Laryngopharyngeal ("Silent") Reflux
Laryngopharyngeal reflux (LPR) can cause a wide variety of symptoms in the head and neck region. It is a condition that is sometimes overlooked by doctors, as frequently there are no other classical symptoms of gastro-oesophageal reflux (GORD), such as a burning feeling in the chest, or pain around the stomach after eating. I have a specialist interest in the management of LPR, and am a founding member of the pioneering reflux multidisciplinary team at RefluxUK.
What is LPR?
LPR occurs when the contents of the stomach travels back up the gullet to the back of the throat and nose, and sometimes into the airways. The contents of the stomach is usually quite acidic, and also contains a number of substances that can irritate and inflame these areas. The gullet has good protective mechanisms to protect it from exposure to the contents of the stomach. As a consquence it can be exposed to gastric contents repeatedly without necessarily causing any symptoms. However, the back of the nose, the throat and the airways don't have such good protective mechanisms, so small amounts of exposure to gastric contents can cause inflammation in these areas. This is why it is sometimes called 'silent' reflux, as in about 80% of cases, patients just have throat symptoms, without any of the classical symptoms of reflux such as indigestion and heartburn.
What are the symptoms of LPR/Silent reflux?
LPR can cause various symptoms, that can occur either by themself, or in combination. Some people have a sensation of a lump in their throat, others a pain in their throat, (sometimes, but not always a burning type). If the vocal cords become inflamed, then it can cause a husky/hoarse voice. Irritation of the voicebox, or reflux going into the airway can cause an irritating cough. A common symptom is the sensation of mucus at the back of the nose or throat, which often causes people to continually clear their throat. In some cases it can cause difficulty swallowing. The ears also drain into the back of the nose via the Eustachian tubes, so occasionally LPR can cause problems with blocked ears.
Occasionally, LPR is associated with more serious illnesses. Longstanding LPR can give rise to complications, and occasionally other conditions can masquerade as LPR. If you have symptoms of LPR and the following conditions apply then a specialist referral is appropriate:
- Neck swelling or lump
- Gruff or hoarse voice for more than three weeks
- Smoking or excessive alcohol consumption
- Age over 50
- Food sticking in the throat ('dysphagia')
- Coughing up blood
- Unexplained weight loss
- Persistent indigestion
- Persistent hiccups
- Recurrent vomiting
- Persistent cough
- Regurgitation (bringing back up food after eating)
Diagnosis, or How do you know if you have LPR?
So how do you know if you've got LPR? It's sometimes more difficult than it sounds. If you have some of the symptoms I've just mentioned, it may be the case that you have LPR. However, there are other conditions that can cause these symptoms, which can make diagnosis difficult. There are quite a few tests that are often helpful, but none of these will tell you with certainty if you have LPR.
In addition to the history of the condition, an examination can be helpful. Usually this involves a telescope examination through the nose to examine the back of the throat and the voicebox, and sometimes a telescope examination of the gullet and stomach.
There are also other tests known collectively as gastro-oesophageal physiology tests that involve placing a tube through the nose and down into the stomach, or attaching a small probe to the lining of the gullet (BRAVO test). These probes stay in place for 24 hours or more and can measure acid reflux and the pressures in the gullet, helping make a diagnosis.
Trials of treatment can also play a role in diagnosing the condition. Usually this is with a class of medicine known as proton pump inhibitors, or PPIs. The most common of these are omeprazole and lansoprazole. These act by suppressing acid production in the stomach, and can be a very effective treatment in the 60 or so percent of patients who have acid reflux. However, because the throat is much more sensitive to injury, it often takes many months of treatment to have an effect. There is also the issue that this form of treatment may not help the 40% of patients that have non-acid reflux. To confuse matters further, a significant number of patients taking this medicine will feel better, even though the medicine isn't actually treating the condition (placebo effect).
How do you treat and cure LPR?
There are three main treatment approaches for LPR: diet and lifestyle modification; medicines; and surgery.
There are many things that you can do to prevent or reduce LPR, these include:
- Eating smaller amounts throughout the day, rather than having a large lunch and supper.
- Reducing acidic foods in your diet such as orange juice and tomato-based sauces
- Avoid or reduce foods and drinks containing caffeine, alcohol and peppermint.
- Avoid fizzy drinks.
- Avoid wearing tight-fitting clothes
- Raise the end of the head end of your bed slightly by putting a brick under the legs of your bed
- Consider losing weight if your body mass index is greater than 25.
- Don't eat late at night - try and avoid eating three hours before going to bed
- Avoid eating two hours before exercise
- Stopping smoking
There are a number of medicines that can be useful in the treatment of LPR. These include:
Proton pump inhibitors (PPIs) such as omeprazole or lansoprazole (see above)
H2-blockers - these medicines also work by reducing the production of stomach acid, but are not as powerful as PPIs
Antacids - these help neutralise stomach acid
Alginates - these medicines can coat the lining of the stomach and gullet and reduce symptoms of LPR
Neuromodulatory medication - in certain situations, medicines such as gabapentin or nortyptilline can help reduce the sensitivity of the lining of the throat and gullet
There are several procedures that can be effective when lifestyle changes and medication have not worked. These procedures principally aim to restore the function of the sphincter at the bottom of the gullet. Some procedures can be performed with a telescope inserted into the gullet, others can be performed with keyhole surgery.