by Dr. Christopher Chang, last modified on
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 a few
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).
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. This situation also leads to a shorter esophageal length as the stomach is closer to the throat with a hiatal hernia. 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 here.
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.
In the throat, there is no protective lining. Therefore, even one single episode of LPR could cause symptoms. If an individual has LPR and only has one or two reflux episodes that get up into the throat, these few episodes would not cause heartburn as the protective lining of the esophagus would be present, but cause LPR symptoms. Indeed, research has shown that it takes as few as three reflux events to cause voicebox inflammation and injury. It has also been found to be a risk factor for throat cancer [more info].
Furthermore, sensory nerve endings in the throat region is much closer to the surface then further down in the esophagus. As such, symptoms will occur more readily with less irritation from LPR events [more info].
What are the symptoms of LPR?
A patient may have some or all of the following:
- Chronic (ongoing) cough
- Frequent throat clearing
- Constant mucus or phelgm in the throat
- Dry or sandpaper like sensation in the throat
- Pain or burning sensation in the throat
- Feeling of a lump in the throat (globus pharyngeus)
- Problems swallowing
- Bad/bitter taste in the mouth (especially in morning)
- Asthma-like symptoms
- Ear pain and/or persistent ear infections
- Post-nasal drip
- Large lingual tonsils
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
- Irritated arytenoids (structures at the back of the vocal folds)
- Irritated larynx
- Small laryngeal ulcers
- Swelling of the vocal folds or around the vocal cords
- Granulomas in the larynx
- Significant laryngeal pathology of any type
Further studies may be ordered to diagnose LPR including barium swallow, esophagoscopy, 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).
A simple spit test can also be performed to determine if LPR is present as well. This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. You can purchase the test online here. We recommend the standard 3 sample kit. It typically takes about 1 week to get the results back. For most accurate results, make sure you get the "phlegm" in your throat and not just the spit in your mouth. This may require aggressive hocking up of the phlegm.
There is an even worse LPR condition called nasopharyngeal reflux where the reflux does not just reach the throat level, but can extend all the way up into the nose! Called nasopharyngeal reflux, this possibility is raised with certain abnormal endoscopic findings seen in the very back of the nose. Known as mulberry like changes of the posterior inferior nasal turbinate, the mucosa is not just swollen, but bumpy in appearance [reference]. The full clinical picture needs to be considered as well given mulberry inferior turbinates may also occur due to allergies and rhinitis medicamentosa, though the mucosa tends to be more "smooth" in appearance for these other conditions.
How is LPR treated?
- Stress Reduction: Stress increases risk of GERD and LPR by stimulating acid production in your stomach.
- Drink alkaline water (pH>8)
- Avoid the following foods
- Spicy, acidic and tomato-based foods like Mexican or Italian food.
- Acidic fruit juices such as orange juice, grapefruit juice, cranberry juice, etc..
- Fast foods and other fatty foods.
- Caffeinated beverages (coffee, tea, soft drinks) and chocolate.
- For those suffering from phlegmy throat, avoid dairy, wheat, and egg which are probably the top 3 most common mucus generating foods products.
- Adjust your meals:
- Do not gorge yourself at mealtime
- Eat sensibly (moderate amount of food)
- Eat meals several hours before bedtime
- Avoid bedtime snacks
- Do not exercise immediately after eating
- Lose weight! Being overweight can dramatically increase reflux.
- Elevate the head of your entire bed 4-6 inches by placing books, bricks, or a block of wood under the legs of the bed to achieve a 20-30 degrees or more slant.
- Avoid tight belts and other restrictive clothing.
- Stop smoking! Smoking dramatically increases reflux.
If these more conserative measures do not adequately address LPR, there are medications one can take. Such medications include proton pump inhibitors like Prilosec or Prevacid (which are over-the-counter) as well as Nexium, protonix, etc as well as H2-blockers like zantac, pepcid, axid, etc. There are also prescriptions your physician may prescribe. Be aware that these medications only work for acid reflux. If you are suffering from non-acidic reflux, alternative treatments need to be pursued (click for more information). Check out our online store for different types of reflux meds that you can buy over-the-counter.
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.
Unfortunately, medications do not help everybody. Indeed, one study found that up to 30% of patients will not improve with reflux medications.
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 and other incisionless lower esophageal sphincter tightening procedures are less invasive options that that may also help.
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- New Non-Invasive, Non-Medication Treatment for Laryngopharyngeal Reflux (LPR)
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- I Am Taking a Reflux Medication & My Symptoms are Not Improving!
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- Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults
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