Hoarseness and chronic cough: Would you suspect reflux?

Laryngeal endoscopy may reveal many changes from diffuse irritation. Diffuse erythema, edema, and interarytenoid hypertrophy/cobblestoning are the most useful findings for an LPRD diagnosis.^9,10 But in most cases, only a few nonspecific signs with a number of possible causes (infection, environmental irritants, allergies, temperature/climate change, among others) are seen on endoscopic examination, with little correlation with symptom severity. In fact, 74% of otolaryngologists responding to a recent survey said they relied more on patient symptoms than on laryngeal signs for an LPRD diagnosis.¹⁰

The Reflux Finding Score (RFS), available at http://www.nature.com/gimo/contents/pt1/fig_tab/gimo46_T3.html, is a clinical tool developed to quantify laryngeal inflammation and standardize objective endoscopic findings. The RFS incorporates the following endolaryngeal signs:

• subglottic edema
• ventricular obliteration
• erythema/hyperemia
• vocal cord edema
• diffuse laryngeal edema
• posterior commissure hypertrophy
• granuloma/granulation tissue
• thick endolaryngeal mucus.

A numeric value is assigned to each, based on whether it is present or absent; partial or complete; local or diffuse; or mild or severe. However, the RFS, too, is an imperfect tool. Clinicians who have used the RFS report that a score higher than 7 identifies LPRD with 95% sensitivity.¹¹ But laryngeal findings may be due to other causes, such as infection, autoimmune reaction, or even allergies, and studies have found the RFS to have poor specificity and inter-rater reliability.^12-14

Ambulatory dual probe pH monitoring was considered to be the gold standard test for LPRD at one time, but newer studies have raised questions about its validity and usefulness, especially in patients taking proton-pump inhibitors (PPIs).^1,5,7 Newer advanced probes featuring less invasive data collection and greater sensitivity are under development. Ambulatory 24-hour multichannel intraluminal impedance with pH monitoring is the most promising new diagnostic tool, as it can monitor both acidic and nonacidic reflux and distinguish between gas and liquid.¹⁵

TABLE 1
When to suspect laryngopharyngeal reflux disease^1,5,24

Treatment, like diagnosis, is not clear-cut

LPRD is often called a diagnosis of exclusion, because of the nonspecific nature of its signs and symptoms and the importance of considering a range of other etiologies. The differential diagnosis includes excessive voice use, postnasal drip, upper respiratory infection, habitual throat clearing, allergic rhinitis, environmental irritants, temperature/climate change, chronic or episodic use of alcohol and/or tobacco, and psychological problems related to tics, such as habitual throat clearing or coughing.⁵

Diagnosis is often based on an empiric trial of high-dose PPIs, with confirmation dependent on symptom relief. Because there have been few placebo-controlled trials with PPIs and those that have been completed had conflicting results, diagnosis based on a combination of medical history and endoscopic laryngeal examination may be a better approach.^16,17

Acid suppression therapy with either PPIs or histamine-2 (H2) receptor blockers such as ranitidine or famotidine is the mainstay of treatment for LPRD. But medical societies offer conflicting advice. The American Gastroenterological Association cautions clinicians not to prescribe acid-suppression therapy for patients with LPRD unless they also have GERD.⁶ The American Academy of Otolaryngology–Head and Neck Surgery recommends twice-daily PPI use for ≥6 months.^1,13 The general consensus, based on clinical experience alone, is that patients should be treated with high doses of PPIs (eg, 40 mg omeprazole twice a day) for ≥6 months, with the addition of an H2 receptor blocker to help reduce overnight acid production.^1,18 Prophylactic antacid use is also recommended in anticipation of reflux, such as before exercising and right after a meal.

Symptoms should start to improve within 6 to 8 weeks, and patients should be reassessed in about 3 months. To avoid a rebound effect from the abrupt cessation of medications, we suggest a gradual taper over 16 weeks. For the first 8 weeks, the H2 blocker should be discontinued and the PPI decreased from twice a day to once. If symptoms are still controlled, the PPI dose can be reduced to once every other day for another 8 weeks, then stopped if symptoms do not recur.¹⁸

Lifestyle and dietary changes (TABLE 2), such as smoking cessation, weight loss, and avoidance of alcohol, are an important part of LPRD treatment, and may be used as a first-line therapy before prescribing medication.¹⁹ In fact, some studies have found PPI therapy to be inferior to behavioral/lifestyle modifications.¹⁷

Fundoplication surgery, a procedure in which the gastric fundus of the stomach is wrapped around the lower end of the esophagus and stitched in place to prevent reflux, may be an option for patients who do not respond to, or cannot tolerate, aggressive medical treatment for LPRD. A 2006 prospective controlled study found that surgical fundoplication did not consistently relieve laryngeal symptoms.²⁰ But other studies have found that a carefully selected population with medically unresponsive laryngopharyngeal symptoms can benefit from this procedure.^21,22 One study showed a significant improvement within one month of fundoplication, with continued improvement observed during a 3-year follow-up.²¹ In another prospective study, researchers showed that while LPRD-related laryngeal symptoms such as coughing and throat-clearing improved with both medical therapy and laparoscopic fundoplication, voice quality and endoscopic laryngeal/pharyngeal findings improved significantly only with the surgical procedure.²³