1. Cough, Hoarseness, Sore throats & Globus: NOT so 'silent reflux'!
Dae Kim
MBChB, BDS, MSc, FRCS (Orl-HNS), PhD
Consultant ENT & Thyroid Surgeon
St George’s University Hospital
Institute of Cancer Research, London.

2. Professional Background
Current Positions:
RCSEng National Specialty Lead for Endocrine Surgery Research
NCRI/NIHR Clinical Trials Committee for Head & Neck Surgery
Specialist Advisor to National Institute of Health Care Excellence (NICE).
Academic Activity:
Targeted Therapy Group, Institute of Cancer Research, London.
PhD Clinical Research Fellow, ICR, London: molecular immunotherapy in thyroid cancer
MRC PhD Clinical Research Fellow: epithelial-mesenchymal transtion in thyroid and Head & neck cancer.
PhD Clinical Fellow, University of St George’s, London: outcomes in minimally-invasive parathyroid surgery

3. Aims: What is 'silent' or laryngopharyngeal reflux (LPR)
Pathophysiology of a common throat disorder.
Management of common throat symptoms of LPR.

4. What is Laryngopharyngeal reflux (LPR)
is an extra-esophageal variant of gastroesophageal reflux disease (GERD).
‘Silent’ reflux: >80% of people with LPR do not have symptoms of heartburn or an upset stomach.
symptoms are multiple and nonspecific: hoarseness (95%), chronic cough (97%), and globus (95%).
diagnosis of LPR is considered if edema & erythema of the larynx is noted on laryngoscopy.
Increasing entity: >10% of all ENT patients & >50% of laryngeal complaints.
Controversy: No set diagnostic guidelines & unpredictable outcome.

5. ‘Neck Lumps’ Referral: Patient with a neck/throat lump:
Internal vs External
Patient perceived vs Clinically palpable
“Even within ‘fast-track’ neck lump clinic an increasing proportion of patients present with ‘feeling’ of a lump but have no palpable lump”.
Up to ~80% of urgent 2WW head & neck referrals

6. Symptoms of LPR or ‘Silent’ Reflux
Typical symptomology:
Dysphonia/Hoarseness
Chronic cough
Lump or FB sensation – ‘Globus’
Throat discomfort/pain* – can be unilateral & ‘discrete’
Excessive throat-clearing*
Dysphagia – partial, intermittent & no weight loss
‘laryngospasm’ attacks
Metallic (bad) mouth taste
Dry mouth/Thick saliva/Excess saliva/PND

7. What causes LPR?
‘LPR is believed to be caused by stomach acid/contents that bubbles up into the throat as a result of GERD’
Direct acid irritation causes soreness, cough and choking.
Sensitivity in laryngeal and pharyngeal nerve endings upregulated by the chronic inflammation.
Delicate ciliated respiratory epithelium of the posterior pharynx/pharynx damaged causing mucus stasis.
Causing PND sensation & clearing of throat.

8. BUT exact pathophysiology poorly understood…
Reflex Theory:
Moderate response to anti-acid suppression therapy
Successful response to Gabapentin & Pregabalin
Common embryological origin of respiratory tract and digestive tract.
Reflux irritation in oesophagus leads to an oesophagobronchial reflex.
Refluxate with pepsin:
Normal pH monitoring.
Pepsin found in pharynx and bronchial tree of patients with LPR.

9. How is LPR diagnosed? Typical symptomology:
Dysphonia/Hoarseness*
Chronic cough*
Lump or FB sensation – ‘Globus’*
Throat discomfort/pain* – can be unilateral & ‘discrete’
Excessive throat-clearing*
Dysphagia – partial, intermittent & no weight loss
‘laryngospasm’ attacks
Metallic (bad) mouth taste
Dry mouth/Thick saliva/Excess saliva/PND
Problem = Broad and nonspecific symptoms that can be seen in many other medical conditions!

10. Reflux Symptom Index (Belafsky et al 2002)
Self-administered 9-Qs survey.
Each graded in severity 0-5.
Score >13 shown to be correlated to positivity on pH study.

