Clinical Presentations of Atypical Laryngopharyngeal Reflux (LPR)

[Dr. Inna Husain]
I will tell you that how I started being aware of these symptoms. I was really fortunate to work with really great rhinology colleagues early in my career, who very much included me in the conversation. In patients with like persistent post-nasal drip and things like that. I started clinically seeing a lot of these patients where they had a full rhinological workup.

They're coming to me already, essentially, teed up. We know it's not their allergies or sinus disease, but they're having these symptoms. One of the things I started noticing was there are some common physical exam findings you can see when you're really looking. One of them and I'm going to give a shout out to a colleague from France, Dr. Lechien, who does a lot of research on LPR, because he coined the term for me.

It's a finding when you look at the posterior aspect of the turbinate, you'll see this edematous quality just in the posterior aspect. I had been seeing that repeatedly and didn't know what that was, especially since these patients were coming to me from my rhinology colleagues. He coined the term this mulberry pattern. It's something we often see with patients with LPR that's, actually, reaching the nasopharynx.

We have evidence that shows that reflux can make its way up there. We have literature in adults, in pediatrics, contributing to things such as recurrent or recalcitrant sinusitis, eustachian tube dysfunction, otitis media, especially in children. I think this can be a really big player in some of these common ENT symptoms that you may see even if you're not a laryngologist or specializing in the larynx.

[Dr. Ashley Agan]
Yes, so your patient who's coming in, it may look very much, like you said, like a rhinology patient where their symptoms are predominantly in the nose. Is that right? They may not even have any of the typical globus or throat symptoms at all, or is it a combination? Do they have both?

[Dr. Inna Husain]
Correct. We see both. That's, to be honest, why LPR can be so challenging to treat because there isn't necessarily a typical patient once you start seeing a lot of patients. Yes, initially when we all talk about this, we think of the throat clearing and the globus, but the more and more you look for this and try to really identify what's causing these symptoms, you'll find more patients where it is really just more isolated, almost nasopharyngeal type of symptoms.

They'll have this posterior fullness sensation or congestion, the mucus sensation of it just being back there. We do find patients where they're like, "Those are their only symptoms." That's something, I think we're trying to figure out, why do some people present with those types of symptoms and not what we call the traditional laryngeal symptoms?

[Dr. Ashley Agan]
Those patients on exam, other than the mulberry edema, the posterior part of the inferior turbinate, is there anything else? Can LPR cause the nose to look like an allergic rhinitis nose? Does it cause the level of inflammation where they would look similar?

[Dr. Inna Husain]
Yes, it, definitely, can. you'll see like erythema, sometimes thick mucus or even crusting. The nasopharynx may be hyperemic. I think one of the challenges with really focusing on exam findings though, as opposed to the patient's overall clinical picture, is that-- Just with the larynx, we know some people have the frank hyperemia inflammation look, which teases off for right off. It's like you see that redness and you're like, "Oh, you have reflux, for sure."

Remember, reflux is not all acidic and there can be more subtle changes and patients may feel more than you see. That is very common with the head and neck. We are an area that is so sensitized and so many peripheral nerve endings that oftentimes the patient will feel something before we can see it. I really advocate for patients or providers to really just listen to what the patient is telling you. They're often leading you to the diagnosis.

[Dr. Ashley Agan]
One of your interviews with, I think it was with Dr. Lechien-

[Dr. Inna Husain]
Lechien.

[Dr. Ashley Agan]
Is that--? Yes, with Dr. Lechien, he talked about reflux being like gaseous reflux as opposed to like a liquid reflux and that making its way up into the nose in a different way than liquid would.

[Dr. Inna Husain]
Yes. Remember the word reflux just means mechanical movement. It doesn't specify what's actually moving. I think as we continue this conversation and get into some esophageal pathology, that'll play a bigger role. Yes, the refluxate can be solid, but usually you would feel that, can be liquid, and it can be gaseous. Gaseous refluxate is what we think contributes the most, these nasopharyngeal symptoms.

