Some Laryngopharyngeal Reflux Resists PPI Treatment

A patient presents with cough, saying she feels as if there’s something stuck in her throat and sometimes her throat burns. These symptoms are consistent with laryngopharyngeal reflux (LPR) and, after taking a careful history and a detailed symptom profile, her otolaryngologist decides to put her on a proton pump inhibitor (PPI), the No. 1 medication indicated for LPR.

At a six-week follow-up, the patient’s symptoms haven’t diminished. She thought she was getting relief in the first month, but at the time of her appointment she is experiencing the same suite of irritating symptoms. What is the best course of action now?

This problem—how best to proceed with LPR patients who don’t respond to treatment—is a tricky one. The issue has been discussed, dissected and argued about by otolaryngologists. The jury is out on this issue, and there’s no good published evidence basis for creating practice guidelines.

“There have been several panels at academic meetings on this topic in the last few years,” said John Krouse, MD, PhD, chair and professor of otolaryngology-head and neck surgery at Temple University in Philadephia. “It’s a common problem: patient failures and incomplete responses.”

If there’s any consensus, it’s this: Reevaluate the diagnosis. “It’s a very challenging group of patients,” said John DelGaudio, MD, director of the Emory Sinus, Nasal, and Allergy Center and vice chair and professor of otolaryngology-head and neck surgery at Emory University in Atlanta. “If they don’t respond to proton pump inhibitors, reevaluate and be more diligent in ruling out other causes.”

The Basics of LPR

Symptoms of LPR may or may not include the sensation of a globus in the throat that won’t dislodge, postnasal drip, intermittent hoarseness, chronic sore throat and frequent throat clearing. “LPR is an extension of gastroesophageal reflux disease [GERD],” Dr. Krouse said. However, patients may have no clear GERD symptoms, such as heartburn or indigestion.

“Some degree of gastric regurgitation is normal,” said Kenneth Altman, MD, PhD, an associate professor of otolaryngology at Mount Sinai Hospital in New York City. “The problem is when it’s often, severe or it results in pathologic changes.”

It’s not clear how often LPR is diagnosed compared with the more common GERD. (See “Controversies Surrounding the Management of Patients with Reflux Disease,” below). But if it continues to follow in its big brother’s footsteps, it’s undoubtedly on the rise. Dr. Altman documented a quadrupling of GERD cases over about a decade, from 1990 to 2001 (Laryngoscope. 2005;115:1145-1153).