Granulomas

Complications may include granulomas, most commonly at the posterior end of one vocal cord, as well as much less commonly in the supraglottis and subglottis. When present on the vocal cords, granulomas can cause abnormal or poor adduction of the cords resulting in a rough voice quality, voice fatigue and difficulty in projecting.8 In rare, extreme, cases, airway obstruction can occur (see figure 1).

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Figure 1

Left vocal cord granuloma.

Laryngeal scarring, strictures and sulci

Chronic refluxing of gastric contents is thought to play a part in scarring of the glottis and sub-glottis. This can subtly affect the mobility of the vocal cords causing dysphonia.8

Polyps and cysts

Vocal cord inflammatory polyps and cysts are common abnormalities with some levels 3 and 4 evidence of association with reflux. Contralateral damage to the other cord from contact can occur, with ‘kissing lesions’ and possibly haemorrhage on either side. It is further believed that cysts can burst, leaving subsequent scarring and sulci (axial grooves) of the cords9 (see figure 2). Other causes of sulci are also hypothesised, such as congenital and traumatic.

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Figure 2

Right anterior vocal cord polyp.

Chronic cough

Irritation of the larynx may lead to a persistent dry cough and hypersensitivity.8 Hypersensitivity is characterised by a decreased cough and throat symptom threshold to various noxious and non-noxious stimuli for example, cold drinks, cold air, aerosols.10 A small study has shown that in patients with chronic cough and LPR who have not previously been treated, the expected improvement after initiating reflux treatment is 60% at 3 months. In 10% of patients, complete resolution of cough was reported by 4 months.10

Laryngitis

A persistent feeling of sore throat without evidence of an acute viral, fungal or bacterial infection is a common complication of LPR.8 The pain can result from a combination of active inflammation and reactive muscle tension (internal and external), and both require attention. It is worth considering muscle tension dysphonia (anxiety related) and candida as differentials.

Upper oesophageal strictures, webs and spasms

Oesophageal narrowing can occur, producing classical symptoms of choking, sticking, tightening, spasm or regurgitation when swallowing.8 There is various terminology used to describe oesophageal narrowing, including oesophageal webs, bars and strictures. It most commonly affects the cricopharyngeal area at the upper oesophagus where the cricopharyngeus muscle can spasm and hypertrophy in the presence of chronic inflammation.8 Such problems are often associated with synchronous uncontrolled GORD which requires MDT management with gastroenterology.

Sinusitis

The relationship between reflux and chronic rhinosinusitis (CRS) is controversial. A few research papers have found that pepsin A levels have a higher expression in the nasal mucosa of patients with CRS, suggesting a correlation between LPR and CRS.11

Chronic otitis media with effusion

Some of the literature shows that the prevalence of otitis media is higher in patients with LPR than those without.12 One study demonstrated that Eustachian tube dysfunction was more likely to be associated with low nasopharyngeal pH and a higher Reflux Finding Score (RFS). The pathogenesis is not well understood but the association between LPR and otitis media may be due inflammation of the mucosal lining of the eustachian tube and middle ear, leading to oedema and obstruction of the outflow and drainage of middle ear mucus. Since there is no barrier stopping the influx of naso/oro or laryngopharynx secretions into the eustachian tubes, anatomically this may explain the spread of acid in the laryngopharynx and eustachian tube resulting into inflammation in the middle ear (otitis media).13

Reflux symptoms index

The RSI (table 2), designed in 2002 by Belafsky et al, 14 comprises a nine-item self-reported questionnaire whereby a patient is asked to rate (0, no impact to 5, severe impact) LPR-associated symptoms and how they have impacted their lives over the preceding month. The maximum score is 45; a score of greater than 13 is considered a reliable diagnostic indicator for LPR and these patients often proceed to laryngoscopic examination to further quantify their LPR using the RFS.13

Reflux Finding Score

The RFS comprises an eight-item index, designed to score patients based on endoscopic findings;scores range from 0 to 26, with a score of 11 or more generally considered to be diagnostic for LPR.14 (table 3)14

Comprehensive Reflux Symptom Score

The CReSS comprises a 34 reflux symptom score, combing elements of the RSI and the Gastro-Oesophageal Symptom Assessment Scale.1

Voice Handicap Index

The VHI is a subjective scoring system that evaluates the psychosocial impact of voice disorders on a patient’s quality of life. The shorter more commonly used 10-item index questionnaire, VHI-10 (a truncated version of the thirty-item VHI) is scored between 0 and 40 with a higher score indicating a more significant voice-related handicap (table 4).15

Lifestyle advice

Patient education is vital for patients to make informed lifestyle choices and modifications. Avoiding common triggers such as caffeine, carbonated drinks, alcohol, spicy or high fat foods can alone be transformative.19 Triggers are patient specific and recommending symptom and dietary diaries can be useful in making links with triggers and symptoms. Smoking cessation or reduction is imperative and sources of assistance should be accessed where required.24 Adequate hydration, stress reduction and weight loss are also advised.25 Patient information leaflets can be a helpful adjunct in clinic as an aide memoire for patients to take home.

Medical management

The mainstay of medical therapy is with alginate-based medicines, such as Gaviscon Advance if throat symptoms alone, or with the addition of PPIs if related to GORD.25 The majority of patients referred to ENT clinics in secondary care for LPR will be experiencing moderate to severe ENT-related symptoms and/or have sequelae of the disease. ENT specialists meet patients at various points along their disease process with huge variation in previous management. For moderate to severe cases, the literature, up until recently, has advocated for a trial of PPI (Lansoprazole 30 mg two times per day, taken 30 min before meals) for 3 months, followed by review.8 However, O’Hara et al have questioned such liberal use of PPI’s without robust trial support.1 In addition, sodium alginate with potassium bicarbonate (Gaviscon Advance or equivalent, 10mls, 20 min after meals and before bedtime) can be trialled.25 Regular review is vital in order for doses to be reduced or PPIs stopped if there is no improvement. Refractory cases may need referral to gastroenterology for further investigation and potentially upper gastrointestinal (GI) intervention to help treat the reflux reaching the laryngopharynx.

