Acid reflux is one of the most common digestive problems. It is typically known for causing heartburn and nausea. However, reflux can affect the throat and even the mouth. When it reaches as high as the throat, it may irritate and injure the throat tissue. It can affect the voice and even cause airway or lung problems. This condition is known as LPR.
What is LPR?
Laryngopharyngeal reflux (LPR) is irritation and damage to the throat caused by acid reflux (gastroesophageal reflux disease or GERD). Laryngo- refers to the larynx (voice box) and pharyngo- refers to the throat. The stomach acid and digestive enzymes are highly corrosive. When it makes contact with tissue outside of the stomach, it can cause extensive tissue damage.
The classic symptoms of acid reflux such as burning chest pain (heartburn), nausea and regurgitation may not be evident. Instead there may only be throat symptoms like a sore throat (usually a morning sore throat), a hoarse voice and bitter taste in the mouth. Therefore LPR is associated with silent acid reflux. Both terms are used interchangeably at times.
However, it is important to note that laryngopharyngeal reflux disease is a combination of both gastrointestinal and airway disease. The symptoms extend beyond the typical heartburn and nausea since the larynx is involved. It typically affects the upper airways but can exacerbate conditions such as asthma. It is believed that a significant number of cases of asthma in infants may be related to aspiration of gastric contents into the airways.
Signs and Symptoms
The throat and airways are not equipped to deal with the acidic stomach contents. The delicate respiratory epithelium is easily injured by the acid and the ensuing inflammation in these areas lead to a host of signs and symptoms in these areas including :
- Chronic sore throat, especially a morning sore throat
- Chronic cough
- Hoarse voice
- Lump in the throat feeling
- Itchy throat – tickling, irritation
- Swallowing problems – painful swallowing (odynophagia) and/or difficulty swallowing (dysphagia)
- Abnormal breathing sounds
Initially the symptoms may be very mild and patients report excessive mucus in the throat, a constant need to clear the throat with a sore throat and hoarse voice only apparent in the morning and eases up by the afternoon/evening. Sometimes the gastric acid may reach as high as the posterior part of the nasal cavity. In these cases, patients may also report a post nasal drip and soreness on the roof of the mouth, especially upon waking.
Causes of LPR (Throat Reflux)
The stomach has mechanisms to deal with the corrosive acid and powerful enzymes within it. These mechanisms prevent the acid and enzymes from damaging the stomach tissue. However, other parts of the digestive tract are not as capable of dealing with the acid and enzymes. The airway tissue is very delicate and the acid can cause extensive damage in this area.
Weak Lower Esophageal Sphincter
Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal problem among adults. It is largely associated with dysfunction of the lower esophageal sphincter (LES). This dysfunctional sphincter cannot prevent the backward flow of stomach contents up into the esophagus. In LPR reflux, the acid reaches as high as the throat and then may pass into the airways (aspiration).
Apart from dysfunction of the lower espohageal sphincter, any increase in pressure within the abdomen can also lead to acid reflux. This may be seen with obesity and pregnancy in particular. Therefore LPR reflux is a consequence of acidic stomach contents moving upwards into the esophagus and possibly higher.
Certain foods, alcohol and cigarette smoking may be exacerbating factors. However, these are not the cause of acid reflux. The stomach has inherent mechanisms to withstand the strong acid within it. Most other tissues and organs in the body do not have these protective mechanisms against strong acid. When the acid enters the throat and voice box, it causes damage and inflammation of the tissue. In addition, it elicits coughing and choking in an attempt to expel the acidic substances.
Treatment of LPR (Throat Reflux)
Although the classic signs of GERD are not always present, LPR reflux should be considered as a possible cause of throat and airway symptoms in the absence of allergies or infections.
In untreated cases, the condition can progress to pneumonia (aspiration pneumonia) and the inflammation of the lower airways and lungs will also present with the signs and symptoms typical of these conditions. Asthmatic patients may also find an exacerbation of the condition. Shortness of breath is usually an indication of the lower airways being affected by the reflux.
LPR needs to be diagnosed and assessed by an otolaryngologist (ENT specialist). Untreated cases can lead to a host of complications like damage to the vocal cords. Treatment involves the use of antacids, acid-suppressing drugs like proton pump inhibitors and H2-blockers and medication to speed stomach emptying (prokinetic drugs). By treating acid reflux, the root cause of LPR reflux is removed.
Additional therapeutic measures may depend on the extent of airway involvement. In severe cases it may even require surgery. LPR reflux may have significant permanent airway complications that can be irreversible even with treatment. The problem is that many patients often do not seek treatment at an early stage in the disease.
Diet and Lifestyle
Certain diet and lifestyle changes can be helpful.
- Avoid foods that tend to worsen symptoms like heartburn and nausea. Some trigger foods are obvious, like spicy foods. Other foods and beverages may need to be identified through an elimination diet.
- Do not eat at least 2 hours before bedtime. Reflux tends to worsen when sleeping and is more likely to occur when the stomach is full.
- Use a specially designed wedge or elevate the head of the bed. This slight incline can limit the extent to which the stomach acid will rise.
- Do not overeat. This can trigger or worsen acid reflux. Instead eat small meals more frequently throughout the day.
- Stay away from alcohol and caffeinated beverages. Many people find that these substances tend to worsen acid reflux.