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BackTable / ENT / Podcast / Transcript #83

Podcast Transcript: Laryngopharyngeal Reflux

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). You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Laryngopharyngeal Reflux (LPR): Definition & Causes

(2) Presentation & Diagnosis of Laryngopharyngeal Reflux

(3) The Diagnostic Role of Laryngoscopy & Stroboscopy

(4) Managing LPR: Medical Treatments & Lifestyle Adjustments

(5) LPR Treatment: Proton Pump Inhibitors & Tapering Strategies

(6) LPR Treatment: Alginate Therapies

(7) Utilizing the pH Impedance Probe

(8) Interpreting the pH Impedance Probe Results

(9) A Look at Endoscopic Procedures & Neurosensory Reflux

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Laryngopharyngeal Reflux with Dr. Inna Husain on the BackTable ENT Podcast)
Ep 83 Laryngopharyngeal Reflux with Dr. Inna Husain
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[Dr. Ashley Agan]
Hi, everybody, welcome to the Back Table, ENT podcast. We're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by.

Now, a quick word from our sponsor. Cook Medical's Otolaryngology Head and Neck Surgery Clinical Specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs. Areas of focus include head and neck, ontology, and laryngology with products ranging from a full suite of interventional silent endoscopy products and the Doppler blood flow monitoring system to the Biodesign otologic repair graft, and the Hercules 100 transnasal esophageal balloon. For more information, visit cookmedical.com/otolaryngology. Now, back to the show.

[Dr. Ashley Agan]
I'll be your host today. I'm Ashley Agan, general ENT in Dallas, Texas. I've got a great guest today. We've got Inna Husain. She is a board-certified otolaryngologist who completed her training from Northwestern and then went on to do a fellowship in Laryngology from Mass Eye and Ear Infirmary, Harvard Teaching Hospital. She spent seven years as the section head of Laryngology and associate professor at Rush University in Chicago, and now will be transitioning to Northwest Indiana to spearhead her regional voice airway and swallowing program.

She's been actively involved with education as the associate Residency program director at Rush, as well as an active member of the AOHNS Laryngology and Bronco-esophagalogy Committee. She's also active on social media as the #throatdoc, and she uses her platform to educate and advocate for patients. Her clinical and research interests include idiopathic subglottic stenosis and LPR, Laryngopharyngeal Reflux, which is what we're going to get into today. Welcome to the show.

[Dr. Inna Husain]
Thanks so much, Ashley.

[Dr. Ashley Agan]
Before we get into it, maybe just tell us a little bit about you. Where you came from how you became a laryngologist, just a little bit of background to set the stage.

[Dr. Inna Husain]
Sure. I would love to. Actually, I was introduced to the field of otolaryngology actually as a child. My mom's actually an otolaryngologist. I'm second generation, grew up very familiar with tonsils and ear tubes and all that stuff. I ended up going to medical school because I thought I wanted to become an oncologist and treat patients with cancer, but once you start in medical school and start exploring things, you find different areas of interest and I found that it was really drawn to the head and neck anatomy. I'm sure there was a certain component of familiarity associated with that and comfort. I was really fascinated with how intricate everything was so I ended up going into ENT.

Then laryngology, I actually didn't really know really much about it at all until I did a pediatrics rotation. We spent a lot of time, it was actually here in Chicago and we did a lot of pediatric airway cases and I just loved it. I mean, I was like, "This is, I think, what I'm supposed to do," and my heart just wasn't in treating sick kids and I didn't think I would be able to be strong enough to do that. I remember asking my mentors, "How do I do this but with adults? Is that a thing?" They're like, "Yes, it is a thing. It's called laryngology." I was like, "Wow, okay." The first time I think that I really got immersed in laryngology as a field was actually on the interview trail. When I went around and interviewed for fellowships, and I'm so glad I did because I absolutely love it. I think it's a perfect fit for me. I really, really enjoy the topics regarding voice, airway, and swallow. I love the in-office procedures that we do. I'm a laryngologist a 100%. That's what I do now.

[Dr. Ashley Agan]
That's awesome. Did you find that you were maybe trying to not be an otolaryngologist because your mom was one? Was there a feel like, "Oh, I'm going to make my own way."

