Dr. Hazenfield -- Ear, Nose, and Throat Doctor in Hawaii

Acid Reflux Disease

Laryngopharyngeal Reflux (LPR)

Gastroesophageal Reflux (GERD)

Hugh N. Hazenfield, M.D., F.A.C.S.

Many articles are appearing in both the medical literature and the popular press about heartburn and acid reflux disease.  I hope that this brief discussion will help you to understand the causes, symptoms, warning signs, diagnosis, and treatment of this extremely common disease.

 

The Normal Larynx

(Voice Box)

Anterior

(Front)

^{Left side       Right side}

Posterior

(Back)

The Larynx with Reflux

Thickening of the

Posterior Commissure

Laryngopharyngeal Reflux and Acid Reflux Disease

• What is acid reflux disease?

  • When you eat or drink something, the food or liquid reaches your stomach by passing from your throat, behind your voice box, and then through a muscular tube called the esophagus to arrive in your stomach.

  • Once the food reaches your stomach, your stomach puts out acid and pepsin (a digestive enzyme) to digest the food. 

  • Your esophagus has two sphincters (bands of muscle fibers that close off the tube) to help keep the digested food, acid, and pepsin where they belong. 

    • The first sphincter is at the top of the esophagus at its junction with the upper throat just behind the larynx.

    • The second sphincter is at the bottom of the esophagus at its junction with the stomach.  Normally this remains closed until the bolus of food and/or liquid reaches it.  However, in many individuals including children, the muscle tone is poor.  The sphincter remains open, allowing stomach contents to "reflux" up the esophagus and into the throat.

    • The refluxed stomach contents may even be aspirated into the trachea, bronchi, and lungs, causing further difficulties.

  • There may also be a hiatal hernia associated with acid reflux.  This is a condition in which part of the stomach slides up above the diaphragm into the chest.  Not only do symptoms of reflux occur, but there may be pain around the lower part of the sternum.

 

 

 

 

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If you click on the following picture, you may watch a video of an esophagogastroduodenoscopy (EGD), or endoscopic examination of the esophagus, stomach, and duodenum:

 

 

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• What is GERD or LPR?

   

  • Acid Reflux occurs when stomach contents pass up into the esophagus and sometimes into the throat.  There are two types of reflux which may occur independently or together:

  • GERD (Gastroesophageal Reflux Disease): 

    This occurs with an  excessive amount of reflux of stomach acid up through the lower sphincter and into the esophagus.  This is commonly associated with "heartburn", which occurs in almost 100% of patients with GERD.

    

    Acid burns at the junction of

    the esophagus and the stomach

• LPR (Laryngopharyngeal Reflux): 

  This occurs when reflux into the esophagus extends above the upper sphincter into the throat.  The structures and tissues of the larynx (voice box), throat, trachea, bronchi, and lungs are more sensitive to stomach acid and digestive enzymes than the esophagus.  It usually occurs without heartburn.  Only 14% or less of the patients with this problem experience heartburn.

   

• "But, Doctor, I don't have any heartburn!" 

  Many patients in whom I diagnose laryngopharyngeal reflux appropriately make this statement.  Smaller amounts of reflux or "less acid" stomach contents refluxing into the larynx, throat, and lungs can cause significant damage, and the individual usually does not even feel heartburn.  Only about 14% (the percentage varies in different studies) of patients with LPR actually have heartburn.  Heartburn (occurring in GERD) is due to irritation of the esophagus and occurs when the reflux contents are more acid.
  
  For those who are familiar with pH, the larynx and hypopharynx burn at a pH of 5.0, but the esophagus burns at a pH of 4.0.  Therefore, the larynx and hypopharynx may be affected but not the esophagus.  Even though the acid and pepsin travel through the esophagus, it is better protected by several factors and will be spared damage.  Patients who have laryngopharyngeal reflux disease often have no abnormal findings in the esophagus when examined using esophago-gastro-duodenoscopy (EGD).

• Most of the "damage" of GERD occurs at night when patients are lying in bed and asleep.  Symptoms of GERD at night which may awaken the patient include coughing, chest pain or burning, and a burning or bitter taste in the throat or mouth. 

• Most of the damage and symptoms of LPR, on the other hand, occur during the day with the patient upright.

