LARYNGOPHARYNGEAL REFLUX DISEASE ("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 gastroesophageal reflux disease (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. Please get in touch if you are interested in silent reflux treatment (UK).

WHAT IS LPR?

LPR occurs when the contents of the stomach travel back up the gullet to the back of the throat and nose, and sometimes into the airways. The contents of the stomach are usually quite acidic, and also contains several substances that can irritate and inflame these areas. The food pipe (oesophagus) 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, giving rise to ear, nose and throat symptoms. This is why it is sometimes called 'silent' reflux, as most people with LPR just have throat symptoms, without any of the classical symptoms of heartburn and indigestion.

SILENT REFLUX SYMPTOMS

LPR can cause various symptoms, that can occur either by themselves or in combination. Some people have a sensation of a lump in their throat, others 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 voice box 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.

WARNING SIGNS

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 silent reflux 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 have got LPR? It is sometimes more difficult than it sounds. If you have some of the symptoms mentioned above, 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 voice box, and sometimes a telescope examination of the gullet and stomach.

There are also other tests known 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 medications 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 per cent 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.

However, this form of treatment may not help the 40% of patients that have non-acid reflux, when the enzymes (especially pepsin) in the stomach contents cause inflammation. To confuse matters further, some patients taking this medicine will feel better, even though the medicine isn't actually treating the condition (placebo effect). PPIs are generally well-tolerated, although they can occasionally cause side effects such as headache, upset stomach and sleeping problems.

HOW DO YOU TREAT AND CURE LPR?

Many patients are looking for a silent reflux cure. This is often possible using the three main treatment approaches: diet and lifestyle modification; medicines; and surgery.

There are many things you can do at home to help manage symptoms of reflux without seeing a doctor. The changes below will often have a cumulative effect, so if a small benefit is derived from many changes, this can lead to a significant overall improvement in symptoms and a long term improvement (if the changes are maintained).

There is good evidence to suggest that losing weight and raising the head end of the bed by 15-20 cm helps reduce the symptoms of reflux. Good studies have not definitively confirmed the helpfulness of the other measures, but it is likely that many people will find making these changes helpful.

DIETARY CHANGES

THINGS TO AVOID

Food and drinks that contain caffeine, such as coffee, tea, and some fizzy drinks, can weaken the protective sphincters at the top and bottom of the gullet (oesophagus). The purpose of the sphincters is to keep food in the stomach and gullet, so it is a good idea to avoid consuming products that compromise their effectiveness. It is worth noting that decaffeinated drinks usually contain about 10-30% of the caffeine of their caffeinated equivalents and are rarely caffeine-free. The effects of caffeine last for about 10 hours. Other foods such as chocolate and peppermint contain chemicals that have a similar effect to caffeine, and can also promote acid production.

High-fat foods such as full-fat dairy products, fried food and fatty meats may also cause the sphincter at the bottom of the gullet to relax, making reflux worse. They also tend to sit in the stomach for longer. As large quantities of food and drink in the stomach are more likely to reflux into the gullet and throat, it is preferable to eat smaller amounts throughout the day, rather than eating two or three large meals.

Carbonated (fizzy) drinks and alcohol have both been found to have a significant impact on reflux. If your symptoms are particularly troublesome, it may also be worth reducing your intake of more acidic and spicy foods, which can directly irritate the lining of the throat. These include many fruits, particularly citrus fruits such as oranges and lemons, tomatoes and salad dressings.

THINGS THAT MAY HELP

Chewing gum has been found to help reduce symptoms of reflux. It does this by increasing the production of acid-neutralising saliva and increasing the frequency of swallowing, which helps clear stomach acid from the throat.

A recent study has suggested that drinking alkaline water, and eating a plant-based Mediterranean diet is as effective as taking proton-pump inhibitors (a powerful acid-reducing medication).

LIFESTYLE CHANGES

THINGS TO AVOID

Anything that causes a bloated stomach, or increases pressure within the abdomen, will markedly increase the likelihood of reflux.

Avoid wearing tight-fitting clothes. Wearing clothes that put pressure on your abdomen, increases the pressure in the stomach. This makes it more likely that the contents of your stomach will reflux back into your gullet, and up to your throat.

Consider losing weight if your body mass index (BMI) is greater than 25. Your BMI is calculated by taking your weight in kilograms and dividing it by your height in metres squared (BMI = kg/m2). A healthy BMI is in the range of 18-25). If you have too much fat this can increase the pressure inside the abdomen, making the contents of your stomach more likely to reflux back into the gullet. There are, of course, many other health benefits from losing weight.

Don't eat late at night - try and avoid eating three hours before going to bed. If you eat just before going to bed, the food you have eaten has less time to pass through the stomach and is more likely to reflux when you lie down flat.

Avoid eating two hours before exercise. Take care with fluid intake before and during exercise, as drinking too much will distend the stomach.

Stopping smoking, as the nicotine in tobacco stimulates acid production by the stomach. It also causes the sphincter at the bottom of the gullet to relax and reduces the production of saliva, which helps to neutralise stomach acid.

THINGS TO DO

Raise the head end of your bed by putting a brick or blocks of wood under the legs of your bed. This allows gravity to prevent reflux into the gullet and throat. It is not helpful to increase the number of pillows you use, as this usually causes the head and neck to be positioned at an unusual angle, but doesn’t significantly elevate them above the stomach and gullet.

MEDICATION

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

SURGERY

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.