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Laryngopharyngeal Reflux (LPR): Symptoms, Subtypes & Patient Presentation

Author Taylor Spurgeon-Hess covers Laryngopharyngeal Reflux (LPR): Symptoms, Subtypes & Patient Presentation on BackTable ENT

Taylor Spurgeon-Hess • Sep 19, 2023 • 98 hits

Laryngopharyngeal reflux (LPR), commonly referred to as silent reflux, presents an intricate interplay of symptoms, diagnostic challenges, and an evolving understanding of its subtypes. As clinicians encounter patients exhibiting unique throat-related manifestations, distinguishing LPR from conditions like traditional GERD becomes pivotal. Moreover, the path to a precise LPR diagnosis is fraught with obstacles, from subjective laryngoscopic findings to the complexities of identifying direct and indirect LPR subtypes. This exploration delves into these diagnostic intricacies while emphasizing the importance of understanding LPR's diverse manifestations.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Laryngopharyngeal reflux, originally defined as acid reflux's impact on the larynx, now includes effects on the broader upper aero-digestive tract.

• LPR symptoms encompass sore throat, globus, voice changes, mucus, throat clearing, postnasal drip, and chronic cough.

• Direct acidic LPR entails acid directly irritating the throat tissues. Direct non-acidic LPR involves digestive enzymes, especially pepsin, causing direct harm to throat tissues. Indirect LPR is characterized by neurally mediated symptoms originating in the distal esophagus but felt in the throat.

• Distinguishing between episodic and chronic LPR is essential for effective patient management. Chronic LPR often manifests as persistent neurosensory symptoms like continuous throat clearing or feeling of mucus.

• Laryngopharyngeal reflux is distinct from traditional gastroesophageal reflux disease (GERD), though they may share some overlapping symptoms.

• Findings from a laryngoscopic examination, such as post-cricoid edema or an intra-arytenoid mucosal bar, are often subjective and can vary from one clinician to another.

Laryngopharyngeal Reflux (LPR): Symptoms, Subtypes & Patient Presentation

Table of Contents

(1) LPR Symptoms: Direct vs Indirect Subtypes

(2) LPR Patient Presentation & Diagnostic Challenges

LPR Symptoms: Direct vs Indirect Subtypes

Laryngopharyngeal reflux, commonly known as silent reflux, has evolved significantly in its medical definition over recent years. Once simply identified as the effect of acid reflux on the larynx, it is now recognized as a multifaceted condition, encompassing both acidic and non-acidic reflux, with both direct and indirect implications on the upper aero-digestive tract. Non-acidic agents like pepsin have been identified as instrumental in LPR, causing direct harm to throat tissues. On the other hand, indirect LPR, believed to be neurally mediated, represents symptoms that stem from the distal esophagus but manifest in the throat. This intricate landscape underscores the pressing need to categorize LPR into distinct subtypes, ensuring more precise LPR diagnosis and tailored treatment for chronic sufferers of LPR symptoms.

[Dr. Ashley Agan]
Let's get into LPR, Laryngopharyngeal reflux, silent reflux, there's many names. The more I think about LPR, the more I feel like I have no idea what I'm doing with it. If I'm treating it right, if I'm like, what's the latest treatment algorithms and let's just talk about like what is it and how do these patients present?

[Dr. Inna Husain]
Yes. As ENTs, I feel like we're all very familiar with the term LPR and silent reflux and how it can definitely cause a lot of throat symptoms. The way I describe it to patients is I essentially tell them LPR symptoms are basically a bunch of symptoms that have to do with your throat. Things like sore throat, globus, voice changes, mucus, throat clearing that we think are caused by reflux so we give them the term LPR.

We know it can also contribute to ear issues as well as things like postnasal drip and chronic cough. It's interesting because LPR when it was first coined in the 1990s and then in early 2000, a formal definition was given by the academy. It really was just focused on issues of the larynx related to the effect of acid reflux, and that's kind of initially what the diagnosis was. We know now that it is so much more than that, but unfortunately, that understanding hasn't really transcended into the general population of physicians or even ENTs.

