Laryngopharyngeal Reflux (LPR)

Supraesophageal reflux, esophagopharyngeal reflux, extraesophageal reflux (EER), and posterior laryngitis ...

Laryngopharyngeal Reflux (LPR) - Posterior commissure hypertroph

Laryngopharyngeal reflux (LPR) is a common disease that occurs in approximately 30% of the population and causes complaints such as hoarseness, sore throat, and chronic cough. LPR is seen in the majority of asthmatics and those with sleep apnea.

Gastroesophageal reflux (GER) is the escape of stomach contents back to the esophagus (esophagus) without vomiting or strain. Laryngopharyngeal reflux (LPR) is the passage of stomach contents through the upper part of the esophagus to the larynx and pharynx (larynx and pharynx). Normally 50 oesophageal damage occurs in 50 GER attacks per day, and experimentally 3 LPR attacks per week cause damage to the larynx and pharynx. GER usually occurs after meals and at night while the LPR is mostly day and standing.

Gastroesophageal reflux is the retrograde movement of gastric contents contents such as gastric acid, pepsin, bile acids and pancreatic enzymes back into the esophagus. Monitoring this as part of normal swallowing and nutritional function after meal is called physiological reflux. Gastroesophageal reflux disease (GERD) is defined as the increase in the number and duration of reflux episodes, independent of food, and escaping the esophagus to the upper aerodigestive system. It is called laryngopharyngeal reflux (LPR) with a more specific definition that causes the stomach contents to rise in the esophagus and reach the oropharynx and larynx. You can find more details about Gastroesophageal reflux (GER) at >> Gastroesophageal Reflux Disease (GERD) - Laryngopharyngeal Reflux (LPR) - Extraesophageal Reflux Disease

Throat reflux, also called laryngopharyngeal reflux (LPR), is an acid burn disease caused by gastric acid reaching the throat, vocal cords and nasal region.

LPR and gastric reflux are different. While stomach reflux, chest pain, burning and souring complaints are experienced, throat reflux these complaints are not encountered.

Patients with LPR present to the physician with complaints of insomnia, cough, hoarseness of the nasal discharge, and sometimes bad breath. Diagnosis can be made easily by direct evaluation of the patient's history and endoscopic examination.

LPR, smoking, alcohol use, as well as habits such as cancer in this region may pave the way to prepare. Therefore, early diagnosis and treatment of LPR is extremely important. However, if left untreated, throat reflux also deteriorates the patient's quality of life.

Why reflux occurs?

Normally, the pharynx (esophagus) and esophagus (esophagus) where the junction of the esophagus (esophagus) and the stomach, the muscular structures of these regions and because of the nature of the attachment system has a valve. The upper esophageal sphincter of this valve system is called the lower esophageal sphincter. Normally, these sphincters prevent the contents of the stomach from escaping into the esophagus and further into the pharynx, throat and mouth. At the same time, salivary secretion, mucus secretions and movements of the muscles in the esophagus contraction of this region is constantly cleaned. Bicarbonate in the salivary secretion, which is also released from the mucosa, neutralizes the acid and prevents damage. In addition to acid contained in the stomach, pepsin, bile salts, pancreatic enzymes also damage the mucous membranes covering the esophagus, throat and mouth. Reflux and related damages occur in cases where these mechanisms fail. These situations;

Laryngopharyngeal Reflux (LPR) - Posterior commissure hypertroph
  • Decrease in lower esophageal sphincter pressure: Fatty foods, Chocolate, Mint, Alcohol, Smoking, Gastric hernia, Drugs (anticholinergic, calcium blockers, nitrites, diazepam, theophylline, etc.), Hormones (secretin, cholecystokinin, glucagon, VIP) can cause this.
  • Impairment of esophageal acid clearance: That is, disorders in the clearance of acid escaping the esophagus, such as esophageal motility disorders, can cause this.
  • Decreased esophageal mucosal resistance: Reduction in saliva and mucus production may result.
  • Impairment of upper esophageal sphincter function: Reduction in cricopharyngeal muscle tone may cause this.
  • Delay in gastric emptying: Stomach exit, smoking, alcohol and inappropriate diet may cause this.
  • Increased intraabdominal pressure: Obesity, tight clothes, pregnancy may cause this.
  • Excessive acid and pepsin release from the stomach: Stress, smoking, alcohol, some medications may cause this.
In fact, LPR; the reflex mechanisms (pharyngospheric contractile reflex) that prevent further contact of pharynx with increasing acidic content to the pharynx, or reflex mechanisms that prevent contact with the larynx (pharyngoglottal closure reflex).

