LPR Diagnosis: Laryngoscopy, Stroboscopy & pH Impedance

[Dr. Ashley Agan]
With your scope exam, is stroboscopy ever-- does that ever add anything or really you just need to look down there and make sure you're not seeing anything bad?

[Dr. Inna Husain]
Yes. As a laryngologist I love my stroboscopy, so I'm like a poster child, I have it on my hoodie, that sort of thing, but the reality of this for most patients as initial stroboscopy is not realistic. Like to say that, "Oh, you need to strobe everyone." Let's be a little bit realistic here. No, primarily nasal laryngoscopy distal chip ideally, but even flexible fiber optic is fine for initial diagnosis. I add stroboscopy into my practice when there's things such as, for example, chronic cough and especially if the patient is older, so I'm really looking for that glottic insufficiency.

If the primary complaint is something like hoarseness, then, of course, I want to add s stroboscopy if they're coming to see me, but for a lot of these, for example, globus and stuff as an initial scope, I think realistically just a plain nasal laryngoscopy is good.

[Dr. Ashley Agan]
The findings that we talked about that you listed, they are, would you say pretty non-specific? Like could be caused by other things too or?

[Dr. Inna Husain]
100%, yes. That's the reason why I don't like saying that this scope proves you have LPR, because if your patient's coming in and they're like, "I've been throat clearing for two years." Well, of course, they're going to have mucus on their vocal folds. It's the chicken and the egg, like which one came first, so the act of throat clearing itself will produce mucus. The act of chronically coughing will cause pseudosulcus and irritation at the vocal fold level. A lot of these things can be the result of the symptom itself as opposed to causing the symptom.

[Dr. Ashley Agan]
Yes, that pseudosulcus, sometimes I see it in patients that don't have any [chuckles] complaint of their throat too, and I'm like, "Huh well, that's there, yes."

[Dr. Inna Husain]
Right. We see it in our elderly patients too with the idea being that it's probably somewhat compensatory for some of the [unintelligible 00:23:21] changes that are happening. If you treat every pseudosulcus with the PPI which unfortunately probably does happen in some places, you're doing an injustice to patients.

[Dr. Ashley Agan]
Let's talk about interpreting those results. You get the catheter, everything in place, and I assume it's hooked up to some sort of monitoring device, so they just clip that on their belt, or their shirt, or something?

[Dr. Inna Husain]
Yes, it's like a little messenger bag purse type of thing that they have that's continuously recording, and then patients have the ability to press buttons based on symptoms. There's a button for-- You can program it for three symptoms that they might be having, so they could press when they have a symptom. Then they can also press a button when they're starting a meal, [unintelligible 00:44:09], that sort of thing.

For about 24 hours, it's continuously recording. Patients come in the next day, the nurse is able to just remove the catheter. Just make sure it's still taped in place and that it didn't shift, and then we take the recording. There's programs that come with it, which will plot out the pH and then timestamp it for symptoms. The program is really helpful because it does all of that plotting for you, and then you can look at how many reflux events the patient have. We have some normative data from GI, which again is primarily based on distal esophageal reflux events that we do have some for the pharynx.

The tricky part about where this gets to not being a perfect test is the idea that like, what if there is no correlation but you see reflux events. For GI, for GERD, they consider that negative if there's no correlation. With ENT or laryngology, we're a little bit softer on that because we do know that there's a neurosensory network. I usually look for any sort of events. The correlation part I'm not as concerned about because if people are having LPR events, yes, an hour later they could have throat clearing. There's a little bit of a temporal delay in throat symptoms as compared to heartburn, so I'm looking really for any type of reflux events. If there's correlation, fantastic, but often, there just isn't that exact correlation.

[Dr. Ashley Agan]
Does it break it up between acidic and non-acidic events?

[Dr. Inna Husain]
It does. That's why I like the pH impedance probe because I tell patients, "Tell me about your lower esophagus and upper." They'll tell me if it's acidic or not, and then it tells me if there's any correlation, so it does provide a lot of information. Again, the alternative would be an empiric trial. It provides a lot more information than us just looking with the scope.

[Dr. Ashley Agan]
Then what do you do with that information? Once you have established that a patient is having reflux events whether acidic or non-acidic, does your treatment look similar to what your empiric treatment was going to look like, or is it different?

[Dr. Inna Husain]
Definitely. If I see a lot of abnormal amount of acid, then I know this patient should be in an acid-suppressing medication. If we see a lot of non-acid reflux, then I usually talk to them about the alginate suspension. For both of these if we're seeing a lot of reflux and it encourages patients, I'm like, "Listen, there's a lot of dysmotility or something happening here contributing to this reflux." By the time that they come for the testing, most of these patients have already tried the diet behavior. They're very strict about it. If you're still having a lot of dysmotility, then we probably need to add further testing in that way with regards to motility testing, need to get our GI colleagues involved, and I even refer some patients for reflux surgery if we see it there.