially tablets or solid foods)

  • A sore, dry and sensitive throat

  • Occasional unpleasant "acid" or "bilious" taste at the back of the mouth

  • A feeling that too much mucus/phlegm is collecting in the throat.

  • Sudden coughing or choking spasms at night.

  • Chronic cough

  • Excessive burping, particularly during the day

  • No Symptoms – Silent Reflux.

 

Diagnostic Challenges and Multidisciplinary Approaches:

Diagnosing LPR-induced vocal dysfunction can be complex due to the absence of typical GERD symptoms and the overlap with other voice disorders. Clinicians often employ a combination of laryngoscopy, Patent rating Outcome Measures (PROMS), pH monitoring, and impedance testing to accurately diagnose LPR and assess its impact on vocal function.

 

Treatments

Mechanisms of Alginates in LPR Management:

Alginates (ie: Gaviscon) are polysaccharides derived from seaweed, known for their unique gel-forming properties. In the context of LPR, alginates function by creating a physical barrier at the gastroesophageal junction. Upon contact with gastric contents, alginates form a gelatinous raft that floats on the surface, acting as a protective shield against the corrosive effects of acid and pepsin. This barrier mitigates the upward movement of gastric contents into the larynx and pharynx, addressing the root cause of LPR symptoms.


Clinical Evidence Supporting Alginate Therapy:

The efficacy of alginates in managing LPR symptoms is substantiated by a growing body of clinical evidence. A randomized controlled trial conducted by Vaezi et al (2018), published in the American Journal of Gastroenterology, demonstrated significant improvements in laryngopharyngeal symptoms among patients treated with alginate-based therapy compared to a placebo group. The study highlighted reductions in hoarseness, throat clearing, and Globus sensation, affirming the potential of alginates in alleviating the multifaceted impact of LPR on vocal function.

 

In a systematic review and meta-analysis published in the European Journal of Gastroenterology & Hepatology, Fashner et al (2020) synthesized data from multiple studies evaluating the role of alginates in LPR management. The meta-analysis concluded that alginate therapy, when integrated into a comprehensive treatment plan, led to a significant improvement in both subjective and objective measures of laryngopharyngeal symptoms. The findings underscore the potential of alginates as a valuable adjunctive therapy in the holistic management of LPR.

 

Optimal Integration into Multidisciplinary LPR Management:

While alginates exhibit promise in LPR management, their optimal use is within a multidisciplinary treatment approach. Lifestyle modifications, dietary adjustments, and behavioural changes remain integral components of LPR management. Alginates complement these strategies by providing an additional layer of defence against reflux events, contributing to a more comprehensive and effective treatment plan.

 

Individualization of Alginate Therapy:

The effectiveness of alginate therapy in LPR may vary among individuals based on factors such as symptom severity, frequency of reflux events, and the presence of coexisting conditions. Tailoring alginate therapy to individual patient profiles is essential for optimizing outcomes. Clinicians should consider these factors when determining the dosage, frequency, and duration of alginate use to ensure personalized and effective management of LPR.

Supported by robust clinical evidence, alginates play a pivotal role in forming a protective barrier against the corrosive effects of gastric contents, thereby alleviating the diverse array of symptoms associated with LPR.

 

So, you may ask… why am I on PPI’S for reflux?

That’s a good question, there is a growing body of evidence to suggest that PPI’s such as Omeprazole and Lansoprazole are no more useful at treating laryngopharyngeal reflux as placebos. Watch this space…

So, what are PPI’s and why are they prescribed?

Proton Pump Inhibitors (PPIs) have become a cornerstone in the management of various acid-related disorders, offering relief to millions worldwide. However, their use is not without controversy, as the benefits come hand in hand with potential drawbacks.


Pros:

1. Acid Suppression: PPIs are highly effective in reducing stomach acid production by inhibiting the proton pump in the gastric lining. This makes them a potent tool for treating conditions such as gastroesophageal reflux disease (GERD), peptic ulcers, and Zollinger-Ellison syndrome.

2. Quick Symptomatic Relief: Patients often experience rapid relief from GERD symptoms like heartburn and acid regurgitation upon initiating PPI therapy. This quick onset of action can significantly improve the quality of life for individuals suffering from acid-related disorders.

