Swallowing disorders, speech disorders, and chronic cough fit a diagnosis of Laryngopharyngeal Reflux or LPR. LPPR symptoms:
- I have a lump in my throat.
- My voice sounds raspy.
- I have to clear my throat often
- I have a sore throat where I feel a lump in my throat.
- Something is stuck in my throat on my left side, but sometimes it moves to my right side.
- Sometimes my throat feels like it is burning,
- I get coughing spells
- With these symptoms I have trouble swallowing sometimes.
Imagine if you are the patient with sensation of foreign body in the throat. Imagine you have been to the University. They used a flexible scope and looked in your throat and all the way down to your stomach. They told you they could find nothing wrong. They gave you a month of Prilosec, then a month of Aciphex and you feel worse. We see these patients at Tower ENT all the time.
Dr Martin Hopp: ” Patients are told to take pills and rest their voice. But often the patient is earning their livelihood by their voice. In many patients, the careful examination finds a cause that can be corrected.”
When you have Laryngopharyngeal Reflux, (LPR) the diagnosis and treatment may be difficult without looking at the whole person including allergy, lifestyle, muscle spasm and other factors.
What Causes LPR
LPR is not much different from Gastroesophageal reflux or GERD. However the patient with the raspy voice/lump in the throat may have no stomach acid symptoms. In one study, ½ the patients had no stomach burning whatsoever. Somehow the stomach acid doesn’t seem to affect the esophagus but bothers the voice and lower throat.
The lump sensation is a muscle spasm caused by the irritation from the acid. Think of an eye irritation and you keep squeezing your eye shut. The doctor can palpate a thickened muscle “lump” of the muscle around the eye.
The sore throat is the acid irritation. Problem is that even on very careful examination with the best instruments, doctors may not see anything. The sore throat, as well as the lump in the throat feeling comes from muscle spasm associated with the irritation.
The Voice Disorder
The raspy voice is the effect of the acid on the vocal cord mechanism. The back of the vocal cord is the first place where the acid spills over from the esophagus. At times the throat specialist can see redness and irritation there to explain the symptoms. That is when you have a diagnosis. On the other hand, postnasal drip, chronic sinusitis, and allergy can create thick mucus that accumulates on the vocal cords, irritates them and causes constant clearing and voice changes. Clearing the throat often is due to your body trying to dilute the refluxed acids. The body secretes a thick liquid that lands on the vocal cords and requires the cough like clearing. Sometimes this becomes a full-fledged cough.
A sensation of a physical object in the throat is the irritation combined with muscle spasm. When there is an actual bone stuck in the side of the throat, is is accompanied by muscle spasm too. Even after the bone is removed, the same sensation may persist with the same “something in my throat” sensation and show a palpable muscle spasm.
How to Treat LPR
The common drug for this is called a Proton Pump Inhibitor or PPI. These include
- Prilosec omeprazole
- Prevacid lansoprazole
- Aciphex rabeprazole
- Protonix pantoprazole
- Nexium esomeprazole
As the name implies, these drugs inhibit the production of stomach acid.
Other drugs may be used called H2 blockers. These include
Histamne stimulates certain stomach cells to produce acid. These H2blockers prevent that action. Usually the H2 blockers are taken at night.
In my practice we see the patient who has not responded to standard treatments. If a reevaluation doesn’t find a specific ulceration or muscle spasm, we look for:
LPR From Sinusitis
Is there postnasal drip? Poor cilia movement of the nose may be responsible for infected material dripping into the throat causing symptoms. Or the infected material may be irritating the lower esophagus and causing the sphincter that closes off the stomach to be weak. This condition along with any chronic sinus condition is cleared with pulsed nasal/sinus irrigation to restore normal sinus function. For example the Hydro Pulse ™ irrigation is done twice a day until the drainage is cleared. Without the drainage, many patients respond.
If there is a definite lump palpable, that is not a gland or from a growth, pulsatile irrigation to that area with the throat attachment of the Hydro Pulse™ done twice a day reduces that swelling / lump formation.
In a review of LPR just published, there were statistics showing that the thick mucus of allergy, postnasal drip or chronic sinusitis can cause the same symptoms as LPR. It is vital to make the right diagnosis
When Treatment Fails
Patients I see have already had multiple courses of drugs, but symptoms persist. Yes there are no physical findings.
Here we reinforce dietary factors:
- Avoid eating three hours before bedtime
- Avoid spicy, minty, hot pepper foods
- Avoid alcohol and excess caffeine
- Avoid carbonated drinks
- Elevate the head of the bed.
- Essentially follow the GERD diet. (these are available at your docotor’s office.
Another help it to avoid muscle spasm or tightness. Look in the mirror. Breathe in count of four and out count of six. See the face, jaw and shoulders relax in the mirror. Must practice this daily. See book, Stressed? Anxiety? Your Cure is in the Mirror for more details.
Imagine you have the symptoms of LPR and you have already seen two other doctors without relief, and are now seeing your third doctor. Do you feel tense, anxious, and nervous? Of course you do, if you are human. These patients were often put down as “hysterics” or imaginers or diagnosed with psychological problems such as “displacement.” Today we can appreciate that most of those patients tagged Globus Hystericus were probably LPR – Laryngopharyngeal Reflux.
The symptoms of voice disturbance, burning throat, lump in the throat, and constant clearing of the throat can be caused by allergy, postnasal drip, chronic sinusitis and excess acid. Although Nexium or Prilosec alone may clear the symptoms, it is best to consider dietary and nasal/sinus factors as well for therapy