Cricoid Pressure May Minimize Symptoms of Reflux (LPR)

Specifically throat symptoms attributable to reflux such as globus, throat-clearing, phlegmy throat, chronic cough, etc. However, cricoid pressure may not be realistic nor practical even if it does help.

In one of the more unusual studies I have seen, researchers deliberately infused 60 cc of hydrochloric acid into the esophagus of 14 patients who suffered from LPR as well as 12 healthy controls. 9 patients exhibited confirmed LPR (laryngopharyngeal reflux) events, but none in the control group. With moderate sustained cricoid pressure (20-30 mmHg), only one patient had a confirmed LPR event.

Theoretically, why would cricoid pressure work?

The cricoid cartilage is located immediately below the voice box. It is a circular cartilage that is right at the level where the throat connects to the esophagus. By putting pressure on the cricoid cartilage, the top part of the esophagus is manually compressed shut which theoretically would prevent reflux from regurgitating up into the throat.

It is based on this theory that anesthesiologists often perform cricoid pressure to prevent aspiration during intubation for surgery, especially if a patient is suspected of drinking/eating something prior to surgery.

The problem with cricoid pressure is that in order for this to work, it needs to happen continuously which may make it unrealistic and impractical for patients who suffer from LPR. Continuously means 24/7/365. Not just when symptoms are present (because it's too late than).

Reference:
Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24735.

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Esophagoscopy without Sedation [VIDEO]

Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.

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30% of Patients with Reflux will NOT Respond to Medications

Specifically, patients who are suffering with throat symptoms of reflux will often not respond to proton-pump inhibitor (PPI) medications. Such throat symptoms include throat-clearing, phlegmy throat, cough, hoarseness, and globus. Known as LPR (laryngopharyngeal reflux), a study was done measuring the pH at the throat level after 4+ weeks of twice daily PPI.

This retrospective study found that although 67.4% had symptom normalization, 32.6% of patients showed no subjective or objective treatment response. For all patients whose symptoms did not normalize, pH scores also did not normalize.  For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score.

Based on these findings, one should NOT assume that lack of response to reflux medications indicative of reflux being an incorrect diagnosis. Further study with a pH or impedance monitoring should be performed in non-responders to help figure out what is going on.

Reference:
Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014 Mar 19. [Epub ahead of print]

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New Incisionless Device to Correct Reflux by Medigus

A new trans-oral incisionless device to surgically treat reflux was announced by Medigus, an Israeli company, called the "SRS system." It is a competitor to two other incisionless devices currently available: Stretta (Mederi Therapeutics) and Esophyx (Endogastric Solutions).

Common to all incisionless devices is the fact that the procedure is performed using an endoscope introduced through the mouth threaded down into the stomach. At this point, the technique used by the devices to tighten the valve separating the esophagus and stomach varies.

With Stretta (first on the market), radiofrequency energy is used to induce scarring of the valve causing it to constrict.

With Esophyx (next to market), a 270 degree 2-3cm fundoplication is performed by manipulating the esophago-gastric tissue in a rotating twisting manner and anchoring in place using 12 or more full-thickness polypropylene fasteners.

With SRS, the stomach is folded up against the esophagus and anchored in place using a few staplers. Watch the video below to see how this system works.

The technique that is best for a given patient will vary based on surgeon's comfort and experience with the device as well as unique patient variables. As such, no technique is perfect or applicable to everybody. Also, only time will tell if this or any other incisonless technique provides long-term reflux relief with minimal risk and side effects.

Ask your GI or general surgery specialist on what option is best for you.

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Lisa Marie Presley Throat Cancer Scare

Image from Wikipedia

The National Enquirer reported 1/20/14 that Lisa Marie Presley suffered a throat cancer scare when she was told by a medical expert that "the 45-year-old singer’s throat is so severely ravaged that ... the damage could lead to deadly esophageal cancer!" [link]

The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.

In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.

However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).

Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.

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Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?

Image by Steven Fruitsmakk from Wikipedia

Over the last 30 years, the incidence of esophageal cancer has been steadily rising in spite of increased use of reflux medications. In fact, one can almost say that there is an inverse relationship between risk of esophageal cancer and reflux medication usage.

BUT, it is also a foregone conclusion that reflux increases the risk of esophageal and throat cancer too. So, why would there be an increased incidence of esophageal cancer when reflux is being better "controlled" now more than ever with medical acid suppression?

The answer might be bile... the substance made in the liver and secreted into the small intestine via the gallbladder. Bile is what helps the body digest dietary fat.

