What is laryngopharyngeal reflux disease?

Laryngopharyngeal reflux disease is a disorder pertaining to the voice box, vocal cords, and the upper esophagus. Acid backing up from the stomach and into the esophagus can sometimes reach the upper esophagus (pharynx) and affect structures in the area (voice box and vocal cords). Acid can cause irritation to the tissues and result in symptoms in some patients. Typical symptoms include upper respiratory problems such as asthma and chronic cough. Other symptoms may include frequent need to clear the throat, a "lump" sensation in the throat (called "globus" sensation), hoarseness, sour taste, recurrent sore throat or sensations of choking or trouble swallowing.

How is laryngopharyngeal reflux disease diagnosed?

Eliminating the possibility of other causes for symptoms such as allergies, sinus problems and pulmonary disease is important to be sure the correct treatment is started.

• Barium swallow studies (thick barium contrast solution is swallowed to see esophagus structures by x-ray and potentially note reflux of stomach contents).
• Fiberoptic nasopharyngeal laryngoscopy (a scope test performed by Ear, Nose & Throat specialists evaluating the upper esophagus and voice box).
• A small measuring device (Bravo capsule) can be placed in the lower esophagus by upper endoscopy or through the mouth to record acid events over a 48 hour period. The device has special sensors that measure how often you have acid backing up into your esophagus and how long it stays there. Alternatively, a 24-hour pH monitoring test is also available. During the 24-hour test, a thin tube is placed through the nose and into the esophagus. The tube remains in place for 24 hours and the information is recorded on a small computer monitor.
• Upper endoscopy or EGD (esophagogastroduodenoscopy) is a procedure where a small lighted tube is passed through your mouth into the esophagus, stomach and first portion of the small intestine. This test allows the doctor to see the lining of your upper GI tract and take biopsies (tissue samples) if needed.
• If symptoms resolve with trials of anti-reflux medications, the treatment may be used to diagnose laryngopharyngeal reflux disease.

What causes laryngopharyngeal reflux disease?

This problem can be caused by stomach contents backing up into the esophagus. This is allowed to occur if areas of specialized muscle tissue called the lower esophageal sphincter (LES) and upper esophageal sphincters (UES) are weakened. The LES is located at the junction of the esophagus and the stomach. The job of the LES is to act as a one-way valve, allowing food to enter the stomach and prevent it from coming back up into the esophagus. Reflux occurs when the LES is too relaxed and does not prevent stomach fluids and food from backing up into the esophagus. The UES performs the same function as the LES, but in the upper esophagus. The lining of the esophagus is not protected from stomach acid, unlike the stomach's lining. The acid contact with the esophagus, voice box, and vocal cords causes inflammation and may cause irritation of the structures leading to the symptoms of reflux.

What are the treatments for laryngopharyngeal reflux disease?

Lifestyle Changes:

• Avoid foods that cause symptoms, that cause the LES and UES to relax or that are irritating to the GI tract and may cause an increase in acid production. These foods include: caffeinated drinks (coffee, some teas, colas, and other sodas high in caffeine) chocolate, tomato based products (spaghetti, lasagna, pizza, and chili), spicy foods, citrus, garlic, onions, peppers, fatty foods, and mint/peppermint.
• Avoid using tobacco products: this means no smoking or chewing tobacco.
• If you are over weight, weight loss is encouraged.
• Avoid eating for 3 hours before you go to bed or lie down.
• Avoid wearing clothing that is tight around your abdomen.
• Eat smaller meals.
• Avoid vigorous exercise within 2 hours after eating.
• Avoid alcohol.
• Avoid the use of aspirin and other non-steroidal anti-inflammatory medicines like ibuprofen.
• Elevate the head of your bed by using 4-6 inch blocks to help prevent acid from rising up at night.
• Don't bend over after eating if you are prone to regurgitation after meals.

Medications:
Treatment with twice per day Proton Pump Inhibitors: These include omeprazole (Prilosec), lansoprazole (Prevacid), dexlansoprazole (Kapidex), pantoprazole (Protonix), rabeprazole (Aciphex) and sodium bicarbonate (Zegerid) and esomeprazole (Nexium). These medications work by stopping the production of acid by certain cells in the stomach that make acid.

Additional treatments:
If medications fail to resolve symptoms, endoscopic or surgical interventions may be necessary. New endoscopic treatment options are available to control acid reflux as an alternative to chronic medications or to avoid surgery. These options can be discussed with your gastroenterologist.

Surgery:
This option is reserved for when the above measures aren't working. It can also be used as an alternative to chronic medication therapy. The surgery is called "Nissen Fundoplication". This is a surgical procedure where the upper portion of the stomach is wrapped around the lower esophageal sphincter area to prevent reflux.

When to seek medical advice?
In cases of chronic hoarseness or no improvement in symptoms with treatment, please call your doctor for additional advice. You may be referred to ENT for additional testing to rule out other problems. If heartburn, significant trouble swallowing or chest pain occurs, please call your doctor to discuss symptoms as this is atypical for laryngopharyngeal reflux disease and may indicate other problems and a need for additional testing such as an esophagogastroduodenoscopy (EGD). If significant weight loss has occurred medical attention should be sought.