[Dr. Inna Husain]
Yes. You can always want to do your own saying thing. I remember I studied abroad and I was actually in South Africa at an anthropology type of program because I thought I wanted to maybe go into public health at the time. You try different things, I think. I don't think I actively was like, "Oh, I'm definitely not going to be an ENT, but it's so funny how what you're exposed to really gets embedded into who you are and your outlook in life and I think that definitely played a role.

[Dr. Ashley Agan]
Were you at UT Southwestern for medical school? Did I read that?

[Dr. Inna Husain]
Yes, I was.

[Dr. Ashley Agan]
We got that Dallas connection then.

[Dr. Inna Husain]
Yes. No, for sure.

(1) Laryngopharyngeal Reflux (LPR): Definition & Causes

[Dr. Ashley Agan]
Awesome. Well, 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 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.

[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.

(2) Presentation & Diagnosis of Laryngopharyngeal Reflux

[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 diagnosis LPR 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 [unintelligible 00:17:55] 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 [unintelligible 00:19:45] 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 diagnosis of LPR 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.

(3) The Diagnostic Role of Laryngoscopy & Stroboscopy

[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.

(4) Managing LPR: Medical Treatments & Lifestyle Adjustments

[Dr. Ashley Agan]
Yes. Getting into empiric medical therapy, when I was in residency, it was PPI. The main thing would be okay, the good thing is your scope exam is pretty normal. We're not seeing anything that looks like cancer. This is probably LPR, because that's the waste basket diagnosis, so we're going to try PPI, you need to make sure you take it on an empty stomach at the beginning of the day. Here's some dietary modifications, yada yada yada. What's the latest paradigm? What are you doing for patients if they decide they want to hold off on that pH probe?

[Dr. Inna Husain]
Definitely, we talk about the effects of lifestyle on the throat. Lifestyle meaning what you're eating, drinking, when you're eating and drinking, and then smoking. Smoking, vaping, marijuana, all of those things. Symptoms are generally describing symptoms of laryngeal irritation. What irritates our larynx? Are there ways in your own personal lifestyle that you can make some of those adjustments? Coffee is usually a big one. Late night eating for a while. Especially in the summer, carbonated water is a huge issue, especially with the lovely flavors that exist and stuff.

That usually we talk about where in your own personal diet you can maybe make a few adjustments because everybody's triggers can be a little bit different. The decision to add on an antacid, again, I support it when it's needed. These are great medications. These have saved lives and improved the quality of life for many people. It's just the discussion should be why am I giving you an antacid or why am I recommending it? Definitely, if patients describe traditional GERD symptoms, like yes, I have heartburn a lot, feeling a lot of burning, that sort of thing. Then I say, "Yes, we should add on an antacid." I talk to patients about the idea that 50% of patients with LPR don't improve with an antacid or PPI. Again, the problem with part of this is how was the LPR initially diagnosed, but I'm very upfront with patients that, "Hey, there are these medications called proton pump inhibitors. I can't tell you that they will do anything for you, but it's definitely an option. Once we talk about the potential risk factors of taking them." For short-term course treatments, most patients are open to giving it a try.

If they have any acid reflex symptoms, I definitely recommend it. If they don't have acid reflux symptoms, then I offer it, say we can try it, or your alternative would be something known as an alginate suspension which tries to address more of the mechanical reflux component of it. Everybody gets the recommendations for the diet behavior, smoking, vaping, all of that stuff.

[Dr. Ashley Agan]
Yes. For the lifestyle modifications, when you talk to people about taking away coffee, sometimes I get that look like don't take away my coffee. Is it completely zero coffee or no caffeine at all, or can it be like, okay let's just limit it to one cup in the morning, or is everybody different?

[Dr. Inna Husain]
What I say with that is, when I've scoped you and I've ruled out any big bad things we have a really heart-to-heart conversation here about this is quality of life which means the ball is in your court. Raise your hand if you've ever had LPR symptoms, and I raise my hand like I get LPR all the time, and that's why I feel very comfortable talking to patients about this in a realistic manner. If you enjoy something and it brings you joy whether that's your morning coffee, if that's Friday night barbecue whatever it is, put it into context of what you're feeling. You clearly came to see me, because something was bothering you. I'm trying to provide you reassurance, help be a guide here for your journey, but this is all quality of life.

