Laryngopharyngeal Reflux (Silent Reflux)

Laryngopharyngeal reflux (LPR) is similar to another condition -- GERD -- that results from the contents of the stomach backing up (reflux). But the symptoms of LPR are often different than those that are typical of gastroesophageal reflux disease (GERD).

With LPR, you may not have the classic symptoms of GERD, such as a burning sensation in your lower chest (heartburn). That's why it can be difficult to diagnose and why it is sometimes called silent reflux.

Causes of LPR

At either end of your esophagus is a ring of muscle (sphincter). Normally, these sphincters keep the contents of your stomach where they belong -- in your stomach. But with LPR, the sphincters don't work right. Stomach acid backs up into the back of your throat (pharynx) or voice box (larynx), or even into the back of your nasal airway. It can cause inflammation in areas that are not protected against gastric acid exposure.

Silent reflux is common in infants because their sphincters are undeveloped, they have a shorter esophagus, and they lie down much of the time. The cause in adults is not known.

Symptoms of LPR

Symptoms in infants and children may include:

• Hoarseness
• "Barking" or chronic cough
• Reactive airway disease (asthma)
• Noisy breathing or pauses in breathing (apnea)
• Trouble feeding, spitting up, or inhaling food
• Trouble gaining weight

With LPR, adults may have heartburn or a bitter taste or burning sensation in the back of the throat. But they are less likely to have such classic signs of GERD. More often, symptoms in adults are vague and may be easily confused with other problems. The most common symptoms include:

• Excessive throat clearing
• Persistent cough
• Hoarseness
• A "lump" in the throat that doesn't go away with repeated swallowing

Other symptoms may include:

• A sensation of postnasal drip or excess throat mucus
• Trouble swallowing
• Trouble breathing
• Sore throat

Complications of LPR

Stomach acid that pools in the throat and larynx can cause long-term irritation and damage. Without treatment, it can be serious.

In infants and children, LPR can cause:

• Narrowing of the area below the vocal cords
• Contact ulcers
• Recurrent ear infections from problems with eustachian tube function
• Lasting buildup of middle ear fluid

In adults, silent reflux can scar the throat and voice box. It can also increase risk for cancer in the area, affect the lungs, and may irritate conditions such as asthma, emphysema, or bronchitis.

Diagnosis of LPR

Although silent reflux is harder to diagnose than GERD, a doctor can diagnose it through a combination of a medical history, physical exam, and one or more tests. Tests may include:

• An endoscopic exam, an office procedure that involves viewing the throat and vocal cords with a flexible or rigid viewing instrument
• pH monitoring, which involves placing a small catheter through the nose and into the throat and esophagus; here, sensors detect acid, and a small computer worn at the waist records findings during a 24-hour period. Newer pH probes placed in the back of your throat or capsules placed higher up in the esophagus may be used to better identify reflux.

Treatment of LPR

Silent reflux treatment for infants and children may include:

• Smaller and more frequent feedings
• Keeping an infant in a vertical position for at least 30 minutes after feeding
• Medications such as H2 blockers or proton pump inhibitors, as directed by the pediatrician
• Surgery for any abnormalities that can't be treated in other ways

Silent reflux treatment for adults may include these lifestyle modifications:

• Lose weight, if needed.
• Quit smoking, if you are a smoker.
• Avoid alcohol.
• Restrict chocolate, mints, fats, citrus fruits, carbonated beverages, spicy or tomato- based products, red wine, and caffeine.
• Stop eating at least three hours before going to bed.
• Elevate the head of the bed about 4 to 6 inches.
• Avoid wearing tight-fitting clothes around the waist.
• Try chewing gum to increase saliva and neutralize acid.

You may also need to take one or more types of medicine such as:

• Proton pump inhibitors such asdexlansoprazole (Dexilant), esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), omeprazole, or rabeprazole (Aciphex), and sodium bicarbonate (Zegerid) to reduce gastric acid.
• H2 blockers such as cimetidine (Tagamet), famotidine (Pepcid), or nnizatidine to reduce gastric acid.
• Prokinetic agents to increase the forward movement of the GI tract and increase the pressure of the lower esophageal sphincter. These medications are not as commonly used, because they have been linked to adverse effects on heart rhythm and diarrhea.
• Sucralfate to help protect injured mucous membranes.
• Antacids to help neutralize acid; these are used more commonly for symptoms of heartburn.

Some people respond well to self-care and medical management. However, others need more aggressive and lengthy treatment. If this is not effective or if symptoms recur, your doctor may suggest surgery.

Fundoplication is a type of surgery which involves wrapping the upper part of the stomach around the lower esophagus to create a stronger valve between the esophagus and stomach. It is usually done laparoscopically, with small surgical incisions and use of small surgical equipment and a laparoscope to help the surgeon see inside. Fundoplication can also be done as a traditional open surgery with a larger incision.

Other techniques can also be done laparoscopically, including placing a ring of titanium beads around the outside of the lower esophagus that strengthens the valve while still letting food pass through.

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