SAN DIEGO—When it comes to laryngopharyngeal reflux (LPR), the standard treatment is clear: proton pump inhibitors (PPIs). But, as experts explained here at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting, an array of options is out there, many of them non-pharmaceutical.
Explore This IssueDecember 2016
LPR occurs in an estimated 30% to 40% of the adult population in the United States, with a higher incidence among people who are obese, are older, smoke, suffer from high stress, and consume certain diets, said Marilene Wang, MD, professor of head and neck surgery at the University of California, Los Angeles (UCLA) School of Medicine.
Debate Over Treatment
Michele Morrison, DO, FACS, a laryngologist and chair of otolaryngology-head and neck surgery at Naval Medical Center in Portsmouth, Va., said that while LPR has been accepted as a separate entity from gastroesophageal reflux, there is some lingering debate over the condition’s diagnosis and management. LPR can lead to a variety of symptoms, including chronic mucosal injury, laryngitis, and granulomas, as well as pulmonary issues such as pneumonia, and can be a trigger for head and neck cancers, including esophageal cancer and laryngeal and pharyngeal squamous cell carcinomas.
Cough, globus, dysphonia, and throat clearing are some of the ways patients present. A typical work-up includes a complete head and neck exam with flexible laryngoscopy, along with tests to obtain a reflux symptom index (RSI) score and a reflux finding score (RFS). The RSI can be helpful because patients are followed and are later retested to see how they’re doing, Dr. Morrison said. “Sometimes patients aren’t the best historians to tell you whether they’re actually better,” she said.
Objective testing options, typically performed during follow-up after patients have started treatment, include upper endoscopy, high-resolution esophageal manometry (HREM), and multi-channel intraluminal pH-impedance.
Dr. Morrison said she will typically start patients on 20 mg of a PPI twice a day, with an H2 blocker at night. At the end of treatment, PPIs should be tapered, she said, due to the risk of a rebound effect. Discussions about lifestyle changes, including not eating the day’s biggest meal at night and not eating within three hours of bedtime, are a must, she said. “I can’t emphasize enough that it’s worth those extra few minutes to really talk to the patient about their diet and their lifestyle,” she said. If patients don’t respond, the investigation should continue. “Don’t use LPR as a ‘fall-back’ diagnosis,” she said.
Voice therapy also has a role to play in correcting LPR’s effect on the voice, said Nausheen Jamal, MD, assistant professor of otolaryngology-head and neck surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia. LPR can cause increased muscle tension, hard glottal attack, restricted pitch range, and abnormal shimmer and jitter, among other things. Acid suppression can help with these issues, but it doesn’t work for everyone, Dr. Jamal said (Laryngoscope. 2005;115:1230–1238).
A 2012 study of 100 patients diagnosed with LPR, half of whom were treated with PPI alone and the rest with PPI and voice therapy, found that significantly more patients in the voice therapy with PPI group showed significant improvements in RSI, RFS, and voice handicap index, as well as on the grade, roughness, breathiness, asthenia, and strain scale (Otolaryngol Head Neck Surg. 2012;146:92-97). Many parameters improved in both groups, but greater improvement was seen in several areas among those who had taken voice therapy. “The patients who had voice therapy in addition to the PPI treatment got better faster,” Dr. Jamal said.
Non-Pharmaceutical and Alternative Medicine Options
There are many non-pharmaceutical options that might allow LPR patients to avoid the use of PPIs, said Agnes Czibulka, MD, clinical instructor of otolaryngology at Yale University in New Haven, Conn. Potential long-term complications associated with PPIs include a two-fold increase in the rate of Clostridium difficile, a heightened risk of community-acquired pneumonia, drug-induced acute interstitial nephritis, possible cardiovascular events, bacterial overgrowth of the stomach and small intestine, increased risk of hip fracture, and development of food allergies, Dr. Czibulka said.
One alternative option is probiotics, which she said can help optimize gut flora so that it can better break down complex carbohydrates, defend against “foreign invaders,” and help “train” the immune system. Dosing can range up to 10 billion colony-forming units (CFU) a day for infants and from 10 to 20 billion CFU for adults. Probiotics have a good safety record but should be used with extra caution in individuals with compromised immune systems.
Plants that can help ease inflammation include aloe, marshmallow, slippery elm (FDA approved as a safe demulcent plant), plantains, coltsfoot, and Irish moss. Dr. Czibulka drew particular attention to deglycyrrhizinated licorice, which is recommended for long-term use and avoids the potential side effects of hypertension, hypernatremia, and hypokalemia seen with standard licorice. A 700 mg to 1200 mg chewable tablet before meals and at bedtime is the suggested use, with a maximum daily dose of 5 grams, Dr. Czibulka said.
I can’t emphasize enough that it’s worth those extra few minutes to really talk to the patient about their diet and their lifestyle. —Michele Morrison, DO
Iberogast, available over the counter in the U.S., has been found, in in vitro studies, to reduce acid secretion and increase mucous production. Clinical studies have found it increases gastric motility. Dr. Czibulka added that melatonin has been found to protect gastric mucosa from free radicals in stress-induced ulcers by increasing blood flow and anti-inflammatory molecules in the esophageal mucous.
Underscoring the role of non-pharmaceutical approaches, Dr. Czibulka invoked Thomas Edison, who said future doctors “will give no medicine, but will instruct his patient in the care of the human frame, in diet and in the cause and prevention of disease.”
Malcolm Taw, MD, FACP, associate clinical professor and director of the UCLA Center for East–West Medicine in Westlake Village, Calif., said it can be helpful to think about LPR treatment in terms of the Chinese medicine concepts of “hot” and “cold” foods. “Hot” foods and drinks include alcohol, spicy foods, fried foods, garlic, coffee, red meat, chocolate, cheese, and refined sugars. “Cold,” or cooling, foods that can ease or prevent reflux symptoms include melons, green-leaf vegetables like kale and Swiss chard, bananas, kelp, and celery. “The way that we treat reflux in Chinese medicine is that we cool the patient down,” Dr. Taw said. “The Chinese medicine version of hot versus cold foods is very consistent [with] or similar to the low-acid diet.”
In a small study, 20 patients with recalcitrant LPR were put on a low-acid diet for two weeks, during which time every food with a pH of less than 5 was eliminated. Reflux symptoms were measured before and after. Researchers found that 95% of the patients had improvement, with three having no symptoms at all by the end.
Dr. Taw also emphasized the importance of warming up the digestive tract before eating, by consuming something such as a tea or soup, and of eating in a relaxed environment. “If you’re rushing through your meal or you’re doing business over your meals, your body is in a low-grade fight or flight mode, so it has some of this adrenaline in the system, and your body’s not relaxed to have optimal digestion and assimilation of your nutrients.”
Evidence shows that acupuncture can also help, he said. In a study of 30 patients with refractory heartburn randomized either to standard PPI dosing plus acupuncture or double PPI dosing, those in the acupuncture group had significant decreases in daytime heartburn, nighttime heartburn, and acid regurgitation, while those in the double-dosing group did not (Aliment Pharmacol Ther. 2007;26:1333–1344).
Thomas Collins is a freelance medical writer based in Florida.