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LPR Too Often Used as a Default Diagnosis

1014-RefluxLaryngopharyngeal reflux (LPR) is often diagnosed when patients complain of cough or hoarseness, but it often is not the cause of the problem. Instead, physicians need to expand their options during diagnosis, according to speakers at the September 30 Miniseminar “All that’s Red Isn’t Reflux: Getting Smarter About LPR.”

“We need to remain open to the possibility that the patient’s complaints are not reflux-related. We need to carefully and critically analyze our approaches to reflux diagnosis and treatment,” said Lee M. Akst, MD, the session moderator. “If we are treating empirically with proton pump inhibitors for presumed reflux and it is not working, we have to be open to the possibilities of other diagnoses that are not reflux-related.”

Speakers at the Miniseminar looked at diagnostic processes for reflux, discussing pepsin assays, pH probes, patient history, and physical examinations. In addition, speaker Lucian Sulica, MD, presented data that LPR is overdiagnosed, especially when patients complain of hoarseness, said Dr. Akst, Director of the Johns Hopkins Voice Center, Baltimore, MD.

“Dr. Sulica presented data that for hoarseness, reflux may be diagnosed too readily when other things may be the true cause of the voice complaint,” Dr. Akst said. “Things like vocal cord paresis, sulcus vocalis or scar, and muscle tension dysphonia—look pretty normal at first glance unless you look more critically with stroboscopy.

“There also are Academy-based position statements that suggest that as ENTs we are diagnosing reflux a little too much.”

Other speakers at the Miniseminar focused on LPR diagnosis:

  • Jonathan M. Bock, MD, Associate Professor, Division of Laryngology and Professional Voice, Medical College of Wisconsin, Milwaukee, WI, discussed the use of pepsin assays, which show great promise in diagnosis. However, assays are not available commercially in the United States, and interpretation of the results is not yet well-established.
  • Thomas L. Carroll, MD, Director of the voice program at Brigham and Women’s Hospital, Boston, MA, reviewed the use of pH, pH-impedance monitoring, esophageal manometry, and the role of empiric therapy. Many pH probes are available, and factors that influence which one to use include the patient’s condition and whether the patient is receiving therapy. On a positive note, objective measures are available to help improve certainty in diagnosis.
  • Catherine R. Lintzenich, MD, an otolaryngologist at Riverside ENT Physicians and Surgeons, Williamsburg, VA, explained the importance of a thorough patient history and a physical exam, including flexible laryngoscopy, in reflux diagnosis. However, she cautioned that history and exam alone are not conclusive.