We have our worrisome characteristics when we talk about reflux which our GI colleagues are great at handling. We've scoped the larynx, we've taken a look at it. This is all quality of life now, so if you want to give yourself the best chance of not having these symptoms, then yes, that coffee has to go, but I also understand that quality of life comes in many different forms, and so if that morning cup of coffee, reading The New York Times is what gets you through your day, it's okay. We're not trying to take away everything here. We're just trying to guide you.

[Dr. Ashley Agan]
Just kind of equip them with that information that like, "Oh, if you feel a little bit more phlegm after your coffee the morning, just be like, 'It was worth it.'" [laughs] Or it wasn't.

[Dr. Inna Husain]
Exactly.

[Dr. Ashley Agan]
When you think about the lifestyle modifications, the biggest offenders from a diet standpoint, would it be the same things we think about as we do things that cause heartburn; coffee, acidic beverages, tomato-based, think of Italian food like pizzas and stuff like that.

[Dr. Inna Husain]
Definitely. I mean, it's definitely the acidity in the food. So citrus is a big one, cooked tomatoes. I try to explain to patients it still irritates your throat on the way down. That's why you still have to do that even if you're doing something like an acid suppression trial because the PPI doesn't work on the way down. It only helps once it hits the stomach, so that all has to go hand in hand.

[Dr. Ashley Agan]
You mentioned the late-night eating, is there a particular number that you give patients to shoot for as far as I want you to stop eating two hours before you lay down or is there a guideline around that?

[Dr. Inna Husain]
Yes, I generally tell them about two to three hours. Now, this gets more complex with some of our more medically complex patients or diabetics or elderly who probably have a little bit more slowing in the GI track, but generally the initial [unintelligible 00:29:15] is two to three hours.

[Dr. Ashley Agan]
As far as the PPI therapies, I will frequently have patients ask me about the safety of being on that for long term. I think short trials are helpful because if it does help, it allows us to say, okay, that is what's going on. Then if it does help, does that mean we're going to continue that therapy indefinitely, and is that safe?

(5) LPR Treatment: Proton Pump Inhibitors & Tapering Strategies

[Dr. Inna Husain]
Yes. Big concern over acid suppression over the last couple of years and it's made its way into popular culture and media and stuff as well. Very honest with patients, I'm like, "Listen, proton pump inhibitors are awesome drugs for what they do." They really suppress acid and there's a whole population of patients that benefit from this. When we're doing something empirically trying, there's going to be the potential for some side effect, all drugs, every drug out there will cause some potential side effect. My initial trial is usually one to two months and the reason I say one to two months is it really depends on the severity of the symptoms patients are having, so if they're really severe, I want to see them in a month as opposed to more general things and I space it out to about two months.

I tell patients that we would expect something to be different by that one to two-month mark. Now everything is probably not going to be gone, but you would expect to see some result. If there is no result, then I do not think you need acid suppression. That's a fair trial. If there is some response, then we really talk about, am I concerned about you being on this longer or can we push it a little bit?

That's really based on underlying medical conditions and that sort of thing. When we talk about the side effects of proton pump inhibitors, we're really talking about the side effects of acid suppression and we know that our bodies need acid. Acid is really good. It just needs to stay where it needs to stay, so as long as it stays where it's in the stomach, it helps with digestion, absorption of calcium, magnesium B12, that's all fantastic. Now, the tricky part of all this is what does long-term mean? When is it long-term? Is that like a year? Is that two years? We mentioned the medical records and having patients on proton pump inhibitors, people don't even know they're like 10 years, 15 years.

That's really a problem because 10 to 15 years of chronic suppression, you can't get those patients even off of PPIs at that point. When I talk to patients about long-term, again, I'm very upfront being like the literature says that there's potential for these side effects, but it does not tell us what long-term means. I would say for you, we would talk about doing this course of treatment or this type of follow-up with the idea being that we should try to get people off of these medications almost 100% of the time.

[Dr. Ashley Agan]
At what point are we talking like, months or years, or when do you say like, "Okay, we need to get you off of this."

