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BackTable / ENT / Podcast / Transcript #175
Podcast Transcript: Understanding Atypical LPR: Beyond the Larynx
with Dr. Inna Husain
In this episode, laryngologist Dr. Inna Husain joins host Dr. Ashley Agan for a deep dive into laryngopharyngeal reflux (LPR) to illuminate patient presentation, diagnostic tests, and future directions in LPR research. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Typical Diagnostic Journey of Laryngopharyngeal Reflux (LPR) & When to Consider Atypical LPR
(2) Rhinologic Presentations of Atypical LPR
(3) Other Manifestations of Atypical LPR
(4) The Role of Esophageal Pathology in LPR Symptomatology
(5) The Use of Barium Esophagram in LPR Symptomatology
(6) Neural-Mediated LPR
(7) pH Impedance Testing
(8) Managing LPR with Diet Changes
(9) Challenges in Finding the Root Cause of Reflux
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[Dr. Ashley Agan]
My name is Ashley Agan. I'm a General ENT in Dallas, Texas. I'm very excited to have a repeat guest on the show today. We're doing an LPR Part 2 with Dr. Inna Husain. Good morning. Welcome to the show, Inna.
[Dr. Inna Husain]
Good morning. Thanks so much. Ashley. Happy to be here.
[Dr. Ashley Agan]
I'm so excited to have you back. Let me give you a formal introduction for those of you who do not know Dr. Husain. She was on the podcast back, Episode 83. If you have not listened to that, be sure and go back and take a listen. She is a Board-certified Otolaryngologist who completed her training from Northwestern and then went on to do a fellowship in laryngology from Mass Eye and Ear Infirmary, which is a Harvard teaching hospital.
She started her career in academic medicine where she served as the Section Head of Laryngology and the Associate Program Director for Residency Education before transitioning to a community practice to start the first Voice Airway and Swallowing Regional Program in Northwest Indiana, and serves as the Medical Director of Laryngology within the CCNI healthcare system.
She's an active member of the AAOHNS. She's an international speaker, a writer. She's very active on social media as the #ThroatDoc with over 170,000 followers, and she uses her platform to educate and advocate for patients. Her clinical and research interests include idiopathic subglottic stenosis and LPR, Laryngopharyngeal Reflux, which is what we're going to talk about today. She is a force and we're so excited to have her back. Welcome back to the show.
[Dr. Inna Husain]
Thank you.
(1) The Typical Diagnostic Journey of Laryngopharyngeal Reflux (LPR) & When to Consider Atypical LPR
[Dr. Ashley Agan]
I wanted to do just a short little recap of Episode 83 to set the stage. I went back and listened to it again, just in preparation for this, and there's so many good nuggets of wisdom in there. I'll do just like a quick run through of the highlights and then you can come in and add some of your thoughts as well, and then we can do a deeper dive into what we have planned for today.
LPR, which stands for Laryngopharyngeal Reflux, last time we talked about using subclassifications to further categorize this into direct acid, where acid is causing irritation of the throat, direct non-acid, where you might have digestive enzymes like pepsin causing tissue damage, and indirect acid, where there's reflux happening in the distal esophagus that is probably a neurosensory-mediated process where you're having symptoms in the throat related to that.
We talked about symptoms that patients might experience like post-nasal drainage, or mucus, or throat clearing, globus, feeling like something's in the throat or a tightness. We talked about the importance of flexible laryngoscopy to rule out any other diagnoses that can cause similar symptoms, and that reflux cannot be seen on laryngoscopy, but rather you might see nonspecific signs of inflammation.
We talked about the 24-hour pH impedance test, which is the gold standard for diagnosing LPR. Then we talked a little bit about medical therapy with acid suppression, like PPIs or H2 blockers. We talked about alginate suspensions and lifestyle, of course, cutting out coffee, and chocolate, and stopping smoking, and those types of things. That's the main overview. Inna, fill in some commentary for me.
[Dr. Inna Husain]:
Yes, I think we had an amazing talk. I'm just hearing that review and I'm like, "Wow. Yes, that's everything I love to talk about LPR," and everything that I think if you're starting in your journey of either finding answers for your LPR diagnosis, or you are a practitioner treating patients with LPR that really that's the basics of what you need to start off with in terms of understanding. I think when we talked about the definition, I think it's very important that we think of LPR as really LPRD, right?
This is a disease process. When you think of a disease, you often think of different subtypes and how that would relate to clinical presentation and also helps to explain why some people just don't get better, right? They feel like, "I gave up my coffee and I'm taking my PPI, and I'm not eating late at night, and I'm not getting better." That's one of the first things I take patients back to is the definition.