What diseases are associated with LPR?

LPR is blamed as a direct or facilitating factor in the occurrence of many diseases. The most important of these;
  • Asthma exacerbations
  • Microaspirations (escape of acid and stomach contents into the airways) and aspiration pneumonia (pneumonia due to aspiration)
  • Bronchiectasis
  • Obstructive sleep apnea syndrome (respiratory arrest during sleep)
  • Sudden baby death
  • Chronic Cough
  • Chronic laryngitis
  • Chronic pharyngitis
  • Contact ulcers and granulomas of the larynx
  • Functional vocal diseases (muscle tension dysphonies, 70% LPR)
  • Laryngospasm
  • Laryngeal stenosis
  • Laryngeal malacia
  • Subglottic stenosis
  • Laryngeal cancer
  • Inflammation of the middle ear
  • Chronic sinusitis
  • Ulcers and canker sores
  • Tooth decay
Laryngopharyngeal Reflux (LPR) - Posterior commissure hypertrophy

What are the symptoms seen in LPR patients?

Approximately 20% of patients may have LPR without any complaints. Also, most of the complaints seen in LPR patients are not specific to this disease and can be seen in other diseases. For this reason, in order to make the correct diagnosis, ear, nose and throat physicians must make detailed examination.

The most common symptoms of LPR

The most common symptoms of LRF are;
  • Sound changes (71%)
  • Cough (51%)
  • Globus sensation (47%)
  • Frequent throat cleaning (42%)
  • Swallowing sensation (35%)
  • In addition to the above-mentioned complaints, there are frequent complaints of continuous nasal discharge and intermittent noise reduction.
  • Laryngopharyngeal reflux (LPR) should also come to mind when a simple respiratory infection leads to a 2 to 3 month dry cough, especially in predisposed people. Irregular nutrition and fast food habits are the main causes of laryngopharyngeal reflux in patients of our age.
  • LPR should also be considered in cases of serous otitis (fluid in the middle ear) that do not persist in pediatric patients. In this disease with different complaints and criteria from gastroesophageal reflux,
  • Hoarseness or other sound problem
  • Frequent throat cleaning needs
  • Stress when swallowing food, drink or medicine
  • Difficult to breathe or breathing obstruction,
  • Uncomfortable cough,
  • The feeling of something stuck in the throat or something.
  • Burning, pain in the chest area, pain in the mouth and indigestion
    The diagnosis can be made easily by an otorhinolaryngologist examination and endoscopic imaging of the laryngeal esophagus entry.

      How is LPR diagnosed?

      The most important step in the diagnosis is to listen carefully to the patient's complaints and to think that LPR may be. The most valid methods for diagnosis are;

      - Transnasal fiberoptic endoscopic examination: This examination is carried out with endoscopes with a diameter of approximately 3 mm, with light and camera at the end, turning the tip in the direction we want to see almost every area of ​​the throat and throat. These endoscopes are much thinner than the endoscopes used in gastroscopy and can often be performed without requiring local anesthesia. In LPR patients, many findings (pseudosulkus, ventricular obliteration, erythema / hyperemia, vocal cord edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma / granulation, thick endolarengeal mucus) can be diagnosed with 95% accuracy.
      - Videolaryngoscopy: In this examination method, an endoscope with light and camera at the end of the pharynx, larynx and the beginning of the esophagus can be seen in detail and images can be recorded.

