Is LPR being Overdiagnosed?

By Stu Leo︱Published October 28, 2017

Are doctors overdiagnosing laryngopharyngeal reflux(LPR)?

From about 1990 to 2001, the incidence of LPR in the United States has skyrocketed by about 300%. (3) That’s crazy. Either a whole lot of us contracted LPR in just 10 years time or something else is going on.

In this article, I’m going to talk about the problem with most doctors’ LPR diagnosis, the problem with using PPIs to diagnose LPR, and what you can do that may confirm you have LPR.

What’s LPR?

Laryngopharyngeal reflux (LPR), also known as “silent GERD” is thought to occur when acidic stomach contents reflux into the larynx and pharyngeal area causing irritation and damage.

Other fluids thought to irritate the upper airway tract are bile salts, bacteria, pancreatic enzmyes, and pepsin. (1)

Symptoms beyond heartburn and regurgitation are thought to be caused by LPR.

LPR has the greatest impact on quality of life. Patients with LPR often suffer from hoarseness, chronic voice loss, sore throat, and laryngitis. (2) These symptoms can be especially detrimental to teachers, singers, lawyers, and other people who use their voice for a living.

Some studies have found that 50 to 60 percent of patients with chronic laryngitis and sore throat may have GERD. (2)

The Problem with Most LPR Diagnoses Today

Along with the dramatic rise of LPR in the United States, the cost associated with treating the disease has skyrocketed as well.

It is estimated that LPR costs $5,154 per year for one person.

At 5 years, it’s $13,000 a year for one person. (3)

Further, LPR is notoriously hard to treat.

One study found that only 54% of LPR patients experience improvement or resolve their symptoms even after completing reflux therapy. (3

Doctors going misdiagnosing LPR could be part of the reason for the difficulty.

The majority of primary care physicians will diagnose a patient experiencing hoarseness with LPR and prescribe PPIs with no further examination. (3)

One study found that 102 patients with hoarseness supposedly due to LPR, did not actually have LPR upon closer evaluation. Ironically, 86.6% of those misdiagnosed with LPR were originally examined by an ENT(Ear, Nose, Throat) specialist. (3)

Another study performed by a doctor named Lucien Salika, examined 26 patients with a stroboscopy after they were diagnosed with LPR by another doctor. He ultimately found that none of those patients had LPR. He did however find that patients suffered from conditions like lesions and thrush. These conditions can be confused with LPR due to similar symptoms.

Doctors Disagree On What LPR Looks like

Another problem is doctors don’t seem to agree on what LPR looks like.

One study showed a pool of doctors laryngoscopy videos and asked them whether the videos of patients’ throats looked like they had LPR. Some said yes and some said no.

In other words, what looked like swelling and LPR to one doctor looked completely normal to another doctor. (3) That’s a problem. 

On top of that, normal subjects who do not smoke also show signs of laryngeal inflammation and swelling. (8) (9)

It is apparent from these studies that hoarseness and laryngeal redness also called erythema edema, do not necessarily indicate LPR. That’s why LPR is so difficult to diagnose if you’re simply going off of hoarseness and even scope tests alone.

PPIs can make you think you have LPR

PPIs are used by most doctors to diagnose GERD. If a doctor suspects you have LPR they’ll usually instruct you to take PPIs for 4 weeks to see if symptoms improve.

If symptoms improve, it’s likely you’ll get diagnosed with LPR and be told to take PPI medication indefinitely. So what if you take PPIs and they don’t work?

Well, chances are you’ll be instructed to take double the dose for 4 more weeks or even longer to see if that helps. 

The big problem with this sort of treatment is if you stop taking PPIs after long-term use you’ll probably get rebound reflux.

Rebound reflux is likely to occur because when you stop taking PPIs, your stomach tends to over-produce acid to readjust.

That means more reflux episodes and this can trick you into believing you have acid reflux when in reality, it’s the medication you’re taking that’s causing the reflux.

This is why many people continue to take PPIs even when it doesn’t help them. They may even develop digestion and health issues as a result, but because they believe PPIs will help them and not taking them will make things worse—they’re stuck.

Now to be clear, I’m not saying PPIs are bad all the time because many people actually benefit from them.

My point is we should be careful with PPIs. If your doctors suspect you have LPR, getting additional testing to confirm the diagnosis may be a good idea. Making sure you really have LPR from the beginning can save you a lot of time and money.

5 tips to get an accurate LPR Diagnosis

1. If you don’t experience heartburn and regurgitation there is a greater chance that your symptoms could be from something else other than acid reflux. PPIs are notoriously ineffective at treating symptoms that go beyond heartburn and regurgitation.

2. If your doctor prescribes PPIs to see if you have GERD, talk to them about a short 3-month course. Therapy beyond that increases the risk of unwanted side effects and can make rebound reflux worse.

3. If PPIs don’t work and you don’t experience any improvement of your symptoms, pH testing or a multiple intraluminal impedance test could help sort things out.

Typically, this procedure is performed with a thin flexible tubular scope that is inserted through your nose and passed down to your lower esophagus. The scope is placed right above your lower esophageal sphincter to determine acidity levels. (10)

Patients on PPIs will be instructed to get off of them for seven days before the procedure, to ensure the accuracy of pH findings. (10)

The idea is to see if your pH levels are abnormal when you’re off PPIs. This test can confirm the presence of acid in your throat.

4. It may be best to get a second opinion from a laryngologist(or gastroenterologist).

A laryngologist is a doctor who specializes in conditions of the larynx, voice, and disorders associated with the throat. Laryngologists tend to have much more experience than general practitioners in treating GERD. Furthermore, laryngologists have access to all the major reflux tests and can diagnose LPR more accurately.

5. Another test your doctor can perform to make sure you have LPR/GERD is a stroboscopy. A stroboscopy is generally more accurate than an endoscopy or laryngoscopy because it allows the doctor to inspect your vocal cords more closely. This is done with a flashing light that is synced to your vocal cord vibration at a slower speed. (11The stroboscopy can give you a more accurate assessment of your throat, vocal cords, and ultimately confirm whether or not you have LPR.

What’s Next

More research is needed to identify clear, accurate markers of LPR. Symptoms of hoarseness or redness in the throat are simply not enough.

Are you sure you have LPR? It may be best to get further testing to confirm your diagnosis. Getting a false diagnosis of LPR can cost you a lot of time and money.