LARYNGEAL-PHARYNGEAL REFLUX (LPR)
Laryngopharyngeal reflux (LPR), also known as silent reflux, extraesophageal reflux disease, and supra-esophageal reflux, is caused by the flow of stomach contents back up through the esophagus and back into the larynx, oropharynx and/or the nasopharynx. The stomach fluids that cause LPR symptoms can be either acidic or non-acidic. In fact, even gas coming up from the stomach can cause the same problems. The diagnosis of LPR can often be very difficult as patients often have minimal heartburn symptoms. It only takes three episodes of reflux per week into the esophagus and throat to cause chronic symptoms. Patients with LPR often require extensive evaluations to confirm the diagnosis.
SYMPTOMS:
- Difficulty in swallowing (dysphagia)
- Dry cough
- Hoarseness
- Chronic sore throat
- Sensation of a lump in your throat (globus)
LARYNGEAL-PHARYNGEAL REFLUX (LPR):
Laryngoscopy
Typically, your ENT doctor will perform this procedure as part of your initial evaluation to evaluate the features of your throat. It is often the first sign that you may have LPR if the ENT doctor finds that your tissues are irritated. Once other causes of your symptoms are excluded, the ENT doctor may refer you to have further testing to see if you truly have LPR caused by reflux of stomach contents.
Upper Endoscopy
A camera with a light is mounted on a thin, flexible tube (endoscope) which is inserted down your throat. The camera allows your physician to examine the inside of your esophagus and stomach. An endoscopy may detect inflammation of the esophagus (esophagitis) or other complications of GERD that other diagnostic tests do not. During an endoscopy, your physician may also collect a tissue sample which can be tested (biopsy) for other digestive disorders such as Barrett’s esophagus.
Ambulatory Acid (BRAVO pH) Probe Test
After endoscopy, a small probe is attached to your lower esophagus to identify when, and for how long, stomach acid regurgitates there. The probe connects to a small receiver that you wear around your waist or with a strap over your shoulder. For patients with LPR type symptoms, the probe/receiver will collect information for 96 hours. The probe that is attached to your esophagus will fall off and pass into your stool after 7-10 days.
24 hr pH/Impedance Test
This test is considered for patients who have a normal BRAVO pH evaluation. This test allows us to determine if acid or non-acidic fluid is coming into the upper esophagus or throat. The monitor is a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus.
Esophageal Manometry
This test measures the strength of the muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
X-Ray of Your Upper Digestive System
For this test, you drink a chalky liquid (barium sulfate) which coats the inside lining of your digestive tract. This allows your doctor to see your esophagus, stomach, and upper intestine and can help determine the cause of swallowing issues, unexplained vomiting, and severe indigestion. Some patients may also be asked to swallow a barium pill. This helps diagnose swallowing issues caused by a narrowing of the esophagus.
Gastric Emptying Study
This test determines if the stomach is emptying normally. You would eat a light meal containing a small amount of radioactive material. A scanner placed over your abdomen monitors the movement of the radioactive material and the rate at which the food leaves your stomach.
TREATMENT:
Surgery is considered the best solution for patients with severe LPR. LPR is considered to be a mechanical problem due to the fact that stomach contents overcome the lower esophageal sphincter muscle that separates the esophagus and throat from the stomach. Acid-reducing medications can help a bit. However, they only mask the acidity of the stomach contents. Therefore, they do nothing to stop the material from coming into the upper esophagus and throat and causing irritation.
- Magnetic Sphincter Procedure – Magnetic sphincter augmentation involves implanting a small device to reinforce lower esophageal sphincter (LES) muscle which separates the stomach from the esophagus. Therefore, it stops reflux while allowing the patient to eat normally. The device is comprised of interlinked titanium beads with magnetic cores.
- Toupet 270 Degree Partial Fundoplication – In a Toupet fundoplication, the fundus of the stomach is brought posterior to the esophagus. The repair involves securing the stomach to the edge of the lower esophagus at the 10:00 position on the right and the 2:00 position on the left creating a partial wrap or fundoplication. This is used in patients who have poor esophageal function and cannot generate enough strength to overcome the LINX system.
- Nissen 360 Degree Fundoplication – This is an older procedure reserved for patients who are not able to have a LINX procedure. In a Nissen fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter.