Category: For Allergy Fellows > Topics for Medical Professionals  

Laryngopharyngeal Reflux, LPR

As opposed to GERD which is attributed to incompetence of the lower esophageal sphincter, LPR is thought due to dysfunction of the upper esophageal sphincter.   Acidic reflux also contains pepsin which may further affect the larynx or even nasopharynx.  The reflux symptom index score (RSI) is a valuable tool to evaluate patients and their response to treatment but it is our experience that this tool is less helpful during the peaks of allergy season.

Laryngopharyngeal reflux (LPR) may masquerade as many allergic conditions including:

Asthma (coughing and wheezing due to LPR with VCD)
Allergic Rhinitis (due to posterior rhinorrhea)
Anaphylaxis (due to throat tightness)
Sinusitis (posterior rhinorrhea, turbid mucous production)

Noninvasive diagnosis is clinical based upon characteristic symptoms and endoscopic findings but other testing may be necessary if there is not a prompt response to treatement.  Daily poton pump inhibitor (PPI) therapy is adequate for some patients but BID therapy may be necessary.  Some patients require even more frequent dosing or addition of qhs H2 blockers.  Rarely acid suppression is not enough and patients with ongoing bilious reflux require surgical intervention.  Dietary measures may be helpful, especially elimination of carbonated beverages.  Elevation of the head of the bed is imperative for patients who cannot avoid eating late night meals.

LPR may be associated with other laryngeal conditions including muscle tension dysphonia, laryngeal hyperirritability, laryngospasm,  laryngeal polyps, glottic and subglottic stenosis, carcinoma and paradoxical vocal fold motion.

Examples of LPR:
CASE 1
This man noted hoarseness with every cold. He had marked laryngeal edema (ventricular obliteration, true vocal fold edema and posterior commissure edema) which only partially improved with PPI therapy (as is often the case in LPR). The true vocal fold is seen as  only a thin strip on this view but on stroboscopy it was better visualized.

CASE 2

Elderly man with a history of heartburn with large meals, throat clearing, morning mucous and discomfort when swallowing large pills. Symptoms not adequately controlled with b.i.d. proton pump inhibitor therapy. The pooling of secretions in this older man suggested he might be at risk for aspiration. Further testing (FEEST-Flexible Endoscopic Evaluation of Swallowing with Sensory Testing) showed severe bilateral laryngopharyngeal sensory deficits but an intact pharyngeal squeeze (low risk for aspiration).

CASE 3

This woman in her early second trimester was more concerned about her marked nasal congestion than her laryngeal symptoms but both were caused by the same condition, reflux. Note the abundant white secretions coating the nasal mucosa.

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