From silence to omnipresence: perspective on The evolution of laryngopharyngeal reflux

I have been interested in laryngology for thirty-five years; but 1981 was a watershed year for me. That’s when I stopped doing the oto and rhino parts of otorhinolaryngology. That same year, I first became aware of gastroesophageal reflux disease (GERD) that affected the larynx. Ever since, I have specialized in laryngology and laryngopharyngeal reflux (LPR) has been the main focus of my research. From a personal perspective, the early years of LPR weren’t easy. For at least a decade people were very skeptical, even laughed, when I spoke about LPR at national meetings.  The apparent joke was that I was delusional, that I was so preoccupied with LPR that reason and good judgment had abandoned me. That LPR remains so controversial is surprising as there is now credible science; and I believe that clinical observations that I had in the 1980s, expressed in my Triological thesis will stand the test of time.

Some people who deserve credit for seminal thinking in LPR and who most influenced me were Nels Olson, Paul Ward, Paul Chodosh, and Bob Toohill. I remember Dr. Olson warning me that LPR was contentious. He told me that some of his academic contemporaries had tried to discredit him because of his beliefs that LPR was ubiquitous and caused a myriad of airway diseases. Of course when Dr. Olson talked about reflux, it was GERD. It wasn’t until 1991 that I coined the term laryngopharyngeal reflux, the same year as the publication of my thesis.1 I felt that we needed a new term to for the type of “silent” reflux disease that our patients demonstrated. I chose the term laryngopharyngeal reflux to call attention to the fact that the symptoms and manifestations were laryngeal and pharyngeal, that is, not esophageal. I also believed that the diagnosis and treatment of LPR were different than those for GERD.

The idea was to intentionally create a nosological schism between the specialties so that otolaryngologists would consider new ideas that were not yet acknowledged by gastrointestinal (GI) colleagues. Incidentally, the term silent reflux was coined by Dr. Walter Bo, chair of the anatomy department at Wake Forest University. Walter was my patient in 1988, and he had LPR.  After I had explained how one could have reflux without heartburn, Dr. Bo rolled his eyes and then announced, “I see; I have the silent kind of reflux.”

Early on I recognized that LPR was controversial, because for almost five years I couldn’t get anything published on the subject. Papers on the laryngeal findings, prevalence of LPR, as well as papers about the possible relationship between LPR and laryngeal cancer were rejected outright.  Perhaps intended as a warning, the comments of one anonymous reviewer for a prestigious journal were forwarded to me, “Something has to be done about Koufman’s preoccupation with GERD”;  and the reviewer went on to actually suggest that I was on the payroll of one of the big pharmaceutical companies. This was certainly untrue! I was surprised and disappointed by that communication and its implications; it wasn’t exactly a positive testimonial for peer review.

Even before publication of my thesis, it was apparent that resolution of the controversies about the diagnosis and treatment of LPR, as well as its causal relationship to airway disease, would require credible bench research, that is, more than pH-monitoring data. Table 1 summarizes many of the types of research that have helped establish LPR entity.  Twenty years later, the cell biology of LPR is beginning to yield some answers about epithelial defenses of the larynx, the mechanisms of reflux-related inflammation and tissue injury, and the causal relationship between LPR and many laryngeal diseases.

Jamie A. Koufman, M.D., F.A.C.S.
Jamie A. Koufman, M.D., F.A.C.S., Director, Voice Institute of New York

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