What you’ll learn:
Why LPR can be difficult to detect, and how it differs from traditional acid reflux
When to be concerned about LPR symptoms, and how they can impact your overall health and quality of life
How to recognize the signs and causes of LPR, and what lifestyle changes and medications can be used to manage the condition
What to expect from a diagnosis of LPR, and when to seek medical help if symptoms persist or worsen
In this episode of We Nose Noses, the hosts explore a type of acid reflux that often goes undetected: LPR, or laryngopharyngeal reflux. Unlike traditional reflux, LPR doesn’t always present with typical symptoms like heartburn or indigestion, making it difficult to diagnose.
Hosts Undavia, Reddy and Smith, who are experienced ENT doctors, are here to help explain the signs and causes of LPR, and what you can do to manage it. They’ll discuss the various ways that LPR can manifest, such as hoarseness, chronic cough, and even dental problems, and provide insights into the underlying mechanisms that cause LPR.
By the end of the episode, you’ll have a better understanding of how to recognize LPR symptoms and take steps to reduce its impact on your life. Whether you suffer from LPR or simply want to learn more about this stealthy form of acid reflux, this episode is a valuable resource for anyone interested in ENT health.
Listen to the audio version below.
But the most common symptoms that we see with silent acid reflux is some patients might have a cough, some patients might constantly clear their throat, like [inaudible 00:00:13]. Some patients might just complain of a hoarse voice. And the nice thing that helps us decide that this is acid reflux that’s silent, is the timing.
Hey guys, welcome to the We Knows Noses podcast. I’m Dr. Reddy.
I’m Dr. Smith.
And today we will be discussing a really interesting topic, Dr. Undavia’s favorite, Laryngopharyngeal Reflux, or LPR. The colloquial term is silent reflux. So we will get started with Dr. Undavia, because he loves this subject.
Well, first the real question is why do these patients even show up to the office? You would think that if they have something like acid reflux, they would just go to the GI doctor. But the truth is, most of these patients show up to the office because they don’t have any symptoms in the chest or stomach. Everything is up in the neck or in the throat, sometimes in the ears or in the nose. But the most common symptoms that we see with silent acid reflux is some patients might have a cough, some patients might constantly clear their throat, like [inaudible 00:01:42]. Some patients might just complain of a hoarse voice. And the nice thing that helps us decide that this is acid reflux that’s silent, is the timing. So a lot of these patients tend to complain of symptoms either after they eat or they complain of symptoms when they lie down, when gravity is no longer helping the acid stay in the stomach and then it comes up.
So either they’ve been lying down at night or when they wake up in the morning, it’s much worse. But those are the major symptoms. There’s also minor symptoms that you can have, believe it or not, you can have postnasal drip, you can have recurrent ear infections. There’s a whole body of literature on whether silent acid that’s left untreated can give you carcinogenic properties and can lead to cancer. But the main thing that people complain about is they feel like there’s something stuck in their throat, which is called globus. They feel like they’re clearing their throat and they have a cough. Sometimes they’re hoarse.
So yeah, so if a patient has any of those symptoms that Dr. Undavia just spelled out, difficulty swallowing, feeling like something’s stuck, postnasal drip, hoarseness, cough, it definitely warrants a workup and evaluation. If it’s been there for a couple days or so, most patients just ignore it and go on. But we see patients all the time with postnasal drip, reflux type symptoms and they don’t realize and recognize that they’re reflux type symptoms. And so patients come in and kind of what can you expect from an ENT evaluation? Well, certainly you may need both an ENT and a gastroenterologist or a GI doctor to evaluate you, but certainly from a throat symptoms standpoint, often we can make the diagnosis based off of symptoms and some findings that we see on the physical exam. So with any patient, it starts with a well detailed history and then we delve into the physical examination.
And so we may ask things like, “how much caffeine, how much alcohol, how frequently do you eat? What types of foods do you eat? Are there things that aggravate it, make it worse? Are there things that make it better?” And sometimes patients can start to figure out those just from the questions, “oh yeah, maybe there is some acid reflux component to this.” And sometimes there’s not a quite so obvious trigger or something in the questioning. And so then we rely a little bit more on the physical exam. And as Dr. Undavia said, postnasal drip is a very common symptom. And so sometimes patients may think it’s all allergy in nature and sometimes it might be allergy and reflux, and sometimes it might be both. They’re very common problems. And so on our exam, we start to look for things that may show more signs of allergy.
Are there changes within the nasal cavity? So it starts with a full exam, ears, nose, mouth. And then we often take a look with what’s called a nasopharyngoscope and we take that camera, a little tiny camera, and we’re able to take a look through the nose or through the mouth and take a look down at the back of the throat and voice box. I often do it through the nose so that way I can a good idea looking at the nasal cavity, the turbinate, it’s the nasal nasopharynx, which are like where the adenoids or your tonsils in the back of the nose live. And sometimes we can see signs of chronic allergy or sinus disease or something that might be triggering some of those. And the absence of those, we look for reflux findings and signs. And so we take a look down in the back of the nose and we look down at the voice box.
So you’re able to look all the way down to here to where the voice box and the esophagus opening starts. And that’s the lower part of the pharynx or throat. And we’re able to typically see signs of reflux. So we may see some thickening or swelling and redness at the backside of the voice box where the esophagus opening is. And so there are some hallmark signs that we often see. We may see some nodules or calluses on the voice box that can be indicative of vocal abuse with reflux. And so there’s a lot of things that we may find on your exam that may give us a pretty good detail evidence that there might be more reflux findings than allergy findings, and or both.