[Dr. Inna Husain]
Usually what I do is when at that two-month follow-up with patients, we talk about it. So we actually talk about should we try tapering you off? Because often when I first start and I'm doing an empiric trial I'll put them on a high dose because I'm like, "If we're going to do this, let's do this." Let's go 100% into this acid suppression for a short period to really see if there's any effect. At that two-month mark, I definitely want to start bringing you down. When I mean high dose, I mean like 40 milligrams. Usually, I do Omeprazole. I've transitioned away from the BID twice a day and instead doing a high dose of Pepcid at night to get that dual coverage, so definitely at the first follow up we talk about coming down on the dose now.

We start tapering right off the bat and then we talk about-- we can do this slowly over a few months if you really, a lot of patients come to me and they're like, "I want to get off of the medication now." Then we go a little faster with the idea being that you may need to restart it again and then we would bring you off again. When we talk about chronic disease or illness, you talk a lot about it's unlikely to be a one time and then you'll never feel it again, but if you do notice again, we can restart it.

[Dr. Ashley Agan]
What is your dosage for your Pepcid?

[Dr. Inna Husain]
I do 40 as well. 40 for the initial trial. I'm like, "If we're going to do it, let's make sure it's not, the dose is too low." I see lots of patients being put on things like 20 milligrams that's too low, that's fine for heartburn, but if we're trying to talk about extraesophageal symptoms and we want to just do an empiric trial for short term, let's put you on a higher dose and then bring me down.

[Dr. Ashley Agan]
40 omeprazole in the morning, 40 Pepcid in the evening for one to two months. Does it matter as far as taking the omeprazole on an empty stomach? Is that important?

[Dr. Inna Husain]
Yes. You want to definitely take it empty stomach. I usually tell patients about 45 minutes before they eat. Usually, breakfast and ideally the breakfast would have something like protein in it to help activate the pumps that the PPI is then turning off. Again, if we're going to take it, we want to do a decent dose and we want to take it properly to give the drug the best chance of helping. Pepcid works best at night, actually, so after meals and there are some studies that show that it actually has some anti-dysmotility properties, a mild effect on that as well, so I usually do the Pepcid at night.

[Dr. Ashley Agan]
Got you. For patients wanting to get off these medications or let's say you've done your trial and it's time to come off. Correct me if I'm wrong, but it's important to taper because if you decided one day, I'm not going to take any of these medications anymore, you didn't get a rebound hypersecretion of acid. Is that still correct?

[Dr. Inna Husain]
Yes, that's correct. The longer that you've been on it, the more prominent that effect will be and that's why patients will say, "I tried to stop it but I need it because I got heartburn." I'm like, "Well, I don't really know that that's true, but you definitely felt heartburn because of the rebound." I usually tell patients you might have up to five days of rebound heartburn, so to help prevent that rebound heartburn, which can be very uncomfortable, let's taper you down. We generally do half, so we'll go from 40 to 20 and then I'll do 20 and every other day maybe add an extra Pepcid if they need it, customize that part for patients, give them some options. We definitely want to taper so that you don't get rebound heartburn symptoms.

[Dr. Ashley Agan]
If during the taper, if they start to experience their laryngeal symptoms, again, whether it be the mucus or the throat clearing or whatever at some point you say like, "Okay, we're going to hold this dose for a little while and then maybe again, try to taper down a little bit later." How does that work?

[Dr. Inna Husain]
Exactly. That's how we do it. Again, as your tapering symptoms start to come back, I talk to them about your options are to either go back to the dose that was taking care of your symptoms with the understanding that we're doing this with acid suppression or see how you feel. If they're back but they're not that bothersome and you feel comfortable, then let's continue the tapering, so definitely customize it at that point.

(6) LPR Treatment: Alginate Therapies

[Dr. Ashley Agan]
With the alginate therapies, I think I was introduced to the alginate maybe a few years ago, which I really like. I've noticed more and more that patients are having more of a negative feel about being on PPIs and with the alginate therapies it's meaning like Gaviscon or [unintelligible 00:36:37] and there may be others, but it's a different type of medication, different mechanism of action that I think people are a little bit more open to. Can we switch gears and talk about those and how they work?

[Dr. Inna Husain]
Yes. Natural is the way most people trend towards now, natural is considered better. So the alginate suspensions offer a good option for wanting to take something more than not drinking coffee but trying to lean towards the more natural aspects of it. I think it also makes sense to patients when you talk about how an alginate suspension works because again, I'm saying reflux is contributing to your symptoms. I didn't say acid is contributing to your symptoms. I said reflux.

