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Sometimes, refluxing acid travels all the way up the esophagus and makes contact with the tissues in your upper esophagus or throat, injuring those tissues. When this happens, it is called laryngopharyngeal reflux, LPR for short. Unlike the lower part of your esophagus, the tissues of the throat are not designed to tolerate acid at all. Think about it like this: if lemon juice is squeezed onto the skin of your hand, it's just going to feel wet. But if lemon juice is squeezed into your eye, you’re going to feel it! It’s the same difference between the tissues in your esophagus and those in your throat. Your system can tolerate many (50 or more) episodes of acid refluxing in the lower esophagus, but it only takes a few episodes – two or three in a 24-hour period – of acid making its way to your throat to hurt it.
This is why as many as 80% of people that have LPR never have the classic indigestion and heartburn symptoms of typical acid reflux; our bodies generally handle the refluxing acid in the esophagus but cannot handle it in the throat.
SymptomsThe most common symptoms of LPR are:
- The sensation of a lump at the back of the throat (called a globus sensation)
- The need to clear the throat
- Difficulty swallowing
- Sore throat (often a mild, scratchy, or irritated feeling)
- Thick or extra mucus production
Factors that may increase your risk for LPRThe risk factors of LPR overlap with those of traditional acid reflux or GERD:
- Age and getting older, something we cannot control, can contribute to your likelihood to develop LPR. The upper and lower esophageal sphincter muscles– one between your upper and lower esophagus and the other between your lower esophagus and your stomach – are gateway muscles and act as barriers by stopping acid from refluxing. As we get older, these muscles don't always function properly and provide the needed defense against refluxing stomach acid.
- Lifestyle choices top the list of risk factors for LPR that we can control. These range from the types of food you eat, how much you eat, and even when you eat. Certain foods and drinks and activities like smoking either produce more acid or relax the sphincter muscles and allow acid to flow more easily back up the esophagus.
DiagnosisAn ENT doctor can sometimes diagnose LPR based on your symptoms alone and prescribe a treatment regimen. Given the treatment focuses on your digestive system and not your throat, if the medicines work, it’s fairly easy to confirm the diagnosis of LPR. The second diagnostic path may involve a physical exam in the form of a laryngoscopy. Your ENT doctor will insert a very small fiber optic tube into your nose and down your throat to look for redness and irritation which are cardinal signs of LPR. Another test called an esophageal pH test can be done by placing and leaving a tube in the esophagus for 24 hours to measure how much acid comes up. Additionally, measuring the level of pepsin (a digestive enzyme that comes from the stomach and activates the acid in your stomach) in your saliva can indicate that acid has likely entered the throat and caused tissue damage.
TreatmentTreatment involves both medications and lifestyle changes. The primary medicines used are those that you would also take for GERD as they suppress acid production in the stomach. It's not that you necessarily have too much acid, you just have acid that moves in the wrong direction. Nevertheless, it's relatively easy to suppress the amount of acid so it more likely remains where it should. There are two classes of drugs that suppress acid. The first drug class is H2, or histamine, blockers, with brand names Pepcid and Tagamet and generic drug names famotidine and cimetidine.
Then there is a newer class of drugs called proton pump inhibitors, or PPIs. PPI generic drug names all end with -zole – omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole and so forth – and have the brand names Prilosec, Prevacid, Aciphex, Protonix, and Nexium. While H2 blockers shut off most of the acid production, PPIs can shut off acid secretion completely. Because the throat tissues are more vulnerable and need time to heal, we typically prescribe PPIs to be used twice a day for 6-8 weeks, and then taper down to either a once a-day PPI or a PPI in the morning and then an H2 blocker at bedtime. We like to move off PPIs and onto H2 blockers if we can. While PPIs are safe drugs, compared to H2 blockers they have some potential side effects, primarily around calcium and magnesium metabolism and a higher risk of osteoporosis.
In total, the medication phase for LPR can last anywhere from a few weeks to three or four months, and then we control your LPR with lifestyle modifications. In extreme cases, there are some surgical interventions and also endoscopic procedures we do. But very, very few people should require surgical procedures for LPR, as the vast majority can be controlled with medications and lifestyle.
Lifestyle changes to manage LPRThis is the list of foods and drinks you should try to avoid altogether or consume judiciously, as they either increase acid production or relax the upper and lower sphincter muscles, allowing acid to more easily reflux:
- Acidic foods, such as citrus juices and fruits, tomato-based foods, decaf coffee, tea, etc.
- Fatty or fried foods
- Spicy foods
- Caffeinated beverages
- Carbonated beverages
- Eat smaller, more frequent meals
- Drink plenty of water
- Stay upright (don’t lie down) at least two and preferably three hours after your evening meal and before bedtime. Do not eat or drink anything except water during those hours.
- When sleeping, raise your head about 6” so you are more upright. An extra pillow usually won’t achieve the full 6 inches, but you can accomplish this by putting a wedge between the box spring and the mattress, sleeping with a wedge pillow, or placing boards or bricks under the legs of the headboard.
- If you smoke, try to quit
Also, speak with your doctor about whether taking an extra, occasional dose of medication is right and safe for you if you know you’ll be in situations that might disrupt your careful routine. For example, say you're going to a wine and cheese get together with your friends at 6:00pm. You typically take your Pepcid at 11:00pm before you go to sleep. Most people can handle taking an extra dose of an H2 blocker from time to time, so take an extra Pepcid at 5:30pm in this example. Bottom line: while LPR is a condition that you may remain susceptible to, it can be managed well with common-sense lifestyle changes you can control and advice and guidance from your clinician on how best to use medications that are safe and effective.