But when bile not uncommonly refluxes into the esophagus... bad things may happen, especially when acid production has been suppressed by reflux medications.

Disclaimer... The following is hypothetical and unproven.

Bile, if it happens to be in the esophagus or throat, is more destructive to the mucosal lining when acid is suppressed.

Bile salts/acids have fairly complicated acid-base properties, but an over-simplified explanation for the purpose of this blog is as follows.

Bile in a chemically unconjugated state has a pKa of 7. When such bile is in an acid environment (pH less than 6), it is insoluble and relatively harmless. However, when unconjugated bile enters a relatively alkaline environment (pH greater than 6), it becomes water soluble and "active" in its ability to damage mucosal linings.

As such, when acid suppression is induced by medications like zantac and prilosec, yes... the acid is suppressed but by the very fact that it raises the stomach and distal esophageal pH to a relative alkaline state, any bile that may be present now becomes activated and causes potentially just as much damage as acid.

And that's why over a prolonged period of time repeated bile exposure in a relative alkaline environment may explain why esophageal cancer incidence seems to be increasing as the use of acid reflux medications has increased.

Proof?

Regardless of the "how," does taking reflux medications actually increase risk of cancer???

In one study (2011), patients taking proton pump inhibitors were 61.3% to 81.5% more likely to develop esophageal pre-cancerous lesions or frank cancer (adenocarcinoma).

In another study published in the summer of 2013, it was found that patients with reflux were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but NOT proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

To reiterate, antacids reduced risk of throat cancer... but NOT proton pump inhibitors like prilosec and H2 blockers like zantac.

Why? Because antacids work transiently to neutralize acid, but not suppress acid production whereas proton pump inhibitors and H2 blockers actually suppress acid production for a prolonged period of time.

The transient nature of acid neutralizers like TUMS allow for acid to still be produced thereby theoretically preventing bile from becoming soluble and damaging.

Prediction

So which is worse for you? Acid reflux or bile reflux? I'm not sure... but personally, I predict that once additional studies are performed that may ultimately strengthen the relationship between bile reflux and mucosal injury that may lead to cancer formation, reflux medications may go out-of-favor along with a class-action lawsuit. That's a big if... I might end up being completely wrong.

Of course, that may be the reason why drug companies specify that such reflux medications should not be used longer than 2 months and prescribing information stress "short-term" treatment rather than long-term.

More Confusion

We can also throw more mud into this messy predicament... Pepsin, which is a stomach enzyme that breaks down proteins, can also damage esophageal and laryngeal mucosa. However, it is most active in an acidic environment. Once pH levels rise above 6.5, pepsin becomes inactivated. At pH 8.0, it becomes irreversibly inactivated.

As such, acid and pepsin cause damage in an acidic environment. Taking reflux medications to eliminate the acid creates an alkaline environment.

However, an alkaline environment than activates bile which can also cause damage.

Treatment

So what to do?

Ideally, given this no-win situation, the best way to treat reflux would be to keep bile where it is supposed to be (in the small intestine) and acid/pepsin in the stomach where it is supposed to be.

As such, I suspect that even more emphasis will be placed on lifestyle/dietary changes for reflux control. Medication-wise, use of antacids and barrier-type medications like alginate will become the main way of treating reflux long-term while medications that suppress acid will be prescribed only for short-term treatment spans.

Surgical management of reflux will become much more accepted and popular for patients who suffer from bad reflux to try and restore proper anatomical compartmentalization of bile, acid, and pepsin. Surgical management will include LINX, TIF, Nissen, etc. (more info)

At the very least, certainly caution should be present when placing a patient on long-term acid suppression with medications like prilosec and zantac, especially when such medications are already known to cause a whole host of other problems including bone fractures, clostridium difficile infections,  and malabsorption of vitamins and minerals. (more info)

Special thanks to Dr. Kevin Gillian who assisted in writing this blog.


References:
Bile Acid. Wikipedia

Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011 Jul;146(7):851-8. doi: 10.1001/archsurg.2011.174.

Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut 2001 Sep;49(3):359-63.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus. Hepatogastroenterology. 55 (82-83), 442-7.

The role of bile acids in the neoplastic progression of Barrett's esophagus - a short representative overview. Z Gastroenterol. 50 (9), 1028-34.

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We Now Offer Rapid Saliva Test to Look for Laryngopharyngeal Reflux

When you compare a spit test to the current way of how throat level reflux (LPR) is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

The steps to the test are as follows:

   

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is RDbiomed (in Europe) using their Peptest kit.

This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.

