Laryngopharyngeal Reflux Disease and Gastroesophageal Reflux Disease
Reflux means the backflow of stomach contents into the esophagus and even into the throat. Gastroesophageal reflux disease (GERD) is an abnormal flow of stomach contents into the esophagus, and Laryngopharyngeal Reflux (LPR) is an abnormal flow of stomach and esophageal contents into the throat.
GERD is the disease that most Americans think of as “reflux.” The most common symptoms are heartburn and regurgitation. More atypical symptoms, such as cough, may occur in the absence of heartburn or regurgitation symptoms. The esophagus is designed to resist injury from reflux, and GERD symptoms do not typically occur until there is excessive exposure of the esophagus to stomach contents (for example, more than 50 reflux episodes in a 24 hour period). This type of exposure can lead to esophageal erosions, strictures, Barrett’s esophagus, and even cancer. While acid is one of the harmful components of reflux, a more important component is the digestive enzyme pepsin, which is only active in an acidic environment. The most effective currently available reflux medications only control acid and do not actually prevent reflux for occurring. Even when the reflux is not acidic, it can still cause symptoms (sometimes called non-acid reflux). Lifestyle modifications are particularly important in the treatment of GERD. Some people choose to have an abdominal surgery (fundoplication) to control their GERD.
LPR is different from GERD. LPR may be present in up to 50% of people with voice problems. The voice box and throat are very susceptible to damage from acid and pepsin, and as few as three episodes a week can cause damage. This explains why many people with LPR do not have the typical GERD symptoms of heartburn and regurgitation. Symptoms of LPR include intermittent voice changes, cough, throat clearing, globus (lump in the throat), excessive throat mucus, and even swallowing problems. More serious consequences of LPR include subglottic stenosis, spasm of the vocal folds, granulomas, and cancer. Acid production needs to be more tightly controlled for LPR than for GERD, so treatment is often very aggressive (sometimes double or triple the dosage of medication used for GERD). LPR symptoms may not start to improve until several months after treatment is begun.
LPR can be diagnosed based on laryngeal examination and symptoms. Sometimes a trial of reflux medication is used to make the diagnosis. 24-hour pH testing is the best currently available test for diagnosis of reflux disease.