Chronic hoarseness ≠ GERD and how to treat it?
Recently, Professor David A. Johnson (Professor of Medicine, Chief of Gastroenterology, Eastern Virginia School of Medicine) discussed the challenging issue of patients with refractory throat symptoms on the Medscape website. Medscape has compiled the following.
Refractory pharyngeal symptoms
These patients present with complaints of hoarseness, a change in tone, or discomfort in the throat, and they have been to an ear, nose, and throat (ENT) specialist who performs a laryngoscopy and thinks “it’s a red, swollen throat. A gastroenterologist needs to be consulted because, this symptom is associated with GERD.”
However, the gastroenterologist examines the patient and perhaps prescribes a medication; typically a proton pump inhibitor (PPI). Doctors may order a pH test or gastroscopy, which are generally rarely useful. I usually recommend conducting a pH check during treatment to see if the patient has reflux (acidic or non-acidic) and also to try to correlate it with the patient’s symptoms.
If patients are not improving their symptoms on proton pump inhibitors, what is going on with these patients?
Understanding patient lifestyle habits
I hope you understand an important concept that will help you to have a smooth consultation. The so-called habits require a long communication with the patient to understand.
When these patients come in, doctors hear them talk about their symptoms, often a hoarse voice, a change in tone, or a throat discomfort that makes an “um, um,” a throat-clearing sound.
What you should immediately think of is that this is a behavioral habit and these patients may be entering a cycle that they cannot change.
These patients may indeed have gastroesophageal reflux or pharyngeal reflux. As the reflux improves, patients have learned to respond to this symptom by clearing their throat or shifting their voice in a way that actually promotes the inflammatory response that is ongoing.
Because I take a history of the patient’s voice, we listen to the patient when they start talking about hoarseness or laryngeal symptoms.
As I talk about this issue in the clinic, I pay special attention to habitual behavior. I also listen to their experiences and ask questions at the same time. For example, are you a singer? Do you talk on the phone for a long time? Are you used to talking in public? Are you a mom or dad who likes to scream or shout while watching the game? Do you have vocal fatigue after a day of homework? Do you find that your voice gets a little tired or nervous? The answer to many of these questions is “yes”.
You will find a way to say not only “you don’t have GERD,” but “you can develop a way to change this habit.”
Is it repeated habitual behavior?
To help understand, I use the analogy of two-handed clapping. If you clap with both hands, your palms will become red and swollen. This is similar to vocal cord vocalization. I tell patients that when there is discomfort in the throat, they clear their throat or dry cough or cough and it will have the same effect as clapping. Doing so will perpetuate the inflammatory response.
First, you need to make sure that if the patient has reflux symptoms, the reflux can be controlled so it makes sense to try a PPI. If the patient has postnasal drip syndrome, you need to be aware of nasal reflux. If the patient has other changing environmental exposures that may make it difficult to control their nasal reflux or allergies, you need to deal with those factors.
Between patients who have not gotten any better, you need to be aware of habituation assessment.
I would ask these patients several questions, for example, about their tone of voice, the way they speak. Do they find that what people are telling them sounds different than what they are used to hearing?
As patients begin to experience voice fatigue, they will change the speed of their speech. They may speak louder to overcome what is called vocal weakness. They may change the pitch of their speech. All of these efforts take them away from the so-called quiet, serene voice while inducing an inflammatory response, and they will continue this behavior. They continue this habit of repetitive throat clearing and coughing, and cha never goes away.
Breaking the cycle
I have a good point that this sounds like a repetitive habitual behavior, and I discuss this with my patients, and then they do all kinds of things to help themselves.
One thing I insist on is that they carry a bottle of water with them and choose to drink water instead of clearing their throat every time they have a feeling of mucousy discharge, or a swelling in the back of their throat. If they have to clear their throat, I ask them not to vocalize. They should try to clear their throats gently, not harshly, while minimizing the number of clearings.
Make sure the patient understands that this is a process, an educational approach. They need to recognize that they can use their voice to control symptoms if they notice that their voice is starting to become hoarse or tired. They need to reduce talk time and lower yelling at games or parties, or any venue where voice is used excessively. In social settings, they try to keep their voices calm to keep the inflammatory response under control.
If patients fail to carry water with them, I recommend carrying lemon candy, which helps parotid salivary secretions flow more easily. These are handy to have with them when they are out and about. Emphasize hydration and inform patients to minimize the intake of dehydrating substances, such as caffeine and alcohol. If these patients smoke, have them try to quit.
Ensure that the laryngologist has examined the patient’s vocal cords or has performed an endoscopy. Make sure that all aspects of this problem are taken care of.
If cough is the main problem and the patient is a non-smoker and has no evidence of postnasal drip or allergies and is not taking angiotensin converting enzyme inhibitors, much should be resolved by changing the habit response and understanding the true cause of the patient’s cough.
Habits are important and you need to understand how to ask the appropriate questions as these can be very frustrating for the patient. They see ENT specialists and gastroenterologists, but they don’t get better. They get stuck in an ongoing cycle of reactions, even reactions that are now under control but somehow start again. The habit perpetuates the problem.
Voice retraining
I also found the involvement of a voice specialist (a class of physical therapists, specifically trained in voice) very helpful. This is not just the standard speech rehab specialist. He is a specialist who understands the responsible nature of voice retraining. They use vocalizations and exercises to help with intonation and expression, while returning their patients to a more calm voice.