Please note that this testing is ONLY offered to current patients of ours.

However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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What Reflux Meds are Best in Infants and Children?

Once a decision is made to start medications beyond the conservative ways of dealing with reflux, the most common reflux medications used to treat adults are also used to treat reflux in infants and children. They are the same exact medications, albeit at lower dosages.

Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).

In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.

In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.

When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.

Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.

Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.

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Does Drinking Alkaline Water Help With Reflux?

Image by WJ Pilsak from Wikipedia

Treatment in some reflux-sufferers may require addressing not just the acid in reflux, but also the pepsin. In one tantalizing research paper, alkaline water (pH 8.8) was found to instantly and permanently inactivate pepsin in vitro (ie, in a test tube). Pepsin is a stomach enzyme that can cause inflammation and mucosal damage when in the throat area. This peptic enzyme can be deposited outside the stomach due to laryngopharyngeal reflux (LPR) and can cause symptoms of globus, burning, hoarseness, chronic cough, chronic throat clearing, etc.

With pepsin triggered symptoms, treatment to resolve can become exceedingly frustrating given standard treatment with zantac, prilosec, and other "reflux" medications do not work as well. Furthermore, human pepsin remains stable at pH 7.4 and can be repetitively reactivated by acid from any source (ie, orange juice).

BUT... keep in mind that test tube results in this research may not necessarily translate to actual improvement in humans. However, drinking a small amount of alkaline water a few times a day (just enough to coat the throat) can't hurt.

Keep in mind that most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability.

I should also mention that drinking alkaline water will not do much to help acid reflux as the alkaline water will only briefly neutralize any acid and is ineffective for long-duration acid suppression. For those suffering from acid reflux, stick with the traditional reflux medications which work extremely well.

Reference:
Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol. 2012 Jul;121(7):431-4.

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How Does Neuropathy Lead to Lump in Throat or Phlegmy Throat Sensation?

To preface, have you ever been to the dentist and received a novacaine injection prior to a dental procedure? Did you notice that where the injection is performed, it feels as if the area feels really swollen and also you feel like you are drooling... but than when you look in the mirror, there's no drooling and there's no swelling either?

In this dental situation where novacaine got injected leading to a temporary induced neuropathy...  a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).

And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.

Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.

Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.

How is this condition treated?

First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.

SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.

Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.

For more information, click here for globus and here for phlegmy throat.

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Reflux Increases Risk of Throat Cancer by 78%

Brown University researchers found that frequent heartburn was an independent risk factor for not only esophageal cancer but also cancer of the throat and vocal cords. This conclusion was based on a large population study involving 631 patients with throat cancer and 1,234 without throat cancer as a control group.

The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).

Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:

• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus

It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]

In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.

Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.

References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

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Does Milk Cause Increased Phlegm or Mucus Production?

For many individuals, milk and associated dairy products definitely seem to cause an increased production or thickening of mucus in the mouth and throat... the phlegmy throat. It certainly happens to me...

Of course, perception is not always supported by research...

"Milk and dairy product intake was not associated with an increase in upper or lower respiratory tract symptoms of congestion or nasal secretion weight. [...] We conclude that no statistically significant overall association can be detected between milk and dairy product intake and symptoms of mucus production in healthy adults, either asymptomatic or symptomatic, with rhinovirus infection." [link]

However, other research support the possibility that dairy products might increase mucus production only if the milk contains beta-CM-7 protein (not all milk contains this protein). [link]

I have a different hypothesis for why milk may cause the perception of increased mucus production. I should preface that I have no research study to quote to prove this hypothesis. Might be a good research project for a medical student???

In any case, milk contains a protein called casein. When the milk is not refrigerated, it causes bacteria to  metabolize lactose within the milk leading to lactic acid production as a byproduct. When acidity is present, the casein congregate in a process called curdling. That's the "chunks of milk" seen in milk gone bad.

Now, bacteria certainly will not be playing a role in lactic acid production after fresh milk is consumed, BUT, there IS acid present in the stomach which can initiate curdling.

Now what if a patient suffers from acid reflux... and what if some of the reflux episodes reach the throat level?

So, hypothetically speaking, if somebody who suffers from acid reflux drinks a lot of milk, two things might hypothetically happen (or drinks orange juice followed by milk):

1) Milk temperature goes up from body heat (which assists in curdling)
2) Acid present from the reflux will initiate curdling

If acid is present in the mouth and throat from reflux or secondary source (like recently drunk orange juice), curdling to some degree may occur from milk residue mixing with acid residue present leading to perception of mucus production.

