Laryngopharyngeal Reflux Disease (LPR)

What is Reflux?

When we eat something the food reaches the stomach by traveling down a muscular tube called the esophagus. Once the food reaches the stomach the stomach adds acid and pepsin (a digestive enzyme) to digest the food. The esophagus has two sphincters (bands of muscle fibers that close off the tube) to help keep the digested food, acid, and pepsin where they belong. One sphincter is at the top of the esophagus (at the junction with upper throat), and the other is at the bottom of the esophagus (at the junction with the stomach). The term reflux means "a backward or return flow" and refers to the backward flow of stomach contents up through the sphincters and into the esophagus or throat.

What is GERD and LPRD?

GERD (Gastro-esophageal Reflux Disease): An excessive amount of reflux of stomach acid up through the lower sphincter and into the esophagus - commonly associated with "heartburn."

LPRD (Laryngopharngeal Reflux Disease): Reflux that makes it all the way up through the upper sphincter and into the back of the throat. The structures and tissues of the lungs and throat (pharynx, larynx, vocal folds) are much more sensitive to stomach acid and digestive enzymes than is the esophagus, so smaller amounts of reflux into this area can cause more damage - uncommonly associated with "heartburn."

Why don't I have heartburn and stomach problems?

This is a question often asked by our patients with LPRD. The fact is that very few patients with LPRD experience significant heartburn. Heartburn occurs when the tissue in the esophagus becomes irritated. Most of the reflux events that can damage the throat happen without the patient ever knowing they are occurring. We have learned from pH probe testing (see "Is There Diagnostic Testing for LPRD?"), that most LPRD events occur during the day. Singers may be at increased risk for reflux merely by using proper diaphragmatic breath support.

What are the common symptoms of LPRD?

Hoarseness	Bad/bitter taste in mouth
Chronic (on-going) cough	Asthma-like symptoms
Frequent throat clearing	Referred ear pain
Pain or sensation in throat	Post-nasal drip
Feeling of "lump" in throat	Singing: Difficulty hitting high notes
Problems while swallowing

How do you diagnose LPRD?

The following signs seen by the physician are strong indicators of LPRD.
• Red, irritated arytenoids (structures as the back of the vocal folds)
• Red, irritated larynx
• Small laryngeal ulcers
• Vocal fold swelling
• Granulomas in the larynx
• Evidence of hiatal hernia (may or may not be associated with reflux)
• Significant laryngeal pathology of any type

Is there diagnostic testing for LPRD?

We can be fairly certain of the diagnosis from the patient history and physical examination. Based on this presumptive diagnosis, we usually begin treatment for a trial period. However, the 24-hour pH probe (Pharyngo-esophageal pH monitoring) is the gold standard for monitoring reflux events associated with LPRD. A small tube is passed through the nasal passage into the esophagus, in order to monitor the amount and type of reflux during a patient's typical day. One of the biggest advantages is that it allows testing of the patient's system without interfering in the performance of his/her daily routine. In LPRD patients, it is important that the upper channel of the probe is placed at the level of the laryngeal (voice box) outlet. We may refer you to a Gastroenterologist (stomach doctor) for this testing.

What is the treatment for LPRD?

1. Stress: Take significant steps to reduce stress! Make time in your schedule to do activities that lower your stress level, such as exercise. Even moderate stress can dramatically increase the amount of reflux.

2. Foods: You should pay close attention to the way your system reacts to various foods. Each person will discover which foods cause an increase in reflux. As the following foods have been shown to cause reflux in many people, it may be necessary to avoid or minimize some of the following foods:
• Spicy, acidic and tomato-based foods like Mexican or Italian foods
• Acidic fruit juices such as orange juice, grapefruit juice, cranberry juice, etc.
• Fast foods and other fatty foods
• Caffeinated beverages (coffee, tea, soft drinks)
• Peppermint and chocolate.

3. Mealtimes: Do not gorge yourself at mealtime. Eat sensibly (moderate amounts of food), eat meals several hours before bedtime, avoid bedtime snacks, and do not exercise immediately after eating.

4. Bodyweight: Try to maintain a healthy body weight. Being overweight can dramatically increase reflux.

5. Nighttime Reflux: If the 24-hour pH monitoring demonstrates nocturnal reflux, elevate the head of your bed 4-6 inches with books, bricks, or a block of wood to achieve a 10° slant. DO NOT prop up your body with extra pillows. This may increase influx by kinking the intestinal tract. As recent studies have shown that reflux occurs much more often during the day when the patient is upright, elevating the head of your bed may be less important than once believed.

6. Tight clothing: Avoid tight belts and other restrictive clothing.

7. Smoking: If you smoke, STOP!! This dramatically causes reflux and many other evils to your body!!!

8. Other reflux factors: NSAIDS (e.g. Advil^® type medications), aspirin, steroids; all aggravate reflux.

9. Colas and other acidic drinks: The active ingredient in Cola is phosphoric acid. Its pH is 2.8 and will dissolve a nail in about four days. Other acidic beverages and juices with increase or aggravate reflux.

Are there medications for LPRD?

Medications such as proton pump inhibitors may be prescribed by your physician.