Definition

Laryngopharyngeal reflux (LPR) occurs when food and drinks consumed travel back up from the stomach into the esophagus and sometimes into the pharynx. In this process, stomach acid, along with the food, refluxes into the esophagus. The throat, or pharynx, and the esophagus are essential in the passage of food from the mouth to the stomach. They are equipped with muscular rings called the upper esophageal sphincter and lower esophageal sphincter, respectively, which function to prevent the backflow of food and liquids from the stomach into these areas.

When reflux occurs in LPR, stomach acid accompanies the food back into the esophagus. This acidic content can irritate the lining of the esophagus, throat, and voice box, also known as the larynx. Unlike gastroesophageal reflux disease (GERD), where stomach acid typically reaches the throat and voice box, LPR often does not produce typical symptoms like heartburn or a burning sensation in the chest. Hence, LPR is often termed "silent reflux.

Causes

Laryngopharyngeal reflux (LPR) is primarily caused by the upward movement of stomach acid into the throat. During the process of swallowing, food travels through the throat (pharynx) and esophagus before reaching the stomach. The lower esophageal sphincter, a ring of muscle at the bottom of the esophagus, normally tightens to prevent the backflow of food and stomach acid into the upper digestive tract. However, in LPR, this muscle may fail to close properly, allowing stomach contents, including acid, to reflux back into the esophagus and sometimes into the throat.

In infants, LPR, also known as silent reflux, can occur due to the underdevelopment of the esophageal sphincter muscle. Babies have shorter esophagi and spend a significant amount of time lying down, which can contribute to reflux episodes. In adults, the precise cause of LPR is not fully understood.

Risk factor

Everyone is at risk of developing Laryngopharyngeal Reflux (LPR), but certain individuals have specific risk factors that increase their likelihood of experiencing it. These risk factors include:

• Consistently wearing tight clothing or tight-fitting garments
• Being overweight or obese
• Experiencing emotional stress or feeling pressured

Symptoms

Some symptoms that may appear in individuals with LPR include:

• Sore throat and throat pain
• Mild hoarseness
• Feeling a lump in the throat that persists even after swallowing multiple times
• Constant throat clearing
• The sensation of something stuck in the throat and/or post-nasal drip
• Persistent cough (chronic)
• Red, swollen, and irritated vocal cords (laryngeal irritation)

In children, LPR can manifest with symptoms such as coughing, difficulty breathing, hoarseness, stridor (noisy breathing), croup, asthma, breathing difficulties during sleep, feeding difficulties (frequent vomiting), bluish skin (cyanosis), food entering the airway, breathing difficulties, and severe growth delay.

Diagnosis

LPR is typically diagnosed based on the patient's symptoms, such as throat irritation or swelling and redness at the back of the vocal cords. In many cases, confirming a diagnosis of LPR does not require further testing.

However, if testing is needed, there are three types of examinations commonly used to establish a diagnosis:

• Endoscopic examination: During this procedure, a doctor inserts an endoscope—a long tube with a camera at its tip—through the mouth into the esophagus and stomach to inspect the internal structures.
• Esophageal pH testing: This test measures the pH levels in the esophagus using a small, thin tube equipped with an acid sensor at its tip. The device is inserted through the nose and positioned 2 inches above the lower esophageal sphincter. pH levels are monitored and recorded over a 24-hour period.
• Swallowing study: In this procedure, the patient swallows a special liquid called barium, which coats the esophagus, stomach, and digestive tract, making them visible on X-rays. This examination allows the doctor to observe the movement of food as it passes from the mouth into the esophagus.

Management

In most cases of LPR, medical treatment is not necessary and can be managed through lifestyle changes. These lifestyle modifications may include:

• Following a bland diet that is low in acid, low in fat, and non-spicy.
• Eating frequent small meals instead of large ones.
• Losing weight if overweight.
• Avoiding alcohol, tobacco, and caffeine.
• Refraining from consuming meals close to bedtime (within 2 hours).
• Elevate the head of the bed before sleeping by placing a sturdy object, such as a board, under the mattress. This helps support the head and upper body and prevents stomach acid from refluxing into the throat.

In addition to lifestyle changes, doctors may prescribe medications to reduce stomach acid, such as antacids or other acid-reducing medications. In severe cases of LPR, surgery may be recommended.

Complications

LPR can be effectively managed with lifestyle changes, but if left untreated, it can lead to several complications. Some of these complications may include:

• Throat ulcers
• Long-term or chronic cough
• Swelling of the vocal cords
• Open sores on the vocal cords
• Formation of masses or lumps in the throat
• Aggravation of conditions such as asthma, emphysema, and bronchitis
• Development of laryngeal cancer and lung cancer

In children and infants, LPR can lead to additional complications such as:

• Narrowing of the area below the vocal cords,
• Recurring ear infections due to dysfunction of the Eustachian tube. This is because reflux in LPR can reach the nasopharynx or upper throat located in front of the nose. This will interfere with the function of the Eustachian tube,
• Accumulation of fluid in the middle ear that persists.

Prevention

To reduce the risk of developing LPR, you can take several preventive measures such as:

• Avoiding acidic, spicy, fatty, chocolate, and mint-flavored foods, as well as beverages containing alcohol or caffeine like coffee, tea, and soda. Additionally, it's important to avoid tobacco consumption.
• Refraining from wearing tight clothing.
• Managing stress effectively and avoiding excessive pressure or emotional stressors.
• Maintaining an ideal body weight through a balanced diet and regular exercise.
• Avoid eating within 2 hours before bedtime to minimize the risk of acid reflux during sleep.

When to see a doctor?

In adults, LPR can often be managed by lifestyle changes. However, in infants and children, LPR needs prompt medical attention. If your child experiences the symptoms mentioned above, take them to the doctor immediately. Without proper treatment, LPR can hinder your child's growth and pose a risk to their well-being.