      - 24-hour dual-probe pH monitoring: The acid (pH) in the esophagus and pharynx is monitored by a tube inserted through the nose for 24 hours to detect the presence of reflux. Although it is one of the most reliable diagnostic methods, it cannot be used very often because of its cost and the intolerance of all patients.

      - Reflux treatment is one of the most important diagnostic methods in the improvement of symptoms and signs.

      In recent years, “laryngeal sensory test” and “multichannel intraluminal impedance test” tests have been developed for the diagnosis of LPR, but have not been routinely used yet.
      Methods such as barium esophagogram and esophagoscopy are used for GER rather than LPR and related diseases (helmet esophagitis, esophageal cancer) that may develop under the esophagus.

      How is LPR treated?

      There are 3 options for treatment.

      Regulation of diet, eating habits and lifestyle

      • Avoid smoking, alcohol, chocolate, fatty foods, fries, nuts, mint, carbonate, too much tea and coffee
      • Avoiding carbonated and acidic beverages such as cola, soda, mineral water
      • Frequent but little undernutrition
      • Cleaning the throat and esophagus by drinking water frequently
      • Eating at least 3 hours before bedtime
      • Lying with the head higher than the body, preferably lying sideways
      • Lose weight
      • Avoid wearing tight pants, belts or skirts
      • Fighting stress
      • Active and sporty life
      In the treatment of LPR, it is necessary to carefully monitor the treatment steps determined by the physician. In addition to the drugs to be used, the diet to be applied is also the most important part of the process. Adhering to the given diet, accelerates the healing process of the disease, prevents the recurrence of the disease.

      Laryngopharyngeal Reflux (LPR) - Posterior commissure hypertroph

      Drug treatment

      Today, proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, etc.) are mostly used for this purpose. These drugs inhibit acid release from the stomach and reduce pepsin activity. These drugs, which are generally used 1-2 times a day and for 4-6 months, can be increased according to treatment response and examination findings. It is known that 80% of patients benefit from recommendations and medication.

      Surgical treatment

      Gastric hernia, Subglottic stenosis, Laryngospasm, Uncontrolled asthma, Dysplasia may occur in patients who do not respond to medication.

      Different recommendations for the treatment of LPR

      The most important measures are as follows:
      • The upper part of the body and head is high when lying down. For this, the number of pillows can be increased or the head of the bed can be raised.
      • It is recommended to turn to your left.
      • Care should be taken to eat dinner as early as possible; There should be at least 2-3 hours between meals and sleep.
      • Excess weight should be given. Because it will increase intra-abdominal pressure, complaints can be exacerbated.
      • Peppermint, peppermint, chocolate, excess fat and heavy sweet foods should be consumed as little as possible. Because such foods reduce the pressure of the valve between the esophagus and the stomach and delay gastric emptying.
      • Spicy foods, tomatoes and their products, garlic, onions, orange juice, citric acid starched drinks and coffee; In patients with known esophageal acid susceptibility, they may cause septomas by directly stimulating esophageal sensory receptors.
      • It is appropriate to follow a diet that includes low-fat and protein-rich foods.
      • Instead of eating too much at a time, frequent and small amounts of food should be preferred.
      • Avoid using alcohol and cigarettes.
      • Abdominal tightening clothes, corset, belt, tight pants and belt should not be used.
      • Eating white chickpeas and chewing gum can sometimes be helpful in preventing complaints.
      • Some exercises can cause reflux.
      • Some medications you are taking may increase reflux.
      • Increased intra-abdominal pressure during pregnancy may also cause reflux.
      Sources >> LARİNGOFARİNGEAL REFLÜImpact of laryngopharyngeal reflux on subjective and objective voice assessments: a prospective study / Reflux Laryngitis: Correlation between the Symptoms Findings and Indirect Laryngoscopy / Laryngeal and pharyngeal complications of gastroesophageal reflux disease / Textbook of Voice & Laryngology

      Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

      Private Office:
      Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
      Appointment Phone: +90 212 561 00 52
      Mobile phone: +90 533 6550199
      Fax: +90 212 542 74 47