Cough and sore throat: Cold, Flu or Acid Reflux?
The recent sudden temperature drop in Houston ushers the beginning of Cold and Flu season. Sore throat, cough, congestion are common symptoms that most of us associate with viral upper respiratory tract infections. Silent reflux, however, also known as laryngopharyngeal reflux or LPR causes similar symptoms. Gastric content reflux including acid, bile and digestive enzymes like Pepsin are believed to occur in LPR. As a result, mucosal inflammation of throat, vocal cords and nasal passages develop mimicking a viral infection. While Cold and Flu symptoms are seasonal, LPR causes chronic hoarseness, congestion, cough and constant throat clearing. Most LPR patients presenting to Houston Heartburn and Reflux Center have already underwent balloon sinuplasty for chronic sinusitis. Chronic LPR induced mucosal inflammation blocks sinus drainage and results in chronic sinusitis. Silent reflux patients typically report transient relief with balloon sinuplasty. Symptoms, however, soon recur, since the underlying etiology of sinusitis has not been addressed.
LPR is difficult to diagnose and treat. Ambulatory pH testing is typically negative in LPR patients. Upper endoscopy may reveal a small hiatal hernia and distal esophagitis. Ambulatory multichannel intraluminal impedance testing may be better suited to LPR testing as it can detect acid, non-acid and gas reflux. In my experience, however, impedance testing for LPR has shown limited sensitivity and negative predictive value. Laryngoscopy performed by ENT physician shows redness and swelling around the voice box and throat. Such findings are not specific to LPR. Salivary pepsin testing is a promising testing modality that still lacks sensitivity and specificity to rule in or rule out LPR.
LPR is commonly treated with high dose PPIs. The response rate varies from patient to patient. PPIs are less likely to neutralize the erosive effect of bile and pepsin on laryngopharyngeal mucosa. The success rate of hiatal hernia repair and Nissen fundoplication is lower in eradicating LPR related symptoms than classic GERD symptoms like heartburn and food regurgitation. Such discrepancy in outcomes may be secondary to irreversible damage to laryngopharyngeal mucosa that persists after stopping reflux. It may also be related to our lack of understanding of LPR pathophysiology as well as the absence of standardized LPR testing and staging.
At Houston Heartburn and Reflux Center, we have helped many patients with chronic cough, adult onset asthma, hoarseness and persistent throat clearing overcome their symptoms. Nissen fundoplication and hiatal hernia repair remains the best treatment for silent reflux. Our success rate in completely eradicating LPR related symptoms is around 80%. The remaining 20% of LPR patients experienced improvement in symptom severity but not complete eradication at 6 months and one year follow up. It would be interesting to re-evaluate patients 5, 10 and 20 years after fundoplication surgery for LPR to check for complete symptom resolution or lack of symptom progression.