"You were given a definition of LPR, but do we really know which type of LPR it was?" Sometimes we have to go all the way back. When things aren't working and you're not finding an answer, sometimes we have to just stop. I do this with the patient. I say, "Listen, we're going to stop here together and we're going to go back. We're going to start from the beginning and we're going to see if we missed anything with the history. I'm going to repeat my exam."
I often advocate for adding on what's called a Videostroboscopy, right? Which really helps to look at mucosal wave patterns of the vocal folds. We do know a lot of issues with the glottis contribute to some symptoms such as, for example, chronic cough, which is not often what we think of when we think of the vocal cords. Those types of findings often can't just be seen on a regular scope. Again, escalating from where you are when things aren't getting better.
[Dr. Ashley Agan]
Yes, I think that's a really good point. Today, just setting a roadmap for where we're going, building on what we talked about last time, there are extra laryngeal or atypical manifestations of LPR that we're going to get into. We're going to talk about some esophageal pathology and how to find the root because of reflux. In preparation for this, you've done some really good Instagram live recordings, and the atypical manifestations really got me scratching my head and thinking like, "Wow. I'm not sure if I'm thinking of reflux with some of these things." It's really interesting how LPR could cause some symptoms that maybe we're not always thinking about. Can you speak to some of those?
(2) Rhinologic Presentations of Atypical LPR
[Dr. Inna Husain]
Yes. I will tell you that how I started being aware of these symptoms was 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, included me. 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]
You can have allergic rhinitis and have LPR.
[Dr. Inna Husain]
Right. That's, unfortunately, sometimes the bad news that we have to give patients. I think most patients appreciate being told information that's very blunt and direct. I think I come off very friendly when I say these things, but really sometimes you have to be, "Listen, you, unfortunately, have like the triple whammy. You have allergic rhinitis, you get recurrent sinusitis, and I think you have LPR going on and your poor nasal cavity and nasopharynx is just really trying to survive here. Let's break this down."
I love breaking down treatment plans into categories. I explain to patients, "Listen, for this nasal symptom, we're going to do these three things. I also think you have LPR going on, so, hey, let's do a little bit of a workup here for that. Then at the end of it, let's also work on a little bit of your hypervigilance." Having persistent sinonasal laryngeal symptoms is really uncomfortable, affects quality of life. It can be stressful to constantly feel something there that people keep telling you is not there. Sometimes we need to add on a little bit of treatment for the hypervigilance as well.
(3) Other Manifestations of Atypical LPR
[Dr. Ashley Agan]
Okay. Unless there's other nasal symptoms, moving on to other atypical manifestations. Any other symptoms that are outside of what we, typically, think about when we think about LPR that you also see?
[Dr. Inna Husain]
I think one, especially for general community practice, I would say chronic cough, right? We do see a lot of chronic cough being caused by either reflux or esophageal pathology. We often put it under the category of reflux, even though it might not quite be that definition, but a lot of esophageal issues can contribute to chronic coughing. That's a big one that I delve into and try to work through and help patients with.
We often talk about the generalized hoarseness type of phenomenon, and I'm very careful when I say that because very concerned about this idea that like, "Oh, hoarseness, take a PPI." That makes me very nervous when I say things like that, but there are manifestations of the larynx, which can contribute to hoarseness that, again, are not acid reflux-mediated. We do see voice changes associated with reflux, either direct or indirect as well.
[Dr. Ashley Agan]
What about like shortness of breath or dyspnea?
[Dr. Inna Husain]
Yes. This is actually a big one that I commonly see. Basically, there's two forms of shortness of breath that can happen for reflux. The first is this sensation of like not getting a complete breath in. If you describe it to patients like that, they'll often be like, "Yes, that's exactly it." You can be sitting and you just feel like that breath is not complete, but there's no wheezing or stridor. You can still do your activity. It has to do with diaphragmatic breathing or poor diaphragmatic breathing in the setting of reflux.
The second way we think that reflux can actually contribute to shortness of breath or pulmonary issues is through the direct mechanism. We have evidence that shows reflux can be micro-aspirated and as an inflammatory component can contribute to inflammatory pulmonary conditions. Our pulmonary colleagues, I'm very lucky to currently work with some great pulmonary colleagues who try to identify this very early on in some of their patients. We try to either, again, try to suppress the reflux, evaluate it further, so it can contribute to actual pulmonary disease as well.
[Dr. Ashley Agan]
Yes, I can imagine if that's happening chronically over long periods of time that that would add up. For your patients that have trouble just taking a deep breath, is that more around mealtimes or it's a persistent all-the-time thing?
[Dr. Inna Husain]
Yes, it, actually, doesn't have to be. It makes sense around mealtime that you would have it and so that's always something I always ask, "In association with symptoms, is it around mealtime?"With this LPR-mediated shortness of breath, it definitely does not have to be. That's, unfortunately, with LPR symptomology in general, right? It can be delayed from the actual meal because it takes a little while to reach the tissue or because those symptoms.