And then, so I’ll leave it to Dr. Reddy then to talk a little bit about other than the examination, maybe some adjunctive evaluations and some treatments that we start.
Sure. So first we focus on lifestyle modifications. So if we think that you have acid reflux, we talk about diet modification first and foremost, so that’s things like avoiding certain foods that trigger reflux. So the most common foods that cause reflux are things like spicy foods, fried and fatty foods, acidic foods like citrus, tomato chocolate, mint, alcohol, caffeinated foods such as coffees and energy drinks. Basically all the fun stuff is bad for reflux. And so you try to avoid or at least cut back on some of those things. And other things you can do to help is you can try to avoid laying down or sleeping for two hours after eating. And you can also sleep with your head of your bed slightly elevated.
Those can all help prevent some reflux. And then if the lifestyle modifications aren’t enough, or if you have severe reflux, that’s when you consider also adding some medications. And some medications include things like over-the-counter medications like Tums and PEPCID. But for the most part, the mainstay of therapy is a class of medications called proton pump inhibitors. And those include medications like omeprazole and pantoprazole that you take first thing in the morning on an empty stomach. And those typically can help. And if you try those lifestyle modifications and medications and if it’s not enough, that’s when we considered going even further. And there’s other options for those patients. Dr. Undavia, Dr. Smith, you want to talk about those at all?
Sure. The one thing I will say just for patients is that not everybody’s trigger and avoidance things are the same. And so there are certainly things that all make sense, like lemon and citrus things for sure are a big trigger. Coffee, acidic drinks. But some people’s triggers may not be that. So elimination things can sometimes help. Often we see those big lists of “no, no, no, no, no.” And those can be pretty cumbersome.
There are things out there too, like alkaline diets and alkaline waters that try to combat and try to educate yourself as to what might be a better diet as opposed to what to just avoid, too. So those things can help as well. As far as evaluations, if patients aren’t getting better with typical reflux symptoms and typical reflux medications, I do often send, and I’m sure my partners do too, to the gastroenterologist for a full evaluation just to make sure that there’s not anything else going further down that might be triggering it.
Sometimes they’re infectious things within the stomach that can cause more acid reflux production. Sometimes it’s a big hernia or a diaphragm dilation that allows more acid to spill up more easily. And so sometimes diet and medications may not be enough. And so for those patients, the GI evaluation to see maybe there’s another cause, maybe there’s something surgical that might need to be entailed or thought about in the future, too, should that patient fail normal treatment. Dr. Undavia, do you have anything to add?
Basically, I would reiterate that I like to send patients to the GI doctor. I mean, if it’s an isolated event where they have these symptoms up here, once we get them better and it doesn’t happen again, I might not have them see the GI doctor. But if it’s recurring or if it doesn’t get better right away, I do think that a GI doctor valuation is so important because they get to look from here down as opposed to us that look from here to here. And there are, like we alluded to before, there are things that silent acid reflux can do to your esophagus and to your stomach that you might not feel. And it’s a really good idea for them to take a look at the bottom of the esophagus, make sure there aren’t any serious burns going on, and then they get plugged into a gastroenterologist that they could see regularly because there are rules about how often you should see a GI doctor.
I always think the more doctors are better just so you can have everybody find… At least if they find the same thing, you feel you’re on the right path. Because LPR and silent acid reflux can be difficult to diagnose sometimes. I’ve been there so many times where you look inside the nose with the camera and you’re like, “ah, kind of looks like allergies. Kind of looks like acid reflux.” There’s signs of both. And in general, we’ve started talking about this, but when you look inside the nose, an allergic patient might look very yellow or purple and that just… And they have this thick mucus and it gives you this idea that they might be allergic.
But a patient who has acid reflux, when you’re going down into the nose and into the back of the throat, it’s more red and it’s not mucus that you see as much as it is saliva. And that saliva, it’s called instated secretions. But basically your esophagus doesn’t just [inaudible 00:11:22] do it for your food. It actively pumps food from your mouth into your stomach. And if you’re burning your esophagus, that pump that it normally does isn’t working as efficiently. And then all this saliva pools up here. So we’re looking for those things. But sometimes you see both and you can’t really be sure that what you’re doing and you have to treat them by trial and error. And so getting a GI doctorate to weigh in can be very helpful.
Sometimes you have to do combo therapy as well. So as Dr. Reddy was talking about, you can do proton pump inhibitors. Sometimes we have to do double proton pump inhibitors. Sometimes we do PEPCID plus proton pump inhibitors. Sometimes we do things to coat the stomach. Patients are so different. So one may work for one and not for another. So often it is by trial and error. But the first part, which we really, the three of us believe in, is that physical exam where we need to look and see and make sure there’s nothing else going on.
Agreed. So yeah, I think the general gist of it is that it’s a very common condition. It’s something that we see a lot. Often we might initiate therapy and may help guide who may also need to be co-managing. So whether it’s an allergist or a GI doctor or somebody else, often may need to get involved depending on what type of symptoms, where are the symptoms. But there usually is a solution and an improvement for the patients once we get you on the right track. So as far as LPR and silent reflux, I think we’ve kind of touched base on everything. If you guys have anything else to add, if not, we’ll close out today’s podcast.
Great. Well take care guys. Thanks for listening.