Laryngopharyngeal Reflux (LPR) with Dr. Inna Husain

Ashley Agan, MD MBA recently sat down with laryngologist Dr. Inna A. Husain MD to chat about diagnosis, treatment, and multidisciplinary care of patients with laryngopharyngeal reflux (LPR).

"How we as ENTs think about laryngopharyngeal reflux is very different from how our GI colleagues think about it. If we send a patient to get an upper endoscopy because they’re coughing, it depends on which GI doctor sees that patient. They might think that this is not a reflux problem so they won’t see the need to do the endoscopy. Because of this, patients get bumped back and forth between ENT and GI. This happens quite commonly. If ENTs can provide additional information to GI about the results of a 24 hour pH impedance test, GI now has an indication for the upper endoscopy. We can work together to solve this problem."

- Dr. Inna Husain

First, Inna defines LPR as acidic and/or non-acidic reflux that causes direct and indirect effects on the upper aerodigestive system. She emphasizes the importance of utilizing subclassifications of LPR and explains the difference between direct acid, direct non-acid, and indirect acid reflux. Inna notes that each subclassification has different treatment patterns and that overlapping diagnoses can make classification difficult. Another challenge in diagnosing LPR is the need to distinguish chronic problems from isolated episodes. If a patient’s LPR is chronic, she suspects the indirect acid LPR subclassification.?

During her primary visit with a patient, she asks key questions related to the root problem or sensation a patient is experiencing, such as mucus dripping, throat clearing, or globus. She notes the frequency and severity of their episodes. Inna also explains that unilaterality of sensation is unlikely to be LPR, and patients correctly diagnosed with GERD commonly have LPR. After taking an initial patient history, she utilizes flexible laryngoscopy to visualize the throat and rule out other diagnoses, such as polyps or tumors. She notes that she will not be able to see reflux through laryngoscopy, but just signs of throat irritation. Additionally, because there is not one defining visual characteristic of LPR, the imaging results are always interpreted through subjective means; thus, LPR is a diagnosis of exclusion.

For patients suspected to have LPR, Inna initiates empirical medical therapy. She explains to all her patients lifestyle modifications like cessation of smoking / vaping and reduction of coffee, late night eating, carbonated water, and citric foods. Although the conventional treatment of LPR is acid suppression, she only prescribes patients with proton pump inhibitors if they have acid reflux symptoms because 50% of LPR patients don’t actually improve on the medication. Her PPI regime consists of 40 mg omeprazole in the morning and Pepcid at night for 1-2 months. If patients improve, she slowly tapers them off of the PPI to avoid rebound reflux. If the patients do not improve after 2 months, she will switch to another medication, such as alginate suspensions, a more natural alternative to PPI. Alginate suspensions create a barrier that prevents the upward movement of acid. Contraindications include concurrent use with other acid suppression medications and a history of lower GI issues.

Finally, she discusses the 24-hour pH impedance testing, which is the gold standard for LPR diagnosis. A catheter with a probe is inserted into the patient’s throat and sends continuous pH readings to a monitor the patient carries. Patients return after 24 hours, and she is able to find correlations between patient symptoms and acid reflux and classify the LPR subtype. If she interprets any distal esophageal issues or dysmotility issues, she involves her GI colleagues to explore endoscopic solutions. We end the discussion by discussing her treatment regimen for refractory neurosensory (indirect) reflux, which includes neuromodulators (gabapentin, amitriptyline) or a superior laryngeal nerve block.

Listen on:

Apple podcasts here

Spotify podcasts here

Google podcasts here

www.backtable.com/shows/ent