A Family Doctor's Tale - LARYNGOPHARYNGEAL REFLUX

DOC I HAVE LARYNGOPHARYNGEAL REFLUX

Laryngopharyngeal reflux disease (LPR) is a chronic disease of the pharynx (throat) and larynx (voice box) whose mucosa is damaged by abnormal acid backflow (reflux) of gastric acid from the stomach to the esophagus.

The following causes are responsible for LPR:
There are 2 sphincter muscles in the esophagus:
1.the Lower Esophageal sphincter (LES) prevents the backflow of food and acid from the stomach and acid from the stomach into the esophagus

2.the Upper esophageal sphincter (UES) prevents the food and acid from backflowing into the larynx

An incompetant Lower Esophageal Sphincter(LES) allow the acid and gastric juice to reflux up the esophagus giving rise to gastroesophageal reflux disease or GERD.

If the acid and digestive enzymes from the stomach back flows into the larynx then the condition is called laryngopharyngeal reflux or LPR.

An incompetant lower esophageal sphincter may also result from:
1.Hiatus hernia - hole in diaphragm separating esophagus from stomach is enlarged allowing the easier flow of acid up the esophagus

2.Obesity and pregnancy: increased body weight cause pressure in the abdomen to push gastric contents upwards towards esophagus

The most common symptoms are
1.frequent throat clearing

2.throat itchiness

3.sensation of something in the throat

4.excess phlegm in the throat

5.hoarseness- due to inflammation of the vocal cords from the acid reflux

6.frequent sore throat

7.chronic cough - the acid flow up the esophagus can irritate the larynx and spark off the cough reflex

8.Heartburn - there is a burning discomfort behind the breastbone due to acid flow up the esophagus

Diagnosis:
A detailed history of acid reflux into the larynx and pharynx

Useful investigations may include
1.barium swallow X-rays to check the flow a barium dye from the oral cavity down the esophagus to the stomach. It can detect any reflux of the dye into the esophagus and the presence of any growths in the esophagus and stomach.

2.nasoendoscopy - an endoscope is passed through the nose to the level of voice box in the throat under local anethesia to check on the vocal cords

3.24-hour esophageal pH monitoring - measures the acidity of the esophagus

4.Esophagogastroduodenoscopy (EGD) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Treatment is aimed at
A. prevention of reflux:
1.weight loss for the Obese

2.Positional therapy
a.Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients

b.Elevating the head of the bed is also effective.
The head of the bed can be raised by wooden bed risers that support bed posts or legs.
Elevation must be at least 6 to 8 inches (15 to 20 cm) to be able to prevent the backflow of gastric fluids.

c.a bed wedge pillow will also help to raise the patient's body higher

3.Certain foods should be avoided to prevent Laryngopharyngeal reflux:
a.Coffee,


b.alcohol,


c.Acidic foods, such as oranges,tomatoes and excess amounts of Vitamin C


d.Antacids based on calcium carbonate actually increase the acidity of the stomach.


e.Foods high in fats -delay stomach emptying


f.Carbonated soft drinks with or without sugar.


g.Chocolate and peppermint.


h.Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.


i.Milk and milk-based products containing calcium and fat,


j.Eating within 2 hours before bedtime.

k.Large meals- smaller meals reduces reflux as it means there is less food in the stomach at any one time.

4.Smoking reduce lower esophageal sphincter competence, and should be avoided

5.Avoid stress.
Learn to relax or meditate.
Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.

B. Neutralizing the Gastric Acid Reflux
1. Drug treatment
a.Proton pump inhibitors are the best drugs used in reducing gastric acid secretion. (eg Nexium, Losec)

b.Antacids taken before meals half hourly after symptoms begin can reduce gastric acidity (liquid antacid are more useful than tablets)

c.Alginic acid (Gaviscon) protects the mucosa as well as increase pH and decrease reflux.

d.Gastric H2 receptor blockers such as ranitidine or famotidine decrease gastric secretion of acid.

2. Surgical treatment
The standard surgical treatment, done laparoscopically, is the Nissen fundoplication.
The upper part of the stomach is wrapped around the Lower Esophageal Sphincter(LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

3.New treatments
Eight years ago some new endoscopic devices to treat chronic heartburn were approved:
a.The Endocinch apply stitches in the LES to help strengthen the muscle.

b.The Stretta Procedure uses electrodes to use radio frequency energy to strengthen the LES.

c.The Plicator creates a plication, or fold, of tissue near the Laryngopharyngeal junction, and fix the fold using a suture-based implant.

Prognosis:
It is a chronic disease so treatment is lifelong and recurrences are common.

Prevention:
1.Prevent heartburn by limiting acidic foods, such as grapefruit, oranges, tomatoes, or vinegar
2.Spicy foods -Cut back on pepper or chilies.
3.Avoid lying down for two to three hours after meals.
When you are sitting up, gravity helps drain food and stomach acid into your stomach.
4.Eat lean meats and non-fatty foods.
Greasy foods (like French fries and cheeseburgers) can trigger heartburn.
5.Avoid drinks that can trigger reflux, such as alcohol, drinks with caffeine, and carbonated drinks.
6.Eat smaller meals to avoid triggering reflux symptoms.
7.Avoid stress.
Learn to relax or meditate.
8.Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.