Acid reflux is a well known and common condition. It is among the most common upper gastrointestinal conditions throughout the world, especially among adults. While most of us think of it as a condition affecting the food pipe (esophagus) and causing heartburn, the retrograde flow of stomach acid can reach as high as the throat, nose and even the sinuses.
What is reflux pharyngitis?
Reflux pharyngitis is inflammation of the throat (pharynx) caused by gastroesophageal reflux disease (GERD), also commonly referred to as acid reflux. GERD is a common condition affecting as many as 4 out of 10 Americans at some point and depending on the severity, complications such as reflux pharyngitis may arise. A sore throat, hoarseness of the voice, bitter taste in the mouth and cough may be some of the symptoms of reflux pharyngitis.
Laryngopharyngeal reflux (LPR) is the term used to describe the irritation and injury of the throat and voice box caused by acid reflux. The treatment of reflux pharyngitis primarily focuses on GERD with drugs such as antacids and acid-suppressing drugs. Dietary and lifestyle factors are equally important in managing reflux pharyngitis in the long term.
Causes of Reflux Pharyngitis
In order to understand reflux pharyngitis it is important to understand the mechanism of gastroesophageal reflux disease (GERD). Contents in the stomach are prevented from flowing backwards up into the esophagus by the lower esophageal sphincter (LES). The muscles that make up the LES tighten and close the entrance to the stomach, only to relax and open up the entrance when food has to pass down from the esophagus into the stomach.
With gastroesophageal reflux disease, the lower esophageal sphincter (LES) fails to close effectively and the stomach contents may therefore flow backwards up into the esophagus. Since the esophagus is not equipped to bear the strong digestive enzymes and acid from the stomach, it becomes irritated and inflamed. This is known as reflux esophagitis and presents with the typical symptom of acid reflux – heartburn.
The acidic stomach contents can rise up as high as the throat where it can irritate and injure the tissue leading to throat inflammation (pharyngitis). Since the inflammation is caused by GERD, it is referred to as reflux pharyngitis. The acid may even enter the airways and injure the voice box and vocal cords and is known as reflux laryngitis. It can also affect the lower airways and lungs in the same way or reach the nose and sinuses in some instances.
The risk factors for reflux pharyngitis are largely the same as for gastroesophageal reflux disease (GERD). Strenuous physical activity after eating, caffeinated beverages, alcohol and overeating can lead to acute reflux in most people. Persistent reflux is usually associated with obesity, pregnancy, hiatal hernia, smoking and diabetes among a host of other conditions. However, chronic GERD can still occur in the absence of risk factors.
Signs and Symptoms
The symptoms of acid reflux are well known. It typically present with heartburn (burning chest pain) and nausea. There may be other symptoms like excessive belching, bloating and other symptoms broadly referred to as indigestion. However, acid reflux can sometimes be almost symptom-free.
The symptoms of reflux pharyngitis includes:
- Sore throat, typically worse in the morning.
- Hoarseness of the voice
- Excessive salivation (water brash)
- Bitter taste in the mouth
- Dry cough.
- Difficulty swallowing
- Lump in the throat sensation
Many of these symptoms worsen at night or in the morning upon waking. The reason this occurs is due to the increase in gastric acid secretion at night, further weakening of the LES while asleep and the supine position (lying flat) since gravity cannot act to keep the acid down. Prolonged reflux pharyngitis can lead to chronic tonsillitis and orodental problems. Additional symptoms like chronic bad breath may therefore also be present.
Diagnosis of Reflux Pharygnitis
It is not uncommon for reflux pharyngitis to be missed especially in the backdrop of silent acid reflux. The pharyngitis (sore throat) is thought to be due to recurrent infections. However, reflux pharyngitis is relatively common and should be suspected when there is a history of GERD symptoms. Reflux pharyngitis can increase the risk of infectious pharyngitis as the acid may damage the tissue leaving it prone to infections.
The following investigations may be done to confirm the presence of GERD:
- Barium swallow (x-ray)
- Acid (pH) probe test
- Upper GI endoscopy
- Esophageal manometry
GERD is often diagnosed on the presence of symptoms and whether these symptoms respond to antacids and acid-suppressing drugs. Diagnostic investigation may not always be done.
Treatment of Reflux Pharyngitis
The most commonly used medication for reflux pharyngits is antacids, as it is easily acquired over-the-counter. However, these drugs offer short term relief by neutralizing the stomach acid. Other options include acid-suppressing drugs like proton pump inhibitors (PPIs) and H2-blockers. In severe cases, prokinetic agents like metoclopramide may be considered. Surgical procedures such as Nissen fundoplication or the insertion of a Linx device are reserved for severe cases that do not respond to medication.
Diet and Lifestyle
Dietary and lifestyle changes play an integral role in managing gastroesophageal reflux disease (GERD) and therefore reflux pharyngitis. It includes the following measures:
- Avoiding exacerbating foods and beverages such as spicy meals, alcohol and caffeinated beverages. Some individuals may find that specific foods are triggers although these are not common to others.
- Eating many smaller meals during the day rather than a few large meals is advisable. Overeating should be avoided.
- Do not lie down or sleep immediately after a meal. The last meal should be 2 to 3 hours before bedtime. Mild physical activity may assist with gastric emptying but strenuous exercise worsens GERD.
- Weight loss should be considered as part of GERD management for people who are overweight or obese.
- Tight clothing can also aggravate GERD as it increase pressure within the abdomen.
- Elevating the head of the bed can be useful as it GERD tends to worsen at night while asleep.
- Cigarette smoking should be stopped and therefore a smoking cessation program needs to be part of GERD management.