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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 219-221

Laryngopharyngeal reflux in a school-going child with unusual clinical presentation


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
3 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission19-Sep-2019
Date of Decision19-Sep-2019
Date of Acceptance24-Jul-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_42_19

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  Abstract 


Laryngopharyngeal reflux (LPR) refers to laryngopharyngeal manifestations of acid reflux from the gastroesophageal part. LPR is diagnosed by assessing the clinical symptoms, videolaryngoscopic assessment of the larynx, and double-probe monitoring of the pH. Hoarseness of voice is an important symptom for the diagnosis of LPR in children and frequently the only presenting symptom. Ambulatory 24-h double-probe (esophageal and pharyngeal) pH monitoring is both specific and sensitive for the diagnosis of LPR. Early diagnosis and treatment often results in the improvement of hoarseness and prevent complications. Endoscopic examination of the larynx and hypopharynx is an important step for patient selection as selected laryngeal findings are related with diagnosis, treatment, and outcome. Treatment options are medications and lifestyle modifications. Here, we present vocal process granuloma and unusual presentations of prolonged LPR in a 12-year-old boy.

Keywords: Granuloma, hoarseness of voice, laryngopharyngeal reflux, school-going child


How to cite this article:
Swain SK, Behera IC, Mohanty JN. Laryngopharyngeal reflux in a school-going child with unusual clinical presentation. BLDE Univ J Health Sci 2020;5:219-21

How to cite this URL:
Swain SK, Behera IC, Mohanty JN. Laryngopharyngeal reflux in a school-going child with unusual clinical presentation. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Apr 14];5:219-21. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/219/303967



Laryngopharyngeal reflux (LPR) is a commonly encountered clinical entity in daily practice and defined as the reverse flow of gastric content to the pharynx and larynx.[1] It happens when the upper and lower esophageal sphincters do not close sufficiently and help the gastric contents and acid trickle into the larynx, which cause inflammation and edema. LPR presents several manifestations ranging from foreign body sensation in the throat to subglottic edema. The various clinical presentations of LPR in children are usually nonspecific. The clinical presentations are postnasal drip, globus sensation in the throat, throat clearing, cough, and choking sensation in the throat. The endoscopic picture of larynx may cause posterior commissure hypertrophy, edema of the vocal fold, subglottic edema, obliteration at the laryngeal ventricle, laryngeal edema, presence of granuloma, and thick endolaryngeal mucous.[2] Here, we describe a young patient of LPR with giant granuloma at the posterior larynx.


  Case Report Top


A 12-year-old male child presented with irritating dry cough for the past 5 months and dysphonia for the past 3 months. He was an obese child with a habit of taking frequent carbonated drinks and exposed to passive smoking from his family members. He had a breathy voice, with inability for completing sentence. He had also complained of a sensation of fullness in the throat, and had repetitive throat-clearing habit for the past 2 months. The hoarseness of voice was gradually becoming worse accompanied by occasional throat pain. He had no past history of prolonged intubation or any traumatic intubation. On examination with flexible nasopharyngolaryngoscopy, there was a swollen, reddish mass at both vocal processes [Figure 1]. Bilateral vocal folds were mobile and congestions were seen in the posterior part. Sputum sent for acid-fast bacilli came out to be negative. Chest X-ray appeared normal. Routine blood tests were within normal limits. The patient was sent to a gastroenterologist for further evaluation and to rule out gastroesophageal reflux disease (GERD); after 24 h, pharyngeal pH monitoring appeared to be LPR. This confirmed acid reflux-induced granuloma at the posterior commissure. The patient was planned for micro-laryngeal excision of both granulomatous lesions of the larynx at the vocal process. Vocal process granulations in both sides were excised and sent for histopathological examinations. The histopathological report revealed nonspecific inflammations. The child was treated with aggressive anti-reflux therapy along with omeprazole 20 mg orally once daily with steam inhalation for 2 months. He had also undertaken speech therapy after the surgery. The parents of the child were counseled and advised for avoiding passive smoking, carbonated drinks, and coffee chocolates and advised on the reduction of weight of the child. After 2 months of treatment, there was complete resolution of all the symptoms. Examination of the larynx [Figure 2] by fiberoptic nasopharyngolaryngoscopy revealed normal appearance after 3 months of follow-up.
Figure 1: Fibreoptic Laryngoscopic picture of giant granuloma at bilateral vocal process.