The most recent definition that's out there is actually from 2019, and it basically is a much more complex definition. It's the effect of both acidic and non-acidic reflux that's both direct and indirect on basically the entire upper aero-digestive tract. Much more complex definition of what LPR really is. I think that problem with that is because it is such a complex definition and there are so many subtypes of LPR that we don't actually talk of it in that way. That's why the [unintelligible 00:07:32] plan. I really think LPR should be defined into subsections, similar to what our rhinologists have done for chronic rhinosinusitis. I think we as laryngologists definitely need to do that for LPR as well.

[Dr. Ashley Agan]
Wow, okay. There's a lot to unpack there. If we're thinking about the definition, so we have direct and indirect meaning that some sort of refluxes directly coming up and irritating the tissues of the larynx versus indirectly through some other pathway. Then we have acid and non-acid. Break those down for me. What would be the different categories?

[Dr. Inna Husain]
Sure. The easiest category would be direct acid.

[Dr. Ashley Agan]
Right. That's, I think what everybody thinks about, that's the traditional--

[Dr. Inna Husain]
Yes.

[Dr. Ashley Agan]
Okay, that's what's happening. Okay.

[Dr. Inna Husain]
The very traditional, right? Acid is coming up, it's touching my throat tissues and it's causing me problems. Very, very easy to understand that. The second would be the direct non-acid. This is the idea that digestive enzymes actually are not only acidic, they're non-acidic as well. The big player, and this is pepsin, so we talk about pepsin a lot. Pepsin is actually coming up all the way up to the throat and causing tissue damage. That's direct non-acid.
Then we have the indirect category. This is the idea that their reflux, which simply means movement can happen in the distal esophagus, and what happens distally is sensed by the throat. We think that this is more of a neural mediated type of symptomology that occurs, and this has been well documented in the GI literature. You can dilate a balloon in the lower esophagus and patients will grab their throat because that's where they feel the tightness. They've placed catheters and they've injected extra acid in the lower esophagus, and patients feel the burning in their throat. We know that there is a neural mediated indirect form of the most challenging one to treat.

[Dr. Ashley Agan]
Indirect is like basically acid and non-acid. Those are kind of together.

[Dr. Inna Husain]
Correct.

[Dr. Ashley Agan]
Okay, that's really helpful. In thinking of these, do they happen individually or overlapping? Is it like, "Okay, this person has direct acid, so I'm going to treat them this way and this person has indirect, so I'm going to treat them this way? Or is it all of these things are overlapping and potentially happening at once?

[Dr. Inna Husain]
Yes, I would say definitely can be overlapping and happening at once, and that's why it can be quite challenging. Usually, when I really get into this with patients, usually on the second or the third visit, we really try to break it down into when and where the problem is and what is the problem we're trying to address. Because if you think about it, all of us can have direct acid LPR. We've all felt it. That can definitely happen. Is that necessarily a problem or is that an isolated episode? I think that's one of the big distinctions we have to help patients make. By the time they come to see us, usually it is a problem because these symptoms are happening more than just once in a while and occasionally.

Once we lose that really temporal relationship and it becomes more of a chronicity issue, that's when I think we start to see more and more of the indirect LPR because now it's starting to become neurosensory and that's when it really becomes chronic. You've seen these patients where it's like all day they're throat clearing or all day they feel mucus. Well, those aren't all day of having episodes because that really doesn't make sense for most of the patients. That's where you've really developed neurosensory or indirect form of LPR.

Listen to the Full Podcast

Laryngopharyngeal Reflux with Dr. Inna Husain on the BackTable ENT Podcast)
Ep 83 Laryngopharyngeal Reflux with Dr. Inna Husain
00:00 / 01:04

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LPR Patient Presentation & Diagnostic Challenges

Laryngopharyngeal reflux is a condition marked by unique challenges in diagnosis and symptom variability. While often mistaken for traditional gastroesophageal reflux disease (GERD), LPR presents with a range of throat symptoms that do not always align with the expected manifestations of reflux. Key patient complaints include throat clearing, experiencing a sensation of mucus dripping, and the presence of a lump-like sensation, also known as globus sensation. When assessing a patient, clinicians should attempt to not only understand the patient's symptoms but also to distinguish between what is perceived sensations versus what is genuinely felt. Although a laryngoscopic exam can reveal signs of laryngeal irritation, these findings are often subjective, necessitating a careful evaluation to rule out other potential causes. The 24-hour pH impedance test stands out as the most reliable LPR diagnostic tool, though it's not universally embraced due to its invasiveness.