[Dr. Ashley Agan]
Yes, making it even more challenging to figure out.
[Dr. Inna Husain]
Correct.
[Dr. Ashley Agan]
What about halitosis, bad breath?
[Dr. Inna Husain]
Yes, when we think of traditional reflux or traditional GERD, we often talk about like water brash, right? Which is that hypersalivation to try to be a natural antacid. What we also see are other manifestations, like really dry mouth, can come from persistent reflux, mouth irritation. We've all probably seen the patient with the burning mouth syndrome, which again is always thrown into that idiopathic category of, "We have no idea what causes it and it must be some nerve issue."
There is some more and more work coming out or research coming out that shows there likely is probably a link contributing to that hypersensitivity of burning mouth syndrome. Yes, a lot of oral pathology we see in response to reflux as well. Recurrent aphthous ulcers, some patients get those without evidence of Crohn's disease or anything. We think that could be reflux-mediated as well.
[Dr. Ashley Agan]
Okay. In patients who are coming in with nasal congestion, recurrent sinusitis, chronic cough, maybe some dyspnea, bad breath, burning mouth, all of these, we need to make sure LPR is on the differential.
[Dr. Inna Husain]
It is correct. I would say I would be very hesitant to say it shouldn't be. I think it's more prevalent than I think we realize.
(4) The Role of Esophageal Pathology in LPR Symptomatology
[Dr. Ashley Agan]
Yes. I'm sure once you start looking for it, you start finding it. Correct. 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.
(5) The Use of Barium Esophagram in LPR Symptomatology
[Dr. Ashley Agan]
Yes. For your esophageal workup, is there anything else that you think about other than upper endoscopy? Do you ever do, like a modified barium swallow or other testing?
[Dr. Inna Husain]
Yes. I actually order esophagrams a lot. The reason that developed was it can be hard to get in with GI. I don't think that's just in my area thing. I think that's generally procedure based things are a little bit harder in terms of scheduling, getting in. There's also things you have to consider with regards to sedation and overall medical health. I have a patient population that's fairly older.
These are considerations. I use the barium esophagram a lot as a screening tool. I think it's quick. It's easy. It's, definitely, not perfect like any diagnostic test, but we've identified a lot of issues with the esophagus that are contributing to throat symptoms just by using a screening barium esophagram. Modified barium, I obviously use that a lot as a laryngologist for when there's concern for oropharyngeal dysphagia, globus sensation.I'll often add that on to get a complete swallow evaluation.
Then like we talked about last time, still supporter of the 24-hour pH impedance test, there are nasopharyngeal probes that are available, which are a little bit easier tolerated by some patients who have hypersensitivity. We just need to remember that that's not really looking at that indirect effect and it's somewhat of a harsher pH test. There are roles for it, but you should be able to offer the full range of testing for patients.
[Dr. Ashley Agan]
For like a dysmotility, are you ordering like, what is it? Esophageal manometry?
[Dr. Inna Husain]
Yes. Usually I start again with the easiest, which is usually a barium esophagram, and that can usually identify some form of dysmotility. Again, we can take a step back after that and talk with the patient, see where they're at with everything. Esophageal dysmotility is something that I'm still learning about. Again, I am an ENT. I'm not a gastroenterologist. I have interest in these areas, so I'm trying to educate myself and work with my colleagues.
From what I've learned so far is that dysmotility can be very challenging to treat, generally. When there are concerns that the dysmotility is pretty bad or severe, I do recommend getting a manometry to look at it further. I think manometry is also very helpful when patients are having a lot of globus sensation, especially where you think there might be involvement of the upper esophageal sphincter because you can get some data points regarding that muscle.
There's also something that GI will do. It's called an Endoflip. It's a newer procedure that they do during an upper endoscopy. Depending on where you get your upper endoscopy, they may be able to add that to look for some dysmotility as well. Again, this is an area where I'm, as a personal mission, trying to educate myself on more for my patients.
[Dr. Ashley Agan]
Yes. You can see there are findings that can be suggestive of dysmotility on your barium esophagram.
[Dr. Inna Husain]
Oh, 100%. Yes, you'll see it on there.
[Dr. Ashley Agan]
Just because there's like stasis, or is it like a pattern, or what do you see?
[Dr. Inna Husain]
Yes, you'll see both. You'll see there's a normal pattern of contractility of the esophagus. I always use the analogy of like milking a cow for patients. If you don't know how to do it, you're not going to get any milk. That's the same with the esophagus. If it's not squeezing in its normal pattern, then things are not going to flow fast, they're going to hang out, there's going to be stasis, and guess what? Your body's not going to like that. You can see that on the barium esophagram.
