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LPR

LARYNGOPHARYNGEAL REFLUX (LPR)

LARYNGOPHARYNGEAL REFLUX (LPR) DEFINED
LPR is the backflow of stomach contents and acid up to the larynx (voice box) or pharynx (throat) with resultant injury.  While acid must travel up the esophagus to get to the larynx or pharynx, it does not necessarily cause damage to the esophagus during this transit (see LPR DOES NOT MEAN HEARTBURN), and therefore many patients with LPR do not have gastroesophageal reflux disease (GERD). Thus, LPR and GERD are different.

LPR SYMPTOMS
The constellation of symptoms with LPR include hoarseness, throat clearing, lump in the throat sensation, chronic cough, sensation of postnasal drip, trouble swallowing, and excessive mucous. Patients with laryngopharyngeal reflux do NOT necessarily experience heartburn.  In fact, about half of all patients with LPR experience no heartburn at all.  This is why LPR is often referred to as "silent" reflux.

LPR DOES NOT MEAN HEARTBURN
Many patients with LPR do NOT have heartburn or indigestion.  This happens for two reasons. First, the stomach contents move quickly through the esophagus up to the throat, not spending a long enough time in the esophagus to cause irritation.  Second, the esophagus has a lining that is quite resistant to stomach acid, while the throat lining is very sensitive to injury and irritation from stomach acid.  In fact, studies show that the esophagus can usually tolerate up to 50 episodes of acid exposure (reflux events) without damage such as esophagitis developing, but as few as 1-2 episodes of acid exposure to the throat can cause serious damage and LPR SYMPTOMS.  Therefore, many patients have a limited number of acid reflux events- not enough to cause heartburn or esophageal damage- but the most of the reflux events are making it up to the throat, causing injury and LPR SYMPTOMS.

HOW TO KNOW IF YOU HAVE LPR  
If you have many LPR SYMPTOMS, you may have LPR.  Your doctor will likely examine your throat to see if there are signs of redness and irritation.  You may then be prescribed a treatment trial for LPR, or you may be sent for special testing, called dual pH probe testing. This test involves placement of a small flexible tube through your nose and into your throat which is kept in place for about 24 hours. The tube is connected to a small portable computer box that detects acid reflux events.  Your doctor can then review the computer information and determine if you need antireflux treatment.  Esophagoscopy is another important test for evaluating patients with LPR.  This can now be done in the office with a tool called Transnasal Esophagoscopy (TNE), which allows the doctor to view the full length of your esophagus for signs of damage from acid reflux. 

SERIOUS PROBLEMS LINKED TO LPR  
LPR often causes the symptoms listed above.  However, some patients with severe LPR will develop breathing problems (wheezing, shortness of breath) and choking spells.  Very rarely, patients may also develop certain cancers (throat, voice box, esophagus) which are thought to have an association with LPR and gastroesophageal reflux disease (GERD), but it is not clear that LPR or GERD actually causes these cancers.

TREATMENT FOR LPR
Treatment for LPR should be individualized, but there are behavioral steps that all patients with LPR should follow a low fat diet- especially avoid fried foods, & chocolate! Avoid soda and other carbonated beverages.  Avoid alcoholic and caffeinated beverages. Avoid snacks/meals within three hours of bedtime.  Avoid "rough play" or exercise within one hour after meals.  Do not wear clothing that is too tight around the waist.
Over the counter remedies for LPR include chewing gum, especially bicarbonate gum, after meals.  Over the counter medications like Maalox, Mylanta, and Gaviscon may also help treat LPR, but they generally are not as effective as the medications that reduce stomach acid production.  Your doctor may prescribe a medication called a proton pump inhibitor (PPI) such as Nexium, Protonix, Prilosec, Prevacid, or Aciphex to reduce stomach acid production.  You will need to take this medication regularly, and it should be taken approximately 1 hour before meals.   Surprisingly, most proton pump inhibitors raise the stomach acidity (pH>4) for just over 16 hours.  While once daily dosing is good enough to reduce heartburn in most patients, it is generally not adequate for relieving LPR symptoms.  Most patients with LPR require full 24-hour coverage, meaning twice-daily dosing of PPIs (1 hour before breakfast and 1 hour before dinner).

STOPPING TREATMENT FOR LPR  
LPR tends to be a chronic-intermittent disease.  This means that you may improve to the point that you can get off your LPR medications for weeks or even years, but it is quite likely that you will have a relapse at some point.  For people who do not tolerate or respond to LPR medications, anti-reflux surgery may be recommended.  This surgery tightens the valve between the stomach and esophagus, and it can provide relief for many years.