LARYNGOPHARYNGEAL REFLUX: A CAUSE OF CHRONIC COUGH

Chronic cough is a cough that last more than 8 weeks in adults. This is not only disturbing but also can cause sleep disturbances and impair daily activities. There are many causes of chronic cough and often difficult to pinpoint the exact cause. Laryngopharyngeal relflux is one of the cause of chronic cough that underdiagnosed.

LPR occur due to reflux of gastric content, that consist of gastric acid, pepsin, and other digestive enzymes, into throat. Gastric content will cause iritation to throat mucosa and it’s nerve endings, producing LPR symptoms. LPR, along with gastroesophageal reflux disease (GERD), belong to reflux diseases. Main symptoms of GERD is heartburn that usually occur during night and in supine position. It was thought LPR is a manifestation of GERD, but recent studies found some LPR patient doesn’t show any GERD symptoms.

Causes of reflux in LPR is thought due to weakness of upper and lower esophageal sphincters and increase of intraabdominal pressure. Esophageal sphincters are muscles that control esophageal opening, that normally closed if we are not swallowing. When these muscles fail to close, gastric content may travel back up into esophagus and throat. Factors associated with LPR are eating habits, thight clothes, and overweight. Oily, acid, and spicy food, and alcoholic beverages consumption contribute to LPR. Thight clothes can cause intraabdominal pressure that cause gastric content reflux into esophagus and throat. Stress known to cause increase acidic level of gastric contents.

Chronic cough is only one of the symptoms of LPR, other symptoms include throat clearing, lumps in thorat, hoarseness, and asthma-like dyspnea. If GERD symptoms mainly occur at night and in supine position, LPR symptoms occur during day and in upright position. Sometimes refluxates may reach nose and ears causing nasal discharge, congestion, ear fullness, tinnitus, and vertigo. Various and unspesific symptoms of LPR may delay the diagnosis of LPR. Patients usually visit many doctors and already received various treatment, but with unsatisfactory results.

Anamnesis of symptoms and physical examinations are the first step of diagnosis of LPR. Otorhinolaryngologist will perform throat examination using endoscopy to evaluate signs of LPR. These signs are redness, swelling, mucus accumulation, and granulation tissue in larynx. These anamnesis and endoscopic examination result incorporated into reflux symptom index (RSI) and reflux finding score (RSF), and if the score reaches certain point, patient will diagnosed with LPR.

Other method to diagnose LPR is 24 hours pH monitoring using probes placed in upper and lower part of esophagus. This procedure is quite uncomfortable and sophisticated, thus seldom used in daily practice. Esophageal endoscopy that can be performed by otorhinolaryngologist and internist can evaluate LPR and GERD signs.

Management of LPR includes behaviour modification, medicament, and surgery. behaviour modification includes eating habit changes, sleep position, lifestyle changes, reduce weight, and exercise. Patient advised to avoid oily, acid, spicy, and high calorie meals, coffee, and carbonated beverages. Lying after meal also need to be avoided to allow gastric emptying. Last meal before sleep should be 2-3 hours prior.

Rising head using pillows and lying on left side can reduce LPR symptoms. Patient also advised to use loose clothes to reduce intraabdominal pressure and gastric content reflux. Smoking and alcohol cessation should be promoted. Smoking known to cause increase gastric acid production, and alcohol increase reflux. Obesity and low exercise also associated with LPR, thus patient may benefit from weight reduction and exercise at least 30 minutes everyday.

Medications that reduce gastric acid production are the main therapy for LPR. These medication usually given for 3-4 months period. Other medication includes promotility that increase gastric emptying and mucosal protector. Fundoplication surgery usually performed to GERD patients that unresponsive to maximal medication, but it’s efficacy in LPR patients is still controversial. Decision to perform surgery in LPR patient should be done after deep consideration.

LPR is quite prevalent in daily practice but mostly unnoticed because of various and unspecific symptoms, even among doctors. Acurate diagnosis and therapy are important to achieve good result and avoid complications. Good patient compliance is needed in LPR management because long duration of medication and behavioural changes.