Definition and Overview

Laryngopharyngeal reflux (LPR) is a medical condition wherein gastric contents, including acid produced in the stomach, back up through the oesophagus (swallowing tube) towards the larynx (voice box) and pharynx (throat). It commonly affects patients diagnosed with gastroesophageal reflux disease (GERD).

Although closely similar to GERD, LPR is usually not accompanied by heartburn and other classic symptoms of GERD. This is why it is sometimes called silent reflux.

Causes of Condition

Stomach acid reflux linked with LPR and GERD occurs when oesophageal sphincters are not functioning properly due to certain abnormalities. This prevents them from keeping the stomach’s contents in place.

Other possible causes include:

  • Hiatal hernia

  • Abnormal oesophageal contractions

  • Slow emptying of the stomach

Some patients are more likely to suffer from LPR than others due to some lifestyle and dietary factors. These include:

  • Undeveloped sphincters - Infants with underdeveloped sphincters are more prone to experiencing reflux, especially since their oesophagus is shorter and they spend most of their time lying down. However, the condition usually resolves on its own before the baby reaches one year old.

  • Age - Patients become more likely to experience LPR as they age.

  • Patients with unhealthy dietary habits, such as overeating

  • Patients whose diet is excessively high in chocolates, citrus, fatty foods, and spices

  • Patients who are overstressed

  • Patients who regularly wear tight-fitting or binding clothes

  • Overweight or obese individuals

  • Pregnant women

LPR can cause various complications. One of the most serious is inflammation in areas of the body that do not have protection against gastric acid exposure.

Key Symptoms

Laryngopharyngeal reflux can occur with no noticeable symptoms, making it is more difficult to diagnose than GERD. However, some patients show the following symptoms:

  • Excessive mucus

  • Drainage at the back of the throat

  • Burning sensation in the throat

  • Chronic coughing

  • Post-nasal drip

  • Hoarse voice

  • Soreness in the throat

  • Difficulty swallowing

  • Bitter taste in the back of the throat

Some patients, especially those who use their voice professionally, such as singers, may also notice some changes or limitations in their voice. These include losing the higher end of their vocal range or experiencing prolonged vocal warm-up with husky or low voice quality.

In children, LPR is often accompanied by:

  • Reactive airway disease or asthma

  • Noisy breathing

  • Apnea, or abnormal pauses in breathing

  • Trouble feeding

  • Failure to thrive (or inability to gain weight)

  • Trouble spitting up

  • Cyanosis, or turning blue due to inadequate oxygen supply

  • Ear infections

  • Repeated vomiting

Laryngopharyngeal reflux is diagnosed based on visual examinations of the throat, specifically the back of the voice box. If the doctor finds any sign of swelling or irritation in the throat, the patient is likely to be suffering from LPR. The doctor may then order further testing to confirm the diagnosis. These tests may include:

  • Swallowing study - In a swallowing study, the patient is made to swallow a special liquid called barium, which coats the oesophagus, stomach, and the intestines. The liquid helps outline the organs on an x-ray as food passes through them. This allows doctors to detect signs of LPR.

  • Endoscopic examination of the stomach and oesophagus - Doctors nowadays commonly use endoscopy to visually examine the inside of the body without having to make a skin incision.

  • pH test - This test, which uses a 24-hour pH probe, determines how much acid is present in the patient’s throat.

Who to See and Types of Treatments Available

Laryngopharyngeal reflux, like other reflux diseases such as GERD or extraesophageal reflux disease, is commonly treated by a gastroenterologist. However, the condition may sometimes also require the expertise of an otolaryngologist or an ENT (ear, nose, throat) specialist if the patient’s symptoms include voice hoarseness and throat discomfort or if laryngeal lesions and inflammation are suspected.

The most effective treatment for LPR involves a combination of medication and lifestyle changes.

Medications used to treat LPR and its symptoms include:

  • Antacids

  • Foam barrier medications

  • Histamine antagonists

  • Pro-motility drugs

  • Proton pump inhibitors

Additionally, making lifestyle changes can help in preventing and treating laryngopharyngeal reflux. Many foods and drinks can make patients’ symptoms worse, so it is important that they are eliminated. The same is true for lifestyle factors that have a worsening effect on LPR patients; these include excessive alcohol consumption and smoking.

The following are treatment options for people who have LPR. These can also be used as preventative measures.

  • A low-acid, low-fat diet

  • Bland diets that avoid spicy foods

  • Eating small but frequent meals

  • Losing weight (for overweight/obese people)

  • Refraining from eating any food less than 2 hours before bedtime

  • Avoiding alcohol, tobacco, and caffeine

  • Propping up the head or upper portion of the body while sleeping

In severe, chronic cases, a surgical procedure called laparoscopic Nissen fundoplication can be considered. This surgery, which is also used to treat gastroesophageal reflux disease and hiatal hernia, is performed by a general surgeon. During the procedure, the upper part of the stomach is tied around the end of the oesophagus to reinforce the lower oesophageal sphincter. This prevents gastric contents from traveling back up towards the oesophagus. Because it is minimally invasive, the procedure is generally safe and requires minimal recovery time. However, it is only performed when medical therapy and lifestyle changes have failed to help the patient.

References:

  • Martinucci I, de Bortoli N, Savarino E, Nacci A, et al. “Optimal treatment of laryngopharyngeal reflux disease.” Ther Adv Chronic Dis. 2013 Nov; 4(6): 287-301. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3807765/

  • Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assuncao AR. “Laryngopharyngeal reflux: diagnosis, treatment, and latest research.” Int Arch Otorhinolaryngol. 2014 Apr; 18(2): 184-191. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297018/

  • Ford CN. “Evaluation and management of laryngopharyngeal reflux.” JAMA. 2005; 294(12): 1534-1540. http://jamanetwork.com/journals/jama/fullarticle/201573

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