The Dreaded Diagnosis of Laryngopharyngeal Reflux Disease

David A. Johnson, MD

Disclosures

January 29, 2013

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Laryngopharyngeal Reflux: What Does It Mean?

Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another Computer Consult. This series is designed as a fireside chat on important and common clinical problems and how I approach them, with 32 years of experience in dealing with these types of problems.

Today I would like to talk about what has become the bane of existence for gastroenterologists: the dreaded diagnosis of laryngopharyngeal reflux. What does that mean? Acid refluxing back up into the esophagus and then into the larynx, which causes some damage. This reflux results in symptoms such as voice changes, cough, repetitive throat clearing, and pharyngeal sensations of fullness -- not necessarily a globus type of fullness, but a thick phlegm type of fullness.

We see patients with laryngopharyngeal reflux all the time. The train started back in the early '90s in Winston-Salem when Don Castell and Joe Richter were working with James Koufman, and they put together some very interesting work on the relationship between gastroesophageal reflux and extraesophageal disease. Lo and behold, the larynx was part of this focus, and Dr. Koufman really took off on this and started to educate laryngologists that this can occur.

We still agree that this can occur, but the train has accelerated to the fast track. Of new patient referrals to otolaryngologists, 1 in 10 receives a diagnosis of laryngopharyngeal reflux disease. It is believed that anything that refluxes into the larynx is attributable to gastroesophageal reflux disease (GERD), but that's not the case. Certainly when patients are referred to us for a reddened larynx (having been told "you have GERD; go see your gastroenterologist and he or she will make you better"), they come to us, the end of the road, and we are supposed to cure them.

Laryngopharyngeal Damage

It would be easier if GERD was the cause for most of these patients' symptoms, but that is not the case, so let's back up. Why would laryngopharyngeal reflux disease cause mucosal damage? Gastric acid in the wrong place (eg, in the esophagus) can cause damage, but it's the activation of pepsin that results in tissue damage in the esophagus and the larynx. The larynx doesn't have the intrinsic defense systems or clearance mechanisms of the esophagus.

Pepsin in the esophagus can cause damage if the pH is less than 4, explaining why we prescribe anti-GERD agents to raise the pH to 4 or higher. In the larynx, damage can occur at an even higher pH. Pepsin in the area of the larynx is still active at a pH of 6.5 and does not become inactive until the pH is approximately 8. Any pepsin lingering in the larynx can be reactivated within 24 hours if the pH changes. Pepsin in the wrong place for any period of time can become reactivated should the pH drop to less than 8, which occurs in almost everybody given a 24-hour time window.

Classic Findings on Laryngoscopy

What do we see in terms of mucosal damage? An otolaryngologist would describe a variety of classic findings from laryngopharyngeal reflux. In prospective randomized controlled trials, some findings were more likely to be evidence of GERD, such as the changes in the arytenoid and the interarytenoid area, with granularity/granuloma and a cobblestone appearance of the interarytenoid area in the larynx. However, these findings were not predictive of laryngopharyngeal disease, and these patients were treated with anti-GERD therapy. The studies that have looked at this have used high-dose, twice-daily therapy, and there was no response after 3 months of therapy. Even though they had GERD, it didn't predict which patients would have beneficial outcomes.

Furthermore, we don't have a validated instrument to define GERD in patients with laryngopharyngeal reflux. A variety of findings in the larynx can be nonspecific, such as erythema, edema, swelling, and cobblestoning. These findings can be induced by other conditions, such as postnasal drip, allergies, asthma, voice abuse, and even by repetitive behaviors such as throat clearing.

Progressive Clinical Symptoms

Think about what happens in these patients. They may or may not have GERD, and they get into a situation where the larynx becomes a little reddened and they start having symptoms. You treat the reflux disease and the GERD might even resolve. But their symptom is still there, and they start to develop other symptoms. We have seen very nice data from Mike Vaezi's group at Vanderbilt,[1] showing that reflux disease can increase risk for postnasal drip. So these patients may have some primary or secondary postnasal drip. This irritates the larynx further, and these patients start to change their behavior.

These patients might have a chronic cough or repetitive throat clearing, or they experience changes in the tenor of their speech (pace, voice pattern, or pitch). Their laryngeal inflammation can worsen even though their GERD has resolved. In the prospective trials on GERD and laryngopharyngeal reflux disease, when they performed a meta-analysis, it suggested that these patients have increased response to antireflux therapy. However, when they adjusted for a variety of other factors, they found that patients didn't respond to GERD therapy if they didn't have GERD.