Now does this actually happen???

I don't know and I hope some researcher looks into this hypothesis further!

However, in the end, if dairy avoidance helps with a phlegmy throat, than it can't hurt to avoid it! I should also point out that egg and wheat does cause a similar phlegmy problem in some patients.


Reference:
Relationship between milk intake and mucus production in adult volunteers challenged with rhinovirus-2. Am Rev Respir Dis. 1990 Feb;141(2):352-6.

Does milk increase mucus production? Med Hypotheses. 2010 Apr;74(4):732-4. doi: 10.1016/j.mehy.2009.10.044. Epub 2009 Nov 25.

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Top 3 Reasons Why Your Child Can't Shake that Cough

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

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Reflux Medication Addiction

When a patient suffers from reflux, there is an astounding array of very effective medications to induce acid suppression for symptom relief.

Chief among the reflux medications are the proton pump inhibitors that include medications like prilosec, nexium, protonix, prevacid, dexilant, etc.

When such medications are taken by a patient, especially one who does not normally take proton pump inhibitors, effective acid suppression occurs. It works EXTREMELY well; even at low doses.

However, such medications should not be taken any longer than necessary and should be prescribed along with lifestyle changes to minimize persistence and/or recurrence.

Why?

In some ways, a patient suffering from reflux may become "addicted" to the reflux medication for continued symptom relief.

In other words, the reflux medication can induce the stomach to produce even more acid leading to the need for continued medical therapy... or increase dosages for continued symptom relief. Stopping the medication can cause even worse reflux... which leads the patient to resume the medication.

This "addiction"can occur in as little as 8 weeks in up to 40% of normal, healthy individuals. [link]

What happens?

The way proton pump inhibitors work is by blocking protein channels known as proton pumps in stomach cells (B) from producing acid (C).

The stomach cells realizing their proton pumps are being blocked, start revving up production of even MORE proton pump channels to fix its acid shortage which would in turn increase acid production and potentially lead to symptoms.

Sounds like a vicious cycle... because it is.

Although this "addiction" which is really an acid rebound phenomenon, is typically associated with proton pump inhibitors, it can also happen with H2-blockers (zantac, pepcid, etc), though not as severe.

Should you experience acid rebound after stopping a reflux medication, the unusually vigorous acid production and associated symptoms (the "withdrawal") go away if you can stand to wait it out. Since it takes time for the stomach to re-adjust, this wait can be significant:

• After stopping an H2-blocker, rebound symptoms usually start within two days and usually subside within 10 days.
• After stopping a proton pump inhibitor, rebound symptoms usually start after a week and continue for up to two months.

One can also slowly "taper" down the dosage of reflux medication and address any acid symptoms with an antacid.

Now, in certain circumstances, it is imperative that reflux medications be taken for months if not longer because the benefits outweigh the risks (gastric ulcer, Barrett's esophagus, vocal cord granuloma, etc). There is a specific reason for long-term treatment.

But if treatment is solely due to symptom relief alone, such medications should not be used daily indefinitely.

Talk to your doctor if you have concerns.


References:
Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137:80-87. Epub 2009 Apr 10.

Rebound hypersecretion after omeprazole and its relation to on-treatment acid suppression and Helicobacter pylori status. Gastroenterology. 1999;116:239-247.

Systematic review: rebound acid hypersecretion after therapy with proton pump inhibitors. Aliment Pharmacol Ther. 2007;25:39-46.

Results of an intervention in an academic Internal Medicine Clinic to continue, step-down, or discontinue proton pump inhibitor therapy related to a Tennessee Medicaid formulary change. J Manag Care Pharm. 2009;15:344-350.

Safety of the long-term use of proton pump inhibitors. World J Gastroenterol. 2010;16:2323-2330.

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New Webpage on Reflux Medications

Given the degree of ignorance I see about reflux medications, how they work, and limitations of such medications, our office has written up a new webpage that goes over the different categories of reflux medications with an explanation of how such medications help to address acid reflux. Such medications include:

• Antacids
• H2 Blockers
• Proton pump inhibitors
• Barriers
• Combinations

What is also explained are the limitations of such medications when it comes to disorders like non-acid reflux.

Check it out here!

Some example reflux medications that can be purchased over-the-counter:

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John Mayer Undergoes Second Vocal Cord Surgery

On August 27, 2012, media reported that grammy-award winning singer John Mayer underwent vocal cord surgery for a 2nd time in an attempt to permanently remove a recurrent vocal cord granuloma.

