Larengofarengeal Reflü
Özet
Larengofarengeal reflü (LFR), mide içeriğinin üst yemek borusu sfinkteri ve larengofarenkse geriye doğru kaçmasıyla karakterize, ses kalitesini olumsuz etkileyen yaygın bir hastalıktır. Gastroözofageal reflü hastalığından farklı bir klinik yaklaşımla değerlendirilmesi gereken LFR, ses kısıklığı, sık boğaz temizleme, yutma güçlüğü ve öksürük gibi spesifik olmayan kronik semptomlarla KBB polikliniklerine başvuran hastaların önemli bir kısmında görülür. Tanı aşamasında Belafsky ve arkadaşları tarafından geliştirilen 9 maddelik Reflü Semptom İndeksi ile 8 maddelik laringoskopik Reflü Bulgu Skoru'ndan yararlanılır. Tanıda yeni altın standart asit ve asitsiz reflüleri kantitatif ölçebilen HÖMİİ-pH testi olarak kabul edilirken, ayırıcı tanıda akut-kronik larenjit, fonksiyonel ses bozuklukları ve larenks maligniteleri mutlaka dışlanmalıdır. LFR tedavisi, klasik reflüye kıyasla daha agresif ve uzun süreli bir yaklaşım gerektirir. Tedavinin temelini kilo kontrolü, kafeinli, gazlı, yağlı ve baharatlı gıdalardan uzak durulmasını içeren katı yaşam tarzı değişiklikleri ile asitsiz diyetler oluşturur. Tıbbi tedavide mide asidini ve pepsin aktivitesini baskılayan antiasitler, H2 reseptör blokerleri ve en az 3 ay çift doz uygulanması gereken Proton Pompa İnhibitörleri (PPİ) ilk seçenektir. Medikal tedaviye yanıt vermeyen, HÖMİİ-pH testiyle doğrulanmış seçilmiş hastalarda ise uzun dönemde başarılı sonuçlar sunan laparoskopik Nissen fundoplikasyonu cerrahisi önerilmektedir.
Laryngopharyngeal reflux (LPR) is a common disease that adversely affects voice quality, characterized by the retrograde flow of gastric contents into the upper esophageal sphincter and laryngopharynx. Requiring a distinct clinical approach from gastroesophageal reflux disease, LPR is frequently observed in patients presenting to ENT clinics with non-specific chronic symptoms such as hoarseness, throat clearing, dysphagia, and cough. Diagnosis utilizes the 9-item Reflux Symptom Index and the 8-item laryngoscopic Reflux Finding Score developed by Belafsky and colleagues. While the HEMII-pH test is considered the new gold standard for quantitatively measuring acid and non-acid reflux, differential diagnosis must exclude acute-chronic laryngitis, functional voice disorders, and laryngeal malignancies. LPR management necessitates a more aggressive and prolonged approach compared to classic reflux. The cornerstone of treatment involves strict lifestyle modifications, including weight management, avoiding caffeine, carbonated drinks, fatty and spicy foods, and adhering to low-acid diets. For medical therapy, antacids, H2 receptor blockers, and Proton Pump Inhibitors (PPIs)—which must be administered in double doses for at least three months to suppress gastric acid and pepsin activity—are the primary choices. In selected patients non-responsive to medical treatment and verified by HEMII-pH testing, laparoscopic Nissen fundoplication surgery is recommended, offering successful long-term outcomes.
Referanslar
Ricci G, Wolf AE, Barbosa AP, et al. Signs and symptoms of laryngopharyngeal reflux and its relation to complaints and vocal quality. Codas. 2020;32(5):e20180052. Portuguese, English. Doi: 10.1590/2317-1782/20202018052..
Koufman J, Sataloff RT, Toohill T. Laryngopharyngeal reflux: consensus conference report. J Voice. 1996. 10(3):215-6. Doi: 10.1016/s0892- 1997(96)80001-4.
Johnston N, Dettmar PW, Strugala V, et al. Laryngopharyngeal reflux and GERD. Ann N Y Acad Sci 2013;1300:71–9.
Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005; 294(12):1534–40.
Vakil N, van Zanten SV, Kahrilas P, et al; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-20; quiz 1943. Doi: 10.1111/j.1572-0241.2006.00630.x. PMID: 16928254.
Carroll TL. Reflux and the Voice: Getting Smarter About Laryngopharyngeal Reflux. Otolaryngol Clin North Am. 2019;52(4):723-33. Doi: 10.1016/j.otc.2019.03.015. Epub 2019 May 11. PMID: 31088696.
Cherry J, Margulies SI : Contact Ulcer of the Larynx. Laryngoscope 1968: 78: 1937-40
Malcomson, K.G. Globus Hystericus vel Pharyngis (A Reconnaissance of Proximal Vagal Modalities ). J Laryngol Otol. 1968; 82:219-30.
Koufman JA. The otolaryngologic manifestations of gastroesoph-ageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101(Suppl 53):1-78.
Mittal RK, Balaban DH. The esophagogastric junction. N Engl J Med. 1997; 336:924-32.
Kahrilas PJ, Dodds WJ, Dent J, et al. Effect of sleep, spontaneous gastroesophageal reflux, and a meal on upper esophageal sphincter pressure in normal human volunteers. Gastroenterology 1987; 92:466-71.
Vakil NB, Kahrilas PJ, Dodds WJ, et al: Absence of an upper esophageal sphincter response to acid retlux. Am J Gastroenterol 1989; 84:606-10.
Ulualp SO, Toohill RJ, Kern M. Pharyngo-UES contractile reflex in patients with posterior laryngitis. Laryngoscope 1998;108:1354 57.
