What is Laryngopharyngeal Reflux?
“Laryngopharyngeal reflux”, or LPR, is a term that describes a health condition affecting the throat and the voice box. This condition is complex and involves several factors. Generally, it’s about stomach acid escaping from the stomach, moving up into your throat and causing issues like hoarseness, or other symptoms.
Usually, your body has four defenses to stop this from happening: two muscular rings, one at the top and one at the bottom of the tube connecting your throat and stomach (the esophagus), a motion in the esophagus that moves food down towards the stomach, and protection on the surface of your esophagus. These defenses can sometimes become less effective due to various situations like anesthesia, sleep, and smoking, which can all lead to LPR.
The muscular ring at the lower end of the esophagus (lower esophageal sphincter) plays an important role in preventing stomach acid from moving up the wrong way. It works with the diaphragm, a muscle below your lungs, to prevent acid from escaping the stomach. If you have a condition called hiatal hernia, it can make this process less effective, leading to a disease called gastroesophageal reflux disease (GERD).
In a normal condition, if some stomach acid manages to escape, the esophagus uses gravity and a wave-like motion (peristalsis) to clear it out. The surface layer of the esophagus also has mucus to protect the inner lining from stomach acid. There’s an additional watery layer that helps to neutralize the acid and protect the tissue. However, these defenses can fail, causing the condition referred to as laryngopharyngeal reflux.
What Causes Laryngopharyngeal Reflux?
Being exposed directly to stomach acid can harm the tissue of your larynx, or voice box. When the environment is too acidic (lower than pH 5.0), it hinders the movement of hair-like structures called cilia. At a very acidic level (pH 2.0), these cilia completely stop moving. This is important because the cilia help to fight off infections; if they stop moving, your infection resistance drops.
Certain lifestyle choices increase the risk of this condition, known as Laryngopharyngeal reflux (LPR), which is similar to Gastroesophageal reflux disease (GERD). These include eating a diet that is high in acidic or fatty foods, caffeine or alcohol, overeating before going to bed, being obese, and smoking. Smoking is also a risk factor for a condition called Reinke’s edema, which might make your voice hoarse and drop its pitch, much like what happens with LPR.
While smoking is a major cause of Reinke’s edema, it’s important to note that this condition can occur just from chronic acid reflux affecting the vocal cords. The main differences between LPR and GERD lie in their symptoms and where the issue originates in the body. In GERD, the issue stems from a part of the esophagus called the lower esophageal sphincter, while in LPR, the problem tends to come from the upper esophageal sphincter.
Risk Factors and Frequency for Laryngopharyngeal Reflux
Laryngopharyngeal reflux is quite common and can cause a range of symptoms. Reports suggest that around 10% of patients who visit ear, nose, and throat clinics are dealing with this condition. Furthermore, up to 55% of patients experiencing voice issues may have their problems worsened due to laryngopharyngeal reflux.
- 10% of patients visiting ear, nose, and throat clinics have laryngopharyngeal reflux symptoms.
- Up to 55% of people with voice issues (dysphonia) may have these problems due to laryngopharyngeal reflux.
- Nearly all patients with laryngopharyngeal reflux complain of a hoarse voice when first diagnosed, even if they don’t have other typical reflux symptoms.
Signs and Symptoms of Laryngopharyngeal Reflux
Laryngopharyngeal reflux (LPR) is a condition that often manifests diverse symptoms, leading patients to seek medical assessment. The most common symptom among LPR patients is hoarseness, affecting virtually all of them. This is notably different from patients with gastroesophageal reflux disease (GERD), who rarely display hoarseness. However, diagnosing LPR can be complicated if patients also have GERD.
Apart from hoarseness, LPR can cause various other symptoms, such as the sensation of a lump in the throat (globus sensation), chronic throat clearing, post-nasal drip, Eustachian tube dysfunction (causing problems with hearing and balance), heartburn, other changes in voice, and regurgitation. LPR most often affects patients during the daytime, particularly those with good esophageal motor function. Conversely, those with esophageal dysmotility typically have symptoms that present at night.
GERD patients might share similar symptoms with LPR patients, barring hoarseness. However, the key distinction is that GERD involves dysfunction in the lower esophageal sphincter, whereas LPR affects the upper esophageal sphincter. A scoring tool called the Reflux Symptom Index (RSI) can help in tracking the therapeutic outcomes for patients with LPR. This tool has been validated as a reliable way to assess the severity of LPR using a patient-reported questionnaire.
The RSI consists of a nine-item questionnaire where patients rate the severity of their symptoms on a scale of 0 to 5, with 5 being the most severe. A score above ten indicates a high likelihood of reflux pathology, with the highest possible score being 45. The nine domains covered in the questionnaire are:
- Hoarseness
- Throat clearing
- Mucus or post-nasal drip
- Difficulty swallowing (dysphagia)
- Coughing after eating or lying down
- Breathing difficulties or choking episodes
- Chronic cough
- Globus sensation
- Heartburn, indigestion, or regurgitation
Medical examination tools such as laryngoscopy and videostroboscopy can be instrumental in identifying LPR in patients displaying hoarseness and other relevant symptoms. Changes in the larynx, such as thickening and abnormal growth of skin cells in specific areas, granulomas on the vocal processes, swelling, redness, excessive mucus, ulcers, and narrowing of the airway, are often seen in LPR patients. In severe cases, patients can display swelling of the vocal folds’ undersurface extending from the front to the rear, causing a ripple and groove. This condition, also known as pseudosulcus vocalis, is particularly characteristic of LPR. It is crucial, however, to distinguish this from a true sulcus vocalis (a groove where the mucosa adheres to the vocal ligament beneath it) that can result from trauma, surgery, infection, cyst rupture, and other causes.
