Causes of and Treatment for Laryngopharyngeal Reflux
The scene repeats itself daily in my office: I have just informed the patient that I believe that reflux is the cause of his longstanding uncomfortable throat symptoms.
“Reflux?”, he asks. “Isn’t that from stomach acid? But I never have heartburn or indigestion! I never taste acid in my throat! My GI doctor even did an endoscopy and told me my esophagus is normal. How could this possibly be from reflux?”
Your Esophagus Can Handle Reflux; Your Larynx Cannot
The Difference Between LPR and GERD
Here’s the bottom line: we ALL reflux, at least a little. The sphincter that separates our esophagus from our stomach is just not that tight. If it were, it would be impossible to burp excessive air out of our stomachs or to vomit when we are sick. Think of all the spitting up that we do when we are babies. The fact is, reflux, the escape of stomach contents into the esophagus (and sometimes higher), is common enough that the esophagus is specially equipped with defensive mechanisms to protect itself from damage from stomach acid. The esophagus secretes special mucous to coat its lining in addition to bicarbonate to neutralize stray acid exposure. So the esophagus, forever married to the leaky stomach, can handle a little acid reflux without any trouble. The larynx, the delicate organ at the top of the windpipe, cannot handle acid reflux. And therein lays the apparent paradox.
Suppose your lower esophageal sphincter (LES), the muscle that holds the stomach closed at the top while it is churning up all the food you eat, is really loose. Also, perhaps you ate a big heavy dinner that is stretching your stomach and taking a long time to digest. Throw an after-dinner coffee in there to ramp up the acidity. Now lie down so the forces of the abdomen press up on the stomach. You may get heartburn or acid indigestion. A steady gurgling of acidic stomach contents into the lower esophagus is what gives us the classic symptom of heartburn and it happens when the protective mechanisms in the esophagus are simply overwhelmed, whether by our anatomy, our food choices, our eating behavior, or, most commonly, some combination of these. The esophagus becomes irritated and we feel it and recognize it as heartburn. This is classic GERD, or gastroesophageal reflux.
Let’s revisit your food choices and behavior mentioned above but, this time, your body, for whatever reason, does not allow the acid to escape into the lower esophagus in a steady gurgle. Perhaps your sphincter allows leakage of stomach contents only very infrequently but the tiny acid trickle tends to wick quite high up the esophagus (remember that the esophagus is not an open pipe but more like a collapsed sock), spilling out the top of the esophagus and into the throat. This could amount to no more that a drop of acid exposure at a time, far less than one would be aware of. The esophagus can handle this amount of infrequent acid exposure without developing any symptoms. The poor larynx and throat, however, lacking any of the above-mentioned defenses, are easily ravaged by even infrequent exposure to acid (one of my mentors used to ask: how would your eye feel if you put a drop of stomach acid in it once a day?). The result: sore, irritated throat; thick, annoying throat mucous; constant cough or throat clearing; hoarseness; a feeling of thickness, swelling or lump in the throat; difficulty swallowing, especially one’s own saliva. And no heartburn. Sound familiar?
We call this laryngopharyngeal reflux, or LPR. We also call it silent reflux, by which we mean that classic symptoms such as heartburn are absent. But it is not so silent if it is messing up your throat, is it? Of course it is also possible to have both kinds of reflux, if your body allows for both patterns of reflux.
50% of people with LPR also have GERD
But that also means that 50% do not. Interestingly, research shows that people with silent reflux (LPR without GERD) tend to have many of their reflux events upright and during the day, as opposed to GERD sufferers who tend to reflux more lying down at night.
Laryngopharyngeal Reflux (LPR) Symptoms
LPR is diagnosed after an office endoscopy shows the signs of acid irritation in the larynx. These signs are redness and swelling of the part of the larynx closest to the esophagus. People with irritated symptoms (sore throat, cough and throat clearing) tend to have redness, and people with obstructive symptoms (lump in the throat, thickness and trouble swallowing) tend to have swelling. It is possible to have all these symptoms or only combinations of them. Believe it or not, LPR is harder to treat that classic GERD. This again has to do with the body’s natural defenses. If you significantly reduce the amount of acid that the esophagus is exposed to over the course of the day, a person with GERD will do quite well. Not so with LPR; remember, the larynx is hypersensitive to acid and the goal of treatment is complete, 100% protection. “Significant reduction” may not be enough to allow the inflamed larynx to heal. So the initial treatment for people with LPR symptoms tends to involve higher doses of medication and must also involve changes in diet and behavior to reduce the frequency of reflux events and stomach acidity. BergerHenry ENT’s approach to treatment is to commit to a (hopefully) brief period of high-intensity therapy and then a reduction in anti-acid medication once symptoms have been resolved. This way, the patient feels better sooner, and the overall amount of medication usage can be minimized. In the end, each individual requires a different amount of medication and behavioral modification to achieve and maintain an asymptomatic state. A certain amount of customization is involved; some get off medications and maintain themselves with diet changes and an occasional over-the-counter medicine. Some require small maintenance doses but still have one cup of coffee per day. Still, some require long-term medical therapy despite their vigorous adherence to the recommended diet and behavior changes.
Treating LPR with Proton Pump Inhibitors (PPIs)
The mainstays of LPR therapy are the antacid medications known as the Proton Pump Inhibitors (PPIs). PPI’s directly inhibit the enzymes in your stomach acid (also known as hydrogen ions or protons). This class of medications includes the generic omeprazole (Prilosec is the brand name), and all of its cousins: Nexium, Prevacid, Protonix, Aciphex, Dexilant, and Zegerid. All of the generic/ drug names have “-prazole” at the end of their name. Many are now available over-the-counter. They all work on the same enzyme in the stomach, and although some are considered “stronger” than others and they may have different side effects, we use them more or less interchangeably. What you should know about them is that despite the fact that they are pretty good inhibitors of acid secretion, the body attempts to bypass them by increasing the chemical messengers that stimulate acid secretion and also by making more of the enzymes. This means that this class of medications is NOT GOOD for use “as-needed” or on an inconsistent basis. They must be taken every day or, for LPR, often twice a day, to achieve the desired effect. A skipped day or two may result in an above-normal increase in acid production.
Pairing PPIs with H2-Blockers
We often pair the PPIs up with an additional medication, called an H2-blocker. These medications include ranitidine (Zantac), famotidine (Pepcid) and cimetidine (Tagamet). Note the “-idine” ending. [The astute allergics among you will note that these drug names are similar to the medications we use for allergy: loratidine (Claritin) and …… (Allegra)]. These drugs are antihistamines, but they block the H2 receptor that is involved in digestion, not the H1 receptor that is involved in allergy response. We pair them with the PPIs to achieve a more complete acid reduction. They also make better “as-needed” medications than the PPIs because there does not seem to be quite the same acid rebound associated with their use. They are also nice transition medications when we are weaning patients off of PPIs. Diet and behavioral changes are designed to do two things: 1) reduce the acidity in your stomach, and 2) reduce the number of reflux events that you have in a day. Removing acidic food or drink (coffee, carbonated drinks, tomato and citrus products) accomplishes the first goal. Eating a diet that is low in fat and involves smaller more frequent meals helps to reduce silent reflux overall. Also helpful is not eating before bed or exercise, avoiding alcohol and caffeine (both of which loosen the sphincter) and not wearing restrictive clothing.
If, after a month or two, you do not have any response to medication and behavioral changes, then one of two things is true: either we need longer and/or stronger therapy, or we do not have the correct diagnosis. A re-evaluation, perhaps with more in-depth testing, is in order. This, depending on symptoms, may involve a barium swallow, a CT scan, a voice evaluation (including videostroboscopy) or even an endoscopy under anesthesia. Sometimes, we pair further evaluation with more intensive therapy. Our goal is always to work with you to get you better.