Laryngeal Pharyngeal Reflux (LPR)

Laryngeal Pharyngeal Reflux

Many people with throat discomfort are surprised when they are told by their doctor that they have laryngeal pharyngeal reflux (LPR). Gastric acid can cause significant inflammation when it falls on the vocal cords.

If this happens repeatedly, a person can be left with a number of bothersome throat problems. Examples include:

• Hoarseness
• Frequent throat clearing
• Coughing,
• Sensation like something stuck in the throat

There are individuals with gastroesophageal reflux disease (GERD) who have throat discomfort. People with GERD have gastric reflux into the esophagus. This typically causes heartburn and regurgitation (a sense of fluid coming up).

Many people with LPR do not have any of the typical GERD symptoms.This has lead to some controversies and misunderstandings about LPR:

• Is LPR a symptom of GERD?
• Are patients with LPR a subset of GERD?
• Is LPR a completely different medical problem?

There is not a good answer to these questions, as there is some truth to each of them. It may be easier for physicians to manage LPR if it’s approached as a completely different problem.

People with GERD nearly always have heartburn. Additionally, they:

• Usually improve quickly with appropriate medical treatment
• Frequently require life-long medical treatment
• Are at risk for developing significant damage to the lining of the esophagus, including esophagitis or sometimes Barrett’s esophagus

On the other hand, LPR is quite different. Many people with LPR do not have heartburn. Additionally, they:

• Require larger doses of medications for weeks to months before seeing any improvement
• Usually do not require long-term treatment
• Rarely develop complications

LPR frequently begins after an upper respiratory illness. However, some of the symptoms seem to linger after the cold or flu is better. The theory is that there is some reflux of stomach acid into the throat, which irritates the already irritated vocal cords. If the acid reflux continues, the damage to the vocal cords will progress.

The amount of acid reflux required to cause this is very small. This explains why most of these individuals do not have heartburn. The injury may be greater in people who use their voice vigorously, such as singers or teachers.

Individuals with persistent throat symptoms, such as hoarseness, frequent throat clearing, or coughing should seek medical attention. The feeling that there is something stuck in the throat, a globus sensation, is a classic symptom of LPR. Read More About Globus

Throat pain, weight loss, or smoking history should be considered worrisome. Throat pain is an uncommon manifestation of LPR.

Most patients eventually have a test called laryngoscopy by an ear, nose and throat (ENT) doctor. With this test, the ENT physician can visualize the vocal cords and look for the characteristic findings of LPR, such as swelling. Unfortunately, many people with normal examinations or a little redness are told incorrectly that they have LPR.

Once the diagnosis is suspected, two things will help:

1. The reflux needs to be well controlled. This usually requires a twice a day dose of a proton pump inhibitor (PPI). These powerful medications suppress stomach acid and relieve acid reflux. It often requires treatment for 2–6 months before significant improvement is seen.

2. Attempts to improve vocal hygiene should be undertaken. The person should drink plenty of liquids to prevent a dry throat. Caffeine, alcohol, antihistamines, and menthol containing cough drops all have a drying effect and should be avoided. Avoid tobacco. Care needs to be taken to not overuse the voice by shouting, whispering, speaking for a long period of time, or clearing the throat.

Throat clearing is a common symptom. However, it tends to worsen the injury. Here are 3 things that may help stop the throat clearing:

1. Try swallowing to clear the throat
2. Exhale forcefully rather than cough
3. Gently tap the vocal cords together rather than a forceful effort to clear the throat

People who improve should talk to their doctor to try to stop their anti-reflux medications. The majority of individuals with LPR do not require life-long medical treatment for their reflux.

Those who do not improve should see their doctor and consider a repeat laryngoscopic examination to re-evaluate the diagnosis.

The doctor may also consider doing a test to precisely measure acid reflux, such as ambulatory pH monitoring. In this test, a thin tube is passed through the nose and into the esophagus. The pH can be measured every few seconds for 24 hours. Rarely, people with LPR have severe enough symptoms that they require anti-reflux surgery.

Individuals with LPR usually do well with proper diagnosis and treatment. It may take several months for this to happen.

The keys to success are:

• An accurate diagnosis
• Good control of acid reflux
• Good vocal hygiene during the healing process