What is LPR and why does it matter?
Laryngopharyngeal reflux (LPR) is retrograde movement of gastric contents (not just acid) into the larynx, pharynx, and upper aerodigestive tract. Patients may note hoarseness, throat clearing, cough, dysphagia (trouble swallowing), globus sensation, and postnasal drip. It becomes more important as a cause or contributing factor to diseases such as subglottic stenosis, laryngeal granuloma, asthma, and sinusitis; in children and adults. The symptoms do differ from gastroesophageal reflux disease (GERD). Patients do not have heartburn and regurgitation. They have nonspecific symptoms that can be thought to be due to other factors (allergy, smoking, environmental irritants, infection, or vocal abuse).
So how do you take the symptom data and glean from it that your patient may have LPR? Thankfully there are validated measures such as the reflux symptom index (RSI) and the reflux finding score (RFS) that can help. To assess and manage LPR, these questionnaires (RSI, RFS) along with physical exam, laryngeal examination, and further diagnostic studies are key.
However, in general otolaryngology practice, the diagnosis relies on empiric evaluation of symptomatology and physical examination for most cases. Completing questionnaires and / or performing laryngoscopy can be time and / or cost prohibited. It is encouraged to consider all these approaches and then pursue a clinical protocol to control cost as well as hopefully be able to remove prescribed agent for cost and health savings long-term once therapy has been successful.
Treatment is commonly use of empiric proton pump inhibitor (PPI) therapy. PPIs are commonly prescribed medications but have shown detrimental side effects (fractures, increased community-acquired pneumonia, renal damage, Clostridium difficile diarrhea, etc). These agents have also been shown to be less effective than expected in the treatment of LPR! Why would that occur? Possibly LPR is not only an acid issue but relates to gastric aspirate, such as pepsin.
The use of clinical protocols and care pathways in health care is popular. Clinical protocols do help standardize the delivery of care and reduce variability. This can improve quality of care. Care pathways have also been shown to reduce cost and improve documentation. A management protocol is particularly helpful in LPR management due to the high degree of uncertainty in diagnosis. LPR is most often diagnosed based on symptoms and exam findings as I discussed. Because most of the symptoms are non-specific, overdiagnosis may occur. Even 24-hour pH probe testing, which is the gold standard test, has low sensitivity.
Here is a protocol to consider. Evaluate patient, possible or probable LPR, eRx PPI such as esomeprazole or omeprazole at 20 mg po bid, counsel on diet and lifestyle modifications (weight loss, activity, fiber, possible need to see registered dietician). Give 3 month followup. At followup, evaluate better, partial response, or no response. If better, now titrate off PPI continue with diet and lifestyle modifications. If partial response, increase to 40 mg po bid and follow-up in 3 months (now 6 months). If no change, re-assess your diagnosis. At 6 month followup, if resolved, titrate off PPI and continue diet and lifestyle modifications. If not better, evaluate need for gastroenterology input.
You can learn more about this topic by looking to this article:
• Nikita Gupta, Ross W. Green, Uchechukwu C. Megwalu
• American Journal of Otolaryngology
• Vol 37 Issue 3
Other questions regarding eye, ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid? Please do not hesitate to call. ENT is trained in 7 core areas over 5 years after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to the head and neck.
Philip Harris, M.D. FARS
MidMichigan Physicians Group
Midland / Gladwin / Bay City