OUT OF COMMITTEE: Voice | Acid Reflux: Week In and Week Out, What We See, What We Know, and What We Are Learning
Jordan I. Teitelbaum, DO, and Lee M. Akst, MD
What We See
Acid reflux is a common condition in the general population that can present with both acute and chronic symptomology. Gastroesophageal reflux disease, GERD, is estimated to affect one out of five adults. It causes recurrent and burdensome issues that can decrease quality of life and also may lead to dangerous sequelae.1 Typical GERD symptoms include heartburn, esophageal discomfort, dyspepsia, and regurgitation. However, as otolaryngologist-head and neck surgeons, our training and experience demonstrate that reflux may also present with extraesophageal symptoms. Chronic cough, throat clearing, dysphagia, and other complaints may all be related to reflux. This concept of laryngopharyngeal reflux (LPR) was described in a Position Statement by the Academy in 2002.2 Since then, our knowledge of this prevalent disease has only deepened.
What We Know
Prevalent symptoms of LPR include excess throat phlegm, throat clearing, globus sensation, postnasal drip, and trouble with voice or swallowing.3,4 In comprehensive otolaryngology, the aforementioned list of chief complaints makes up a large portion of clinical practice. LPR and GERD have even been implicated in rhinitis, chronic sinusitis, recurrent otitis media, and eustachian tube dysfunction.4-8 With myriad manifestations that cross the breadth of our specialty, it is important for otolaryngologists to maintain an appropriate clinical awareness of the role that reflux may play in their patients’ complaints. GERD Awareness Week (November 20-26) is a good time to review these issues.
In the past two decades since the AAO-HNS Position Statement was released, many astute clinicians, surgeons, and researchers have tried to come up with strategies for accurate diagnosis of LPR. There are concerns that LPR and GERD in the ENT office may be under diagnosed or over-diagnosed, as presenting complaints are nonspecific and have many other etiologies. Though these presenting complaints are quite familiar to all of us, examination findings3 may be nonspecific and clear-cut diagnosis can be elusive.9-12
What We Don’t Know
As the most prevalent gastrointestinal disorder in the United States, the epidemiology GERD is well established.13 Likewise, the diagnosis pathway for GERD, as distinct from LPR, is straightforward. However, for reflux disease affecting the upper aerodigestive tract, pathophysiology remains less well understood.4 It is certain that refluxate that reaches the pharynx passes through the esophagus, and classic GERD symptoms may increase our confidence in a reflux etiology for extra-esophageal complaints.1,4,13,17 However, not all patients with laryngopharyngeal manifestation of reflux have classic GERD complaints. This gives rise to concerns about “silent reflux,” with possible explanations relating to degree and nature of reflux that are adequate to cause laryngopharyngeal complaints remaining beneath whatever threshold might trigger patient awareness of heartburn, acid brash, and more classic GERD complaints. In this setting, establishing that reflux is related to laryngopharyngeal complaints can be difficult.
This heterogeneity can present subtle challenges in evaluation. For one, consensus on diagnosis criteria of LPR is still unclear.16,17 Although some authors have offered state-of-the-art reviews16 and best practice statements,18 it may still be difficult to sort through the controversy of whether to treat LPR the way we treat GERD in clinical practice.
What We Can Offer
As head and neck specialists, we are inundated with patients coming to us for chronic cough, globus sensation, and throat clearing. That reflux may play a role in our patients’ complaints is a commonality that connects us regardless of subspecialty or comprehensive nature of our practices or our practice settings.