In response, Watson et al completed a double blinded RCT (TOPPITS trial)1 2 looking into the effectiveness of PPIs for the treatment of throat symptoms and suspected LPR. Its comparison of Lansoprazole versus placebo did not show any significant difference in outcome and therefore has called into question conventional wisdom on how to manage these patients. Some criticisms of the trial have been raised, however. First, there was no gold standard investigation for LPR (24 hours pH impedance monitoring) and the scoring systems used such as the RSI and RFS (see above) are not specific for LPR alone.26 In addition, not all throat symptoms are caused by acid reflux. A patient without LPR may have a significant score and/or throat symptoms due to a variety of other pathologies and consequently included in the study. Furthermore, selection for the trial included patients with an RSI above 10, whereas ‘abnormal’ was set by the score developers as greater than 13.7 This may have skewed the results negatively towards the benefits of PPIs for those with a true diagnosis. It is therefore important to establish the diagnosis of reflux with more certainty if treatment is to be effective and we should be cautious to completely dismiss the use of PPIs for patients, some of whom may benefit. National guidance based on the trial results (and similar precedents) is likely to reduce PPI prescription for uncomplicated LPR dramatically.

Surgical management

Some patients with persistent reflux that fails drug therapy, may be referred for evaluation of surgical management, for example, patients with diagnosed hiatus hernia may benefit from fundoplication. Antireflux surgery (including various forms of fundoplication and devices such as EsophyX and LINX) for GORD presents alternatives and adjuncts to long-term antireflux medication, for those with refractory symptoms.27 There are stringent criteria for such surgery, outside the scope of this paper. Endoscopic techniques, such as EsophyX, may be performed by interventional upper GI physicians and are minimally invasive. However, laparoscopic surgery under upper GI surgeons (fundoplication, LINX and others) are thought to have better long-term effectiveness.6 27 These would be used following proof of classic GORD through both OGD and 24 hours pH-impedance testing, but their place in assisting extraoesophageal symptoms alone, as with PPIs, is presently controversial. More trials are required.

There are, however, multiple procedures that can be performed to treat the sequelae and complications of chronic reflux.

Oesophageal strictures

Balloon dilation is the mainstay of surgical management for oesophageal strictures, webs and narrowing resulting in dysphagia. This can be carried out under general anaesthetic with rigid pharyngoscopy and oesophagoscopy followed by balloon dilatation and can also be carried out by GI physicians under local anaesthetic with or without sedation. However, delivering the balloons via TNO or flexible gastroscopes provides better views and control with less risk than with rigid oesophagoscopes and is increasingly replacing the latter.21 For small strictures, occasionally passing a rigid oesophagoscope through the upper oesophagus is sufficient in stretching the narrowed area. In specialist tertiary centres this can be performed trans-nasally with topical local anaesthetic in clinic. A flexible oesophagoscope/TNO is passed into the oesophagus down to the stomach with gentle insufflation. The scope is then withdrawn to the area of maximal narrowing (usually the cricopharyngeal area). A guidewire is passed down a port on the scope and a balloon passed over the guidewire using a Seldinger technique. The balloon is inflated for 60–120 s usually to a range of 12–20 mm, depending on the size of the patient and tightness of stricture/spasm. The procedure is generally well tolerated and avoids the need for general anaesthetic or sedation.28

Laryngeal granulomas

Inflammatory granulomas or lesions are conservatively managed if they do not obstruct the airway. Maximal antireflux therapy is advised and speech and language therapy (SLT) is required to reduce secondary muscle tension. For refractory and symptomatic granulomata, botulinum toxin is sometimes injected into the thyroarytenoid-lateral cricoarytenoid complex to avoid forceful adduction (and thus traumatic granuloma generation) of the vocal process.29 If these methods fail, in-office laser (eg, Trublue, KTP) is possible. Otherwise, excision using microlaryngoscopy under general anaesthetic, using microlaryngeal instruments and/or laser may be used. Specimens are sent for histological analysis to confirm the diagnosis. Care needs to be taken to preserve the vibrating mucosal surfaces and superficial lamina propria of the vocal cords. Voice therapy postoperatively is a useful adjunct to improve voice quality and promotion of abduction of the vocal cords.29

Glottic webs, scarring and subglottic stenosis

Chronic reflux has been associated with glottic scarring, particularly in the posterior glottis and interarytenoid area. Similarly, in severe cases, subglottic stenosis can occur. In these cases, a variety of techniques can be used under general anaesthetic with microlaryngoscopy. Cold steel, CO₂ laser, corticosteroid injections and balloon dilatation can all be used in conjunction. Consideration must be made to avoid the creation of new scar tissue and a balance must be struck when improving the airway versus improving voice. Occasionally splints may be used to prevent scarring of the glottis post-operatively and allow for healing.28

Multidisciplinary team

There can be uncertainties and complexity in managing patients with suspected LPR, particularly when the diagnosis is not obvious. Working as part of a multidisciplinary team is crucial to ensure the correct investigations and management is carried out. For ENT specialists, working alongside SLT is imperative. Patients particularly struggling with voice symptoms or dysphagia may be referred for therapy and SLT therapists are trained in advising patients appropriately and providing support with promotion of abduction of vocal cord exercises, prevention of harsh glottic attacks, suppression of cough and throat clearing by sniffing and promotion of deep swallows with sips of water. For those with hypersensitivity in the absence of objective reflux, this is particularly helpful.