Testing for Laryngopharyngeal Reflux
In order to diagnose Laryngopharyngeal reflux disease (LPR), a disease where stomach acid flows back into the throat, doctors typically use a method that monitors the acidity levels in the throat. This is considered the most definitive way to diagnose this condition. The process involves inserting a nasal catheter, a thin tube passed through the nose, which measures the pH level (the measure of acidity or alkalinity) for a full 24 hours. The test can have up to three probes, essentially sensors that continuously monitor acidity level just above the lower esophageal sphincter (the muscle that connects the esophagus and stomach), below the upper esophageal sphincter (the muscle that connects the throat and esophagus), and in the pharynx (the part of the throat behind the mouth and nasal cavity).
If the pH level drops below 4.0 for at least 1% of the total testing time, that suggests the presence of LPR. While imaging tests may also be used, it’s been shown they do not make the detection of the disease more likely. A study done in 1996 showed that using imaging techniques like videofluoroscopy (a type of X-ray that shows motion) and barium esophagography (a procedure where barium is swallowed to show the esophagus in X-ray) had low sensitivity, indicating these tests often missed detecting the disease.
Treatment Options for Laryngopharyngeal Reflux
Making changes to your lifestyle is the first step of managing this condition. These changes include losing weight, eating smaller meals, waiting for at least 3 hours after eating before lying down, following a diet low in fat and acid, avoiding fizzy or caffeinated drinks, quitting tobacco, and cutting down on alcohol. If these changes do not alleviate your symptoms, medical professionals may recommend certain medications. These medications, like histamine H2-receptor antagonists and proton pump inhibitors, work by reducing the production of acid in your stomach.
It’s important to note that not all reflux is acidic, so you might need additional treatments that can shield the tissue lining your stomach from alkaline or neutral stomach fluids. This could involve medications like alginate and magaldrate. If lifestyle changes and medications are unsuccessful, surgical procedures, like Nissen fundoplication, may be considered to help reduce symptoms.
What else can Laryngopharyngeal Reflux be?
There are many medical conditions that can cause symptoms similar to LPR (Laryngopharyngeal reflux). Sometimes, LPR is mistaken for GERD (Gastroesophageal Reflux Disease); however, one way to tell them apart is that LPR often causes hoarseness, while GERD usually doesn’t.
There are other conditions that can cause a chronic cough and the feeling of a lump in the throat, these include:
- Post-nasal drip caused by allergies, rhinosinusitis, or vasomotor rhinitis
- Viral or autoimmune laryngitis
- Esophageal dysmotility
- Myasthenia gravis or other neurological disorders
- Vagal nerve injury
- Functional voice disorders
- Tumors in the larynx, pharynx, or esophagus
What to expect with Laryngopharyngeal Reflux
If left untreated for a long time, laryngopharyngeal reflux, a condition where stomach acid backs up to your throat, can cause chronic damage to your voice. This can result in scarring of the true vocal folds, the delicate parts of your throat responsible for producing sound, leading to a persistent rough or scratchy sound to the voice.
In rare instances, laryngopharyngeal reflux could lead to a narrowing of the airway below the vocal cords, a condition referred to as subglottic stenosis, or to squamous cell carcinoma, a type of skin cancer.
Laryngopharyngeal reflux might also be connected to untreated GERD, which stands for gastroesophageal reflux disease, a long-term condition where acid from the stomach comes up into the esophagus. If GERD is not treated, it could eventually result in damage to the esophagus, known as Barrett’s esophagitis. If this condition is still left untreated, it can develop into a type of cancer called adenocarcinoma.
Possible Complications When Diagnosed with Laryngopharyngeal Reflux
If LPR, or laryngopharyngeal reflux, is not treated or isn’t diagnosed, it can lead to serious health issues over a longer period. Some of these complications include continual coughing, repeated inflammation of the voice box (laryngitis), mouth disorders and ulcers, and repeated injury or infections in the bronchopulmonary system, like pneumonia.
Likelihood of Complications:
- Chronic cough
- Recurrent laryngitis
- Oral cavity disorders/ulcers
- Recurrent bronchopulmonary injury/infections
- Pneumonia
There is also some suggestion that LPR might increase the risk of getting laryngeal carcinoma (cancer of the voice box), but further research is needed to clearly understand this link.
Preventing Laryngopharyngeal Reflux
Laryngopharyngeal reflux, a condition where stomach acid comes up into the throat, can generally be managed through changes in daily habits. However, it can be a little more stubborn than GERD (Gastroesophageal Reflux Disease), a similar condition, which often improves faster with the same changes. But don’t lose hope; with patience and the right adjustments, the symptoms can fade away and the need for acid-reducing medications can lessen.
Understanding and managing your condition is essential. Therefore, you’ll need to learn about lifestyle changes that can help, such as losing weight, eating smaller meals, and not lying down within three hours of eating. Also, tweaking your diet can make a big difference. Cutting back on high-fat and high-acid foods, fizzy or caffeine-rich drinks, and alcohol can prove very beneficial.
