Often patients complain of recurrent throat problems including sore throats, bad breath, coughing, itchiness, foreign body sensation, throat clearing, and swallowing difficulties. These complaints may be caused by acid reflux. Patients do not think they have acid reflux because they do not have heartburn. Laryngopharyngeal Reflux (LPR) is not associated with heartburn or a “burning” sensation in the chest. Gastroesophageal Reflux Disease or GERD is acid reflux that causes heartburn. LPR and GERD are two separate entities that are a result of stomach acid entering into the esophagus (swallowing tube) or the throat (LPR).
GERD is caused in most patients when the stomach “valve” (lower esophageal sphincter – LES) prevents stomach content to enter the esophagus, malfunctions, or becomes too “loose or leaky” (incompetent). The stomach acid refluxing into the esophagus (swallowing tube) potentially may damage the esophagus.
Similar to GERD, LPR occurs when the lower esophageal sphincter does not tighten to prevent acid from leaving the stomach. If the upper esophageal sphincter (UES), which is located at the top of the esophagus (swallowing tube), is also leaky the acid can travel even higher into the throat (pharynx) or voice box (larynx) causing multiple symptoms. In some cases the acid may fall into the lungs or go up into the nose and mouth.
Only on occasion does GERD or LPR cause serious complications. These complications include injury or breaks of the lining of the esophagus (esophageal erosions or ulcer) or narrowing of the esophagus (esophageal stricture). The normal esophageal lining may be replaced with abnormal (Barrett’s) lining. When this condition occurs it is called Barrett’s Esophagitis and it has been associated with an increased risk of esophageal cancer. Other possible complications of untreated GERD/LPR include chronic or recurrent laryngitis (hoarseness) or pharyngitis (sore throats). If stomach acid continues to “leak” or aspirate into the lungs, GERD may cause asthma or lung irritation (bronchitis or tracheitis).
As stomach content reach the throat (pharynx), voice box (larynx), mouth, or even the nose, it causes symptoms different than GERD. One may experience regurgitation of gastric contents into the mouth, sore throat (recurrent pharyngitis), hoarseness (recurrent laryngitis), throat clearing, gagging, or difficulty swallowing. Sometimes, one may feel that something is stuck in the throat (globus sensation). In addition, acid may leak into the lungs in some patients, resulting in coughing.
Hiatal hernia occurs when the upper portion of the stomach pushes through a small opening in the diaphragm (diaphragmatic hiatus) and into the chest. The diaphragm is the muscle that separates the stomach from the chest. Studies have demonstrated a correlation with the presence of a hiatal hernia and a weak esophageal “valve” (sphincter) that may result in reflux.
Dr. Pasha may suspect GERD or LPR first by your health history and physical examination. He may ask you about your voice, chronic cough, or throat clearing. Dr. Pasha will also look at your throat and mouth for evidence of any reflux. He may be satisfied with your history and physical to establish a diagnosis or he may order some tests such as a pH probe, barium swallow, or have you undergo direct laryngoscopy in the office.
The most sensitive test is obtained by placing a thin pH probe (which measures acid) through the nose and into the esophagus. The probe measures the frequency, severity, and duration of acid reflux by detecting changes in the acid content of the esophagus.
A barium swallow or upper gastrointestinal study is completed by having one drink a chalky substance (barium). Barium refluxing from the stomach back into the esophagus can be seen with x-ray.
In office, Dr. Pasha may place a flexible viewing tube through the nose and into the voice box (larynx). Signs of reflux include redness or ulceration of the vocal folds (cords).
If any of the above tests suggest acid reflux, Dr. Pasha will help you manage your reflux to reduce your symptoms and possible complications. You may also be referred to a gastroenterologist (GI) doctor for a scope of the esophagus and stomach.
There are essentially three levels for the management of GERD and LPR. The first is behavior modifications, the second is medical therapy, and the third is surgical intervention. For most patients a combination of behavior modifications and medication suffices in reducing most symptoms and lessening the risk of significant complications of GERD. In most cases after proper diagnosis, Dr. Pasha will prescribe medication/s as well as recommend some steps you may take to manage your reflux.
Here is a list of things you can do to reduce reflux:
- Quit smoking! Smoking causes reflux.
- Loss weight. For patients with recent weight gain, shedding a few pounds may be all that is required to prevent reflux. (Refer to weight charts to match ideal weights)
- Avoid late night meals or lying down after meals. Avoid eating three hours prior to bedtime or a large meal at night.
- Over-the-counter antacids may be considered for minor cases of GERD
- If symptoms occur at night, consider sleeping with your head and upper torso elevated by either using a wedged pillow that extends to the upper back or by placing blocks under the top bedposts.
- Avoid wearing tight-fitting clothing around the waist.
- Eat several small meals rather than single large meals.
- Consider keeping a food diary in order to identify those foods that trigger symptoms in you.
Here is a list of foods you should avoid to reduce reflux:
- caffeine (coffee, colas), citrus beverages, tea, and alcohol
- mints and chocolates
- fatty foods such as cheeses, fried foods, and eggs
- If you have difficulty avoiding these foods, begin by limiting intake and by avoiding these foods at night.
There are three types of medications that Dr. Pasha will prescribe:
- Proton pump inhibitors
- Promotility agents
Proton Pump Inhibitors, PPIs [Aciphex™, Prevacid™, Nexium™, Prilosec™] are stronger than H2-blockers in preventing acid production. Dr. Pasha most commonly prescribes these type of medications if you are having symptoms. PPIs are the mainstay treatment for LPR, often at high doses and 2-3 times per day.
H2-Blockers [Zantac™, Pepcid™, Tagament™] block one of the receptors that causes acid production. These medications are available in low doses over the counter.
Promotility agents [cisapride, metoclopramide] may be considered in some patients. These medications work by speeding up the process of moving food out of the stomach and into the small intestine. The use of these agents are not as common due to known drug reactions that are associated with some heart problems.