It could make its way all the way up there. That's why a lot of times patients may not feel it happening, right? We often talk that they may not feel it happening because the esophagus is less sensitive than the throat. The truth is they also just may not feel it happening because it's not, actually, a liquid reflux. It's gaseous.

[Dr. Ashley Agan]
Even with it being a gas, it's irritating to the tissues and the mucosa, yes. The patient, I'm just thinking about like a patient who's coming in with, yes, maybe like nasal crusting or congestion or runny nose, I don't know, these typical rhinology symptoms. The patients that you've had referred from your colleagues, I assume it's like the non-allergic rhinitis patient who's tested negative for allergies and has failed the typical rhinology workup?

[Dr. Inna Husain]
Right. In my current practice, I see a variety of patients. I have patients who come directly to me with little to no workup or treatment. Then I have patients who, yes, have seen the rhinology service and have had sinus surgery or a full workup before they come to me. I always start the same way with most patients. I get the history from the beginning, I do the physical exam. Most people at this point have tried some type of over-the-counter or prescription-strength nasal steroid spray, nasal antihistamine spray. We do often delve into this non-allergic rhinitis pathway of what we can do to help with that.

For a throat doctor, I feel like I still prescribe fairly a good amount of nasal regimens still because patients sometimes need that reinforcement that perhaps the inflammation is coming from your LPR, but you know what? The surface of the nose still feels better when you're on a nasal irrigation. I think it can still go hand in hand, even though it's not truly a sinus problem or an allergy problem, the nose sometimes just feels better when we treat it topically.

[Dr. Ashley Agan]
Is there anything that can tip you off for patients who are coming in with these atypical manifestations? Is there a symptom or an exam finding that tips you off that, "Oh, maybe LPR is at play here"?

[Dr. Inna Husain]
I think it's often the persistence of symptoms. You get these patients who have the story of that, "I've been dealing with this forever. It's all the time and it's year round, and I've tried everything." Those often tip me off that there's likely something else going on like LPR or pure hypersensitivity based on that pattern of it being just so persistent. Often they don't have like necessarily triggers for it. They're like, "I don't know. It doesn't matter what I eat or drink or where I am, I'm just having this symptom." That usually tips me off that it's going to be something more chronic like LPR or hypersensitivity occurring.

[Dr. Ashley Agan]
Moving on to talk more about esophageal pathology and I saw that you shared on your social media your personal journey with LPR. I don't know if you want to speak to that a little bit.

[Dr. Inna Husain]
Yes. No, I have to share.

[Dr. Ashley Agan]
When you're in the patient's shoes, I think that always gives you extra superpowers as a doctor who also treats that because you've, actually, had that lived experience.

[Dr. Inna Husain]
Oh, right. I always have patients say, "I don't know how to describe." I was like, "Try to describe the feeling you're having. Does it feel like this?" I'm like, "I know because I felt it too." There's this like common relationship there. I did actually share on my social media that last fall-- I've always had reflux like throughout my whole life. I got pretty bad in terms of after pregnancy. I'm a mom of three and so it was a little bit back to back.

I was doing okay with it. Pretty much like, it's here. It's what it is. Last fall, I started having a lot of trouble, actually, swallowing where I had two episodes where like a near choking episode, and it scared me. I reached out to a GI colleague. Again, I'm really grateful that I work with colleagues who are very collaborative and open to ideas. I said, "Listen, I've had a reflux my whole life. I'm having trouble swallowing. I think I need an upper endoscopy just to see what's going on."

Went in and had that done. They actually found what's called a Schatzki's ring. Now, besides the difficulty swallowing, I was having horrible coughing with eating. My husband would like give me like the side eye all the time. I would eat anything and it would just be this horrible hacking cough. That was another reason where I went in and I was like, "I don't love the idea of just empirically treating with chronic acid suppression. I'm a female. I'm a little bit smaller, worried about my bone density and things long-term."

Yes, I went in and got an upper endoscopy and my gastroenterologist found a Schatzki's ring and he dilated it. I can't tell you immediately my cough went away. Literally that night we went out to dinner and besides a little bit of a sore throat, I felt swallowing was easier. I wasn't doing that horrible coughing afterwards. I think that's a great example of this idea of esophageal pathology can also contribute to what we classically call LPR Symptoms.