[Dr. Ashley Agan]
Okay. Any other common findings that you're finding in the esophagus?
[Dr. Inna Husain]
We do often find things like hiatal hernias, for example, and it's interesting because upper endoscopy may not see it all the time. I'm learning this more in clinical practice where patients may have had an upper endoscopy and there's no comment of a hiatal hernia, but then we get an upright barium esophagram that's really distending the system and then we find it. I think things like finding a hiatal hernia are important for patients because as we're going to transition to trying to find the root cause, like, "Why are you having this, for example, reflux to begin with?" It's helpful for patients to have that information, so you can, definitely, see a hiatal hernia on a barium esophagram as well.
(6) Neural-Mediated LPR
[Dr. Ashley Agan]
For the patients who have esophageal pathology, like you mentioned earlier, it may be that they have almost like a secondary LPR because things aren't moving through or LPR-like symptoms that it's being triggered because of things hanging up in the esophagus.
[Dr. Inna Husain]
Yes. I think nomenclature is something that we as a field should start to work on and really define. The way I describe it to patients is, again, your body's responding to something that's happening in your esophagus. We talk about the vagus nerve and the branches of that. It's very similar to the idea of neural-mediated LPR, right? The vagus nerve is transmitting that signal to your throat from something happening in your esophagus.
We have evidence that supports this with regards to things like globus sensation. There was a study, probably about a decade ago now, where they dilated a balloon in the lower esophagus when patients were awake. Where do they squeeze? They squeeze their neck. They squeeze their throat. We know that the sensation can be referred. We often talk about this Neural-mediated LPR Symptomatology. That might be also why the throat doesn't look as inflamed because there is no inflammation.
[Dr. Ashley Agan]
Yes. I think, speaking to like terminology and the words we use, globus pharyngeus, I think for some people is a diagnosis. I've had patients tell me they have it. I've had GI colleagues say like, "Oh, yes. I think they have globus." That's almost like saying, "They have cough," or, "They have a headache." It doesn't actually say what's going on. Globus is more of a symptom of something else. Is that how you would describe it still?
[Dr. Inna Husain]
100%. I say this a lot with post-nasal drip. It's not a diagnosis. It's a symptom. What is the post-nasal drip a symptom of? That's what we're going to try to figure out. I feel that way of globus too. The other thing I will say about globus, please ask your patient what they actually feel. Because if they're coming referred to you, even from primary care and they were told globus, if you strike the conversation on globus, you can go down a very different pathway.
Classically globus we think of as like that lump in the throat, that ledge when you swallow. Some people, when you ask them for their question, it's just mucus. They just feel mucus down there, but somebody told them it was globus. That workup, I think would be very different than if they truly felt obstruction when they're trying to swallow. With globus too, just clarify what it is they feel.
(7) pH Impedance Testing
[Dr. Ashley Agan]
Yes, I think that's a really good point. I think that word has just made its way outside of ENT and it becomes like a diagnosis, like, "Oh. Yes, this is globus." I know what this is, but it's like, "Oh." I did want to, we talked about the 24-hour pH impedance probe last time, but I wanted to just touch on it again a little bit because, as you mentioned, there's the nasal probe. I found Restech, is that the most common?
[Dr. Inna Husain]
Restech. It's one of the common.
[Dr. Ashley Agan]
Basically for that, it's just going through the nose and the tip of it, it's like hanging out like right above the soft palate or so. Is that what it looks like?
[Dr. Inna Husain]
Correct. Yes. It's right there. It's a lot easier for patients to tolerate. Again, another shout out to my colleague, Dr. Lechein, because he uses this a lot more in practice than I do. He said he uses it for primarily nasopharyngeal symptoms. This might be something, for example, a rhinologist may consider adding to their practice since they're seeing patients with primarily nasal or nasopharyngeal symptoms to see if there's any acid involved. It's an easy placement, easy tolerance. You don't need to know anything about the esophagus to do it. It could be helpful.
[Dr. Ashley Agan]
It's going to detect acid and non-acid, anything that would be refluxing would trigger it and you'd be able to see that.
[Dr. Inna Husain]
It's primarily acid.
[Dr. Ashley Agan]
Okay. Whereas with the full probe, it does both. It has acid and non-acid.
[Dr. Inna Husain]
Yes.
[Dr. Ashley Agan]
We can register both.
[Dr. Inna Husain]
Yes. When we talk about the full probe, a lot of times GIs who's doing these pH impedance tests, but we have to make sure they're using what we call the right catheter for ENT. You want to make sure it has sensors in the lower pharynx or very upper esophagus. A lot of GI probes don't have that because, again, GERD is different than LPR, right? How can you have any symptoms in the throat if your lower esophagus is fine? That's the way GIs think about it. We know ENT, we think a little bit differently. PH and impedance, lower esophagus, upper esophagus/pharynx is the ideal probe for that.
