Most otolaryngologists would agree that a red larynx, which can be caused by many factors, is not pathognomonic of LPR.
Explore This IssueMay 2006
There’s a real difference in the patient populations seen by otolaryngologists and gastroenterologists, Dr. Ford pointed out. Gastroenterologists don’t see the patients who complain of postnasal drip, hoarseness, throat clearing, and so forth. The ones they do see are the ones that frustrated otolaryngologists send to them saying that the patient was treated with PPIs and didn’t get better so try to take care of them. In fact, the patients who don’t respond to PPIs often have other things going on.
For example, such a patient may have a really bad hiatal hernia and the dynamics of the esophagus are off and waves are going up and down and he could be getting reflux material into his larynx which is not acid. There was a nice paper last year by C.T. Sasaki and colleagues who studied refluxate in an animal model and found that alkaline material such as bile salts could irritate the larynx. In such instances, surgery such as fundoplication might be helpful.
Indeed, fundoplication is an option for patients believed to have LPR who don’t respond to PPIs or are unable to take them. Said Dr. Koufman: Some patients, for example, may wake up in the middle of the night coughing and gasping for air. For them, surgery can be life-changing.
Treatment Key for Preventing Complecations
Finally, in a recent paper in JAMA (2005; 294: 1534-1540), Dr. Ford warns of the possible danger of neglecting LPR: When a medical practitioner fails to recognize LPR, patients have prolonged symptoms and delayed healing. Inflamed laryngeal tissues are more easily damaged from intubation, have a greater risk of progressing to formation of contact ulcers and granulomas, and often evolve to symptomatic subglottic stenosis and lower airway disease. In a recent report, LPR symptoms were found to be more prevalent in patients with esophageal adenocarcinoma than were typical gastroesophageal reflux symptoms and they often represented the only sign of disease.
Laryngeal cancer is another specter hovering over LPR. Dr. Koufman said that she has reported a series of 50 patients with laryngeal cancer, 76% of whom had reflux disease. Only 22 were active smokers; 21 were past smokers with a median smoking duration of eight years, and seven were non-smokers. A few other studies have had similar findings.
Despite the progress, Dr. Koufman believes that it will be another generation before we have a complete understanding of LPR.