[Dr. Ashley Agan]
When you see these patients in your clinic and you are getting that initial history, are there some key questions that you're always asking or are there key things that patients talk about or bring up that help you think like, oh yes, this definitely sounds like they're having some indirect reflux, or is it just, I know we all have that typical, I've got the mucus, I've got the postnasal drainage. That's pretty common. Then we're going like, oh, like, what are we going to see on scope? Is there anything, particular questions that we need to be asking that are important in helping focus things?

[Dr. Inna Husain]
Yes. I will tell you that a lot of this is, I am somewhat privileged in terms of being this subspecialist who people are coming specifically to talk about LPR. I do have a little bit of a privilege here in that I can sit down and really hone in on just this one specific thing that they're having as opposed to having to see multiple different types of problems that are coming into my clinic. When I talk to patients, usually, they've already been referred in, for example, by another ENT or perhaps even primary, a primary physician who's somewhat familiar with this idea of reflux.

They've probably tried a few things. When they come into me, we take a step back and I say, "Okay, I need to hear what the problem is." Somebody else called it globus, somebody else is calling it throat clearing. Let's start fresh. What is it that you're actually feeling? Are you coughing or is it throat-clearing? Is it that you're feeling mucus dripping? Or are you just throat-clearing so you think it's mucus? That's the very first step of all of this is like, what is the actual thing you're feeling? Because I've had multiple times where it's written that they're coming in for globus and I don't know about you, but when I think globus, I immediately think like a lump in the throat, like a tightness. They're like, "No, no, no, there's no lump. I'm just throat-clearing." The globus actually was a sensation of mucus, which in my mind triggers a different pathway of what I'm thinking about. That's what the very first thing I say is like, what are you actually feeling?

Let's not define it. Let's just say what we're feeling. Then once we get the feeling, then that breaks it down into what type of questions I'd like to note. For example, if it's a globus type of thing, I really want to know, is it all the time? Does it come and go? Does it wake you from sleep? Those type of questions do the same thing with the mucus sensation. I really want to make sure that I don't think it's coming from a nasal source. I definitely ask my general nasal type of sweat symptoms. Then it really becomes a time thing too. Are you noticing more mucus and phlegm after you're eating and drinking after you've been outside first thing in the morning? When is it happening? If we can pull out some of those characteristics that starts help building my differential. Then to be honest, sometimes people are just like all the time. That's all they can tell you, there are no triggers, it's just all the time. That makes me very suspicious for a neurosensory component because what could possibly be happening all the time?

[Dr. Ashley Agan]
Yes, it's like that word congestion. I just have congestion and it just can mean so many different things. Sometimes it's--

[Dr. Inna Husain]
Yes, that's a great example.

[Dr. Ashley Agan]
Sometimes it's like stuffy ears. Sometimes it's like a productive cough.

[Dr. Inna Husain]
No, no. 100% agree. What is congestion?

[Dr. Ashley Agan]
What exactly are you feeling? With LPR, do you find that for one patient it can be mucus, and then for another patient it can be throat clearing, it can be different predominant symptoms even though it's the same underlying pathophysiology?

[Dr. Inna Husain]
100%. It adds to the complexity of some of this because it would be great if you had to have all five symptoms together and then it'd be like, "Yes, that's LPR." Unfortunately, it's not. Now I will say that there are some symptoms that I just do not think are LPR. Not every symptom you have in your throat is LPR. You can have primary [unintelligible 00:15:06] with reflux and that can cause weird feelings in the throat as well. Unilaterally, I take seriously. If patients come in and they're like, "There is this feeling in the left side of my throat only." That is unlikely to be LPR, that just doesn't make any sense and I see that LPR diagnosis all the time, but that's probably a primary laryngeal hypersensitivity and that's a whole different topic. The unilateral reality usually makes me very suspicious that it's not a reflux problem.

[Dr. Ashley Agan]
That's helpful. For patients who have GERD, so gastroesophageal reflux disease, which is so common, you look at the patient's medication list and almost everyone is on a PPI these days. What is the interplay of that? If you have GERD, are you more likely to have LPR? Can you have it in the absence of that? How do those interplay?

