Dr. Benninger said that physicians might need to treat reflux along with chronic rhinosinusitis or allergic rhinitis, making sure not to overlook unique groups of patients whose laryngeal disease is related to an underlying, diffuse hyperactive airway disease. While differentiating these patients may be difficult, Dr. Benninger suggested focusing on the nose first.
Explore this issue:January 2007
If they don’t have the nasal symptoms, then focus on the larynx, he said. Focus your evaluation on the more likely site. If they do not respond to empiric trial therapy, then consider another diagnosis and in some patients consider hyperactive airway disease and reflux exacerbation of chronic rhinogenic condition.
Albert L. Merati, MD, of the Medical College of Wisconsin in Milwaukee, focused on the possibility of LPR causing rhinologic symptoms. His study focused on patients complaining of postnasal drip with no historical or endoscopic evidence of any sinonasal inflammatory infectious disease. Each had a clean nose, but with postnasal drip as their main symptom, he said.
The question we wanted to get answered was whether or not patients with postnasal drip as their dominant symptom have increased prevalence of LPR, Dr. Merati said. We also felt that signs for LPR would improve in postnasal drip patients following PPI treatment.
Dr. Merati said that the data indicated that acid exposure time for the clean nose group was significantly higher than that for controls. And while probe findings did not typically predict the response to therapy, the postnasal drip symptoms improved in terms of severity, frequency, hoarseness, throat clearing, and cough. The study also indicated possible mechanisms by which acid reflux may induce postnasal drip sensation are direct mucosal contact or a neurogenic mechanism.
We know that there is interrelatedness between the foregut derivatives, such as you might get glottic closure form the lower esophagus without the acid ever getting to the pharynx or larynx, he said. We need to detach ourselves from the thinking that the reflux…has to get to the pharynx to cause pharyngeal symptoms.
It does not have to. While that is certainly embraceable and understandable and is probably the dominant cause of most of what we see, it is not the only way it can happen.
Dr. Merati’s College of Wisconsin colleague, Todd A. Loehrl, MD, who cautioned the audience that his data required a very simplified version of the autonomic nervous system in order to be presented in such a short window, followed Dr. Merati.