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Figure 2:Post-operative view of Larynx after 3 months of treatment.

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  Discussion Top


LPR is an inflammatory disease due to backflow of the gastric acid into the larynx and pharynx, where it contacts the tissues of the upper aerodigestive tract.[3] The physiological barriers for preventing LPR are esophageal sphincter, esophageal peristalsis, gravity, and saliva. If these above physiological barriers do not work, stomach content such as acid come in touch with the laryngopharyngeal tissues and cause damage to the lining epithelium, ciliary dysfunction and inflammation. The quality of voice is affected in 6%–23% of school-going children.[4] LPR is a well-established etiology for hoarseness of voice in children.[5] The prominent clinical presentations in LPR are persistent cough, clearing of the throat, globus pharyngeus, and change of voice.[6] Globus pharyngeus is defined as foreign body sensation in the throat and feeling of a lump in the throat, which is nonpainful in nature.[7] Heartburn is a common symptom in GERD and seen in above 75% of cases, whereas < 40% of cases with LPR present heartburn.[8]

Several risk factors aggravate and result in posterior laryngeal granulations such as prolonged intubation, injury during intubation, intubating with larger size endotracheal tube, raised cuff pressure, and anomalous laryngeal anatomy.[9] However, there was no such factor identified in this case. The pathogenesis of vocal process granuloma and its association with LPR is still doubtful, but it may be due to an interruption of the usual healing process after trauma or constant chemical injury of arytenoids or vocal process of the larynx. The critical role of LPR in causing laryngeal granuloma of the vocal process has been documented by the fact that major part of the vocal process of granuloma is cured by conservative treatment of acid reflux.[10]

Laryngoscopic examination is done using a flexible transnasal or a rigid transoral laryngoscope. The laryngeal findings include vocal fold edema, redness, and edema localized to the posterior larynx, arytenoid, and inter-arytenoid area. Sometimes, patients present with subglottic edema, granuloma, pseudosulcus, and vocal fold contact ulcers. These are also commonly seen in clinical presentations during laryngeal examinations for assessing dysphonic patients. Accurate laryngoscopic assessment in LPR patients is often difficult, hence it is usually not suggested to make a diagnosis of LPR only on the basis of laryngoscopic findings.[11] In LPR, the diagnosis is usually done by inquiring the clinical symptoms, endoscopic examination of the larynx, or double-probe monitoring of pH. Ambulatory 24-h double-probe (esophageal and pharyngeal) pH monitoring is highly sensitive and specific for the diagnosis of LPR.[12] There is no ideal diagnostic method for LPR in pediatric age. There are different methods available for the diagnosis of LPR, which include pH monitoring, intraluminal impedance, barium studies, scintigraphy, ultrasound, fluoroscopy, and esophageal biopsy. The present gold standard investigation for LPR is the dual-probe 24-h pH monitoring. As it is an invasive method, false-negative results reach as high as 50%.[13] Some additional studies such as radiographical study, manometry of esophagus, spectrophotometric assessment of bile reflux and histopathological study of the laryngopharyngeal mucosa can be done to confirm the LPR.

