Characteristics and Management of Laryngopharyngeal Reflux in The Elderly : A Case Report

Laryngopharyngeal reflux is a condition resulting from the retrograde flow of stomach acid through the distal esophagus into the laryngopharyngeal area. The prevalence of laryngo-pharyngeal reflux in the elderly population remains uncertain.  Therefore, the symptoms, findings, and therapy for laryngopharyngeal reflux in the elderly require further investigation. To analyze the characteristics and management of laryngopharyngeal reflux in the elderly. A case of laryngopharyngeal reflux in a 70-year-old woman who frequently experiences sudden choking sensations is presented in this report.  Other symptoms include hoarseness, a sensation of throat obstruction, and chest burning. We explored literature on laryngopharyngeal reflux in the elderly through PubMed, PMC, and Google Scholar databases to discuss the case. Laryngopharyngeal reflux in the elderly has a lower reflux symptoms index but a higher reflux finding score. Mental health factors significantly influence laryngopharyngeal reflux incidence in the elderly. Therefore, besides pharmaco-logical therapy, additional non-pharmacological therapies need to be considered to ensure effective laryngopharyngeal reflux treatment. Elderly patients diagnosed with laryngopharyngeal reflux have different presentations and management of the disease compared with younger patients.

INTRODUCTION

Laryngopharyngeal reflux (LPR) is a condition resulting from the retrograde flow of stomach acid through the distal esophagus into the laryngopharyngeal area. LPR induces laryngeal symptoms, including throat clearing, hoarseness, pain, throat irritation sensation, cough, excessive throat mucus, and dysphonia. The term LPR was first introduced in 1996 by Kauffman et al. Initially, LPR was considered another form of Gastroesophageal Reflux Disease (GERD) due to the reflux of gastric contents into the upper aerodigestive tract¹¹. However, by 2002, the American Academy of Otolaryngology-Head and Neck Surgery defined LPR as the backflow of gastric contents into the laryngopharynx²². Specific GERD symptoms such as heartburn and regurgitation are not necessarily present in LPR patients, as LPR exhibits distinct clinical manifestations. In LPR, reflux of acid into the lower esophagus is considered normal and thus not diagnosed as GERD. LPR primarily emphasizes acid reflux into the upper esophagus, directly affecting the laryngopharynx¹¹.

The progression of LPR is associated with high-fat diets, low-protein diets, stress or anxiety, and smoking. Meanwhile, obesity is reported to exa-cerbate the LPR. Due to its pathophy-siological, diagnostic, and therapeutic characteristics, LPR necessitates direct involvement from otolaryngology specialists²².

LPR in elderly patients and young patients is different, and this difference can be seen from the reflux score index (RSI), reflux finding score (RFS), and the therapy given.A study conducted by Lechien in 2021 stated that patients aged >60 years had lower RSI and higher RFS³³. This is inversely proportional to young patients, namely higher RSI and lower RFS. On the other hand, the therapy given to elderly patients and young patients is also different. This is because in elderly patients it is necessary to consider that mental health in the form of somatic anxiety can influence the incidence of LPR, so that in addition to pharmacological therapy giving PPI to LPR it is necessary to give additional medication such as anti-anxiety drugs and non-pharmacological therapy such as anti-reflux diet, healthy lifestyle, and cognitive behavioral therapy(CBT) specifically for elderly patients with symptoms of anxiety/depression so that LPR treatment can be effective^4–6456.

CASE REPORT

A 70-year-old woman presented with complaints of frequent sudden choking sensations and difficulty breathing for the past 3 months. Over the last 3 months, the patient reported experiencing >5 attacks. Additionally, the patient mentioned frequent throat clearing but difficulty in expectorating phlegm and occasional dry cough, albeit denying any changes in voice/ hoarseness. Over the past year, the patient has often experienced heartburn and reported sleeping disturbances for the past three months. There were no complaints regarding the ears and nose. Reflux symptom index (RSI) queried during the anamnesis revealed breathing difficulty (4), frequent throat clearing (2), heartburn, warmth sensation, digestive disturbances (3), and coughing (2), resulting in a score of 111.

Upon physical examination, the patient was in good overall condition with mild pain, alert mentation, blood pressure of 160/90 mmHg, heart rate of 89 beats per minute, respiratory rate of 20 breaths per minute, and temperature of 36.8°C. General status was within normal limits. Local examination revealed granulation in the oropharynx and post-nasal drip. Ancillary examination was conducted using fiber optic laryngoscopy (FOL), as shown in Figure 1.

Figure 1.FOL examination results

The FOL examination results were adjusted with the reflux finding score (RFS) to aid in the diagnosis of LPR. The identified RFS included subglottic edema (2), arytenoid hyperemia (2), severe diffuse laryngeal edema (3), severe posterior commissure hypertrophy (3), and endolaryngeal mucus (2), resulting in a score of 12.

Based on the history, physical examination, and ancillary tests, the patient was diagnosed with LPR. Medication therapy for the patient consisted of Omeprazole tablets 40 mg twice daily, Sucralfate syrup 3 times daily, and Chlordiazepoxide HCL-Clidinium bromide tablets 3 times daily as an anxiolytic. Non-medication treatment included controlling dietary patterns (reducing intake of fatty and acidic foods) and setting a priority scale of daily activities.

DISCUSSION

LPR represents an inflammatory process in the upper respiratory tract, particularly in the larynx, involving the reflux of gastroduodenal fluids onto the laryngeal mucosa, resulting in morphological changes in the aerodigestive tract. Gastroduodenal fluids containing pepsin, trypsin, bile salts, and other proteins can irritate the lower esophagus, stimulating chemoreceptors and triggering cough reflexes, leading to mucosal injury, inflammatory reactions, epithelial thickening, and microtrauma^4,747.

In the elderly, the mechanisms underlying LPR involve reduced salivary flow and bicarbonate secretion, which are associated with decreased acid neutralization during reflux. Additionally, in the elderly, esophageal motility and pressures of the Lower Esophageal Sphincter (LES) and Upper Esophageal Sphincter (UES) weaken, theoretically contributing to increased LPR incidence. The diagnosis of LPR is established based on the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), positive response to empirical therapy trials, or Hypopharyngeal–Esophageal Multichannel Intraluminal Impedance pH monitoring (HEMII-pH). However, diagnosis confirmation of LPR is more commonly achieved using RSI and RFS^7,878.

RSI items are essential questions that need to be asked when patients present with voice changes or hoarseness in otolaryngology clinics. Sataloff RT mentioned in 2010 that 10% of patients visiting ENT clinics have LPR, with almost 100% complaining of hoarseness upon presentation⁹⁹. According to a systematic review by Lechien JR in 2022, the most common clinical symptoms of LPR patients include dysphonia, throat irritation sensation, throat pain, odynophagia, throat