[Dr. Ashley Agan]
Okay. For the full length probe is the tip of that sitting just at the lower esophageal sphincter.
[Dr. Inna Husain]
The way I do it is I'm focused more with regards to the upper sphincter. I want to make sure my upper probes are placed normally, and then the lower one will be somewhere in the distal esophagus. You definitely don't want to be in the stomach, right? Somewhere in the distal esophagus, but I'm more careful about my upper probe placement.
[Dr. Ashley Agan]
If a patient says, "Oh, I've already had one of those. The GI doctor said I'm fine." We need to dig and say, "Okay, let's find out exactly what you had done." Was there a sensor in the pharynx or at the upper esophageal sphincter?
[Dr. Inna Husain]
Correct, because most of the time there is not.
[Dr. Ashley Agan]
We talked about this a little bit last time about the interpretation of the testing because in the GI world, the patients are hitting a button saying when they're having symptoms and they're correlating that with reflux events. In the GI literature, if that doesn't correlate, then it's not positive for ENT. I'll let you finish that.
[Dr. Inna Husain]
Right. For ENT, unfortunately, that is not the case. We don't expect any reflux event to make its way to the throat. That's not normal. Even one episode that doesn't necessarily correlate with the button pressing could definitely contribute to sensitivity and delayed presentation of symptoms. We don't have that in our field in terms of like that strict criteria, the way the GI team does.
You really need to-- again, it depends on how much involvement you'd like to do with this diagnosis and management, but you have to really look at the results of patients get testing done elsewhere. I do recommend-- I don't want to just know that the clinical note that says you're fine. I want to see the actual test because I want to see how many episodes, where did the episodes go? Were they acidic or not? Then put that into context of what you're telling me you feel with your throat.
[Dr. Ashley Agan]
Can you speak to the sensitivity, specificity? If we're using the right probe, which is the one that's going to have a sensor in the pharynx, it's going to be testing acid and non-acid. If that is positive, you can feel pretty confident that the patient does have LPR?
[Dr. Inna Husain]
Yes.
[Dr. Ashley Agan]
What if it's negative? Is it possible that they just had a good day? Do you ever have patients who were like-- it comes up negative, then you're like, "Ah, now what do we do?"
[Dr. Inna Husain]
I'm very careful when I send patients for testing sometimes with regards to that. What I mean by that is if a patient has symptoms all the time, right? They're like, "Every single day I have symptoms." I'm like, "Okay, let's get you tested." Someone comes in and they're like, "You know what, I only get these symptoms like once a month." Then I'm like, "Listen, the testing might not be great for you because we're probably not going to capture what's happening."
Again, sometimes we do diagnostic testing to try to gather information, but there's also the possibility that essentially nothing comes from it. Again, very upfront with patients about this, where I say, "Listen, the reason for testing is we want to know, but we might even either find out or not find out and nothing changes." That's always a possibility, unfortunately, with testing.
[Dr. Ashley Agan]
Do you ever repeat testing or do you ever--?
[Dr. Inna Husain]
I have. I'll be honest, the pH impedance full probe is not the most comfortable thing. Let's be honest. It's not a huge catheter, right? Our scopes are usually wider than it, but it's in the throat and you can feel it when you swallow. I'm very somewhat selected in terms of who I really push to get this done. Most people, I offer it to them. I let them know it exists. We talk about it, but it can be very uncomfortable.
Repeating something like that, I usually think there's more things we can try before that. I can think of a handful of people who've had multiple over the years, and usually those are actually our neurogenic chronic cough patients who 10 years ago were tested, five years ago were tested. Otherwise, we don't really repeat it.
[Dr. Ashley Agan]
Yes. I could imagine that would be pretty uncomfortable. What do you think about the Peptest, like detecting pepsin in saliva? Is that something that you're incorporating or can you speak to that a little bit?
[Dr. Inna Husain]
I don't use it a lot. The reason for that was it was really difficult to get. You have to get it from the UK and send it back. I think part of this is with the diagnostic testing. Let's say we prove that you have pepsin there. What are we going to do about it. We're going to go back to the board and say, "Well, let's stop the reflux from happening." Now, there is some development happening with possible anti-pepsin treatment, which pretty excited about, and then the role of something like the Peptest may be a bigger player, right? You can really identify the people who should take this drug to help with that.
Until we have something like that, we're just going to go back to the board and stop with reflux, try to decrease the mechanical movement.
(8) Managing LPR with Diet Changes
[Dr. Ashley Agan]
Any other additional testing that is in your toolbox?
