Laryngeal Reflux Disease (LPR), often called “silent reflux,” is a condition where stomach contents (acid and enzymes like pepsin) flow back up the esophagus and into the throat and voice box (larynx). Unlike gastroesophageal reflux disease (GERD), LPR often does not cause heartburn, leading to its “silent” nickname. It primarily irritates the sensitive tissues of the throat and larynx, causing symptoms related to the upper airway.
Causes:
LPR occurs when the muscular rings (sphincters) that separate the esophagus from the stomach (lower esophageal sphincter – LES) and the throat (upper esophageal sphincter – UES) do not function properly, allowing stomach contents to reflux upwards. Several factors can contribute to this:
- Esophageal Sphincter Dysfunction: The LES or UES may relax inappropriately, allowing reflux to occur.
- Hiatal Hernia: A condition where part of the stomach bulges up through the diaphragm, which can weaken the LES.
- Increased Abdominal Pressure: Factors like obesity, pregnancy, tight clothing, or overeating can increase pressure on the stomach, pushing contents upwards.
- Dietary and Lifestyle Factors: Certain foods and habits can weaken sphincters or directly irritate the throat. These include:
- Acidic foods (e.g., citrus, tomatoes)
- Fatty or fried foods
- Spicy foods
- Caffeine
- Carbonated beverages
- Chocolate
- Peppermint
- Alcohol
- Eating large meals, especially close to bedtime
- Smoking
- Physical Activities: Bending over, strenuous exercise, or even singing can build pressure that may trigger reflux.
- Sleep Position: Lying flat can allow reflux to travel more easily into the throat.
Symptoms:
The symptoms of LPR are primarily related to irritation of the throat and larynx. They can be chronic and bothersome, often without typical heartburn.
- Hoarseness: A raspy or rough voice, often worse in the morning.
- Chronic Cough: A persistent, dry cough, often worse after eating or lying down.
- Frequent Throat Clearing: A constant urge to clear the throat.
- Sensation of a Lump in the Throat (Globus Sensation): A feeling like something is stuck in the throat, which does not go away with swallowing.
- Sore Throat: Chronic irritation or burning sensation in the throat.
- Excessive Mucus or Phlegm: A feeling of thick mucus in the throat.
- Difficulty Swallowing (Dysphagia): Sensation of food sticking or difficulty moving it down.
- Bitter Taste: A bitter taste in the back of the throat, especially in the morning.
- Postnasal Drip Sensation: Feeling of mucus dripping down the back of the throat.
- Voice Fatigue or Breaking: Difficulty with vocal performance.
- Asthma-like Symptoms: In some cases, LPR can trigger or worsen asthma, croup, or noisy breathing (stridor), especially in children.
Diagnosis:
Diagnosing LPR relies on a thorough medical history, physical examination, and sometimes specialized tests, as there is no single definitive test.
- Medical History and Physical Exam: The doctor will ask detailed questions about your symptoms, lifestyle, diet, and any factors that worsen or improve your condition. They will examine your throat, nose, and voice box.
- Laryngoscopy: An ENT (ear, nose, and throat) specialist uses a flexible or rigid scope to visualize the throat and voice box directly. They look for signs of inflammation, redness, swelling, or irritation caused by reflux.
- pH Monitoring:
- Dual-probe 24-hour pH monitoring: A thin tube with pH sensors is inserted through the nose into the esophagus and throat to measure acid exposure over a day. This is the most objective test.
- Reflux symptom index (RSI) and reflux finding score (RFS): Questionnaires and scoring systems used by doctors to assess symptoms and findings.
- Trial of Proton Pump Inhibitors (PPIs): Often, a course of acid-reducing medication is prescribed as a diagnostic trial to see if symptoms improve.
- Esophageal Manometry: Measures pressure and movement in the esophagus to rule out motility disorders.
- Barium Swallow (Esophagram): An X-ray study to observe the movement of food and liquid through the esophagus and detect structural abnormalities.
Treatment:
Treatment for LPR often involves a combination of lifestyle changes, dietary modifications, and medications. Consistency is key for managing symptoms.
- Lifestyle and Dietary Modifications (First-line treatment):
- Avoid eating and drinking for 2-3 hours before lying down or bedtime.
- Eat smaller, more frequent meals.
- Limit or avoid trigger foods: acidic foods, spicy foods, fatty foods, chocolate, peppermint, caffeine, carbonated drinks, alcohol.
- Elevate the head of your bed by 4-6 inches using blocks under the bedposts (not just extra pillows).
- Lose weight if overweight.
- Quit smoking and avoid secondhand smoke.
- Avoid wearing tight clothing around the waist.
- Manage stress.
- Avoid excessive throat clearing; try swallowing or sipping water instead.
- Medications:
- Proton Pump Inhibitors (PPIs): Reduce stomach acid production (e.g., omeprazole, lansoprazole, esomeprazole). Often prescribed at a higher dose than for GERD and taken before meals.
- H2 Blockers (Histamine-2 receptor antagonists): Also reduce stomach acid (e.g., famotidine). May be used in combination with PPIs or for breakthrough symptoms.
- Antacids/Alginates: Provide temporary relief by neutralizing stomach acid or forming a protective barrier (e.g., Gaviscon Advance).
- Surgery:
- Anti-reflux surgery (Fundoplication): Rarely considered for LPR, typically only when severe symptoms do not respond to aggressive medical and lifestyle therapies, and objective reflux is confirmed. It involves wrapping part of the stomach around the lower esophagus to strengthen the LES.
- Voice Therapy: May be recommended by a speech-language pathologist for hoarseness or voice changes related to LPR.
LPR is a chronic condition that requires consistent management. Working closely with an ENT specialist and a gastroenterologist can help achieve symptom control and prevent long-term complications.
