Laryngopharyngeal Reflux (LPR): Symptoms, Subtypes & Patient Presentation

[Dr. Ashley Agan]
When you see these patients in your clinic and you are getting that initial history, are there some key questions that you're always asking or are there key things that patients talk about or bring up that help you think like, oh yes, this definitely sounds like they're having some indirect reflux, or is it just, I know we all have that typical, I've got the mucus, I've got the postnasal drainage. That's pretty common. Then we're going like, oh, like, what are we going to see on scope? Is there anything, particular questions that we need to be asking that are important in helping focus things?

[Dr. Inna Husain]
Yes. I will tell you that a lot of this is, I am somewhat privileged in terms of being this subspecialist who people are coming specifically to talk about LPR. I do have a little bit of a privilege here in that I can sit down and really hone in on just this one specific thing that they're having as opposed to having to see multiple different types of problems that are coming into my clinic. When I talk to patients, usually, they've already been referred in, for example, by another ENT or perhaps even primary, a primary physician who's somewhat familiar with this idea of reflux.

They've probably tried a few things. When they come into me, we take a step back and I say, "Okay, I need to hear what the problem is." Somebody else called it globus, somebody else is calling it throat clearing. Let's start fresh. What is it that you're actually feeling? Are you coughing or is it throat-clearing? Is it that you're feeling mucus dripping? Or are you just throat-clearing so you think it's mucus? That's the very first step of all of this is like, what is the actual thing you're feeling? Because I've had multiple times where it's written that they're coming in for globus and I don't know about you, but when I think globus, I immediately think like a lump in the throat, like a tightness. They're like, "No, no, no, there's no lump. I'm just throat-clearing." The globus actually was a sensation of mucus, which in my mind triggers a different pathway of what I'm thinking about. That's what the very first thing I say is like, what are you actually feeling?

Let's not define it. Let's just say what we're feeling. Then once we get the feeling, then that breaks it down into what type of questions I'd like to note. For example, if it's a globus type of thing, I really want to know, is it all the time? Does it come and go? Does it wake you from sleep? Those type of questions do the same thing with the mucus sensation. I really want to make sure that I don't think it's coming from a nasal source. I definitely ask my general nasal type of sweat symptoms. Then it really becomes a time thing too. Are you noticing more mucus and phlegm after you're eating and drinking after you've been outside first thing in the morning? When is it happening? If we can pull out some of those characteristics that starts help building my differential. Then to be honest, sometimes people are just like all the time. That's all they can tell you, there are no triggers, it's just all the time. That makes me very suspicious for a neurosensory component because what could possibly be happening all the time?

[Dr. Ashley Agan]
Yes, it's like that word congestion. I just have congestion and it just can mean so many different things. Sometimes it's--

[Dr. Inna Husain]
Yes, that's a great example.

[Dr. Ashley Agan]
Sometimes it's like stuffy ears. Sometimes it's like a productive cough.

[Dr. Inna Husain]
No, no. 100% agree. What is congestion?

[Dr. Ashley Agan]
What exactly are you feeling? With LPR, do you find that for one patient it can be mucus, and then for another patient it can be throat clearing, it can be different predominant symptoms even though it's the same underlying pathophysiology?

[Dr. Inna Husain]
100%. It adds to the complexity of some of this because it would be great if you had to have all five symptoms together and then it'd be like, "Yes, that's LPR." Unfortunately, it's not. Now I will say that there are some symptoms that I just do not think are LPR. Not every symptom you have in your throat is LPR. You can have primary [unintelligible 00:15:06] with reflux and that can cause weird feelings in the throat as well. Unilaterally, I take seriously. If patients come in and they're like, "There is this feeling in the left side of my throat only." That is unlikely to be LPR, that just doesn't make any sense and I see that LPR diagnosis all the time, but that's probably a primary laryngeal hypersensitivity and that's a whole different topic. The unilateral reality usually makes me very suspicious that it's not a reflux problem.

[Dr. Ashley Agan]
That's helpful. For patients who have GERD, so gastroesophageal reflux disease, which is so common, you look at the patient's medication list and almost everyone is on a PPI these days. What is the interplay of that? If you have GERD, are you more likely to have LPR? Can you have it in the absence of that? How do those interplay?

