What is laryngopharyngeal reflux?

Laryngopharyngeal reflux (LPR) occurs when stomach acid back-flows or refluxes into the food channel (oesophagus) and into the throat and voice box (larynx).

What are the symptoms of laryngopharyngeal reflux?

Symptoms of laryngopharyngeal reflux include:

• Frequent throat clearing
  
• Throat itchiness
• Sensation of something in the throat
• Excessive phlegm in the throat
• Hoarse voice
• Frequent sore throat
• Chronic cough
• Heartburn

What causes laryngopharyngeal reflux?

There are two sphincter muscles in the oesophagus – the lower oesophageal sphincter (LES) and upper oesophageal sphincter (UES).

The LES is a muscle that prevents back-flow of food and acid from the stomach into the oesophagus. The UES is a muscle that prevents food and acid in the oesophagus from back-flowing into the larynx. When the LES is weak and does not close tightly, you will have gastrooesophageal reflux disease (GERD), also known as chronic acid reflux.

If acid (and digestive enzymes) from the stomach back-flows into the larynx, you will have laryngopharyngeal reflux (LPR).

How is laryngopharyngeal reflux diagnosed?

A diagnosis of LPR is achieved with a combination of detailed history, physical examination and occasionally some tests. Procedures that may be performed to diagnose this condition include:

• Fibreoptic nasoendoscopy
  A thin scope with a camera attached at the end of it is passed through the nose down to the level of the voice box in the throat under local anaesthesia.
• Barium swallow
  An X-ray test in which you swallow a dye and serial X-rays are taken to assess the dye flow from the oesophagus to stomach. The dye will line the cavity of the oesophagus and stomach and allow detection of large growths. The serial X-rays can also detect acid reflux of the dye into the oesophagus.
• 24-hour pH probe testing
  This procedure is used to evaluate the amount of stomach acid that back-flows into the esophagus and larynx. Two pH sensors (sensors that measure acidity of gastric contents) are used. One is located at the lower end of the oesophagus just above the LES and the other at the upper oesophagus or just above the UES.
• Upper gastrointestinal endoscopy and transnasal oesophagoscopy
  These procedures involve passage of a scope through the mouth or nose, into the oesophagus and stomach. In transnasal oesophagoscopy the scope can be passed through the nose with minimal discomfort and no sedation.
  
  It allows visualisation of infl ammation of the oesophagus due to acid reflux, hiatus hernia which may indicate a weak LES and also abnormal growths in the oesophagus and stomach. A sample can be taken (biopsy) if necessary to exclude cancer or infection.
  

How is laryngopharyngeal reflux treated?

The treatment of LPR is essentially similar to the treatment of gastrointestinal reflux disease (GERD) or chronic acid reflux. It consists of lifestyle modifications, dietary modifications, anti-acid medication, and rarely surgery.

Lifestyle modifications

Eat smaller, more frequent meals. A large meal will expand your stomach and increase upward pressure against the oesophageal sphincter.

Limit your intake of acid-stimulating foods and beverages. Refer to dietary modifications outlined on the following page.

Do not lie down for three hours after you eat. Lying flat makes it easier for the stomach contents to enter the oesophagus. When sleeping it sometimes helps to have the head higher than the stomach. This can be achieved by raising the head of the bed or using a mattress wedge.

Maintain a reasonable weight. Being overweight increases the pressure in the abdomen which can push the stomach contents against the LES.

Do not smoke. Nicotine in cigarettes relaxes the oesophageal sphincter. Smoking also stimulates production of stomach acid.

Do not wear tight clothing or belt around the waist. This can squeeze the stomach, forcing its contents into the oesophagus.

Dietary modifications

Avoid or reduce intake of spicy and ‘heaty’ foods such as chilli, peanuts and chocolate. Fried foods, oily foods and sugary foods like ice-cream should also be avoided. Drinks such as orange and grapefruit juice, fizzy drinks, milkshake, coffee, tea and alcohol can also worsen reflux and should be avoided.

Medications

Medications to reduce acid production include proton pump inhibitors, such as omeprazole, and histamine receptor agonists, like ranitidine. Prokinetic medicines, such as domperidone, may also be prescribed to help the stomach empty more quickly and clear acid effectively. Antacids, like Gaviscon, can form a protective layer that shields the oesophagus from damage caused by stomach acid and digestive enzymes.

Surgery to prevent reflux

Surgery may be indicated in severe LPR that does not respond to maximal medical therapy and lifestyle/ dietary modification. The surgery is performed to tighten the junction between stomach and esophagus. The procedure known as Nissen Fundoplication involves wrapping the top part of the stomach around the junction between stomach and esophagus and securing it in place.