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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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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I Am Taking a Reflux Medication & My Symptoms are Not Improving!

On an almost daily basis, I get an email from somebody with the same exact question or near-variation:

"Dear Dr. Chang,  

I have been taking a [insert reflux medication] for [insert number] weeks and I see no improvement in my [insert symptom]. What should I do?"

The reflux medication typically mentioned include nexium, dexilant, prilosec, prevacid, protonix, or some other proton pump inhibitor.

The most common symptoms typically mentioned include:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

What Should You Do?

Well, assuming you never have taken a reflux medication in the past, proton pump inhibitors work extremely well in suppressing acid; even at low dosages.

As such, if you indeed have been taking a proton pump inhibitor for at least 3 weeks and see no improvement in symptoms, one must consider the possibility that acid reflux may not be the problem.

I rarely if ever just increase the dosage of a reflux medication in somebody who previously was never on one. Increasing the medication dosage MIGHT be considered only if somebody has already been on reflux medication for some time baseline.

So if acid reflux is not the problem, what may be causing above-mentioned symptoms?

There could be an anatomic problem...

• Zenker's diverticulum

• Cricopharyngeal spasms/hypertrophy

• Esophageal dysmotility

• Esophageal web or stricture

etc

Essentially, there's something wrong with your swallowing tube such that things back up into the throat causing symptoms. Think of it like a clogged sink... the pipe (esophagus) has a physical issue that causes water to backup into the sink (throat).

Workup to evaluate these possibilities include trans-nasal endoscopy, EGD, barium swallow, and/or manometry.

It could still be a reflux problem...

Just maybe, it's NOT acid reflux however, but mucus or non-acid reflux. Standard reflux medications do not work for non-acid reflux. The best way to evaluate this possibility is to undergo a 24 hour multichannel pH and impedance testing. Of note, BRAVO or pH monitoring alone is NOT good enough. Impedance must be measured as well as having sensors near the throat level.

In the meantime, one could also try avoiding eating anything that contains dairy, egg, and wheat (flour). These foods are considered highly mucogenic (most people can relate to the fact that when drinking too much milk, the mouth and throat can get phlegmy).

Is it allergy?

Post-nasal drainage can sometimes lead to throat symptoms. If you do have some sino-nasal allergies, try taking a steroid nasal spray and an anti-histamine nasal spray. Oral medications typically do not work as well.

There's also a condition known a eosinophilic esophagitis that can cause throat symptoms. The only way to diagnose this condition is an upper endoscopy (EGD) with biopsies of the esophageal lining.

Summary

Now this article just scratches the surface in FULLY addressing an individual patient's throat symptoms. After all, not everybody is exactly the same. For a more in-depth evaluation and individualized treatment of YOUR throat issues, please make an appointment with your ENT.

Here are some related articles that may be helpful:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

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Video on Zenker's Diverticulum Surgery (Endoscopic Staple Diverticulostomy)

Our office has produced a new video describing Endoscopic Staple Diverticulostomy to treat Zenker's Diverticulum.

We have the unusual honor of having treated patients throughout the United States for this rare condition. Patients we have successfully treated have come from as far away as Oregon, New York, Florida, Pennsylvania, Louisiana, Arizona, etc.

For more information, please visit us here.

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