Laryngopharyngeal Reflux (LPR)
Laryngopharyngeal reflux (LPR) is a condition in which acid that is made in the stomach travels up the esophagus (swallowing tube) and gets to the throat.
Gastroesophageal reflux into the larynx (laryngopharyngeal reflux) is considered a cause of chronic hoarseness when other causes of abnormal vocal fold vibration (such as tumor or nodules) have been excluded by laryngoscopy.
At either end of your esophagus is a ring of muscle (sphincter). Normally, these sphincters keep the contents of your stomach where they belong – in your stomach. But with LPR, the sphincters don’t work right. Stomach acid backs up into the back of your throat (pharynx) or voice box (larynx), or even into the back of your nasal airway. It can cause inflammation in areas that are not protected against gastric acid exposure.
Silent reflux is common in infants because their sphincters are undeveloped, they have a shorter esophagus, and they lie down much of the time. The cause in adults is not known.
Gastroesophageal reflux disease (GERD) has also been suggested as a contributing factor to other symptoms, such as throat clearing, throat discomfort, chronic cough, a sensation of postnasal drip, esophageal spasm, and some cases of asthma. Since less than half of patients with laryngeal acid exposure have typical symptoms of heartburn and regurgitation, the lack of such symptoms should not be construed as eliminating this cause.
Indeed, most patients with symptomatic laryngopharyngeal reflux, as it is now called, do not meet criteria for GERD by pH probe testing and these entities must be considered separately. The prevalence of this condition is hotly debated in the literature, and laryngopharyngeal reflux may not be as common as once thought.
Symptoms in infants and children may include:
- “Barking” or chronic cough
- Reactive airway disease (asthma)
- Noisy breathing or pauses in breathing (apnea)
- Trouble feeding, spitting up, or inhaling food
- Trouble gaining weight
Evaluation should initially exclude other causes of dysphonia through laryngoscopy; consultation with an otolaryngologist is advisable. Many clinicians opt for an empiric trial of a proton-pump inhibitor since no gold standard exists for diagnosing this condition. Such an empiric trial should not precede visualization of the vocal folds to exclude other causes of hoarseness. When used, the American Academy of Otolaryngology—Head and Neck Surgery recommends twice-daily therapy with fullstrength proton-pump inhibitor (eg, omeprazole 40 mg orally twice daily, or equivalent) for a minimum of 3 months.
Patients may note improvement in symptoms after 3 months, but the changes in the larynx often take 6 months to resolve. If symptoms improve and cessation of therapy leads to symptoms again, then a proton-pump inhibitor is resumed at the lowest dose effective for remission, usually daily but at times on a demand basis. Although H2 -receptor antagonists are an alternative to proton-pump inhibitors, they are generally both less clinically effective and less cost-effective.
Nonresponders should undergo pH testing and manometry. Twenty-four-hour pH monitoring of the pharynx should best document laryngopharyngeal reflux and is advocated by some as the initial management step, but it is costly, more difficult, and less available than lower esophageal monitoring alone.
Double pH probe (proximal and distal esophageal probes) testing is the best option for evaluation, since lower esophageal pH monitoring alone does not correlate well with laryngopharyngeal reflux symptoms. Oropharyngeal pH probe testing is available, but its ability to predict response to reflux treatment in patients with laryngopharyngeal reflux is not known.