What is reflux?
Reflux is short for ‘laryngopharyngeal reflux,” also abbreviated LPR. This describes the backward (upward) flow of digestive acid and enzymes from the stomach through the esophagus to the level of the vocal folds. This is the same process as gastroesophageal reflux disease, or GERD, except that otolaryngologists are preoccupied with its effects at the level of the larynx , not the esophagus.
Reflux is significant because the acid and enzymes that reach the larynx cause injury and irritation. The larynx is not as well protected as tissues closer to the stomach, and thus, it is damaged by contact with less stomach fluids than it takes to damage the esophagus. This accounts for the phenomenon of ‘silent reflux’: reflux can cause irritation in the throat without creating more typical symptoms like heartburn or chest discomfort, which are caused by esophageal irritation.
Irritation from reflux causes symptoms by itself, as well as contributes to other problems. It is a major factor in the formation of vocal fold granuloma. Ongoing research is looking into reflux as a factor that compounds the effects of phonotrauma and smoking, and contributes to respiratory difficulties like asthma.
Figure 1: This person has severe redness and swelling of the vocal folds from a combination of smoking and reflux.
What are the symptoms of reflux?
Reflux causes irritation and swelling of the larynx. This can make it feel as if there is a mass or mucus in the throat. This has caused many people to attribute the symptoms of reflux to ‘post-nasal drip,’ a term that probably has more meaning in advertising than in medicine. In fact, reflux is far more common than irritation from nasal discharge.
Sometimes, there can be an accompanying sensation of tickling or pricking that triggers throat clearing or coughing. Swallowing can become difficult, particularly swallowing of dry solids. More severe reflux can cause throat pain and laryngospasm, a sudden involuntary closure of the vocal folds that makes it impossible to breathe for a few moments. People with reflux symptoms typically cough and clear their throats constantly. During both of these actions, the vocal folds collide violently, and over time the chances of damage increase.
What do the effects of reflux look like?
Reflux-related irritation causes redness and swelling of the larynx, especially the parts close to the esophagus at the back of the vocal folds. Because such findings are so common in the general population, it has become clear that almost everyone occasionally experiences some reflux. The important clinical question is therefore not “Do you have reflux?” but “Is reflux responsible for the problem which is bothering you?”
Figure 2: This is a milder case of reflux with some swelling of the tissue at the back of the larynx and reddening of the vocal folds.
Reflux is commonly related to irritative symptoms like cough, chronic throat clearing, or a foreign-body sensation in the throat. Reflux alone is rarely responsible for hoarseness, although it frequently aggravates the effects of nodules, polyps, or other lesions. As mentioned above, reflux is a major causative factor in granulomas.
Figure 3: There is redness, swelling and thickening of the mucosa involving the back of the larynx (top of picture) and both vocal folds in this nonsmoker with severe reflux.
Diagnosis of reflux may be made after examination of the larynx alone, based on typical findings. It may be diagnosed with more certainty by testing the acidity (pH) of the area around the larynx over a 24 hour period by means of a probe. The results of an esophagoscopy, in which a doctor looks into the esophagus and stomach, are not particularly helpful for laryngeal disease, although they sometimes reveal reflux-related disease in other parts of the digestive tract. An x-ray study known as a Barium swallow may reveal a common anatomic abnormality called a hiatal hernia which predisposes a person to reflux.
How is reflux treated?
It is not usually possible to “fix” reflux. It represents a problem that must be controlled through dietary measures and sometimes medication. Food which is greasy, fatty or very sugary tends to make reflux worse, as does alcohol, caffeine and nicotine. In addition to avoiding specific foods, it is important to eat smaller meals, and to eat earlier, at least three hours before lying down to sleep.
In more severe cases, particularly when there are nighttime symptoms, raising the head of the bed on bed blocks may be helpful. Sleeping on several pillows, or on a foam wedge does not accomplish the same thing. In fact, it often makes reflux worse by bending the torso and increasing pressure on the gut.
Medical treatment of reflux should be undertaken in conjunction with behavioral measures in order to be effective, and in consultation with a physician. The most powerful anti-reflux medications currently available are known as proton-pump inhibitors (e.g. Nexium™ , Prevacid™, Protonix™, Aciphex™, and Prilosec™). The last is available without a prescription in a reduced strength. These are taken once or twice a day, 30-60 minutes before a protein-containing meal, which is needed to maximize the effects of the drug. Side-effects are usually absent or mild. Reflux may also be treated with an older, less-effective class of medications known as H2-blockers (Zantac™, Tagamet™, Axid™) or common over the counter remedies such as Tums™. Since reflux is a chronic problem, it may take several weeks to see a change in most laryngeal symptoms. The relative advantages and disadvantages of medications should be discussed in detail with your doctor.
Surgery is available to correct a hiatal hernia, if present. This is reserved for instances of severe reflux in which medication has not been effective.