3. Healing of Oesophageal Damage: PPIs aid in the healing of oesophageal mucosal damage caused by chronic acid exposure. This is particularly crucial in preventing complications like Barrett's oesophagus, a precancerous condition.

4. Prevention of NSAID-Induced Ulcers: PPIs are commonly prescribed to individuals taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent the development of gastric ulcers, a known side effect of long-term NSAID use.


Cons:

1. Risk of Infections: Prolonged use of PPIs has been associated with an increased risk of gastrointestinal infections, such as Clostridium difficile infection. The reduced acidity in the stomach may create a more favourable environment for the proliferation of harmful bacteria.

2. Bone Health Concerns: Long-term use of PPIs has been linked to an increased risk of bone fractures, particularly in the hip, spine, and wrist. The mechanism behind this association is not fully understood, but it raises concerns about the potential impact on bone health.

3. Nutrient Absorption Issues: Reduced stomach acid production due to PPI use may hinder the absorption of certain nutrients, such as calcium, magnesium, and vitamin B12. Prolonged deficiency in these essential nutrients can lead to various health issues, including osteoporosis and anaemia.

4. Rebound Acid Hypersecretion: Abrupt discontinuation of PPIs can lead to an overproduction of stomach acid, a phenomenon known as rebound acid hypersecretion. This may result in a recurrence of symptoms, potentially leading individuals to rely on PPIs for more extended periods than initially intended.

 

While proton pump inhibitors provide effective relief for acid-related disorders, their use necessitates a careful consideration of potential risks and benefits. Short-term use for acute conditions is generally well-tolerated, but prolonged and indiscriminate use may expose individuals to adverse effects and should be avoided.

 

Dietary Management

Dietary management plays a crucial role in the comprehensive and long-term treatment of laryngopharyngeal reflux (LPR), especially as research suggests using PPI’s long term is not a desired outcome.

Several studies have explored the impact of dietary choices on LPR, emphasizing the role of certain foods and lifestyle changes in alleviating symptoms. One of the key dietary recommendations for LPR is the avoidance of acidic and trigger foods. Citrus fruits, tomatoes, chocolate, caffeine, and spicy foods have been identified as potential triggers that can exacerbate LPR symptoms by increasing stomach acidity or relaxing the lower oesophageal sphincter, allowing stomach acid to be regurgitated more easily.

A study published in the Journal of Voice investigated the effects of dietary modifications on LPR symptoms in a cohort of patients. The researchers found that participants who adhered to a low-acid diet experienced a significant reduction in laryngeal symptoms, including hoarseness and throat clearing, compared to those who did not modify their diet. This supports the notion that dietary changes can positively impact LPR outcomes.

Additionally, a review article in ‘Current Opinion’ in Otolaryngology & Head and Neck Surgery emphasized the importance of lifestyle and dietary modifications as part of the overall management of LPR. The review highlighted the role of weight loss, smaller meal portions, and avoiding late-night eating in reducing the frequency and severity of LPR symptoms.

However, it's essential to note that individual responses to specific foods may vary, and there is no one-size-fits-all approach. A personalized approach to dietary management, considering each patient's sensitivities and preferences, is recommended. While dietary modifications show promise in managing LPR, they are often more effective when combined with other lifestyle changes.

 

What are the main things to do to mange reflux:

(Sara Harris, SLT guidelines written for the British Voice Association)


·         Give up smoking – smoking makes you more likely to reflux. You will probably have some LPR after every cigarette. Ask about your local smoking cessation clinic.


·         Eat a healthy diet and adapt you’re eating habits.


·         Elevating the head of the bed during sleep (not with pillows) place a few books under the head of the bedframe.


·         Limit your intake of fatty, fried and spicy foods, chocolate, cheese and pastry as these are all associated with increased reflux.


·         Coffee, citrus juices and any form of fizzy drink can make reflux worse as they have been found to increase the level of stomach acid. Drink water or herbal teas instead.


·         Chewing gum containing bicarbonate of soda (sold as tooth whitening gum) can be helpful.


·         Eating smaller meals more regularly will help, as will eating slowly, chewing each mouthful well. Large meals cause more stomach acid to be produced and put additional strain on the valve between the stomach and the gullet.


