Laryngopharyngeal reflux
Encyclopedia
Laryngopharyngeal reflux (LPR), also extraesophageal reflux disease (EERD) refers to retrograde flow of gastric contents to the upper aero-digestive tract, which causes a variety of symptoms, such as cough
, hoarseness, and asthma
, among others.
Although heartburn
is a primary symptom among people with gastroesophageal reflux disease
(GERD), heartburn is present in fewer than 50% of the patients with LPR. Other terms used to describe this condition include atypical reflux, and supraesophageal (or supra-esophageal) reflux.
(GERD) was recognized as a clinical entity in the mid 1930s and now is the most prevalent upper gastrointestinal (GI) disorder in clinical practice. Around the same time, in 1934, Bray suggested a link between gut symptoms and airway disease. Acid-related laryngeal ulcerations and granuloma
s were first reported by Chery in 1968. Subsequent studies suggested that acid reflux might be a contributory factor in other laryngeal and respiratory conditions.
In 1979, Pellegrini and DeMeester were the first to document the link between these airway symptoms and reflux of gastric contents. They also proved that treatment of reflux disease results in elimination of these airway symptoms.
People who suffer from GERD usually have symptoms such as esophageal damage that result from the stomach acid shooting up into the esophagus
. The acid can irritate the tissues of the esophagus resulting in a sore throat and persistent coughing. Patients who suffer from laryngopharyngeal reflux, or LPR, are more likely to experience symptoms as a result of stomach acid refluxing into the larynx
.
, difficulty swallowing, indigestion, wheezing, chronic cough
, globus pharyngis
and chronic throat-clearing. Some people with LPR have heartburn, while others have little or none of this symptom. This is because the material that refluxes does not stay in the esophagus for very long. In other words, the acid does not have enough time to irritate the esophagus.
Adults who are afflicted with LPR often experience the acrid taste of bile emanating from the back of their throat
. This is also likely to be accompanied by a lump-like sensation in the throat, making it difficult to swallow. The throat may also seem to burn and breathing can be difficult. These symptoms are most often prevalent just after waking.
, edema
, laryngeal granulomas, and interarytenoid hypertrophy have been used to establish the diagnosis; but these findings are very nonspecific, and have been described in the majority of asymptomatic subjects undergoing laryngoscopy
. Response to acid-suppression therapy has been suggested as a diagnostic tool for confirming diagnosis of LPR, but studies have shown that the response to empirical trials of such therapy (as with proton-pump inhibitors) in these patients is often disappointing. Several studies have emphasized the importance of measuring proximal esophageal, or, ideally, pharyngeal acid exposure in patients with clinical symptoms of LPR, to document reflux as the cause of the symptoms.
Before a diagnosis can be made, the doctor will need to record the patient’s medical history and may ask for details about the symptoms that the patient is experiencing. The doctor will then need to perform a physical examination with particular concentration around the head and neck
. The doctor may need to use a specialized camera lens made of fiber optic
strands. This is gently fed down the patient’s throat which then feeds back images to a monitor. This enables the doctor to get a clearer look at the throat, particularly the larynx. Tell-tale signs include redness, swelling
, and obvious irritation. Once a diagnosis is made, the doctor will propose a treatment method. In cases where severe damage has occurred to the throat, the doctor may be forced to take immediate action to improve the physical state of the larynx and surrounding tissues.
spectrum is difficult. Once these patients are identified, behaviorial changes including weight loss and dietary changes are advised. Further medical management using Proton-pump inhibitors is common practice. When medical management fails, Nissen fundoplication
can be offered. A recent study by Dr. Jamie A. Koufman
suggests that a strict low-acid diet appears to be beneficial for patients with ph-documented LPR . In this study a low-acid or acid-free diet was shown to improve both the symptoms and the laryngeal findings of patients with recalcitrant (PPR resistant) LPR.
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...
, hoarseness, and asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, among others.
Although heartburn
Heartburn
Heartburn, also known as pyrosis or acid indigestion is a burning sensation in the chest, just behind the breastbone or in the epigastrium...
is a primary symptom among people with gastroesophageal reflux disease
Gastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
(GERD), heartburn is present in fewer than 50% of the patients with LPR. Other terms used to describe this condition include atypical reflux, and supraesophageal (or supra-esophageal) reflux.
Background
Gastroesophageal reflux diseaseGastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
(GERD) was recognized as a clinical entity in the mid 1930s and now is the most prevalent upper gastrointestinal (GI) disorder in clinical practice. Around the same time, in 1934, Bray suggested a link between gut symptoms and airway disease. Acid-related laryngeal ulcerations and granuloma
Granuloma
Granuloma is a medical term for a tiny collection of immune cells known as macrophages. Granulomas form when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate. Such substances include infectious organisms such as bacteria and fungi as well as...
s were first reported by Chery in 1968. Subsequent studies suggested that acid reflux might be a contributory factor in other laryngeal and respiratory conditions.
In 1979, Pellegrini and DeMeester were the first to document the link between these airway symptoms and reflux of gastric contents. They also proved that treatment of reflux disease results in elimination of these airway symptoms.