[Dr. Inna Husain]
I think to be honest, that's most of the testing that we do. I always tell patients with your GI or GERD workup, initially if you're having those symptoms or even silent reflux, let's make sure things like H. pylori have been ruled out. Those are things that my gastro colleagues work with patients on. Making sure that's been tested. I don't do a lot of nutritional testing if that makes sense. The reason for that is I don't know a lot about it. I wasn't formally trained in that.
I do work closely with dieticians, some of them more remotely who are not in my town or anything like that to work patients through some of the diet component of reflux for all of that stuff. I don't do that testing myself.
[Dr. Ashley Agan]
Got you. For like food sensitivities, is that what you -
[Dr. Inna Husain]
Right. Yes.
[Dr. Ashley Agan]
As far as treatment and therapy goes, any changes in your approach since the last time we talked? It's been about, I think our last episode was maybe a little over a year ago.
[Dr. Inna Husain]
Yes. I think I still lean towards more addressing mechanical reflux with alginates as opposed to acid suppression. I don't want GI doctors to come after me when I say I'm not a huge fan of acid suppression because there are definitely cases where I think it helps a lot. Those are more of our traditional GI symptoms. I think addressing more mechanical reflux. I do a lot of alginate use. I've been doing that for a while, but really supporting that use over acid suppression.
I do a lot about ensuring patients are getting good nutritional information, help with the dietician to work through when and what they're eating and drinking. No other real interventions I think that are different. I think we probably talked about neurosensitivity last time. Still doing all of that using neuromodulators, using the superior laryngeal nerve block for primarily laryngeal symptoms. Pretty similar.
[Dr. Ashley Agan]
Yes. For diet, is there a one diet fits all or is it, "Let me give you a list of things that tend to cause problems that you may want to try to eliminate. Here's the list of things that you can try that make it better."
[Dr. Inna Husain]
Yes, it's unfortunately the latter because we really don't know. Everyone's different in terms of what triggers them. People will say that about traditional heartburn as well. some people can eat tomato sauce and wine and be just fine. Others are like, "Oh my God, just the thought of that is horrible." We see that similarly with that. I do a lot of focus on things that I think contribute more to mechanical reflux. I think carbonation is a huge one, I think for throat symptoms. Really trying to eliminate carbonation. Coffee is interesting because of its acidity, but also it's caffeine and its effect on the lower esophageal sphincter.
I've recently got into really supporting the use of fiber. I came across a study and I think this is actually really fascinating that fiber actually absorbs nitric oxide and nitric oxide relaxes the lower esophageal sphincter. If you have fiber in your diet, you're going to soak up some of that nitric oxide and help the sphincter not loosen. I've been focusing more on things that contribute to mechanical reflux as opposed to acidity.
Now, that being said, acid on the way down can definitely cause issues for patients too, right? If you have a chronic soreness in your throat or irritation, it's not even a reflux thing at that point when you ingest acid, it's a touching the tissue thing. Yes, unfortunately, oftentimes it is a broad list of recommendations.
[Dr. Ashley Agan]
You're taking away the Topo Chico and the bubbly water.
[Dr. Inna Husain]
The summer, the LaCroix, the beautiful buses with the pinks and the purple, new flavors. I'm like, "Yes, that definitely, unfortunately, you can't have."
[Dr. Ashley Agan]
Can't have it. Cut it out. What about things to add? Things like-- you mentioned fiber. Does it matter if the fiber is coming from a vegetable source versus from Metamucil? Or just any fiber is good?
[Dr. Inna Husain]
Yes, I like it in the diet, in the food for more natural use. In terms of adding things, again, I often defer to my dietician colleagues for this because it gets very nuanced. To be very frank, I spend a lot of time with patients undergoing the medical work of diagnostic testing. Talking about nutrition is a whole another visit. I think you should really be speaking to someone who's really an expert in that and spending your time more wisely there. We often spend more of our time talking about the medical aspect of it in terms of testing and diagnosis and all of that.
(9) Challenges in Finding the Root Cause of Reflux
[Dr. Ashley Agan]
Yes. How do you go about finding the root cause of your reflux? Yes. Go ahead. Speak more to that.
[Dr. Inna Husain]
Yes, this has become definitely a hot topic in terms of finding-- I don't feel like I've heard this as much in the last few years as in this past year in terms of finding the root cause. I agree with it. It's not that I'm against finding the root cause. A lot of patients now come in and they say, "I want to know why I'm having reflux." That's a big question that they're having. You have to break it down.
You have to have discussion about lifestyle, body habitus, when they're eating and drinking, are there underlying medical conditions. Sleep apnea is a huge one. Sleep apnea causes a lot of reflux at night. Are there other things in your medical history going on? Are you on medications that could be contributing to things? Diagnostically we use our testing, the same testing we spoke about in terms of reflux, to see if we can identify what's causing it. Do you have esophageal dysmotility as the root cause? A hiatal hernia, an H. pylori infection.
