HomeServicesAbout UsFacilityReseach and AcademicsContactInformationWhats New

Laryngopharyngeal Reflux

Reflux of stomach acid into the throat is one of the leading causes of hoarseness and voice dysfunction in adults. The term laryngopharyngeal reflux disease, or LPRD, has been used to describe this disorder. While LPRD can occur in any individual and singers are at particularly high risk. Gastroesophageal reflux disease, or GERD, is the general term used to describe all disorders caused by excess production and reflux of stomach acid. 

Stomach acid is relatively concentrated hydrochloric acid produced by special cells in the lining of the stomach. The acid is used in the digestive process. When food passes down the esophagus and into the stomach, it signals these special cells to produce and secrete the acid. Under normal circumstances, a muscular valve between the stomach and esophagus, known as the lower esophageal sphincter (LES), prevents stomach acid from flowing back into the esophagus. When this valve does not function properly, acid can reflux into the esophagus and produce symptoms. Valve dysfunction can be caused by a number of factors. Many of these factors occur commonly in the general population but are particularly common in singers. For example, increased pressure within the abdomen, as often occurs during a performance, can cause the valve to open and promote reflux. Tight clothing around the waist and certain exercises like sit-ups can also increase intra-abdominal pressure.

Obesity can cause the stomach to be pushed up toward the diaphragm. This pushes the valve into the chest, a condition known as hiatal hernia, and causes it to become weak, provoking acid reflux. Increased pressure within the stomach itself can also affect the valve. Large meals and carbonated beverages that over-distend the stomach can stretch open the valve. 

Also important in this disorder is the amount and timing of acid production by the stomach. Certain foods and other products are very strong stimulants of stomach acid. Alcohol, tobacco and caffeine are the worst offenders. Other examples include spicy foods, foods high in fat (fried, rich foods) and throat lozenges containing mint, menthol or eucalyptus. Ironically, many people with LPRD take such lozenges to relieve symptoms and this will often aggravate the condition. Timing of meals is also important. The acid content of the stomach is always greatest right after a meal; further, meals eaten just before bedtime will often promote reflux. 

Symptoms of reflux depend on the frequency of reflux episodes as well as the height to which the reflux reaches. Heartburn is the classic symptom of acid reflux and occurs when the esophagus is affected (GERD). Since the esophagus is part of the digestive system, its lining is fairly resilient to acid and symptoms occur only when reflux episodes are frequent.  

When the refluxed acid reaches the height of the pharynx (throat) and larynx (voice box and vocal cords), many symptoms can occur including hoarseness, a sensation of a lump or mucus in the throat, throat clearing, and coughing that can be quite violent. These are the symptoms of LPRD and they can be harmful to singers and others. Unlike the esophagus, the larynx is part of the respiratory system; its lining is very sensitive to acid and even small, infrequent reflux episodes can produce significant symptoms. As a result, more than half of patients with symptoms of LPRD do not have the classic symptom of heartburn. 

Proper management of LPRD should begin with evaluation by an otolaryngologist. A complete review of symptoms, diet, lifestyle habits and medications, as well as examination of the larynx and pharynx, is important in making the diagnosis.  

Prevention is a very important aspect of treating LPRD. Standard LPRD precautions include the following: 

  • Avoid alcohol, tobacco and products that contain caffeine
  • Avoid carbonated beverages
  • Avoid large meals. Instead, try more frequent but small meals
  • Avoid eating within 3-4 hours of bedtime
  • Avoid lozenges containing mint, menthol or eucalyptus. Instead, drink noncarbonated water to soothe throat symptoms
  • Avoid foods that are spicy or high in fat. Eat well-balanced meals. Broiled and baked foods are better than fried foods
  • Elevate the head of bed approximately 3-4 inches using bricks or wooden blocks. This helps promote the movement of stomach acid down into the intestine rather than back up into the esophagus. Pillows alone will not help

There are many medications available to treat LPRD and GERD. Antacids work by simply neutralizing acid in the stomach. H2 (histamine-2) blockers, such as Zantac® and Pepcid®, work by reducing the amount of acid produced by the cells of the stomach lining. Proton pump inhibitors, such as Protonix®, Nexium® and Prevacid®, work by a slightly different mechanism and reduce acid production by these cells to even a greater extent. Some medications are available over the counter. Nevertheless, patients should consult their otolaryngologist before taking any medication.