Evaluation of these patients should focus on creating a differential diagnosis based on history followed by a directed exam. For any extraesophageal complaint, this differential might include—but should not be limited only to—reflux. History for any presumed reflux patient should include asking about typical GERD symptoms, as their presence may increase pretreatment probability that reflux is driving extraesophageal complaints. Inquiring about reflux influences such as diet, stress/anxiety, and association of rhinologic and laryngologic symptoms is paramount. Likewise, red flag symptoms such as hemoptysis, lymphadenopathy, and referred otalgia also need to be elucidated. Guidelines and algorithms exist to help us and our colleagues evaluate symptoms and sort through the confounding factors in GERD/LPR diagnosis.4
In our hands, flexible fiberoptic laryngoscopy (FFL) can be beneficial in most patients with LPR complaints, and videostroboscopy may also be indicated.2,17,18 FFL can also provide useful information on the nasal cavity, paranasal sinus inflammation, and the nasopharynx. With that in mind, it is worth noting that the value of an endoscopic exam is evaluating for other conditions (rhinitis, sinusitis, vocal fold motion impairment, etc.) that might mimic reflux complaints – laryngopharyngoscopy itself should not be considered diagnostic of reflux. Many of our patients will have erythema and edema on laryngopharyngeal exam, even if they don’t have pathologic reflux; even rigorous scoring of endoscopic findings has shown that exam doesn’t correlate with symptoms, pH probe data, or response to treatment when it comes to using exam to "diagnose" reflux.
For treatment, empiric antireflux medication with proton pump inhibitors (PPI) has been part of otolaryngologic practice for decades now.2 Improvement in patient education and multifactorial disease management has also led to better discussion of dietary and lifestyle changes. Certainly, an empiric trial of PPI medication once or twice daily can be straightforward for both the otolaryngologist and the patient.17 Nonetheless, our recent endeavors into categorization and treatment of GERD and LPR suggest that PPI therapy protocols may need to evolve with our updated understanding of this condition.16
Current Directions and (Nonacidic) Food for Thought
Acid reflux disease, in the form of GERD or LPR—or perhaps concurrence of both—is prevalent. In ENT practice, this constellation of complaints is pervasive, and it requires keen evaluation and potentially multidisciplinary management.
It is likely that LPR is being over diagnosed, and that PPI therapy is being over prescribed.3,4,16,18,19 PPI safety has been questioned not only in our literature, but also in the public eye. The efficacy of PPI therapy remains poorly understood, and meta-analysis of randomized controlled trials did not show superiority of PPI over placebo for chronic laryngopharyngeal complaints such as throat clearing, throat irritation, and hoarseness.4,19,20 Conversely, it may be that nonacid LPR is underappreciated, and pepsin might mediate reflux-related tissue inflammation in the larynx, pharynx, and related structures even if acid itself is pharmacologically suppressed.16 This leads to an increasing focus on lifestyle modifications for reflux as well as use of barrier therapies such as alginates. Continued emphasis on objective testing with hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH), despite debates on diagnostic thresholds,19 may aid in clinical diagnosis and also improve our understanding of LPR overall. A reasonable goal in this era of personalized medicine is that non acid reflux be considered along with acid reflux, and treatment plans extending beyond PPI alone to also include possibilities of lifestyle changes, H2-blockers, and alginates should be advocated.4,17,19
While an empiric trial of PPI or other reflux medication may be convenient, an astute ENT must be prepared to abdicate a presumed diagnosis of GERD if an empiric trial has no effect. Likewise, while we focus on GERD awareness, we also encourage awareness of new literature that contradicts outmoded paradigms for evaluation and treatment of these disorders.
In many respects, we have entered a new era of reflux therapy. Increased patient cognizance of GERD and common medication toxicity demands thoughtful management in our field. Diagnostics such as pH probe testing, nutritional considerations, and multidisciplinary collaboration with internists, speech pathology, and GI will be very helpful toward precise patient care. Treatment algorithms have also entered a new era, with minimally invasive procedures such as transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) being studied in both GERD and LPR patients and demonstrating safety and efficacy in both populations.21-23
In treating acid reflux as ENT specialists, we must be aware of the changing data and trends in GERD and LPR diagnosis. Taking a balanced history and awareness of the broad differential can be just as essential as a comprehensive therapy plan. This presenting symptomology is a hallmark and mainstay of otolaryngology-head and neck surgery, and we must be ready to treat accordingly and yet also ready to abandon our previous algorithms and to cohesively and collectively embrace new management strategies for this provocative entity within our field.
GERD Awareness Week: November 20-26, 2022
Enthealth.org is dedicated to helping patients. The content is developed from a team of AAO-HNS members, and information is delivered via peer-reviewed articles, interactive features, and video content featuring physicians. Learn more about the site and our contributors at https://www.enthealth.org/about-us/.