“LPR can be difficult to quantify,” he said. Non-acid reflux components such as pepsin can still be active with a pH up to 5, possibly even at a neutral pH level. Additionally, he said, “We have to consider pepsin as an active agent of inflammation during non-acidic reflux. There’s even some speculation, although not proven, that pepsin gets into the hypopharynx and larynx and may be reactivated as we eat and drink things that are acidic.”
Explore This IssueOctober 2012
Dr. Carroll considers a pH-impedance test to have a positive result for a patient on a high dose of twice-a-day PPI if one of three things happens: There’s breakthrough acid, with a DeMeester score of more than 14.7; there are significant numbers of proximal esophageal non-acid reflux events (more than 31) with or without a positive symptom index; or if there’s a positive symptom index alone demonstrating more than half of symptom events reported by the patient that actually correspond with reflux events inside of them.
Opportunity for Involvement
Chronic cough can come from a variety of directions. There are rhinologic triggers, pulmonary triggers, a large potential for reflux associated with cough, neurologic triggers and triggers associated with tumors. But otolaryngologists can play a bigger role than they have been playing, Dr. Altman said. “Even though we’re ear, nose and throat physicians,” he said, “we do have some mastery of the lungs and the esophagus. And we do take a primary role in tumors that can also influence the potential for cough.”