Laryngopharyngeal Reflux: Diagnosis, Treatment, and Latest Research

Similar effects were demonstrated after ingestion of white wine and beer in patients with endoscopic evidence of reflux esophagitis and abnormal pH study [Pehl et al. 2006]. Few data are available for voluptuary habits such as cigarettes smoking and alcohol consumption. Smokers have an increased incidence of reflux symptoms compared with nonsmokers [Talley et al. 1994; Watanabe et al. 2003]. Nilsson and colleagues [Nilsson et al. 2004] revealed, in a multivariate analysis, that among individuals who had smoked daily for more than 20 years, the risk of reflux was significantly increased by 70%, compared with those who had smoked daily for less than a year (OR 1.7; 95% CI 1.5-1.9). A relation has been considered between smoking cigarettes and a prolonged acid exposure, a decrease in LES pressure, and diminished salivation, which decreases the rate of esophageal acid clearance [Kahrilas and Gupta, 1989].

Although the complications of LPR may require surgical management, aggressive perioperative reflux therapy should be initiated if the patient is to achieve an optimal outcome. All three of these complications can be avoided with proper treatment for frequent heartburn or GERD. Your doctor will likely begin treatment immediately if you’ve been diagnosed with esophagitis, as an inflamed esophagus can lead to more health complications. Esophagitis is an inflammation of the esophagus that makes it prone to injuries like erosions, ulcers, and scar tissue. Symptoms of esophagitis may include pain, difficulty swallowing, and more acid regurgitation.

To review the current literature on extraesophageal manifestations of reflux should assist in clinical decision making. Lin RJ, Sridharan S, Smith LJ, Young VN, Rosen CA. Weaning of proton pump inhibitors in patients with suspected laryngopharyngeal reflux disease. Laryngoscope. 2017 Jul 21. [Medline].

The apparent advantage of operative therapy is that it corrects the antireflux barrier at the gastroesophageal junction and prevents the reflux of most stomach contents, thus preventing acid and nonacidic material from coming in contact with the pharyngolaryngeal mucosa. Candidates for antireflux surgery are often patients who require continuous or increasing doses of medication to maintain their response to acid suppressive therapy.

Laryngopharyngeal reflux is defined as the reflux of gastric content into larynx and pharynx. A large number of data suggest the growing prevalence of laryngopharyngeal symptoms in patients with gastroesophageal reflux disease.

Acid reflux and how it can affect your throat

These can include belching, wheezing, difficulty swallowing, or a chronic cough. While most people experience occasional acid reflux, some people may develop a more serious form of acid problems. This is known as gastroesophageal reflux disease (GERD).

If diet and behavior changes don’t help, a medication may be prescribed – usually, treatment starts with a proton-pump inhibitor (PPI). Commonly prescribed PPIs include rabeprazole (Aciphex), esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), and pantoprazole (Protonix). They all work by reducing the amount of acid made in the stomach. Sometimes acid reflux presents without heartburn, causing what is known as silent reflux.

Many people with LPR do not have symptoms of heartburn. Why? In order for refluxed acid to cause heartburn, it has to stay in the esophagus long enough to cause irritation.

  • LPR should be considered as part of extraesophageal reflux (EER), reflux involving structures other than, or in addition to, the esophagus, and airway reflux involving proximal gastric reflux into the airways.
  • People with reflux laryngitis usually complain of hoarseness, frequent throat clearing, sensation of lump in the throat, cough, or sore throat.
  • Summary of different medical therapies in laryngopharyngeal reflux disease (LPRD) with proven or uncertain efficacy.
  • The diagnostic work-up of patients presenting with symptoms of laryngopharyngeal reflux begins with a thorough history and a meticulous physical examination.
  • The most common and effective surgery for long-term relief from GERD is called fundoplication.
  • In the same study, consumption of dietary fibers was found to be a protective factor [Nilsson et al. 2004].

In one study10 of patients with GERD and laryngeal disease, 82 percent of the patients had resolution of laryngeal symptoms and normalization of laryngoscopic findings by six months or more after antireflux surgery. Patients in this study had GERD documented by 24-hour pH monitoring and laryngoscopic evidence of laryngeal pathology. They were referred for surgical therapy (Nissen fundoplication) because of an unsatisfactory response to medical therapy. Other symptoms include constant throat clearing (caused by increased secretions and irritation of the laryngeal mucosa); dysphonia (caused by edema or inflammatory lesions of the true vocal cords); chronic sore throat (often misdiagnosed as recurrent or chronic tonsillitis); coughing; cervical dysphagia (caused by dysfunction of the upper esophageal sphincter); halitosis; buccal burning; otalgia (explained by the common sensory innervation of the esophagus and external auditory canal by the 10th cranial nerve); food sticking in the throat; pharyngeal tightness; a choking sensation; aerophagia; and water brash (hypersalivation). Laryngopharyngeal reflux should be suspected in patients who present with any of these symptoms.

PPI therapy is considered to be the mainstay of care in patients with GERD; however, its efficacy for the treatment of LPRD remains doubtful. In clinical practice, consistently with the assumption that the upper aerodigestive tract is more sensitive to acid refluxes than the esophagus, it is believed that patients with reflux-related laryngitis require higher doses and a longer trial of PPIs to achieve an improvement of laryngeal symptoms than those with typical GERD symptoms [Ford, 2005; Koufman et al. 2002; Park et al. 2005].

While horizontal, the stomach contents can more easily pass backwards up the esophagus. Other individuals may simply not experience heartburn even though reflux is present. Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention.

GERD symptoms are usually worst when you are lying down, while LPR often occurs when you are standing or bending over or exercising. According to the ACG, GERD is acid reflux that occurs more than a couple of times per week. That said, it’s not the case that a person who has occasional heartburn will necessarily progress toward having GERD, says Louis Cohen, MD, gastroenterologist and assistant professor of medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York City. But the symptoms are the same as those of acid reflux, such as the burning feeling in your chest and the sensation that your stomach contents are in your throat. You may also have a dry cough or trouble swallowing.

Furthermore, the dosage and duration of PPI therapy in LPRD represent further current matters of debate. To date, whenever typical GERD symptoms are present in addition to the extraesophageal symptoms and/or there is objective evidence of GERD by endoscopy or reflux monitoring [Katz et al. 2013], it is a pragmatic clinical strategy to start with an empirical 2-month therapy with twice-daily PPIs [Kahrilas et al. 2008]. If there is symptom improvement, then tapering to once-daily PPI followed by reducing the dose or the interval of acid suppression is highly recommended [Vaezi, 2010].

However, laryngopharyngeal reflux is a multifactorial syndrome and gastroesophageal reflux disease is not the only cause involved in its pathogenesis. Current critical issues in diagnosing laryngopharyngeal reflux are many nonspecific laryngeal symptoms and signs, and poor sensitivity and specificity of all currently available diagnostic tests. Although it is a pragmatic clinical strategy to start with empiric trials of proton pump inhibitors, many patients with suspected laryngopharyngeal reflux have persistent symptoms despite maximal acid suppression therapy.

However, further research is needed to develop a definitive diagnostic test for LPR. Cigarette smoking and alcohol consumption associated with gastro-oesophageal reflux disease in Japanese men . Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients .

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December 15, 2014

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