Singer John Mayer Diagnosed with Vocal Cord Granuloma

On Sept 19, 2011, media reported that singer John Mayer has been forced to cancel all upcoming concert plans and delay release of a new album due to a voicebox growth.

This growth was described as a "granuloma."

What exactly is a granuloma?

It is a benign mass commonly due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining.

To be more precise, rather than the vocal cord itself, granulomas are most commonly found on the vocal process which is the "hinge" that allows for vocal cord movement. It is located in the back area of the voicebox.

An imprecise analogy of what a granuloma is would be a keloid of the skin.

Symptoms include mild (if any) hoarseness, mild intermittent pain on the side of the voicebox where the granuloma is located with talking/singing, rarely coughing up blood, and if large, shortness of breath.

Just like keloids of the skin, surgical removal alone is almost certainly going to fail with recurrence of the granuloma within weeks to months. All repetitive trauma to the area must be addressed to minimize risk of recurrence which is why restricted voice use must be pursued for several months (no loud talking/singing, talking ONLY when you must). Voice therapy helps to "teach" a person how to talk when they talk without causing further injury to the area. As such, botox injection to the vocal cord has been found helpful to semi-paralyze the vocal cords from coming together (chemically induced vocal cord paralysis). Reflux medications are necessary even if a patient has no symptoms as ANY acid exposure to the area is just as bad a trauma due to yelling.

Steroid injections are helpful to minimize the underlying exuberant inflammatory reaction that leads to granuloma recurrence and may need to be performed several times for effect.

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended.
2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology
3) Follow-up with steroid injections to the granuloma site. Watch video below.
4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

Read a Rolling Stone report here.

Read more about voicebox granulomas.

Read More

Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered "silent" and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue... Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms...

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

Read More

New Video on Esophageal Manometry and 24 Hour Multi-Channel pH and Impedance Testing

Our office has created a new video describing what a patient goes through when they undergo esophageal manometry as well as 24 hour multi-channel pH and impedance testing.

This test is often ordered when a patient is suspected to be suffering from reflux, whether acid or non-acid, or is possibly suffering from abnormal muscle activity of the esophagus.

Symptoms that a patient may experience that may lead to such testing include:

- phlegmy throat
- lump sensation in the throat
- chronic throat clearing
- chronic cough
- difficulty swallowing

Watch the video here!

Read More

What is Considered a Normal Number of Reflux Episodes?

Depending on whether one is talking about GERD (gastroesophageal reflux disease) or LPR (layrngopharyngeal reflux), I believe the answer is completely different.

As it pertains to GERD and what literature, doctor, or testing equipment is used, 73 plus or minus some change is what is considered a normal number of reflux episodes a typical adult may experience in a 24 hour period of time.

What exactly does this number mean? This number describes how many times stuff in the stomach regurgitates up into the esophagus which is the tube that carries food down to the stomach after food is swallowed.

The reason why heartburn is not initially experienced is because the lining of the esophagus has a protective layer preventing acid damage. However, once the number of reflux episodes goes higher than 80, the protective layer breaks down and acid damage starts to occur leading to typical symptoms of heartburn and/or chest pain.

Now what about laryngopharyngeal reflux (LPR)?

I would argue that even ONE episode is not normal if symptomatic. (Also see references below.)

LPR is when stomach contents regurgitate up to the level of the voicebox. At its most basic limited definition, LPR is a near-vomit (vomit being stomach contents that reach the mouth level and beyond). The only difference between LPR and vomit is the volume of regurgitation and location it reaches.

When such regurgitation reaches the voicebox level, a number of symptoms occur, even if it happens one single time.

First, when LPR occurs, the throat feels phlegmy leading the patient to throat-clear the mucus up and out or to re-swallow.

Second, when enough LPR episodes occur, the mucosal lining of the voicebox region starts to get irritated that may lead to a chronic cough. At its worst, it may lead to vocal cord dysfunction and even laryngospasm. Some episodes may even be aspirated into the lungs leading to bronchitis and reactive airway disease.

Third, the sphincter (upper esophageal sphincter) that separates the esophagus from the voicebox may start to tighten which is the body's way of attempting to prevent further reflux from reaching the voicebox. Such muscle tightening may lead to symptoms of difficulty swallowing with food getting stuck at the voicebox level as well as lump in throat sensation (globus).

Heartburn is not very common with LPR (though it may occur) as one needs to remember that there is a protective barrier preventing acid damage to the mucosal lining.

Also, non-acid reflux may be present rather than acid reflux. With non-acid reflux, heartburn symptoms are not as common due to lack of acid presence that would lead to damage (though other factors are present including bile, enzymes, etc).

Given even a single episode of LPR can be considered abnormal if symptomatic, many studies will come back NORMAL due to timing. A barium swallow typically does not take more than a few minutes to perform done during business hours. Same goes for upper endoscopy. BUT... what if the few episodes of LPR occur in the evening or early morning NOT when the studies are performed?

