Symptoms of Laryngopharyngeal Reflux
What do chronic dry cough, hoarseness, difficulty swallowing solids, throat clearing, sore midline lower throat, postnasal drip, and midline lower throat lump sensation all have in common? Their most common source for one or more of these symptoms is reflux of acid contents into the larynx (voice box), silent in the sense that one does not necessarily have accompanying heartburn or bitter taste sensation. In fact, 40% of people who have reflux have no heartburn.
In regard to chronic (>2 weeks) dry COUGH, this may begin with an upper respiratory infection such as a cold or sinus infection, or perhaps an allergy flare. However, long after the nasal symptoms have resolved, one may continue to have a dry cough or throat clearing. The cough or throat clearing from the respiratory drainage has “unmasked” the underlying previously asymptomatic reflux, and unless the patient treats this source, symptoms will continue. Another source of a chronic dry cough includes ACE inhibitors (lisinopril, captopril, enalopril), and even if a patient has been on an ACE inhibitor for years, this cough can occur at any time. Once a patient is changed to another blood pressure medication upon stopping the ACE inhibitor, the cough will typically resolve within several weeks. Of course persistent productive cough (green or yellow sputum) beyond a week would suggest either a bacterial sinusitis or perhaps pneumonia. Finally, some types of asthma will cause a chronic dry cough, but this is rare (except in the pediatric population).
HOARSENESS is also commonly secondary to reflux of acid. Again, this may begin with an upper respiratory infection, which resolves, but leaves the patient with continued hoarseness. Hoarseness following a vocal performance (or yelling) that persists beyond 2 weeks suggests a reflux contribution. Many adults who sing in a choir or the shower who go on to develop hoarseness are exhibiting signs of reflux. Voice changes following endotracheal intubation for surgery is likely secondary to silent pre-existing reflux. Other sources of hoarseness include vocal cord paralysis, growths (vocal nodules or malignancy), and certain neurologic conditions. For children, hoarseness or a deep, husky voice (sometimes since birth) typically herald underlying silent reflux.
Difficulty SWALLOWING solids, pills, rice, or dry breads can be secondary to untreated reflux. The patient can swallow liquids without difficulty, but will have the sensation of food/pills hanging up at the level of the larynx. Other sources include strictures (narrowing) of the esophagus, masses in the esophagus, and motility disorders of the esophagus.
SORE MIDLINE LOWER THROAT at the level of the larynx, or the sensation of a “LUMP in the throat” low in the neck is from irritation of the laryx from acid exposure, and is not actually a physical lump, but feels like it. Neoplasm is a much rarer source.
Perhaps the most surprising symptom for patients is that of “POSTNASAL DRIP”, which is rarely nasal in origin. Again, one may start with a respiratory infection or allergy flare, but persistent NONPRODUCTIVE or white postnasal drip with no further drainage out of the FRONT of the nose is most likely silent reflux. Acid, in contacting the larynx, will cause the larynx to “weep”, producing phlegm that the patient experiences in the back of the throat.
Diagnosis of Laryngopharyngeal Reflux
Evaluation of the above symptoms begins with a nasal, oral, and laryngeal examination in the office. The latter may be with a mirror placed into the back of the mouth, or a narrow flexible scope placed through the nasal cavity, visualizing the voice box from above. Although one could have an upper endoscopy performed by a GI doctor for the symptoms of difficulty swallowing, this requires going under anesthesia, may utilize a pH probe placed at the time of the endoscopy, and can be cost prohibitive. A diagnosis can usually be made in the ENT office with the mirror or the scope, both awake. Classically, redness and perhaps some mild swelling of the back of the voice box will herald the presence of reflux.
Direct visualization of the lower throat is critical to assess for malignancy, but once this is ruled out, treatment can commence. In addition, potential contributors such as allergy or sinusitis can be assessed with allergy testing or CT scan in our office.
Treatment of Laryngopharyngeal Reflux
Treatment of laryngeal reflux requires more aggressive, but doable, measures, and include prescription medication to reduce acid production, dietary changes, and elevation of the head of the bed. These will be discussed at length at the office visit. In contrast to symptoms of heartburn, treatment of silent reflux symptoms takes 4-6 weeks before a patient may turn the corner. One may feel no different at two weeks. Hoarseness in particular can take 2-3 months. Patients usually are seen at 6 weeks. If the patient is not better, additional studies may include a barium swallow, neck CT, and/or an examination of the larynx under anesthesia in the OR.