Gastro-oesophageal Reflux Disease

Many patients know of GERD (gastro-oesophageal reflux disease), where acidic stomach contents are returned back up the oesophagus, often with a burning sensation in the chest (heartburn). However, reflux may occur without alerting symptoms of heartburn. This is known as laryngopharyngeal reflux (LPR) – the ‘silent reflux’.

Because most people do not realise that reflux can occur without heartburn, LPR is often under-diagnosed or misdiagnosed as other conditions with similar characteristics.

In LPR cases, the acidic stomach contents are returned beyond the oesophagus, reaching the throat and back of the nose, causing various problems in these areas.

The pharynx and larynx serve as a passageway for air to reach the lungs and for food to reach the stomach via the oesophagus. At each end of the oesophagus is a muscular ring (sphincter), which prevent regurgitation of the contents of the stomach. When these sphincters are incompetent, acidic stomach contents can regurgitate back into the oesophagus, sometimes reaching the throat and back of the nose. This commonly occurs when an LPR patient lies horizontally, such as while sleeping.

The regurgitated contents include stomach acids that irritate and burn the sensitive larynx. Saliva is alkaline and the lining of the oral cavity and throat are resistant to alkaline media, but not to acidic media. LPR patients usually do not experience heartburn because the oesophagus is more resistant to acid than the larynx.

LPR is common in infants and children because their oesophageal sphincters are underdeveloped, they have shorter oesophagus, and they are often lying horizontally.

Snoring and obstructive sleep apnea can predispose a patient to LPR.

COMMON SYMPTOMS

• Excessive throat clearing and hoarseness
• Chronic cough that worsens at night and wakes one up from sleep; even mild airway infections or irritants can trigger violent coughing fits in throats already sensitised by LPR
• Throat discomfort, dryness or soreness, made worse by swallowing saliva
• Sensation of a lump in the throat
• Excessive phlegm in the throat
• Bitter taste at the back of the throat
• Exacerbated asthma, bronchitis or upper airway infection

POTENTIAL COMPLICATIONS

• In infants
  • Subglottic narrowing
  • Ulcer or inflammatory polyps in the larynx
  • Regurgitation and vomiting
  • Middle ear inflammation

• In adults
  • Ulcers, polyps and granulomas in the larynx
  • Increased risk of cancer of the throat and oesophagus

DIAGNOSIS

• LPR is often misdiagnosed and incorrectly treated as chronic cough, sinusitis, pharyngitis, tonsillitis, allergy, or as psychosomatic
• Videorhinolaryngoscopy often reveals congestion and inflammation, and – in severe cases – granulations, ulcers and polyps
• pH monitoring

TREATMENT

• Lifestyle Modifications
  • Small and frequent meals; avoid heavy meals
  • Stop eating and drinking two to three hours before bedtime
  • Avoid spicy food and carbonated or acidic drinks, eg citrus juice and vinegar
  • Elevate the head of the bed by four to six inches
  • Avoid tight-fitting clothes around the waist
  • Lose weight (obesity increases LPR)
  • Manage stress (stress raises gastric acidity)
  • Chew gum (it increases saliva production, which neutralises acid)
  • Get treated for snoring and obstructive sleep apnea

• Medical and Surgical
  • Antacids
  • Anti-acid medications (eg proton pump inhibitors)
  • Prokinetic agents such as Motillium (to promote gastric emptying and increase oesophageal sphincter pressure)
  • In severe cases, surgery to tighten the lower oesophageal sphincter may be considered