[Dr. Inna Husain]
Definitely, a lot of times obviously we refer back to the literature in terms of what does the literature tell us. The problem is that our definition of LPR has evolved so much over time and our diagnostic criteria is pretty poor currently. To really get a true incidence is difficult. I will tell you that from what we know in the literature if patients have true GERD, they're definitely more likely to have LPR-type of symptoms, which makes sense because they're definitely having that volume reflux or that acid reflux. With LPR, it's a little bit more complex. We think that very few people probably are having true GERD symptoms. I think we all see that clinically where patients will say, "I don't have reflux, I don't have acid reflux." And I believe them, they're not feeling heartburn. The tricky thing is, you can still have reflux and not feel the heartburn. That's why we like to call it silent reflux, which to be honest isn't really true either because it's not silent. You're clearly having symptoms, you just didn't know that those were symptoms of reflux. Silent reflux is a little bit, I use that term all the time myself, but that's not really true either. It's not silent, that's why you're here.

[Dr. Ashley Agan]
Yes, it's so common to have patients say, "No, I don't have reflux. No, it's not that." Let's get into diagnostic criteria. How do we say for sure, okay, your symptoms are related to LPR because of boom, boom, boom, these things. What are you looking for when you start to move on to your physical exam, your scope exam?

[Dr. Inna Husain]
For any throat complaint, I always offer flexible nasal laryngoscopy no matter what the throat symptoms. That's why you're here to see me and I need to do that physical exam. I think it's really important to understand though, when I'm doing my scope, I'm not doing it to rule in reflux, I'm doing it to rule out other things. I'm doing a physical exam because I don't want to assume that there's some reflux there and you had insufficiency or a polyp or something contributing. Doing it to rule out things. Now classically when we think about LPR findings, we think of certain things. We definitely all think of that post-cricoid edema or erythema, the classic intra-retinoid bar of mucosal hypertrophy. We think of mucus at the level of the vocal folds. The vocal folds themselves are producing mucus and then we think of the pseudo sulcus. The pseudo sulcus is that thickening where it looks like chronic edema type of picture on the undersurface of the vocal folds.

Lingual tonsil irritation hypertrophy has been associated as well with LPR. The challenge with all of these are a lot of these findings are subjective. Is my intra-retinoid bar, what you would call a bar? What is post-cricoid edema? What if someone's just born with that size of post-cricoid mucosa? That's definitely very challenging. Now, a lot of my colleagues, a hot topic in laryngology these days is the artificial intelligence world. Can we upload these images onto a program that could then give us a diagnosis? Sure, that would be fantastic if that gets developed. Currently, it's incredibly subjective what we see. What I always tell patients because this is a little bit of a pet peeve of mine, is that they'll say, "Well, I was scoped and they saw reflux." No, you can't see reflux because it's happening in your esophagus. What they saw were signs that looked like your larynx was irritated. Again, that's not a direct definition of LPR because lots of things can irritate. The reason we scope is to make sure we're not missing something.

I've had cough patients where we found a tumor causing their cough or dysphagia and there's a tumor. The reason we scope is to make sure we're not missing anything else. Then we look for signs of really, really inflammation. Most of these patients, when we scope them, there's not really anything striking. It's all very subtle changes, and how much of that is somebody's baseline. Well, we don't scope everyone all the time, so it's really challenging to use your scope to make an actual diagnosis. Coming back to your question about what diagnostic testing or tools are available to us, we're somewhat limited right now. I do consider the gold standard for LPR diagnosis kind of the 24-hour pH impedance test. That's probably the best diagnostic tool we currently have. This is also incredibly limited because it is not necessarily an easy test. It's not offered in a lot of ENT practices. It's uncomfortable for patients. Part of what I do when I see patients again, a lot of them have already seen an ENT previously, but what we talk about is the test. We talk about it being the gold standard for diagnosis. Then we say, "Well, if you're not ready, and I can understand that for these symptoms, then we can talk about perhaps empirically treating you, but we have to be very clear that it's an empiric treatment." So, I cannot say that you actually have LPR if we're empirically treating you, but again, a lot of these are quality-of-life symptoms. We've ruled out big bad things. We have the flexibility to work through some of this.