With these alginate suspensions, they use the mechanism of normal acid production to be activated. Your normal acid is in your stomach, you take an alginate suspension, it hits that normal acid that's meant to be there and creates a raft or a barrier to help reduce the amount of movement or reflux that's happening. Again, I'm not suppressing your acid for digestion and all of that but we're trying to limit the amount of movement that's happening to hopefully help your throat symptoms.

[Dr. Ashley Agan]
How do you dose that? What do you recommend for patients? Just taking it after they eat or in the evenings or?

[Dr. Inna Husain]
Usually after meals because the acid production gets revved up during mealtime and that's what we're really trying to limit the movement of. So usually after meals, sometimes they'll throw in a bedtime, especially if they have a lot of morning symptoms like the morning mucus, morning throat clearing, or if they're waking up at night because of symptoms.

[Dr. Ashley Agan]
Are there any contraindications or interactions that we need to be aware of or careful with when using those medications?

[Dr. Inna Husain]
Yes, generally, I don't use them with other forms of acid suppression because again, they need acid to go into suspension. When I first started, I would give them hand in hand, but I stopped doing that. It's kind of you pick which pathway you want to be on, acid suppression or alginate suspension. Not too many contraindications. Some of them, like the original Gaviscon does have a lot of sodium in it, so that's one thing to be mindful of. I've had a few people have some lower GI issues with it. I think with any GI medication that's possibility for the lower GI issues exist like diarrhea and colitis and things like that, so I tell patients to look out for that sort of stuff, but generally, they're well tolerated.

[Dr. Ashley Agan]
They shouldn't interact with any other medications that they're taking or affect the absorption of them really. Right?

[Dr. Inna Husain]
Yes, they really shouldn't. No.

[Dr. Ashley Agan]
I feel like we've done a really good job of breaking down the empiric medical therapy part. Anything else we need to cover for that before we move on to pH probe and testing?

[Dr. Inna Husain]
I will say that there's some exciting stuff on the horizon. One of the things that we really aren't addressing with any of these empiric trials really is the idea of pepsin damage or non-acid damage. There are some exciting trials and things being done with some HIV medications, actually, that have anti-pepsin properties. There's some exciting stuff in the field coming. There may be an anti-pepsin treatment out on the market soon. That would, I think, be a little bit of a game changer and add a little bit to all of this. So some exciting changes in the medical treatment of LPR.

(7) Utilizing the pH Impedance Probe

[Dr. Ashley Agan]
Okay, so that'll be something to look out for that might be coming up on the horizon. Right now for your patients who are like, "Look, I've been to 10 ENTs, and I've tried all the therapies, and now I'm coming to see you because you're the expert and let's do this pH probe monitoring thing." Let's get into that. What's that conversation go like? What does it entail as far as putting that in? What happens with that?

[Dr. Inna Husain]
Being a laryngologist when I first started in practice, I was like, "I need to be able to offer something different." Because if I'm just offering what everyone else is offering, how is this a sub-specialty kind of visit? I started actually doing my own pH impedance probe placement just to be able to offer that to patients, so that's what we talk about. We say basically, "This is really the only diagnostic tool we currently have. It's not perfect by any means, but it's what we have." Generally, what we do is I actually place the catheter. I have a nurse place [unintelligible 00:41:05] with an NG tube, and then I scope through the other side and just watch the placement of it so I can see that it's being placed with the probes at the post-cricoid region. Yes, it's uncomfortable. I tell patients it's going to feel weird having something in your throat. Most patients do not enjoy the whole experience, but by the time again that they're coming to see me, they're really bothered by these symptoms, they need some more information so we offer it. They usually come back the next day, and then we're able to review the recording and look for episodes of reflux and if it correlates to the symptoms that they're having.

[Dr. Ashley Agan]
Okay. That catheter, that probe when it's placed, is the tip of it just beyond the upper esophageal sphincter or does it go all the way down?