Most of the postintubation injuries on posterior larynx resolve spontaneously, whereas acid reflux has been associated with long-term injury at the posterior part of the larynx. The symptomatic improvement is made possible by altering dietary patterns. Patients should take early dinner, i.e., at least 2 h before the bed time. They should avoid excessive coffee or carbonated drinks, which increase acidity and lead to reflux.[14] Patients should avoid spicy diets, high-fat foods, chocolate, and high-calorie diet because they aggravate acid reflux.[15] LPR patients are advised to stop or avoid smoking. Weight reduction is an important criterion for patients affected with LPR, particularly in obese patients. Patients are advised for regular exercises of at least 30 min each day as less active children are more prone to develop LPR.[16] Giant granulomatous lesions at vocal process affecting laryngeal function requires micro-laryngeal surgery and biopsy as done in this case.


  Conclusion Top


In the present case, LPR was suspected from the patient history and endoscopic findings. Granuloma at posterior larynx is a long-term and severe complication of LPR. Multichannel intraluminal impedance and pH monitoring studies are useful for the confirmation of LPR. There are no specific tests for diagnosing LPR. Empirical treatment with Proton pump inhibitor(PPI) s is widely considered a diagnostic test and treatment option for LPR. Other options are dietary and lifestyle modifications such as avoiding passive and active smoking, alcohol, and caffeine, weight reduction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005;294:1534-40.  Back to cited text no. 1
    
2.
Vengatesh R, Sanjeevan N, Nik Hassan NF. Unusual cause acute airway obstruction. Egypt J Ear Nose, Throat Allied Sci 2017;18:303-5.  Back to cited text no. 2
    
3.
Lin BZ, Yang MT, Lin CL, Chen KY, Lin TJ. Association of laryngopharyngeal reflux and gastrointestinal reflux disease. J Gastrointestinal Disord Liver Funct 2019;5:1-4.  Back to cited text no. 3
    
4.
Swain SK, Behera IC, Sahoo L. Hoarseness of voice in pediatric age group. Our experiences at an Indian teaching hospital. Indian J Child Health 2019;62:74-8.  Back to cited text no. 4
    
5.
Swain SK, Nahak B, Sahoo L, Munjal S, Sahu MC. Pediatric dysphonia-A review. Indian J Child Health 2019;6:1-5.  Back to cited text no. 5
    
6.
Franco RA Jr., Laryngopharyngeal reflux. In: UpToDate, Kunins L, editor. UpTo Date, Waltham, MA. Available from: https://www.uptodate.com/contents/laryngopharyngeal-reflux. [La?st accessed on 2018 Mar 30].  Back to cited text no. 6
    
7.
Lee BE, Kim GH. Globus pharyngeus: A review of its etiology, diagnosis and treatment. World J Gastroenterol 2012;18:2462-71.  Back to cited text no. 7
    
8.
Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002;127:32-5.  Back to cited text no. 8
    
9.
Jang M, Basa K, Levi J. Risk factors for laryngeal trauma and granuloma formation in pediatric intubations. Int J Pediatr Otorhinolaryngol 2018;107:45-52.  Back to cited text no. 9
    
10.
Walner DL, Stern Y, Gerber ME, Rudolph C, Baldwin CY, Cotton RT. Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg 1998;124:551-5.  Back to cited text no. 10
    
11.
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108:308-28.  Back to cited text no. 11
    
12.
Postma GN, Belafsky PC, Aviv JE, Koufman JA. Laryngopharyngeal reflux testing. Ear Nose Throat J 2002;81:14-8.  Back to cited text no. 12
    
13.
Karkos PD, Leong SC, Apostolidou MT, Apostolidis T. Laryngeal manifestations and pediatric laryngopharyngeal reflux. Am J Otolaryngol 2006;27:200-3.  Back to cited text no. 13
    
14.
Fass R, Quan SF, O'Connor GT, Ervin A, Iber C. Predictors of heartburn during sleep in a large prospective cohort study. Chest 2005;127:1658-66.  Back to cited text no. 14
    
15.
Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol 2007;5:439-44.  Back to cited text no. 15
    
16.
Nocon M, Labenz J, Willich SN. Lifestyle factors and symptoms of gastro-oesophageal reflux–a population-based study. Aliment Pharmacol Ther 2006;23169-74.  Back to cited text no. 16
    


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