People who suffer from GERD usually have symptoms such as esophageal damage that result from the stomach acid shooting up into the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
. The acid can irritate the tissues of the esophagus resulting in a sore throat and persistent coughing. Patients who suffer from laryngopharyngeal reflux, or LPR, are more likely to experience symptoms as a result of stomach acid refluxing into the larynx
Larynx
The larynx , commonly called the voice box, is an organ in the neck of amphibians, reptiles and mammals involved in breathing, sound production, and protecting the trachea against food aspiration. It manipulates pitch and volume...
.
Signs and symptoms
Extraesophageal symptoms are the result of exposure of the upper aerodigestive tract to the gastric juice. This causes a variety of symptoms, including hoarseness, postnasal drip, sore throatSore throat
A sore throat or throat pain is a common physical symptom usually caused by acute pharyngitis, or throat inflammation, though it also occurs in a number of other situations, such as post trauma and in diphtheria. It can cause mild to extreme pain....
, difficulty swallowing, indigestion, wheezing, chronic cough
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...
, globus pharyngis
Globus Pharyngis
Globus pharyngis is the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none...
and chronic throat-clearing. Some people with LPR have heartburn, while others have little or none of this symptom. This is because the material that refluxes does not stay in the esophagus for very long. In other words, the acid does not have enough time to irritate the esophagus.
Adults who are afflicted with LPR often experience the acrid taste of bile emanating from the back of their throat
Throat
In vertebrate anatomy, the throat is the anterior part of the neck, in front of the vertebral column. It consists of the pharynx and larynx...
. This is also likely to be accompanied by a lump-like sensation in the throat, making it difficult to swallow. The throat may also seem to burn and breathing can be difficult. These symptoms are most often prevalent just after waking.
Diagnosis
As there are multiple potential etiologies for the respiratory and laryngeal symptoms, establishing LPR as the cause based on symptoms alone is unreliable. Laryngoscopic findings such as erythemaErythema
Erythema is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin. It occurs with any skin injury, infection, or inflammation...
, edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
, laryngeal granulomas, and interarytenoid hypertrophy have been used to establish the diagnosis; but these findings are very nonspecific, and have been described in the majority of asymptomatic subjects undergoing laryngoscopy
Laryngoscopy
Laryngoscopy is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper...
. Response to acid-suppression therapy has been suggested as a diagnostic tool for confirming diagnosis of LPR, but studies have shown that the response to empirical trials of such therapy (as with proton-pump inhibitors) in these patients is often disappointing. Several studies have emphasized the importance of measuring proximal esophageal, or, ideally, pharyngeal acid exposure in patients with clinical symptoms of LPR, to document reflux as the cause of the symptoms.
Before a diagnosis can be made, the doctor will need to record the patient’s medical history and may ask for details about the symptoms that the patient is experiencing. The doctor will then need to perform a physical examination with particular concentration around the head and neck
Neck
The neck is the part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk. The adjective signifying "of the neck" is cervical .-Boner anatomy: The cervical spine:The cervical portion of the human spine comprises seven boney...
. The doctor may need to use a specialized camera lens made of fiber optic
Optical fiber
An optical fiber is a flexible, transparent fiber made of a pure glass not much wider than a human hair. It functions as a waveguide, or "light pipe", to transmit light between the two ends of the fiber. The field of applied science and engineering concerned with the design and application of...
strands. This is gently fed down the patient’s throat which then feeds back images to a monitor. This enables the doctor to get a clearer look at the throat, particularly the larynx. Tell-tale signs include redness, swelling
Swelling
Swelling , is the enlargement of tissue.Swelling can also mean:*Die swell, the increase of volume of material due to absorption of a solvent, common for plastic polymers*Neutron-induced swelling caused by neutron radiation....
, and obvious irritation. Once a diagnosis is made, the doctor will propose a treatment method. In cases where severe damage has occurred to the throat, the doctor may be forced to take immediate action to improve the physical state of the larynx and surrounding tissues.
Treatment
Management of symptoms for patients within this subgroup of the GERDGerd
In Norse mythology, Gerðr is a jötunn, goddess, and the wife of the god Freyr. Gerðr is attested in the Poetic Edda, compiled in the 13th century from earlier traditional sources; the Prose Edda and Heimskringla, written in the 13th century by Snorri Sturluson; and in the poetry of skalds...
spectrum is difficult. Once these patients are identified, behaviorial changes including weight loss and dietary changes are advised. Further medical management using Proton-pump inhibitors is common practice. When medical management fails, Nissen fundoplication
Nissen fundoplication
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure...
can be offered. A recent study by Dr. Jamie A. Koufman
Jamie A. Koufman
Jamie A. Koufman, M.D., F.A.C.S. is a researcher on acid reflux and has lectured on the subject both nationally and internationally. She coined the terms “laryngopharyngeal reflux” and “silent reflux."...
suggests that a strict low-acid diet appears to be beneficial for patients with ph-documented LPR . In this study a low-acid or acid-free diet was shown to improve both the symptoms and the laryngeal findings of patients with recalcitrant (PPR resistant) LPR.