As such, what I consider the BEST study to evaluate for LPR is a 24 hour multi-channel pH and impedance testing. This test looks for reflux during a continuous 24 hour period of time. If it sees reflux, it records what time, how long it lasts for, how high does the reflux go up, what the pH level is, etc. BRAVO or single or dual-probe pH studies are inadequate as they measure ONLY whether acid GERD is occurring or not. These alternative tests can not evaluate for LPR or non-acid reflux.

BOTTOM LINE

With GERD, up to around 73 episodes of reflux is considered normal.

With LPR, even a single episode can be considered abnormal if symptomatic. Check out references below.

Watch a video I made below showing a patient who is experiencing a non-acid LPR episode during an examination. This patient had a normal upper endoscopy, normal pH study, and normal barium swallow. Look at all the frothy mucus that is bubbling up to and around his voicebox leading to his complaint of phelgmy throat and chronic cough/throat-clearing. Treatment was surgery (nissen fundoplication).

References:

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg. 2012 Jan;16(1):16-24; discussion 24-5. Epub 2011 Oct 28.

Gastroesophageal and laryngopharyngeal reflux detected by 24-hour combined impedance and pH monitoring in healthy Chinese volunteers. J Dig Dis. 2011 Jun;12(3):173-80. doi: 10.1111/j.1751-2980.2011.00502.x.

The importance of the number of reflux episodes in the diagnosis of laryngopharyngeal reflux disease. Otolaryngol Head Neck Surg. 2013 Feb;148(2):261-6. doi: 10.1177/0194599812466534. Epub 2012 Nov 2.

Read More

Gaviscon Advance by Reckitt Benckiser

Our office has received a number of inquiries on where one can purchase Gaviscon Advance made by Reckitt Benckiser (not available in the US which only carries the plain Gaviscon without the "advance").

This product, sold in the United Kingdom, is only available through online pharmacies.

The Gaviscon Advance made by Reckitt Benckiser actually maintains a list of online pharmacies that carry this product here:

http://www.gaviscon.co.uk/resources/useful_links.php

Specifically, these online pharmacies are listed:

ExpressChemist
ChemistDirect.co.uk
Pharmacy2U
MyPharmacy.co.uk

Amazon.com occasionally will have some in stock as well.

Please note that this information is provided for patient convenience. Our office does not vouch for nor has confirmed the legitimacy of these online pharmacies. Purchase at your own risk!

Read More

Laying on Right Side Worsens Acid Reflux!

Well that's according to a recent New York Times article on October 25, 2010.

This claim is based on several studies published whereby “the total amount of reflux time was significantly greater” when the subjects laid on their right side after eating a high-fat meal.

This makes sense anatomically. Keep in mind that the stomach is located on the left side and the esophagus (swallowing tube) is located in the middle (comes off the stomach's "right side" so to speak). When you lay down on the right side, gravity is literally "emptying" the stomach into the esophagus located in the middle. Laying on the left side has gravity keeping stomach contents inside the stomach as the middle is now above the stomach.

Of course, the best thing to do is lifestyle changes to minimize reflux including- avoid eating high-fat, spicy, acidic foods as well as not eating/drinking within 3 hours of laying down when the stomach is empty. Keeping the head and chest elevated 30 degrees is also helpful thereby using gravity to help keep things down. Mattress wedges are helpful. Should lifestyle changes not help, there are plenty of medications that can help.

Read the NYT article here.

Read more about reflux here.

References:
Body position affects recumbent postprandial reflux. J Clin Gastroenterol. 1994 Jun;18(4):280-3.

Effect of different recumbent positions on postprandial gastroesophageal reflux in normal subjects. Am J Gastroenterol. 2000 Oct;95(10):2731-6.

Read More

Gaviscon Advance for Non-Acid Laryngopharyngeal Reflux (LPR)

Over time, I have received a number of emails from patients regarding the best type of Gaviscon Advance they should purchase for relief of NON-acidic laryngopharyngeal reflux (LPR). The blunt answer is to get the Gaviscon Advance Suspension/Liquid made by Reckitt Benckiser which contains at least 500mg of sodium alginate in 5ml dose (1 tsp) or 1 gram in 10cc dose (2 tsps). This formula of Gaviscon Advance cannot be purchased in the United States, but instead overseas via online pharmacies located in the United Kingdom (link). Occasionally, Amazon.comdoes stock it.

The Gaviscon (without the "advance") sold in the United States is manufactured and distributed by GlaxoSmithKline (GSK) and not Reckitt Benckiser. The US brand of Gaviscon by GSK contains less of the key ingredient sodium alginate which helps with NON-acidic reflux. Alginate is a natural product derived from seaweed. The alginate reacts with the acid in the stomach to produce a "raft" barrier that acts as a physical block to reflux. It is the only non-surgical treatment that can physically prevent reflux disease regardless of whether it is acidic or not. Alginates work rapidly, are long lasting, inexpensive, and have no known side-effects.

