Swallowing difficulty & laryngopharyngeal reflux (LPR)

What is laryngopharyngeal reflux (LPR)?

In every normal person there is acid and enzymes in the stomach to allow digestion of food. The stomach wall has a protective lining to prevent these liquids from causing damage; if this lining fails, an ulcer may occur.

At the top of the stomach, at the junction between it and the oesophagus (or ‘gullet’), is a muscle that acts as a valve (or ‘sphincter’) to prevent acid from entering the gullet, as — unlike the stomach — the gullet does not have a protective lining. However, even in normal people some acid does enter (or ‘reflux’) into the gullet, particularly after large meals, but usually without causing problems. If reflux is frequent or prolonged, it does start to cause damage to the gullet lining, and may give symptoms of heartburn — this is termed gastro-oesophageal reflux disease (GORD).

If the acid reaches the top of the gullet, it may penetrate through the sphincter at this point and enter the back of the throat and larynx (voice box), causing symptoms at this level — this is termed laryngopharyngeal reflux (LPR). The muscles of the top of the throat and voice box react to the irritation caused by the acid by squeezing together in an attempt to protect your throat and windpipe, giving problems with your voice and swallowing. It has been estimated that up to 70% of people with voice and laryngeal disorders have reflux.

How is LPR diagnosed?

At present there is no simple and reliable test for diagnosing LPR. The diagnosis is usually made on the characteristic symptoms you are experiencing, along with a camera (endoscopy) examination of your larynx and the top of your gullet in outpatients, using an anaesthetic spray in your nose and throat; this often shows characteristic inflammation around the larynx. We sometimes perform a barium swallow X-ray to exclude a more sinister cause for any throat symptoms, but often this does not confirm or exclude the presence of LPR. Sometimes a diagnostic endoscopic examination of your larynx and gullet under general anaesthetic (i.e. asleep) may be performed for a similar reason.

What symptoms may I experience with LPR?

The commonest problems you may get with LPR are:

• Persistent or intermittent alteration in your voice
• Heartburn
• Voice fatigue, or sudden alterations in pitch during speaking
• A constant need to clear your throat
• A bad taste in the mouth, or bad breath
• Excessive throat mucus, or ‘post-nasal drip’
• Long-term cough
• Difficulty in swallowing, or a feeling of a constant lump in the throat
• Wheezing or difficulty in breathing

Although GORD and LPR are caused by the same process of acid reflux, we are increasingly realising that the symptoms they give — and therefore their treatment — can be very different:

• Up to 50% of patients with LPR don’t have heartburn, so just because you don’t feel the sensation of acid or burning in the throat or chest doesn’t mean you don’t have LPR. Similarly, you may not have symptoms related to swallowing despite experiencing problems with your voice.
• Patients with LPR often have reflux both in the upright and flat positions. GORD is often worse at night or early in the mornings after lying flat for a period, but this may not exclusively be the case in LPR.
• Patients with LPR need a larger dose of anti-acid medication, in a twice-daily formulation (anti-acid medication is usually given once daily), for much longer than usual. In GORD such treatment is often beneficial after 4 to 6 weeks, but in LPR treatment may be necessary for 6 months, with ongoing maintenance treatment often required afterwards.

What can I do to make it better?

• Eat little and often, and avoid eating late at night, as a full stomach increases the amount of acid around, with the potential to reflux up into the throat.
• Avoid tight clothes (especially around the waist), as this increases the pressure on the abdomen and the likelihood of reflux.
• Try to lose a little weight if necessary, and avoid weight gain.
• Try not to bend over — bend your knees, keeping your back straight, if you need to pick something up.
• Avoid smoking, chocolate, peppermint, spicy or fatty foods, fizzy drinks, caffeine and alcohol, which all stimulate the stomach to produce more acid. Some medications can also stimulate acid production and are best avoided or taken in moderation (e.g. aspirin, vitamin C and beta-blockers).
• You may want to modify your diet to decrease acid production. There are cookbooks that aim to help, such as Dropping Acid: The Reflux Diet Cookbook & Cure by Jamie Koufman et al., and The Acid Watcher Diet by Dr Jonathan Aviv.
• Raise the head of the bed to help gravity keep the acid down. Do this by placing bricks or books under the feet at the top end of the bed, rather than propping yourself up on pillows.
• Antacids such as Rennie or Gaviscon may help, but avoid using them to excess.

What medical treatment may I need?

• H2 antagonists (e.g. ranitidine or nizatidine) act to block the action of histamine, which normally stimulates the production of acid in the stomach.
• Proton pump inhibitors (PPIs) (e.g. omeprazole, lansoprazole or esomeprazole) act by blocking the ‘pumps’ in the stomach wall that secrete acid. Acid is not the only constituent of stomach secretions that irritates your throat, however, so these medications are not a guaranteed cure for everybody, and can interact with other medications or cause side effects of their own.
• Prokinetic agents (e.g. domperidone or metoclopramide) act by increasing the emptying of the stomach (to prevent acid build-up) and promoting contraction of the gullet sphincter muscles (to prevent reflux).
• Surgery. In selected cases this may be necessary, where medication fails to help or where patients are very unwilling to take long-term medication. Fundoplication is an operation to wrap the top of the stomach around the bottom of the gullet, acting as a new sphincter to prevent reflux; this can be performed via keyhole (laparoscopic) surgery to avoid large scars and long hospital stays.

What is a hiatus hernia?

The stomach is continuous with the gullet through an opening in a sheet of muscle between the chest and the abdomen, called the diaphragm. A small part of the top of the stomach can rise up through this opening into the chest, which is called a hiatus hernia. This can be seen (and therefore diagnosed) on a barium swallow X-ray. Many patients with a hiatus hernia have symptoms of acid reflux, but conversely not all people with acid reflux have a hiatus hernia.

What about globus?

Globus is a feeling of a lump in the throat without any physical reason for it. This sensation is often accompanied by a dry and tight throat, which may cause hoarseness and increased effort to swallow. Globus is often associated with stress or anxiety, and alongside this there are often symptoms of acid reflux. The initial treatment is often reassurance from us after we have examined you, and Speech and Language Therapy (SALT) may be very helpful for further advice and reassurance. See our Globus Pharyngeus leaflet for more detail.