Food not passing through the esophagus fast is going to trigger the protective responses of your upper aerodigestive tract, right? Food getting stuck on my Schatzki's ring, whether or not it was frankly coming upward was triggering my body to say, "This is not normal," and start coughing and producing mucus.

I work a lot with patients on that aspect too. We often just coined the term LPR, but I think it's important to break it down and say, "Maybe it's just LPR symptoms caused by esophageal dysmotility, some sort of obstruction distally," that sort of thing. I'm a big proponent of investigating esophageal causes that could be contributing to your upper aerodigestive tract symptoms.

[Dr. Ashley Agan]
Yes. Because on our flexible laryngoscopy, we're not seeing the esophagus. I'm always telling patients, like, "I'm not seeing anything from where my scope can go, but my scope only goes to here. For your patients who are seeing you for LPR, that the esophagus needs to be investigated? Like that they need that scope, we need to look further down?

[Dr. Inna Husain]
Right. I will tell you that my way of being a physician is, I feel like I put everything out on the table for patients because that is what I would want to know. Most of the time what we're dealing with is quality of life. When I would say when it's a quality of life issue, the ball is in your court. That's like my little spiel for patients. I say, "Listen, I suspect that you probably are having LPR or something related to your esophagus happening. These are the things we can do."

I lay it out on the patients, on the table for them. I tell them, "I'm happy to do further workup with you and we have a variety of things we can do. I'm happy to do empiric medication trials, natural remedies, get you in with the dietician. You let me know what you feel you're most comfortable with." I, definitely, still get patients who just wanted to know it wasn't throat cancer.

We still get those patients and that is the first thing we go over. The patients where I really push for that is the patients who also have traditional GI symptoms. Those are the ones I'll really push for and say, "We need to start with an upper end endoscopy," because early satiety, horrible burning, those types of things is not typical and we really need to make sure we rule that out because my scope can't see it.

[Dr. Ashley Agan]
You're sending those patients to GI to have a formal like EGD to look at the full upper digestive tract?

[Dr. Inna Husain]
I do. The reason for that is there's different practice patterns and there's a lot of laryngologists who will do what we call T&E. Where I started my practice, we used to work with GI closely. At this point in my career, I enjoy collaborating a lot with GI. I do have my gastro colleagues do the upper endoscopy, but I'm still involved. I think that's one of the key things with working patients through LPR is that, if you're going to be an LPR specialist, you're not going to work in isolation at all.

You have to work in collaboration. I tell patients, "I'm sending you to the GI doctor, not really to necessarily work you through your LPR, but I need data. I need to know what your EGD results show. Make sure you send them to me. I need to know what the testing shows, so send it to me," and then we'll follow up and put it together. I think that's one of the frustrations patients really have with this disease is that they are shuffled back and forth.

"My ENT says it's not an ENT problem. My GI says they don't have acid damage. Where do I go here?" The truth is no one has really taken ownership, frankly, in terms of LPR, right? Working in collaboration, I think as an ENT or a provider, you just need to decide for yourself, is this something that you will be involved with or not? Because recently thinking about this, we know just enough about LPR to actually not be helpful.

We know enough to say, "Hey, I think your post nasal drip is LPR," and then we shuttle them out the door because we've given them a diagnosis. You can't imagine some of these patients who get this diagnosis and it puts them in a tizzy. Like, "My doctor said, I have LPR. I don't want esophageal cancer, but I'm not drinking coffee. How can I have LPR?" We just need to be very careful when you give a patient a diagnosis that there's some follow through, there's some handing off of the patient.

Because this is how a lot of my patients find me is that they've just been told they have LPR, but there's no guidance. There's no, "What do I do next?" Really advocating for that collaborative approach here. If it's not something you want to treat, that's okay. No one is saying you have to, but you can't give them that diagnosis and then shuttle them out the door. That's really not appropriate.