[Dr. Inna Husain]
Yes, so I actually use the GI one. There are some on the market, for example, that just sit in the nasopharynx. For me, I felt if I was going to do it, I want to know what's happening in the esophagus as well. Because if we see a lot of distal issues, I need to get my GI colleagues involved. If we want, we can talk a little bit about how we interact with GI with all of these as well. I decided if I was going to do it, I wanted to do the full probe.

[Dr. Ashley Agan]
Got you, and is there a marker on the probe that let's you know?

[Dr. Inna Husain]
There is.

[Dr. Ashley Agan]
That's how you know the depth, basically?

[Dr. Inna Husain]
Yes, so two ways. When GI does it, they obviously don't scope in the office and so they can use a pressure gauge to mark when they're at the lower sphincter. For ENT scoping is so routine for us that I usually just scope to see where the upper marker is.

[Dr. Ashley Agan]
Okay. Is there any reason to do either esophagoscopy in the OR, or transnasal esophagoscopy in the office? Does that ever give you any additional information that you need?

[Dr. Inna Husain]
Yes. There's definitely patients where that is recommended, and I think a lot of that has to do with the symptoms of it. If any traditional GERD symptoms, any concerning symptoms, for sure, I get my GIs involved incredibly early in this process. Even maybe the first visit based on the symptoms. For some of these very upper symptoms, if it's more globus probably and we're not getting anywhere, we would include an esophagoscopy in that workup. It's tricky when we're talking about things like dysphagia because usually, we end up doing some imaging early on for that as well even if we think it's due to LPR. Definitely work hand in hand with the GI component here.

[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?

(8) Interpreting the pH Impedance Probe Results

[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.

(9) A Look at Endoscopic Procedures & Neurosensory Reflux

[Dr. Ashley Agan]
What's the most common reflux surgery these days?

[Dr. Inna Husain]
I'm seeing a lot more of like the LINX procedure. Like an endoscopic magnetic tightening of the lower esophageal sphincter. So there's definitely more endoscopic. There's also one called the TIF which is more like radio frequency, but there's definitely more endoscopic options for patients now. I obviously don't do those surgeries, but there's different criterias.

If someone has a massive hiatal hernia, then yes, they're probably going to offer the [unintelligible 00:47:31] application. For these patients with some of these more dysmotility or more reflux events without the hiatal hernia, there are some endoscopic options available for patients. I think having this type of testing helps guide patients where they should go next, or how much more diagnostic work they should have, as opposed to just the person who first time comes in your office.

[Dr. Ashley Agan]
I'm sure it's nice to have some objective information to share with patients to say, "Okay. Look, this is what's happening." As opposed to the, "Well, let's try these medications and see what happens." Some people really like to have that data, hard facts about what's happening.

[Dr. Inna Husain]
Yes, and the other challenging thing is, how we think about LPR is very different than how GI thinks about LPR. If you send a patient and say, "I think you need an upper endoscopy because you're coughing." Depends on which GI sees that patient, but a lot of times we'll be like, "You're not having reflux, so we don't need to do that upper endoscopy." Patients get bumped back and forth between, "My ENT says it's LPR. My GI says I don't have reflux. I don't know what's going on." That unfortunately happens quite often. I think if you can provide some additional information to GI and say, "Hey, I did this pH impedance test and there's these reflux events occurring." Now they have an indication. Now they have a reason to go and make sure that the esophagus is healthy, so it just helps work together for some these patients.

[Dr. Ashley Agan]
Yes, that makes sense. As far as refractory cases, you mentioned getting GI involved. I'm looking at motility studies. Anything else that we need to be thinking about for patients who we've demonstrated that they're definitely is reflux, we've done the pH impedance testing, and then we've tried these medications and things just aren't getting better. What do you do at that point?

[Dr. Inna Husain]
Yes, so then we start having really the conversation about neurosensory reflux with the idea being that you might be having normal amount of reflux that we all have, but the response to it is heightened. Then we start talking about the use of neuromodulators, such as Gabapentin, Amitriptyline. Amitriptyline is often used for functional heartburn as well. The idea being that patients are feeling burning, but there's no abnormal amount of acid there. We start talking about the use of some of those medications. I've actually started to do a lot of superior laryngeal nerve blocks for irritable larynx syndrome, those type of things. With the idea being that there, again, is a sensory component to a lot of this, but again, that's more of a diagnosis of exclusion. A lot of times patients have to go through a lot of this other testing and empiric trials and all of that.

