Some Laryngopharyngeal Reflux Resists PPI Treatment

The standard approach to diagnosing LPR is to take a good history: How long have symptoms been occurring and when do they occur? Also, most otolaryngologists will do a laryngoscopy and look at the vocal cords, said Dr. Altman. This will provide the two basic indices of a diagnosis: the reflux symptom index (RSI), which includes the severity of symptoms such as hoarseness, throat clearing and coughing; and the reflux finding score (RFS), which checks for signs such as edema of the vocal cords and subglottis, and thick mucus.

Dr. Altman reviewed clinical practice guidelines for reflux disease in an abstract published in The Laryngoscope, in which he and his co-authors noted that most contributions to the guidelines came from gastroenterologists and not otolaryngologists (2011;121:717-723). Diagnosing by symptomology and prescribing medication comprised the most common approach for uncomplicated GERD. Defining GERD versus LPR and long-term management of patients were more variable and define the basis for the controversy that continues today.

Dr. Altman said that once a diagnosis is reached, the first thing to do is educate the patient about reflux. Some people may be prone to reflux because of their anatomy and physiology, but they may also have diet and lifestyle behaviors that contribute. “In my opinion, the first line of treatment is diet and behavior modification,” he told ENTtoday. “Acidic foods are a culprit, and our highly processed foods tend to be acidic.” In addition, he counsels patients on the seven most common things prevent reflux: foods and drinks that are carbonated, spicy, fatty, minty, caffeinated or alcoholic and—last but not least—tobacco.

The standard treatment regiment involves PPIs such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix) and esomeprazole (Nexium). Otolaryngologists who prescribe PPIs will also advise patients about dietary and behavioral changes that can help.

Positive patient response to PPI treatment reinforces the idea that LPR was the problem, said Dr. Altman. Conversely, when they don’t respond, physicians should go back and re-assess the diagnosis.

Treating the Nonresponsive Patient

Patients who don’t respond to initial PPI treatment may warrant further testing, as with a pH or impedance probe to measure the number of reflux episodes over a day or two, said Dr. Altman. “Otherwise, you’re wasting everyone’s time and delaying a diagnosis. Everyone talks about tests and the costs of health care. But what about the costs of delayed diagnosis—or treating when there’s no disease?”