Fans know that in September 2011, John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

On Oct 20, 2011, he underwent surgery for the first time to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma had recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

Well, it seems that whatever intervention pursued since March 2012 did not work completely given the repeat surgery.

Given this is his second surgery for the same problem, I suspect that not only was the granuloma removed, but perhaps steroid was injected into the wound bed to try and prevent the tissue growth that may lead to granuloma reformation as well as application of mitomycin C, a chemotherapy agent. Post-procedure treatment with PDL or KTP laser may also be pursued to ablate any proliferative blood vessels that my encourage granuloma formation. Botox may even have been injected to partially paralyze his ability to bring the vocal cords together to prevent phono-trauma to the site.

Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

That means strict voice rest.

Indeed, John Mayer stated (or wrote) after his most recent surgery:

"Silent for the next few months, no singing for probably six, but all signs point to this being the last step in getting to perform again."

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications.

Surgical removal of the granuloma may have looked something like this video...

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:
Surgery silences singer John Mayer for a spell. CNN 9/1/12

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New Webpage on Non-Acid Reflux

Given the frequency of patients I have seen over the years suffering from non-acid reflux causing symptoms of:

• Chronic cough
• Chronic throat-clearing
• Phlegmy throat
• Lump in throat sensation (globus)

I have decided to write a formal webpage to this condition.

Check it out here!

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Saliva Test for Laryngopharyngeal Reflux (LPR)

Various groups have been developing a fast, cheap, non-invasive saliva swab test to determine whether laryngopharyngeal reflux (LPR) is present or not. LPR may cause symptoms of:

• Hoarseness
• Chronic (ongoing) cough
• Frequent throat clearing
• Constant mucus or phelgm in the throat
• Dry or sandpaper like sensation in the throat
• Pain or burning sensation in the throat
• Feeling of a lump in the throat (globus pharyngeus)
• Problems swallowing
• Bad/bitter taste in the mouth (especially in morning)
• Asthma-like symptoms
• Ear pain and/or persistent ear infections
• Post-nasal drip
• Large lingual tonsils

When you compare a spit test to the current way of how reflux is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is rdbiomed using their Peptest kit.

Unfortunately, such testing is not offered in most labs except in Europe. (This test is currently not FDA approved and as such, is not even available for purchase yet in the United States. However, FDA approval is expected in 2014.)

However, we do offer this test in our office for current patients of ours. Click here for more info.

However, you can order this test yourself as an individual. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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FDA Approves New Surgical Reflux Treatment

On March 22, 2012, the FDA approved the LINX Reflux Management System to treat gastroesophageal reflux disease (GERD). Developed by Torax Medical, the

"LINX system is composed of a series of titanium beads, each with a magnetic core, connected together with independent titanium wires to form a ring shape like a bracelet of beads. It is implanted at the lower esophageal sphincter (LES), a circular band of muscle that closes the last few centimeters of the esophagus and prevents the backward flow of stomach contents. The force of the magnetic beads is designed to provide additional strength to keep a weak LES closed. Upon swallowing, the magnetic force between the beads is overcome by the higher pressures of swallowing forces, and the device expands to accommodate a normal swallow of food or liquid. Once the food passes though the LES, the device returns to its resting state."

Traditionally, surgical management of reflux entailed a stomach wrap called Nissen Fundoplication which is analogous to cinching a belt and is currently the gold standard. Trans-oral incisionless fundoplication is a newer approach to the Nissen fundoplication and is in essence an "internal" stomach wrap.

It is only a matter of time to see whether this new LINX system is as effective if not more effective than fundoplication over a long period of time or whether it will go the way of the Dodo bird.

An immediate disadvantage of this system... Patients can never undergo a MRI scan in the future (LINX uses magnetic beads... MRI which utilizes a strong magnet... Visualization of beads being yanked out of the human body in a MRI machine...)

Reference:
FDA approves LINX Reflux Management System to treat gastroesophageal reflux disease. FDA 3/22/12

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Singer John Mayer Has Recurrence of Vocal Cord Granuloma

In September 2011, grammy-award winning singer John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

On Oct 20, 2011, he underwent surgery to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma has recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

 Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential. However, it is not unusual that steroid injections to the granuloma site as well as even botox injection to partially and temporarily paralyze the vocal cord may need to be pursued for complete resolution. Laser and mitomycin C application has also been found to be helpful.

Surgical removal of the granuloma may have looked something like this video...

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:

John Mayer's Granuloma Returns, Singer Taking "Indefinite Break From Live Perfoming". E Online 3/9/12

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