The other thing I will say is if a patient comes to me as a second opinion or third opinion we still start from the beginning. I still do a good nasal exam, make sure if I'm concerned about allergies, have we tested for that? Sometimes we need to repeat some of this testing, keep it all within the same time period. Because if you had testing 20 years ago and then you use your PPI trial three years ago, is that really where I'm at now? Patients being very upfront about, I understand you've had this done before, but if we're going to do the second opinion, we got to start fresh here and start checking off boxes. Just expectations for patients laying them out at the very beginning.

[Dr. Ashley Agan]
Another thing I wanted to ask you about, something that's I feel like a trendy hot topic these days is talking about the microbiome and how does that play into all of this and is that, are we going to start thinking about that when we talk about reflux and LPR?

[Dr. Inna Husain]
Yes, so that was actually something I was before leaving my-- due to this new position, that was something I was actually working on and researching. I do believe that there is a relationship between the microbiome and reflux, in general. We know that's well-documented. I think that this was a lot of implications in terms of who develops these symptoms, right off the bat, and then the negative potential for some of the ways we treat this. By using acid suppression, we are changing the microbiome of the GI tract and we know that has implications for things such as Parkinson's. These things are all interconnected. I do think that there is a connection there.

[Dr. Ashley Agan]
In the future, we might be using probiotics or some sort of bacteria readjustment to get symptoms under control. I don't know.

[Dr. Inna Husain]
I do talk about probiotics with patients, again, as more of a natural type of treatment option. The tricky thing with some of these probiotics is the idea that they're not really being absorbed anyways that people can market and sell probiotics, but are they actually being absorbed? That part is very difficult to really figure out if it's actually doing anything.

[Dr. Ashley Agan]
The different strains and different mixtures, it's like there's no standardization yet of like what is the right mix of bugs to have in your gut and it's different for different people. Well, wonderful. We've gone deep into LPR. I think we've covered it really well. Anything that I've missed, anything that we need to make sure we leave our listeners with?

[Dr. Inna Husain]
Yes, I think that was a great conversation today. Ashley, thank you. I think just the idea that LPR can have different subgroups and subtypes, and so I think if we can as a field have a little bit of consistency in understanding that it's not just an acid problem, I think we will help our patients a lot just by that.

[Dr. Ashley Agan]
Yes, that's new to me. I will go forth and better describe LPR to my patients now.

[Dr. Inna Husain]
Awesome.

[Dr. Ashley Agan]
I can't let you go without just commenting and shining a light on your social media presence. I follow you on Instagram, but you're also on Twitter and TikTok. Tell me about that.

[Dr. Inna Husain]
It's just a great way to connect and outreach and I started doing it as a way for me to find connection with others in my field. What I found was that a lot of connection with patients and educating, I joke around that I've become the mucus queen on Instagram and TikTok. I did not realize there were so many people who really are looking for help with that regard. I've become the mucus queen of social media talking about these issues and I talk to the followers like I would with patients and just being authentic and just helping to get patients where they can find care. I think with laryngology it's definitely helped get patients to the laryngologist nearest to them and just knowing that we're out there.

[Dr. Ashley Agan]
Yes, it's certainly a service to patients because that's how patients get their information these days. They're out there, they're looking for it. To be a shining star, that's someone who's putting out good information, I think that's wonderful. It's awesome. If our listeners want to find you, what are your handles on your various social media platforms?

[Dr. Inna Husain]
Oh, sure. On Instagram, I'm just in Inna Husain MD and then at TikTok, I'm Throatdoc.

[Dr. Ashley Agan]
Nice, Throatdoc. Check out Inna Husain. Thank you so much for taking the time today. It was so fun. We appreciate you.

[Dr. Inna Husain]
Thank you.

[Dr. Ashley Agan]
Reach out to Inna and let her know how this landed for you. If you have any questions, hit her up on the socials, follow her, and we'll see you guys next time.

[music]

Thank you so much for listening. If you haven't already, make sure to subscribe. Rate the podcast five stars and share with a friend. If you have any questions or comments, direct messages @ _backtableENT on Instagram, LinkedIn, or Twitter. Back Table ENT is hosted by Gopi Shah and Ashley Agan.

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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