Background
Non-acidic LPR is when stomach contents other than acid such as mucus, pepsin, bile, and other digestive secretions backflow up to the throat and cause damage. The symptoms include phlegmy/mucus sensation in the throat, constant throat-clearing, dry/irritated throat, globus, chronic cough, etc. Traditional reflux medications like prilosec, prevacid, nexium, zantac, pepcid, etc do NOT help with NON-acidic reflux... those meds ONLY help with acid reflux. Non-acidic reflux is typically diagnosed by 24 hour multichannel pH and impedance testing. Simple 24 hour pH testing (ie, Bravo capsule) will not diagnose this disorder... impedance testing must be included.

Treatment
Initial therapy to treat non-acidic LPR would be to keep the head of bed elevated more than 30 degrees. Best way to do this is by placing 2-3 bricks/books under the legs at the head of the bed to tilt the entire bed. Or, sleep in a chair recliner. Or, purchase a mattress wedge. Sleeping with several pillows is not adequate as one needs the chest region also to be higher than your stomach (not just the head).

Medications that may help include robinul forte, Maalox (less preferable) or Gaviscon Advance made by Reckitt Benckiser (RK) as stated above.

The only known "cure" is a Nissen Fundoplication or LINX surgical procedure performed by general surgeons. Trans-Oral Incisionless Fundoplication (TOIF) is a less invasive option that may help.

References:
An evaluation of the antireflux properties of sodium alginate by means of combined multichannel intraluminal impedance and pH-metry. Aliment Pharmacol Ther. 2005 Jan 1;21(1):29-34

The value of a liquid alginate suspension (Gaviscon Advance) in the management of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2009 Feb;266(2):243-51. Epub 2008 May 28.

The role of an alginate suspension on pepsin and bile acids - key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol. 2009 Aug;61(8):1021-8.

Read More

H. Pylori Infection Can Cause Urticaria and Angioedema!

Thanks to a recent blog post by medical blogger, Dr. Ves Dimov, I was made aware of how H. Pylori (Helicobacter pylori) infection of the stomach can cause chronic (idiopathic) urticaria as well as angioedema and that eradication of H. Pylori thru antibiotics and acid suppression can significantly improve the problem!

For those who do not know what H. pylori is... It is a germ that is the most important cause of gastritis and peptic ulcer disease. It can be diagnosed by measurement of H. pylori-specific (IgA and IgG) antibodies, urea breath test, or upper endoscopy. And... this germ is now becoming implicated in causing problems beyond the digestive system like angioedema and urticaria.

In one study, 88% of infected patients in whom the bacterium was eradicated after therapy showed a total or partial remission of urticaria symptoms. Symptoms remained unchanged in all uninfected patients.

Another study documented the disappearance (67%) or improvement of urticaria (24%) in most antimicrobially treated patients after 3-12 weeks.

Triple therapy is considered to be the standard treatment for children and adults. A proton pump inhibitor combined with two antibiotics has been shown to be very effective in clearing H pylori from the stomach. The current recommendation is treatment with amoxicillin, clarithromycin, and a proton pump inhibitor (Prevpac) for 2 weeks. Triple therapy regimens that are effective in children include a proton pump inhibitor combined with clarithromycin and metronidazole or amoxicillin and metronidazole.

References:
Beneficial effects of Helicobacter pylori eradication on idiopathic chronic urticaria. Dig Dis Sci 1998 Jun;43(6):1226-9.
Prevalence of Helicobacter pylori-associated gastritis in chronic urticaria. Int Arch Allergy Immunol 1998 Aug;116(4):288-94.

Read More

New Webpage on Chronic Throat Clearing

We have added a new webpage to our practice website addressing a common complaint of patients called "Chronic Throat Clearing."

Check it out here!

Read More

New Treatment Options for Non-Acidic Reflux (LPR)?

It just came to my attention through anecdotal reports that there may be two additional options to treat non-acidic laryngopharyngeal reflux (LPR) causing symptoms of:

• Hoarseness
• Throat clearing
• Phlegmy throat
• Cough
• Globus (sense of swelling in the throat)

Non-acidic reflux is different from the more widely known acid reflux in that traditional medications such as prilosec, zantac, pepcid, etc do not help. Non-acidic reflux basically is when gastric secretions without acid refluxes up into the esophagus to as far as one's voicebox causing symptoms listed above. Heartburn does not occur.

Traditional treatments for non-acidic reflux include the medication reglan (which has gone out of favor) and gaviscon advance  as well as the surgical option Nissen fundoplication or LINX. However, there are now anecdotal reports that the medication robinul forte may be helpful by decreasing the overall amount of secretions the stomach produces as well as less invasive procedures called TOIF (Trans-Oral Incisionless Fundoplication) performed endoscopically without skin incisions.

Read more about non-acidic reflux here.

Read More