That's where we include some of the diagnostic workup and why I say treating these patients is more than just, "Oh your larynx looks great. It's probably reflux," because we know that no one else is going to work them through LPR. We know that as ENT that when you diagnose and you send them to GI-- I love my gastroenterology colleagues but they are not trained in LPR at all. When you send a patient saying it's reflux their mind is focused on GERD which to be honest it should be. They're ruling out GERD.
You know when you send that patient out the door that their best chance of LPR information is now gone. I really advocate for these patients that, again, if you're going to be diagnosing people with LPR, have a plan. Talk to that GI colleague you refer to and say, "Hey do you even believe in LPR?" Because I've had patients come back and say, "I saw this GI and he said it's not a thing. He said LPR is not a thing. Non-acid reflux is not a thing."
It happens. When you're going to have referral patterns, have these conversations. Be like, "What are your thoughts on LPR? Do you treat this? Do you work this up?" It just takes a conversation. You'll know if the people you work with believe in it or not.
[Dr. Ashley Agan]
Yes, you hate to send a patient and then come back and it have felt like a complete waste of their time to get it. What about stress? What about the whole gut-brain axis?
[Dr. Inna Husain]
Yes, a hundred percent. A hundred percent. This is again things that are outside of our traditional medicine teaching to be very honest. I think all of us who are now in practice we know this is true. We know it. We can we can do a PubMed search and we'll find papers that also support this because they're there. Yes, stress contributes to reflux in multiple ways and it can be something that propagates the symptoms as well. Maybe something in life happened that caused stress but now you're having symptoms so you're having stress over the symptoms and then it just continues to propagate itself.
Stress also activates the vagus nerve. It contributes again to that hypervigilance that we're talking about. If you're going to look out for globus you're going to feel it. Same with tinnitus. I always tell patients, "If I listen for it I will hear it too." It's the same idea. Trying to break that cycle. I talk a lot with patients about figuring out ways to help with their stress. Whether it is yoga or going for walks or getting acupuncture.
When I started my new practice, one of the things I did was investigated where was where were therapists. Could I get your cards? This is what I treat. Would you be happy to see these patients? I have cards that I give patients. I have referrals I can place. I looked up and tried to find where I could send patients for these type of things. Sometimes I feel uncomfortable having these conversations with patients because of course you never want to come off as like, "Oh it's just your stress."
We know whether it's the primary or the secondary it's likely playing a component and patients need to hear it from your medic-- from you. You're their expert their medical team. You need to say, "Listen we're going to keep looking for the root cause and trying to work through it but I need you to work on this as well."
[Dr. Ashley Agan]
Yes, I agree I think it's really important. Anything else with finding that root cause?
[Dr. Inna Husain]
I think I think that's a lot of it. I think when you're looking for the root cause and things like that you need to also remember that it can be acidic or non-acidic. That can sometimes be challenging that a lot of GI workup is really only looking for acidic reflux. That's why if you're going to be the person managing their LPR, you have to put that in context. We've ruled out acid damage.
That's one of the things I tell patients with upper endoscopies is, "I need to know if you have acid damage and if it's severe." The word Barret's comes up often. I need to know if that's there because that's going to change my way of thinking. I'm going to be more aggressive with you and when I say aggression, I actually mean acid suppression with you than a person who does not have that. We work through acid, non-acid, neural mediated with patients as well.
[Dr. Ashley Agan]
We touched a little bit on it last time but just to bring it back around because I think it's still very much in the popular culture and news but gut bacteria, microbiome, how-- I think you and Dr. Lechien talked a little bit about how reflux can change the normal floor of the mouth.
[Dr. Inna Husain]
I think this is all next-generation LPR and I'm-- I tell you I'd like doing this stuff because I get really excited about it. I'm so excited about this. I think this is essentially going to be the help us answer that question of why do some people get these symptoms and others don't, because it doesn't make sense. Reflux is so prevalent or GERD is so prevalent. Why don't doesn't everybody have these LPR symptoms? I think looking into the microbiome of the GI tract, the laryngopharyngeal region is going to be really important in terms of figuring out what is actually the root cause of this symptomatology.
[Dr. Ashley Agan]
Yes it's exciting. As we round it out, I did poll some of our listeners and followers on social media to ask some questions. I do have some questions. The first question is, is Gas-X something that would be okay to take for LPR bubbling symptoms?
[Dr. Inna Husain]
Gas-X is usually-- I believe it's simethicone which helps with bloating. I don't think it would necessarily directly help your LPR but I would say if you have a component of bloating with it-- It's interesting. Bloating and constipation are interesting with reflux with regards to it makes sense. If things aren't flowing, when we talk about the constipation, they're more likely to backflow a little bit. With simethicone itself, I think if you have bloating symptoms okay to try. If you have bubbly gas symptoms, it would be fine to try but I don't think I'd be on it long term if you didn't notice a difference in a day or two.