The underlying presenting symptoms of heartburn, regurgitation, and indigestion may be the only predictors we have in patients who present with laryngopharyngeal reflux disease-associated symptoms. So, I consider these symptoms when I take a GERD history. The idea of "silent GERD" causing these symptoms as a "tip of the iceberg" phenomenon is not likely in most patients.

The Patient History

So, how do I take a GERD history in the patient with suspected laryngopharyngeal reflux disease? I ask them if they have heartburn, indigestion, or regurgitation. In the meantime, I'm listening to these people, and what you often hear is that these patients are coughing repetitively or speaking in a gravelly voice, or the tenor of their speech may be more rapid, or the pitch of their speech may be a little squeaky. Ask the patient what their day-to-day job is. Many of these patients spend a lot of time on the telephone or are singers. I had 2 patients who were school teachers and had ongoing voice overutilization.

Once we get out of a "restful voice," the inflammation in the laryngeal area increases. When these patients come in and are already on proton pump inhibitor (PPI) therapy but are not responding, it's important to take a good voice history. Ask about postnasal drip and allergies. Listen to these people when they describe their symptoms, and that might give the diagnosis away right there in the office.

Diagnostic Evaluation

What do we do with these patients? I study all of these patients with pH monitoring. I keep them on therapy during monitoring, but almost never will you find that these patients have ongoing reflux disease.

It has been suggested that some of these patients have nonacidic reflux, and I still don't know what to do with those patients. I don't think surgery is the answer, but nonetheless, the voice history is critical. In my practice, I put these patients on twice-daily GERD therapy (or once daily with the newer PPIs), and this achieves pH control in 18-18.5 hours. I put them through a very extensive voice history. We don't want to say, "It's not GERD -- go see somebody else; it's not our problem."

If the patient needs to see an allergist, refer the patient to an allergist. If the patient doesn't have adequate postnasal drip control, that needs to be addressed. But take good voice history, listen to what they are doing, watch for repetitive throat clearing and coughing, talk to their family members, and ask what their voice habits are during the day. It's critical to get them involved with an otolaryngologist who is interested in voice. If you don't have an otolaryngologist who is interested in voice, at least develop a relationship with a physical or speech rehabilitation clinician who is interested in voice.

Patient Management and Rehabilitation

These patients need to have voice retraining. They need to learn what I call a "quiet voice." I tell these patients to bring a bottle of water with them until we can get them into voice therapy. I have them swallow rather than cough or repetitively clear their throats. I emphasize the importance of fluids, because if their secretions become viscous, it creates a noxious effect. You want to prevent that by having them be well hydrated so the secretions don't get thick.

If they are going to be out and about and they aren't able to carry a bottle of water with them, I have them carry lemon drops, something to increase parotid stimulation and increase the likelihood that the viscosity of secretions into their larynx is going to be very fluid. I have them work towards recognizing what they're doing.

I talk to their family members if I can to help them cautiously and carefully school that behavior into a less repetitive pattern. A family member might remind the patient, "You aren't supposed to cough like that -- the doctor told you not to clear your throat like that." If they have to cough, I tell them to try a silent cough, a nonphonated cough. The irritation in the larynx is less injurious with that type of cough. This has been helpful in my practice.

A Team Approach to Management

The key is to keep these patients away from a surgeon. Heaven help these patients if they have a little bit of reflux disease -- the success of those patients getting better is very unpredictable. We don't send patients to surgery just to see if they will get better. We know that antireflux surgery has considerable risk, and it is not done very often anymore. The non-PPI responder is the worst patient to send to an antireflux surgeon.

So, my plea to you is to take a good voice history, listen to the patient, look for habituation, develop a relationship with a speech-therapy rehabilitation clinician or a laryngologist who has a vested interest in voice. These patients will need speech rehabilitation, and the habits will go away with time. Prescribe PPI therapy if you are going to study these patients. You don't want to study them and find that they have reflux, and then they say, "Now what do we do?" I study them on therapy and look for events that I can mark as a symptom event. You almost never find that.

Laryngopharyngeal reflux is here to stay. It continues to be the bane of our existence, but we can do a lot of disservice by just washing our hands of it and saying, "We are gastroenterologists and this isn't what we do." We can bridge the gap a little bit and work better with our colleagues in otolaryngology and start to make some inroads to success, rather than being frustrated in dealing with this condition.

I'm Dr. David Johnson. Hopefully this is helpful for you, and when you see your next case of laryngopharyngeal reflux, you can make some meaningful differences in these patients going forward. Thanks for listening.

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