What is laryngopharyngeal reflux (LPR) ?

LPR is a disease in which acid from the stomach flows back (refluxes) up to the voice box/ throat causing irritation and damage to the lining of these organs. If the acid reflux also causes damage to the lining of the esophagus, then a diagnosis of gastroesophageal reflux disease (GERD) is made. The lining of the throat and voice box is more easily damaged by acid reflux than the esophagus hence LPR commonly exists without GERD.

Normal reflux.

Transient normal reflux without symptoms can typically occur after meals. Acid reflux becomes a disease when a person develops symptoms or when the lining of the affected organs is damaged.

What is the cause of LPR ?

The cause is largely unknown but it is postulated that LPR is due to a malfunction in the "natural valve" or sphincter in the upper part of the esophagus. This valve, which should open only when we swallow, malfunctions, thus allowing acid from the stomach to reflux up into the throat/voice box.

Symptoms of LPR:

Sensation of lump in the throat.

Frequent throat clearing.

Excess phlegm in the throat.

Persistent hoarseness of the voice.

Persistent sore throat.

Chronic cough.

Painful swallowing.

Difficulty swallowing.

• Patients with LPR rarely have heartburn, which is the commonest symptom of GERD .

Complications of LPR ?

LPR mainly causes organ inflammation which brings about the symptoms mentioned above. Severe LPR can cause life-threatening spasms, narrowing or cancers of the voice box.

How is LPR diagnosed ?

LPR is diagnosed based on symptoms, endoscopy and response to treatment.

Flexible Nasoendoscopy

This is a clinic procedure used to evaluate the throat and voice box. Under a local anesthetic, a small flexible tube with a light source is passed through the nostrils and then passed down to the throat and voice box to view the lining of these structures. LPR causes a few typical changes in the voice box.

Occasionally, the damage to the voice box / throat is too minor for the nasoendoscopic examination to detect. In such instances, if the clinical suspicion for LPR is high, a course of medication is prescribed and the response to treatment is used to confirm the diagnosis of LPR.

Transnasal Esophagoscopy (TNE)

This is also local anesthetic procedure that is done in the clinic. This endoscope is similar to the nasoendoscope except that it is a longer tube with special features that allow us to examine the esophagus. Patients with long standing or recurrent LPR symptoms and those who have heartburn may have esophageal inflammation or a condition called Barrett’s esophagus (pre-cancer) due to the acid reflux (GERD). The TNE is used to evaluate the lining of the esophagus and tissue biopsies are taken if necessary.

Treatment of LPR.

Patients receiving LPR treatment may take several months to recover.

Medication :

Proton-pump inhibitors form the cornerstone of anti-reflux therapy for LPR. This medication is very effective for decreasing stomach acid production. The treatment duration is for at least 6 months and the medication must be taken about 1 hour before meals. Some patients require life long treatment. Certain diet and lifestyle modifications should be followed to reduce acid reflux.

Diet and lifestyle modification :

§ Avoid reflux inducing foods like excessive caffeine, chocolate, alcohol, peppermints and fatty foods.

§ Avoid late meals – Lying down with a full stomach makes reflux more likely. You should not lie down for two to three hours after eating.

§ Eat smaller meals but more frequently.

§ Elevate your head a few inches while you sleep. You can place bricks, blocks or anything that's sturdy under the legs at the head of your bed. You can also use a wedge-shaped pillow, to elevate your head. With the head higher than the stomach, gravity helps reduce reflux.

§ Don't wear belts or clothes that are tight fitting around the waist- tight clothes squeeze the abdomen causing stomach contents to reflux up.

§ Don’t smoke – smoking relaxes the esophageal sphincter.

§ Weight loss – in significantly overweight people, losing weight may help reduce reflux.

Is LPR curable ?

The treatment for LPR described above does not cure the reflux. Rather, it prevents the acid reflux from damaging the lining of the throat/voice box and esophagus thus alleviating the symptoms. A number of surgical operations (fundoplication) can be performed to prevent reflux in patients not responding to medication or in those with severe life-threatening LPR.