[Dr. Ashley Agan]
Yes, and you maybe just need more fiber.
[Dr. Inna Husain]
More fiber, yes.
[Dr. Ashley Agan]
More fiber, more fiber. The next question is should we avoid dairy, wheat, eggs for LPR?
[Dr. Inna Husain]
Yes. I think this starts getting into a little extended definition of what we're talking about with LPR. For true LPR, I don't recommend voiding all of those things when we're talking about mechanical reflux. Now dairy, we know dairy can contribute to a thicker phlegm sensation, not by overproduction, but by creating an emulsion with your saliva. Yes, dairy can make things not feel great in the throat. Dairy also can sometimes be high fat and so high fat can contribute to reflux.
Gluten is interesting. I think there's a lot of work coming out with regards to gluten and inflammatory properties in the gut. It's never the first thing we talk about with our visit, but if I'm seeing a patient for a second visit or third visit we start to bring up some of this stuff. Maybe we need to start thinking outside the box here because traditional medicine just isn't cutting it for you anymore. That's when we talk about trying to go gluten-free. If patients have concerns sometimes about these things, I do recommend, for example, food sensitivity or seeing my allergy colleagues to talk about that a little further.
[Dr. Ashley Agan]
Yes. Like you mentioned earlier, there's not a one diet fits all for everything.
[Dr. Inna Husain]
Correct.
[Dr. Ashley Agan]
Yes, and then last question. What if dietary modifications, alginates like Gaviscon UK, the UK version, or RefluxRaft and then even fundoplication. What if all of those have been tried and haven't worked?
[Dr. Inna Husain]
I tell patients when things are not working, "Are you sure it's LPR?" Is it really reflux? Because we see this all the time, that definition of LPR persists for years based on one clinic visit. One clinic visit where we didn't see a sinus infection so we said it was LPR. I always tell patients, "Listen you got to undergo diagnostic workup to show that it's still reflux." There are a host of things that can cause vague throat upper aerodigestive tract symptoms. There's only so many ways the throat can manifest what it feels. There's so there's only a handful of things but there's multiple things that can trigger those symptoms.
When nothing is-- I always go back to the very beginning. I say, "I know you've done all this stuff, but what testing has been done? Let's do your exam again. Let's add a stroboscopy. Let's ask about your history. What is still persisting?" One of the struggles with things like fundoplications, unfortunately, is the gaseous reflux component. Is the idea that you can't stop gas from coming through because you need to be able to swallow on the way down and so that can be really difficult.
Again, as I mentioned earlier, there is work being done for possibly an anti-pepsin inhibitor, which I think would be very exciting if that comes out because that would be added to the treatment options for patients.
[Dr. Ashley Agan]
It can get really complicated and confusing but I think I like your way of thinking about it and just trying to keep it simple. Go back to the beginning if you need to, back to the definitions. Let's use our testing to be able to prove what's going on. Excellent. As we round things out, what else do our listeners need to know?
[Dr. Inna Husain]
One thing I would like them to know is that don't give up. We're trying. We're trying to make efforts here to get the education out there to figure out what's happening. A lot of people are doing basic science research to try to find answers. It's not that we've given up on this so don't give up hope. We can work through this. I would always say advocate for yourself if you're not feeling like you're getting the answers where you are, second opinions for things in medicine I always support them. Even if it's a patient who's seen me, if you need a second opinion, I'm happy to refer you to somebody.
Yes, mostly for the patients just don't give up, work through this and good things are coming.
[Dr. Ashley Agan]
Stay optimistic.
[Dr. Inna Husainn]
Stay optimistic for sure.
[Dr. Ashley Agan]
[laughs] Awesome. I think this was an amazing further deep dive into LPR, and I really appreciate you taking the time to come back on the show. Listeners, again, go back and check out Episode 83 if you haven't listened to it. It's a great primer for this episode. Follow on social media. Remind me, what's your Instagram handle?
[Dr. Inna Husain]
Instagram is just my name, innahusainmd, and then TikTok, for those of you who are on TikTok, it is throatdoc.
[Dr. Ashley Agan]
[laughs] Check out her socials. She's got a lot of really great information on there. When we're done here, I'm going to make her teach me how to create a social media page like she's got going on. All right. Thanks for listening everybody. Thank you, Inna. That's a wrap.
[Dr. Inna Husain]
Bye. Thanks, Ashley.
Podcast Contributors
Dr. Inna Husain
Dr. Inna Husain is the medical director of laryngology with the CCNI Network and Community Hospital in Munster, Indiana.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 11). Ep. 175 – Understanding Atypical LPR: Beyond the Larynx [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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