S4 Ep 2: Persistent Throat Symptoms

Welcome to the latest episode of BLA Connect, A Clear Voice, where we join host, Natalie Watson and Mr James O’Hara, Clinical Senior Lecturer at Newcastle University and Honorary Consultant Otolaryngologist at Newcastle-upon-Tyne Hospitals, to talk about a topic that is incredibly common in the laryngology clinic – persistent throat symptoms.

James and Natalie discuss the many and varied causes of an irritated larynx and persistent throat symptoms, and the historic low-level of evidence for standard treatments such as proton pump inhibitors. The results of the TOPPITS (Trial of Proton Pump Inhibitors) run by James O’Hara with Prof Janet Wilson showed that these were no more effective than placebo treatment. So where does that leave us? Treatment is moving towards the use of alginates, such as Gaviscon, and James is involved in a new pre-clinical trial, (TALGITS – Trial of Alginates and Throat Symptoms) to look at the effectiveness of these in treating persistent throat symptoms and hopefully improve the management of these symptoms in primary care.

Ultimately, we all want to provide the best care for patients and providing a diagnosis or label for their symptoms can seem a good way of doing this. However, the lack of clear treatment pathway for persistent throat symptoms can lead to unnecessary worry with patients often referred to Head and Neck Cancer clinics. When we do see patients in clinic, James and Natalie emphasise the importance of letting the patient talk, being honest about the lack of evidence-based treatment in this area, considering comorbidities such as fibromyalgia and chronic pain symptoms, and discussing behavioural modifications and strategies for how patients can take ownership of and manage their own symptoms.

The take home message from this episode must be to always question and improve what we do for the patient’s benefit. 

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Chapters

• 1:17 Introduction to the topic and guests.
• 1:43 Let's start with the concept of laryngo-pharyngeal reflux or LPR… What's your take on throat symptoms and LPR?
• 3:17 I guess if people see a bit of redness, bit of swelling, erythema and oedema, and different things in the reflux finding scale, then we just point towards reflux don't we?
• 4:29 My big bugbear is there's no real gold standard investigation to prove reflux in the larynx and pharynx.
• 5:06 An irritated larynx and the consequences of an irritated larynx can be from refluxate from the stomach, but it also might come from a number of other irritations... Are these as likely to be the cause of persistent throat symptoms as reflux?
• 6:47 Let's go back to the beginning of what got you interested in throat symptoms?
• 8:20 We have to try and give our patients some kind of trust in us. We're seeing this irritation; we've got to give it some kind of label and most of us do say, that's a bit of reflux or that's an irritation. And a lot of it is based on sand really, isn’t it?
• 9:47 You were instrumental in the TOPPITS study with Prof Janet Wilson. Can you maybe give us a brief summary of that with the outcome?
• 11:58 So persistent throat symptoms, just to be clear for everyone who's listening, would be globus, pain in the throat, hoarseness, cough, throat clearing, those types of things?
• 14:49 You're now looking at recruiting for a new follow-on trial with Gaviscon Advance. Can you tell us a bit more about that?
• 21:51 That's actually the only thing that matters, that patient reported outcome measures improve, whatever the treatment course is, because what are we trying to treat here? Are we trying to treat a picture on a screen, or are we trying to treat the person?
• 22:29 More and more I've been looking at patients and really digging deep into what other co-morbidities they have… I think chronic pain, fibromyalgia, may be related to hypersensitivity of the larynx in certain cases.
• 26:12 I look forward to hearing the results of the trial. If people do want to still get involved, who is it open to [and how should they get in touch]?
• 27:20 Once we've got all this evidence and with the evidence that we've got so far, what's your personal approach to someone coming in with persistent throat symptoms?
• 31:23 What are your take-home messages?