11. definitive diagnosis of LPR’
How is LPR diagnosed?
Initial & primary diagnostic test:
Trans-nasal (video) oesophagoscopy
Common Laryngoscopic Signs:
Generalised inflammation of pharynx
Oedematous and inflamed larynx (arytenoids)
Inflamed vocal cords
Laryngeal findings are nonspecific
and shown to be subjective
(inter-rater variability).
‘No set guidelines for
definitive diagnosis of LPR’

12. The Reflux Finding Score. (Belafsky et al 2001)
To overcome inconsistency in the diagnosis of LPR.
A scoring system for documenting the physical findings and severity.
The Reflux Finding Score is based on 8 laryngoscopic findings.
95% certain that a person with a score higher than 7 has LPR.

13. 24hr Multi-channel pH Monitoring
Ambulatory Dual-Channel pH monitoring:
Gold standard for diagnosing reflux, but less reliable in patients who have laryngeal symptoms.
Pharyngeal pH monitoring: (more accurate?)
Studies show pharyngeal reflux was more frequent and in greater quantity in patients with laryngeal signs.
However, still inadequate sensitivity & specificity

14. Management of LPR Treatment is ‘empirical’:
Explanation & Reassurance
Dietary & life-style advice
Trial of PPI +/- Gaviscon
Speech therapy
Mention that >80% of patients presenting with throat symptoms may not have classic reflux symptoms such as heartburn.
Dietary advice:
Caffeine
Diet (eg, soda, spicy foods, fatty foods)
Alcohol (wine)
Certain drugs (NSAIDs).

15. ‘Independent predictor of response to PPI therapy’
Lifestyle changes (& prevention measures):
Follow a bland diet (low acid levels, low in fat, not spicy)
Eat frequent, small meals
Lose weight
Avoid excess alcohol, tobacco, and caffeine
Do not eat food less than 2 hours before bedtime
Raise the head of the bed before sleeping.
Avoid clearing of the throat
Increase water intake
‘Independent predictor of response to PPI therapy’

16. Empiric PPI Treatment
Proton Pump Inhibitors (PPI) are considered the cornerstone of pharmacological treatment of LPR.
Placebo effect important in early period.
Long-term and twice-daily dosage shown to be more effective.
Optimal effect exerted when taken mins prior to meals.
Significant physical exam improvements after 3 months of therapy.
Addition of Histamine-2 receptor antagonist: An adjunctive treatment for LPR to combat breakthrough histamine-regulated nocturnal acid production (ranitidine 300 mg at bedtime).
Gaviscon Advance: shown to be additive to PPI therapy.

17. Surgery
Nissen Fundoplication (endoscopic) is the primary surgical option.
90% 10-years success rate in GERD symptoms.
For patients whose throat symptoms persist despite drug therapy.
70% improvement in LPR-related symptoms.
Poorer success if failed anti-reflux medical therapy.
Newer non-fundoplication endoscopic techniques:
Bard EndoCinch System
Enteryx liquid polymer injection
Stretta Radio-frequency System

18. Algorithm for LPR management

19. Refractory Cases Natural history: 25% spontaneous recovery
50% chronic course with intermittent exacerbations and remissions
In patients who show no improvement, other causes of symptoms and conditions that can mimic LPR should be explored:
malignancy
postnasal drip
allergies
sinus inflammation
various pulmonary diseases
Smoking & alcohol
Environmental irritants

20. What can happen if LPR is not treated?
LPR is associated with and thought to contribute to various medical conditions:
Exacerbate Rhinosinusitis
Laryngospasm
Laryngotracheal stenosis
Reinke’s edema
Granulomas
Worsening of asthma, emphysema and bronchitis.
Laryngeal papilloma & carcinoma.

21. Summary LPR is an increasing problem/workload in ENT Surgery.
Combination of typical history (RSI) and laryngoscopic examination (RFS) is is used for diagnosis.
Controversy remains how to confirm the diagnosis of LPR.
Management focuses on reassurance, explanation, dietary & lifestyle changes.
Empirical PPI Trial: twice-daily for 3 months.
Patients whose symptoms do not respond to a PPI may be considered for surgery but benefit from surgery is unpredictable.
In refractory cases other causes & diagnoses should be entertained.

22. Thank You & Any Questions?