[Dr. Inna Husain]
Definitely, a lot of times obviously we refer back to the literature in terms of what does the literature tell us. The problem is that our definition of LPR has evolved so much over time and our diagnostic criteria is pretty poor currently. To really get a true incidence is difficult. I will tell you that from what we know in the literature if patients have true GERD, they're definitely more likely to have LPR-type of symptoms, which makes sense because they're definitely having that volume reflux or that acid reflux. With LPR, it's a little bit more complex. We think that very few people probably are having true GERD symptoms. I think we all see that clinically where patients will say, "I don't have reflux, I don't have acid reflux." And I believe them, they're not feeling heartburn. The tricky thing is, you can still have reflux and not feel the heartburn. That's why we like to call it silent reflux, which to be honest isn't really true either because it's not silent. You're clearly having symptoms, you just didn't know that those were symptoms of reflux. Silent reflux is a little bit, I use that term all the time myself, but that's not really true either. It's not silent, that's why you're here.

[Dr. Ashley Agan]
Yes, it's so common to have patients say, "No, I don't have reflux. No, it's not that." Let's get into diagnostic criteria. How do we say for sure, okay, your symptoms are related to LPR because of boom, boom, boom, these things. What are you looking for when you start to move on to your physical exam, your scope exam?

[Dr. Inna Husain]
For any throat complaint, I always offer flexible nasal laryngoscopy no matter what the throat symptoms. That's why you're here to see me and I need to do that physical exam. I think it's really important to understand though, when I'm doing my scope, I'm not doing it to rule in reflux, I'm doing it to rule out other things. I'm doing a physical exam because I don't want to assume that there's some reflux there and you had insufficiency or a polyp or something contributing. Doing it to rule out things. Now classically when we think about LPR findings, we think of certain things. We definitely all think of that post-cricoid edema or erythema, the classic intra-retinoid bar of mucosal hypertrophy. We think of mucus at the level of the vocal folds. The vocal folds themselves are producing mucus and then we think of the pseudo sulcus. The pseudo sulcus is that thickening where it looks like chronic edema type of picture on the undersurface of the vocal folds.

Lingual tonsil irritation hypertrophy has been associated as well with LPR. The challenge with all of these are a lot of these findings are subjective. Is my intra-retinoid bar, what you would call a bar? What is post-cricoid edema? What if someone's just born with that size of post-cricoid mucosa? That's definitely very challenging. Now, a lot of my colleagues, a hot topic in laryngology these days is the artificial intelligence world. Can we upload these images onto a program that could then give us a diagnosis? Sure, that would be fantastic if that gets developed. Currently, it's incredibly subjective what we see. What I always tell patients because this is a little bit of a pet peeve of mine, is that they'll say, "Well, I was scoped and they saw reflux." No, you can't see reflux because it's happening in your esophagus. What they saw were signs that looked like your larynx was irritated. Again, that's not a direct definition of LPR because lots of things can irritate. The reason we scope is to make sure we're not missing something.

I've had cough patients where we found a tumor causing their cough or dysphagia and there's a tumor. The reason we scope is to make sure we're not missing anything else. Then we look for signs of really, really inflammation. Most of these patients, when we scope them, there's not really anything striking. It's all very subtle changes, and how much of that is somebody's baseline. Well, we don't scope everyone all the time, so it's really challenging to use your scope to make an actual diagnosis. Coming back to your question about what diagnostic testing or tools are available to us, we're somewhat limited right now. I do consider the gold standard for LPR diagnosis kind of the 24-hour pH impedance test. That's probably the best diagnostic tool we currently have. This is also incredibly limited because it is not necessarily an easy test. It's not offered in a lot of ENT practices. It's uncomfortable for patients. Part of what I do when I see patients again, a lot of them have already seen an ENT previously, but what we talk about is the test. We talk about it being the gold standard for diagnosis. Then we say, "Well, if you're not ready, and I can understand that for these symptoms, then we can talk about perhaps empirically treating you, but we have to be very clear that it's an empiric treatment." So, I cannot say that you actually have LPR if we're empirically treating you, but again, a lot of these are quality-of-life symptoms. We've ruled out big bad things. We have the flexibility to work through some of this.

Podcast Contributors

Dr. Inna Husain discusses Laryngopharyngeal Reflux on the BackTable 83 Podcast

Dr. Inna Husain

Dr. Inna Husain is the medical director of laryngology with the CCNI Network and Community Hospital in Munster, Indiana.

Dr. Ashley Agan discusses Laryngopharyngeal Reflux on the BackTable 83 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, January 3). Ep. 83 – Laryngopharyngeal Reflux [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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