Reflux Disease and its Effect on the Larynx
A large number of disorders can occur when the highly acidic contents of the stomach are refluxed back up into the throat. This disorder is called gastroesophageal reflux disease (abbreviated GERD) when the esophagus is primarily affected. When it involves the larynx and pharynx, we call in laryngopharyngeal reflux disease (LPRD). This page describes in more detail the causes and treatment of LPRD.
Before discussing LPRD it is useful to understand the normal function of the upper digestive system. When we swallow, food passes from the throat down a tube called the esophagus into the stomach. This food stimulates the production of very strong and acidic digestive fluids in the stomach. These juices begin the breakdown of food so it can be absorbed in the intestine. Because they are so corrosive, the digestive juices can cause injury if they pass outside of the stomach. The esophagus has two regions that act as valves or sphincters to prevent stomach acid from travelling backwards up the esophagus. One sphincter is just above the point where the esophagus meets the stomach. The other sphincter is at the upper end of the esophagus in the lower neck. Both of these sphincters should be contracted, or closed, at rest and should relax during swallowing. Reflux occurs when the sphincters do not function well and therefore allow the strong contents to travel back up the esophagus. As the acid contents leak into the throat, one of the first structures it comes in contact with is the larynx (voicebox).
How laryngopharyngeal reflux disease affects the larynx
The lining of the larynx and the upper throat above the upper esophageal sphincter does not have as strong a protective lining as the esophagus. As a result, when acidic stomach contents are refluxed they cause the larynx to become irritated and inflamed. Often the rear portion of the larynx is first affected. Symptoms from this reflux irritation include:
- throat pain
- frequent throat clearing and coughing
- a lump or tickle sensation in the throat
- a bitter taste in the mouth
- sudden shortness of breath or choking sensation
The photograph to the right shows inflammation due to reflux (at the arrow). The white bands forming the inverted "V" are the vocal folds. The posterior portion of the opening into the windpipe (called the posterior glottis) is thickened, due to acid irritation.
Is heartburn always associated with reflux?
No, there can frequently be reflux in the absence of heartburn. In many cases the reflux occurs at nighttime when we lie down. While horizontal, the stomach contents can more easily pass backwards up the esophagus. Other individuals may simply not experience heartburn even though reflux is present.
How is reflux disease diagnosed?
Reflux laryngitis can be diagnosed using a combination of the medical history, findings on physical examination, and various diagnostic tests. The classic symptoms of reflux are those described above: hoarseness, throat pain, frequent throat clearing, a lump or tickle sensation in the throat, and frequent coughing.
Physical examination requires a careful examination of the larynx. The most common site of inflammation is the back of the larynx. This is the first site where refluxed acid comes in contact with the throat. The lining of the throat becomes inflamed, which is seen as increased redness and swelling. The vocal folds themselves may also be swollen.
Several diagnostic tests can assist in the diagnosis of reflux. A barium swallow test is a study in which one swallows contrast (dye) solution while x-rays are taken. If reflux is present during the time of the test, it will be apparent on the x-rays. A more accurate test is called a 24 hour pH probe. In this study a small flexible catheter is passed through the nose into the esophagus. Special probes on the catheter continuously measure the level of acid in the esophagus. After 24 hours the catheter is removed and the amount of the acid recorded by the probe indicates the amount of reflux present.
How is GERD treated?
Prevention/Life Style Changes
The first line of treatment for reflux is prevention. The most important step is to minimize exposure to those factors that interfere with the normal function of the esophageal sphincter. These include caffeine, chocolate, mints, tobacco, carbonated beverages, alcohol and certain spicy foods.
Meals should be eaten at least two hours before bedtime. Food in the stomach stimulates the production of acid. If someone eats and then lies down, acid stomach contents will more easily travel back up the esophagus into the throat.
Another useful treatment is to elevate the head of the bed 4-6 inches. Simply sleeping on extra pillows does not help since it flexes the stomach and could actually worsen reflux. If the entire bed is tilted upwards, gravity reduces the backflow of acid.
If these measures don't work or if the reflux is severe, medications may be useful. Most medications that are used will reduce the acidity of the stomach contents, increase the activity of the esophageal sphincters, or they will increase the motility of the stomach.
There are two common groups of "acid-blockers". These medications do not actually reduce reflux, but they reduce its acidity. The first group is called "H-2 blockers", because the block the histamine 2 receptor that is important in stomach acid production Examples of these medications include cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid). These medications are now available over-the-counter. .
A second group of medications that reduces the acidity of the stomach is called a proton pump inhibitor. These medications reduce activity of a process that "pumps" protons across the cell membrane. This pumping of protons is important to increase the acidity in the stomach. Examples of these include omeprazole (Prilosec) and lansoprazole (Prevacid).
Another medication often used is metoclopramide (Reglan), which will both increase the activity of the sphincter and increase gastric motility.
Finally, if reflux is particularly severe and does not respond to medications or other treatment, surgery may be necessary. The most common surgical procedure, called fundoplication, involves sewing a portion of the stomach around the esophagus to tighten its lower end. This operation can be done trough small incisions in the abdomen using special telescopes called endoscopes.