Ulualp SO, Toohill RJ. Larngopharyngeal reflux: state of the art diagnosis and treatment. Otolaryngol Clin North Am 2000; 33(4):785-801.
Helm JF. Effect of Esophageal Emptying and Saliva Clearance of Acid from the Esophagus. New England Journal of Medicine. 1984; 310 : 284.
Johnston N, Dettmar PW, Strugala V, et al. Laryngopharyngeal reflux and GERD. Ann N Y Acad Sci 2013;1300: 71–9.
Adhami T, Goldblum JR, Richter JE, et al. The role of gastric and duodenal agents in laryngeal injury: an experimental canine model. Am J Gastroenterol 2004;99: 2098–106.
Johnston N, Wells CW, Blumin JH, et al. Receptor-mediated uptake of pepsin by laryngeal epithelial cells. Ann Otol Rhinol Laryngol 2007;116(12):934–8.
Wassenaar E, Johnston N, Merati A, et al. Pepsin detection in patients with lar- yngopharyngeal reflux before and after fundoplication. Surg Endosc 2011; 25(12):3870–6.
Koufman JA, Ami MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg. 2000. 123(4):385-8. Doi: 10.1067/mhn.2000.109935.
Schreiber S, Garten D, Sudhoff H. Pathophysiological mechanisms of extraesophageal reflux in otolaryngeal disorders. Eur Arch Otorhinolaryngol. 2009;266(1):17-24. Doi: 10.1007/s00405-008-0770-1. Epub 2008 Aug 13. PMID: 18704479.
Wong RK, Hanson DG, Waring PJ, et al. ENT manifestations of gastroesophageal reflux. Am J Gastroenterol. 2000;95(8 Suppl): 15-22. Doi: 10.1016/s0002-9270(00)01074-1.
Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia)(update). Otolaryngol Head Neck Surg 2018;158(1_suppl): S1–42.
Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111: 1313-17.
Belafsky PC, Postma GN, Koufman JA. The association between laryngeal pseudosulcus and laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2002;126(6):649-52.
Powell J, Cocks HC. Mucosal changes in laryngopharyngeal reflux--prevalence, sensitivity, specificity and assessment. Laryngoscope. 2013;123(4):985-91. Doi: 10.1002/lary.23693. Epub 2012 Dec 3. PMID: 23208751.
Peery AF, Hoppo T, Garman KS, et al. Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video). Gastrointest En- dosc 2012;75(5):945–53.e2.
Howell RJ, Pate MB, Ishman SL, et al. Prospective multi-institutional transnasal esophagoscopy: predictors of a change in management. Laryngoscope 2016;126(12):2667–71.
Chheda NN, Seybt MW, Schade RR, et al. Normal values for pharyngeal pH moni- toring. Ann Otol Rhinol Laryngol 2009;118(3):166–71.
Yadlapati R, Adkins C, Jaiyeola D-M, et al. Abilities of oropharyngeal pH tests and salivary pepsin analysis to discriminate between asymptomatic volunteers and subjects with symptoms of laryngeal irritation. Clin Gastroenterol Hepatol 2016; 14(4):535–42.e2.
Vailati C, Mazzoleni G, Bondi S, et al. Oropharyngeal pH monitoring for laryngopharyngeal reflux: is it a reliable test before therapy ? J Voice 2013;27(1):84-9
Borges LF, Chan WW, Carroll TL. Dual pH probes without proximal esophageal and pharyngeal impedance may be deficient in diagnosing LPR. J Voice 2018. Doi: 10.1016/j.jvoice.2018.03.008.
Lee YC, Kwon OE, Park JM, et al. Do laryngoscopic findings reflect the charac- teristics of reflux in patients with laryngopharyngeal reflux? Clin Otolaryngol Doi: 10.1111/coa.12914.
Hayat JO, Gabieta-Somnez S, Yazaki E, et al. Pepsin in saliva for the diagnosis of gastro-oesophageal reflux disease. Gut 2015;64(3):373–80.
Calvo-Henr ́ıquez C, Ruano-Ravina A, Vaamonde P, et al. Is pepsin a reliable marker of laryngopharyngeal reflux? A systematic review. Otolaryngol Head Neck Surg 2017;157(3):385–91.
Johnson F, DeMeester TR: Evaluation of elevation of head of the bed, bethanecol, and antiacid foam tablets on gastroesophageal reflux. Dig Dis Sci 1981;26: 673-80.
Bradley LA: The relationship between stress and aymptoms of gastroesophageal reflux: the influence of psychological factors. Am J Gastroenterol 1993;88: 11.
Zalvan CH, Hu S, Greenberg B, et al. A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux. JAMA Otolaryngol Head Neck Surg. 2017 Oct 1;143(10):1023-1029. Doi: 10.1001/jamaoto.2017.1454.
Koufman JA. Low-acid diet for recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Ann Otol Rhinol Laryngol 2011; 120(5):281-87
Liu C, Wang H, Liu K. Meta-analysis of the efficacy of proton pump inhibitors for the symptoms of laryngopharyngeal reflux. Braz J Med Biol Res. 2016;49(7):e5149. Doi: 10.1590/1414-431X20165149.
Lechien JR, Saussez S, Schindler A, et al. Clinical outcomes of laryngopharyngeal reflux treatment: A systematic review and meta-analysis. Laryngoscope. 2019;129(5):1174-87. Doi: 10.1002/lary.27591.
Salminen P, Karvonen J, Ovaska J. Long-term outcomes after laparoscopic Nissen fundoplication for reflux laryngitis. Dig Surg. 2010;27(6):509-14.
