Laryngopharyngeal Reflux

Do you constantly clear your throat??? What about cough or have persistent mucus/phelgm in the throat? Perhaps even hoarseness or lump sensation in the throat?

If you do, you may be suffering from a medical condition called laryngopharyngeal reflux or LPR!

LPR is not quite the same thing as the more common gastroesophageal reflux (GERD). First of all, regardless of whether it is LPR or GERD, reflux is when there is backflow of stomach contents going up towards your mouth instead of down into your intestines. In your esophagus (muscular tube that goes from your mouth to your stomach) there are 2 sphinteric structures to prevent reflux from happening. One sphincter is located at the junction of your stomach and esophagus (LES or lower esophageal sphincter) and the other is located at the junction of your esophagus and throat (UES or upper esophageal sphincter). Reflux occurs when these sphincteric valves fail. As the diaphragm contributes to the lower sphincter, that's why people with hiatal hernias are at risk for reflux since that's when part of the stomach gets pulled (or herniates) into the chest cavity above the diaphragm. Reflux could be either acid (most common) or digestive enzymes (pepsin, bile, etc) and other secretions. Either one can exist without the other. More on non-acidic reflux to the right. —>

So what is the difference between LPR and GERD?

Well, LPR is when the stomach acid gets past both your sphincters and end up in your throat, mouth, and sometimes even up into the back of your nose. GERD is when the stomach acid remains in the chest unable to get past your upper sphincter.

Why don't you have heartburn?

In fact, most people with LPR do not have heartburn. That is a symptom that is mainly associated with GERD. Why is that? Well, the esophagus has a protective lining that prevents acid from doing much damage. In fact, in the normal person, several episodes of reflux is normal and do not cause any heartburn symptoms. In GERD, it is only when there are excessive reflux episodes which wears off the protective lining of the esophagus do symptoms of heartburn begin.

A Word on NON-Acidic LPR

In some individuals, they actually have NON-acidic reflux in which standard anti-reflux medications mentioned on this webpage will not work. Non-acidic reflux is when stomach contents other than acid like mucus, pepsin, bile, and other digestive secretions backflow and cause damage in the throat. The symptoms are the same as for LPR, but evaluation and treatment are different. One test to look for non-acidic reflux is 24 hour Multichannel Intraluminal Impedance (MII) testing. Initial therapy would be to keep the head of bed elevated more than 30 degrees. Best way to do this is by placing 2-3 bricks/books under the legs at the head of the bed to tilt the entire bed. Or, sleep in a chair recliner. Or, purchase a mattress wedge. Sleeping with several pillows is not adequate as one needs the chest region also to be higher than your stomach (not just the head).

Medications that might help include robinul forte, Maalox (less preferable) or Gaviscon Advance made by Reckitt Benckiser (NOT the same as gaviscon sold in the United States by GlaxoSmithKline which contains significantly less of the key alginate ingredient). Read more here. Reglan is another medication that might be helpful, though has the potential for serious (and permanent!) neurological side effects. Research article regarding use of Gaviscon Advance for LPR shown here and here.

The only known "cure" is a Fundoplication surgical procedure performed by general surgeons. Trans-Oral Fundoplication is a less invasive option that requires no incisions that may also help.

NOTE: A few patients reported to us that they have successfully obtained gaviscon advance from chemistdirect.com as well as other locations (This has not been personally verified by our practice. Order at your own risk.).

How is LPR diagnosed?

The first clue are your symptoms. If you have any of the above, LPR is a strong consideration. For confirmation, fiberoptic endoscopy would be performed in order to visualize the entire length of your throat. Your physician would look for:

• Reflux mucus pooling around the voicebox
• Red, irritated arytenoids (structures at the back of the vocal folds)
• Red, irritated larynx
• Small laryngeal ulcers
• Swelling of the vocal folds
• Granulomas in the larynx
• Significant laryngeal pathology of any type
  

Further studies may be ordered to diagnose LPR including barium swallow, EGD, and/or 24 hour pH probe & multichannel intraluminal impedance studies. These studies attempt to either confirm diagnosis or look for other causes of these symptoms (ie, Zenker's Diverticulum, cricopharyngeal dysfunction, etc).

Treatment usually will last from 6 weeks to as long as 3 months. Why so long before symptom resolution? Well, because once damage to the lining occurs, it takes time for it to heal and acid suppression is required throughout the healing. This would be no different than if you burned your hand with acid which would take time to heal with resolution of the discomfort.

If medications do not help and the symptoms are unacceptable, surgical options can be considered including the gold-standard Nissen Fundoplication surgical procedure performed by general surgeons. Trans-Oral Fundoplication is a less invasive option that requires no incisions that may also help.

If LPR is affecting your quality of life, please contact our office for an appointment.

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