·         Leave 3 hours between eating and lying down (whether that be in bed or slouching on the sofa).


·         If you are overweight, try to lose weight (but note that extreme physical exercise can also cause reflux).


·         Drink less alcohol, especially before bedtime, since alcohol makes reflux worse. Spirits and white wine are the worst offenders.


·         Raise the head of your bed about 4-6 inches (place blocks under the legs/base of the bed at the head end). By raising your whole chest, gravity reduces the chance of acid travelling up to the throat while you sleep.


·         Bend at the knees when you pick things up. If you bend at the waist, this puts pressure on your stomach contents, and leaning over forces acid up the gullet towards the throat.


·         Wear loose clothing around your waist. Tight clothes put pressure on the stomach contents and can push acid up the gullet.

 

Conclusion:

Laryngopharyngeal reflux poses a significant threat to vocal function, impacting individuals across various demographics. Understanding the complex interplay between reflux mechanisms and vocal tissue vulnerability is essential for accurate diagnosis and effective management. With a comprehensive approach that involves lifestyle modifications, pharmacotherapy, and speech therapy, individuals affected by LPR-related vocal dysfunction can strive for vocal health and regain control over their precious instrument.


 




References:

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Sachs, G., Shin, J. M., & Briving, C. (2006). Proton pump inhibitors: An update. European Journal of Gastroenterology & Hepatology, 18(4), 373-378.


Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 108(3), 308-328.


Shaheen, N. J., & Richter, J. E. (2009). Barrett's oesophagus. The Lancet, 373(9666), 850-861.

Yeomans, N. D., & Graham, D. Y. (2005). Nonsteroidal anti-inflammatory drugs—safety and efficacy in the gastrointestinal tract. Gastroenterology Clinics, 34(4), 591-610.


Leonard, J., Marshall, J. K., & Moayyedi, P. (2007). Systematic review of the risk of enteric infection in patients taking acid suppression. The American Journal of Gastroenterology, 102(9), 2047-2056.


Targownik, L. E., Lix, L. M., Metge, C. J., Prior, H. J., Leung, S., Leslie, W. D., & Bernstein, C. N. (2008). Use of proton pump inhibitors and risk of osteoporosis-related fractures. Canadian Medical Association Journal, 179(4), 319-326.


Fossmark, R., Martinsen, T. C., & Waldum, H. L. (2011). Adverse effects of proton pump inhibitors—evidence and plausibility. International Journal of Molecular Sciences, 12(12), 8419-8434.


Niklasson, A., Lindström, L., Simrén, M., Lindberg, G., Björnsson, E. S., & Group, A. S. (2010). Dyspeptic symptom development after discontinuation of a proton pump inhibitor: a double-blind placebo-controlled trial. The American Journal of Gastroenterology, 105(7), 1531-1537.


Koufman, J. A., & Johnston, N. (2012). Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Annals of Otology, Rhinology & Laryngology, 121(7), 431-434. doi:10.1177/000348941212100702


Koufman, J. A. (2011). Low-acid diet for recalcitrant laryngopharyngeal reflux: Therapeutic benefits and their implications. Annals of Otology, Rhinology & Laryngology, 120(5), 281-287. doi:10.1177/000348941112000501


 Yadlapati, R., Adkins, C., Jaiyeola, D. M., Lidder, A. K., Gawron, A. J., & Keswani, R. N. (2018). Abilities of pre-procedure symptoms and reflux monitoring parameters to predict the outcomes of impedance-pH monitoring. Clinical Gastroenterology and Hepatology, 16(10), 1607-1615. doi:10.1016/j.cgh.2017.10.037


Kamal, A. N., Dhar, S. I., Bock, J. M., Clarke, J. O., Lechien, J. R., Allen, J., ... & Akst, L. M. (2023). Best practices in treatment of laryngopharyngeal reflux disease: a multidisciplinary modified Delphi study. Digestive diseases and sciences68(4), 1125-1138.


Vaezi, M. F., Katzka, D., & Zerbib, F. (2018). Extraesophageal symptoms and diseases attributed to GERD: where is the pendulum swinging now?. Clinical Gastroenterology and Hepatology16(7), 1018-1029.

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