BackTable / ENT / Podcast / Episode #83
with Dr. Inna Husain
In this episode of BackTable ENT, Dr. Ashley Agan interviews laryngologist Dr. Inna Husain about diagnosis, treatment, and multidisciplinary care of patients with laryngopharyngeal reflux (LPR).
BackTable, LLC (Producer). (2023, January 3). Ep. 83 – Laryngopharyngeal Reflux [Audio podcast]. Retrieved from https://www.backtable.com
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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
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
First, Dr. Husain defines LPR as acidic and/or non-acidic reflux that causes direct and indirect effects on the upper aerodigestive system. She emphasizes the importance of utilizing subclassifications of LPR and explains the difference between direct acid, direct non-acid, and indirect acid reflux. She notes that each subclassification has different treatment patterns and that overlapping diagnoses can make classification difficult. Another challenge in diagnosing LPR is the need to distinguish chronic problems from isolated episodes. If a patient’s LPR is chronic, she suspects the indirect acid LPR subclassification.
During her primary visit with a patient, she asks key questions related to the root problem or sensation a patient is experiencing, such as mucus dripping, throat clearing, or globus. She notes the frequency and severity of their episodes. She also explains that unilaterality of sensation is unlikely to be LPR, and patients correctly diagnosed with GERD commonly have LPR. After taking an initial patient history, she utilizes flexible laryngoscopy to visualize the throat and rule out other diagnoses, such as polyps or tumors. She notes that she will not be able to see reflux through laryngoscopy, but just signs of throat irritation. Additionally, because there is not one defining visual characteristic of LPR, the imaging results are always interpreted through subjective means; thus, LPR is a diagnosis of exclusion.
For patients suspected to have LPR, Dr. Husain initiates empirical medical therapy. She explains to all her patients lifestyle modifications like cessation of smoking / vaping and reduction of coffee, late night eating, carbonated water, and citric foods. Although the conventional treatment of LPR is acid suppression, she only prescribes patients with proton pump inhibitors if they have acid reflux symptoms because 50% of LPR patients don’t actually improve on the medication. Her PPI regime consists of 40 mg omeprazole in the morning and Pepcid at night for 1-2 months. If patients improve, she slowly tapers them off of the PPI to avoid rebound reflux. If the patients do not improve after 2 months, she will switch to another medication, such as alginate suspensions, a more natural alternative to PPI. Alginate suspensions create a barrier that prevents the upward movement of acid. Contraindications include concurrent use with other acid suppression medications and a history of lower GI issues.
Finally, Dr. Husain discusses the 24-hour pH impedance testing, which is the gold standard for LPR diagnosis. A catheter with a probe is inserted into the patient’s throat and sends continuous pH readings to a monitor the patient carries. Patients return after 24 hours, and she is able to find correlations between patient symptoms and acid reflux and classify the LPR subtype. If she interprets any distal esophageal issues or dysmotility issues, she involves her GI colleagues to explore endoscopic solutions. She ends the episode by explaining her treatment regimen for refractory neurosensory (indirect) reflux, which includes neuromodulators (gabapentin, amitriptyline) or a superior laryngeal nerve block.
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[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 is 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.
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