• Singers and professional speakers are at increased risk due to using the support of the abdominal muscles, forcing stomach contents up the esophagus.

• Common symptoms of laryngopharyngeal reflux (LPR):

  • Hoarseness

  • Dysphonia (voice changes)

  • Chronic cough, or a cough during the night

  • Lump sensation in the throat

  • Bitter taste

  • Frequent throat-clearing

  • Throat pain

  • Difficulty swallowing, including pills

  • Bad breath (halitosis)

  • Ear pain

  • Laryngospasm, or the sensation of not being able to catch one's breath for several seconds

  • Asthma, especially if it begins in adulthood

  • Post-nasal drip

  • Difficulty singing, especially loss of vocal range
     

Please note that some of these symptoms (especially difficulty swallowing) may be due to diseases more serious than reflux.  These include cancer of the throat, larynx (voice box), or esophagus.  Do not treat yourself.  If your have these symptoms, you should see your primary care physician and/or an otolaryngologist.

•  Diagnosis of Laryngopharyngeal Reflux (LPR)

   

  • Your otolaryngologist will examine your larynx in the office.  Any or several of the following may be seen:

    • Thickening of the posterior commissure (back part of the larynx).  This is sometimes called "pachydermia" or "cobble-stoning".

    • Redness of the arytenoids (cartilages that move the vocal cords)

    • Edema (swelling) of the vocal cords

    • Small ulcers in the posterior part of the vocal cords or over the arytenoids

    • Granulomas (scar tissue) of the posterior part of the larynx

   

  • Other tests that may be requested include the following:

    • Barium esophagram, or an x-ray taken while the patient swallows barium

    • 24-hour pH monitoring with both esophageal and pharyngeal probes

    • Esophagoscopy or esophago-gastro-duodenoscopy, or an EGD, is helpful in the diagnosis of GERD but not in the diagnosis of LPR.

• Treatment of LPR

  • Stress:  Reduce stress, because it increases the amount of stomach acid and reflux.

  • Do not eat or drink anything, including water, for three hours before lying down.  It takes up to three hours for your stomach contents to empty into the intestine.

  • Discontinue smoking and tobacco use:  Tobacco use causes increased stomach acid and reflux, delayed emptying of the stomach, and relaxation of the gastroesophageal sphincter.

  • Diet - Avoid the following:

    • Caffeine

    • Carbonated beverages

    • Chocolate

    • Mint

    • Menthol

    • Spicy and acid foods, including tomatoes, citrus fruits and juices, cranberry juice, Italian and Mexican foods

    • Fatty foods

  • Avoid obesity; if overweight, lose weight.

  • Sleep with the head of the bed elevated.  Do not prop up your head with more than one pillow, since this will "fold" your abdomen, causing increased reflux.

  • Avoid tight belts and tight clothing.

  • Avoid aspirin, systemic steroids, and NSAIDs.

  • Medications: 

    • Your physician will most likely prescribe or recommend either a proton pump inhibitor (PPI, such as Aciphex^®, Nexium^®, Prevacid^®, Prilosec^®, and Protonix^®) or a hydrogen ion blocker (Zantac^® or Tagamet^®). 

    • In GERD, these are usually given only once a day and may be required for one month or less.

    • In LPR, it may be necessary to take these twice daily (occasionally even more often) and for 3-6 months or longer!

    • Antacids may be used to supplement the above medications, especially if heartburn or burning in the throat occur.

  • Drink at least two liters (8 glasses) of water per day, but not within three hours of lying down nor for two hours before singing.

  • Avoid clearing your throat.

  • Occasionally, if a hiatal hernia is also present and acid reflux cannot be controlled medically, an operation known as a fundoplication may be required.

  • Common misconceptions and mistreatment in the treatment of reflux:

    • All of the following "treatments" can actually make reflux worse.  They all fold your body at the level of the abdomen, thereby applying pressure on the stomach, with increased reflux into the esophagus and/or pharynx and larynx!

      • Wedge pillows

      • Sleeping on more than one pillow

      • Hospital beds with just the head elevated
         

• Long-term effects of acid reflux:

    Acid reflux into the esophagus and throat may cause the following:

  • Barrett's esophagitis

  • Cancer of the esophagus

  • Adult-onset asthma

  • Possibly cancer of the larynx

Acid reflux disease - both GERD and LPR - are common and are treatable.