Laryngopharyngeal reflux

Causes of symptoms

Direct and indirect contact with gastric and duodenal content causes mucosal irritation to the upper aerodigestive tract. Mucosal lesions in this area are primarily caused by pepsin, and this has been found throughout this area in symptomatic patients, in the nose and sinuses of patients with chronic rhinosinusitis, larynx/throat of those with chronic laryngitis and ears of those with chronic otitis media. (104)

Laryngeal symptoms

Chronic but intermittent complaints of:

• Need to clear throat excessively
• Hoarseness
• Voice changes/hoarseness – particularly weakness of the voice worst in the mornings (105)
• Chronic cough
• Painful swallowing/odynophagia
• Ear pressure
• Globus/sensation of a lump in the throat
• Post-nasal drip
• Laryngeal spasm (101)
• Nasal symptoms can lead to insomnia or frequent waking
• Bad breath/halitosis (106)

All of the above can exist in the absence of typical GORD symptoms like heartburn. Symptoms are worst at night when lying down and can wake the patient with choking and coughing. (107)

Laryngeal conditions that GORD can cause

1. Laryngitis. This is persistent irritation of the larynx. Up to 60% of hard-to-treat sore throats and recurrent laryngitis may be due to GORD. It is caused by direct mucosal injury from the acid and pepsin.
2. Laryngeal ulcers.
3. Laryngeal granulomas. Rounded benign masses of inflammatory tissue on the larynx – they may be asymptomatic or cause voice changes, throat discomfort or dyspnoea. GORD is responsible for up to 25% of laryngeal granulomas, and responds to pharmacological treatment in 75% (inhaled steroids, PPIs and alginates). (108)
4. Vocal cord polyps. Whilst voice misuse is the main cause of such lesions, alongside smoking, GORD is also implicated in polyp development. In one study, 50% of patients with polyps also had GORD and 60% had pepsin detected on the area affected. The chronic mucosal damage from the reflux is thought to be responsible for their development. For the most part, these can be managed with either no treatment or treatment of reflux, but 5% require surgery. (109)

Investigations

None may be needed and the patient can be treated empirically on the basis of typical symptoms. However, those treatment-resistant symptoms may need referral to ENT or gastroenterology for consideration of:

1. Laryngoscopy – inflammation, hypertrophy and oedema of the larynx can be seen. Granulomas can also develop. Excess mucus may be visible, as can ulceration. (110,111)
2.  
3. pH monitoring and impedance studies.
4. Oesophageal manometry.

Treatment

• Diet changes. Fried and fatty foods, citrus fruit, tomatoes, mint, acidic dressings, caffeine, carbonated drinks, alcohol can all aggravate LPR. (107)
• Lifestyle change. Smoking cessation, eating slower, regular meal times, eating more than three hours before bed. Sleeping in a left lateral sleeping position and elevation of the head of the bed may also alleviate GORD and LPR. (112) There is some evidence for alkaline water consumption denaturing pepsin in the pharynx and it is a harmless intervention that can be safely tried. (105)
• PPIs. Twice daily PPIs half an hour before meals for at least three months.
• Sodium alginate liquids or tablets such as Gaviscon Advance, three times a day after meals neutralise the pepsin on the throat, minimising mucosal damage. (107)
• Surgical anti-reflux surgery.
• Inhaled steroids are used to treat laryngeal granuloma. (108)
• Voice education may be useful in some patients.
• Surgery to remove polyps and granulomas.