The stomach secretes acid to digest the food that comes to it. The valve system, which exists to prevent gastric contents and liquid from leaving the stomach, tries to prevent gastric liquid from leaking out of the stomach. When the valve between the stomach and esophagus (lower esophageal sphincter) does not work properly, the acidic content of the stomach escapes upwards into the esophagus. This is called gastroesophageal reflux (GER) (Figure 1). When the valve between the esophagus and the throat (upper esophageal sphincter) does not work, the stomach contents reach the throat and larynx, that is, the vocal cords, which are much more sensitive to acid, stomach contents and bile. This condition is called laryngopharyngeal reflux (LFR) (1,2). This reflux is different from the commonly known gastric reflux (GER). While upper throat reflux is more common during the day and while standing, stomach reflux is more frequent and disturbing while lying down (1). The sensitive structure of the larynx and pharynx tissues, some neural reflexes, and esophageal movements also play an important role in the development of LPR.
Voice problems due to reflux occur either with the direct irritative effect of acid, or with the reflex contraction and hardening of the throat, larynx and neck muscles against acid.
It is reported that approximately 30% of the European population suffers from reflux. This reflux to the throat is not uncommon and is seen in one in every 10 patients applying to ENT outpatient clinics. It is also stated that LPR is the main or secondary cause of the voice problem in at least 50% of patients who consult an ENT specialist due to voice problems.
With what complaints does a patient with laryngopharyngeal reflux consult a doctor?
Problems we frequently encounter in our patients;
- Hoarseness, hoarseness, voice problems
- Chronic cough , persistent cough.
- Nasal drip
- Throat clearing
- Feeling of obsession in the throat, foreign body sensation
- Swallowing problems
- Bitter/bad taste in the mouth
- Difficulties in breathing
- Bad odor
- Pain reflected in the ear
- Bitter water coming into the mouth, chest pain , acid coming from the stomach, indigestion
LPR is diagnosed How is I diagnosed?
It is not always easy to make a diagnosis. Because the complaints of our patients are not specific to this disease. First of all, a detailed history should be taken from our patients, their diet, lifestyle, body mass index (weight/height2), smoking, alcohol, tea and coffee habits, use of drugs that affect the stomach, the time between dinner and bedtime, chocolate, nuts, bitters, vinegar. , spicy sauces, fatty and sugary eating habits, stress and ability to cope with stress, and even the use of tight belts and clothing should be questioned. The previous stomach diseases of our patients, the medications they used for these diseases and the surgical operations they underwent are also points we need to know.
Again, a detailed ENT and Head and Neck examination should be performed. Videolaryngoscopy is the visual endoscopy system that gives us the most information about reflux. This system is not similar to gastric endoscopy. With camera endoscopes, recorded images are obtained from the throat, larynx, vocal cords and the beginning of the esophagus (Figures 2,3,4). While the normal larynx structure is seen in Figure 2, the endoscopic images of the vocal cords and larynx structure of our 2 patients with reflux are shown in Figures 3 and 4.
Our patients' complaints are scored on the Reflux Symptom Index (RSI) scale (Figure 5). This scoring is repeated on the dates when our patients come to us for follow-up, and a subjective evaluation of the treatment is made.
Which examinations are used?
Endoscopic Laryngoscopy imaging methods are the most valuable method for us. These are imaging and evaluation of the upper respiratory and digestive tracts with fiberoptic endoscopy or videolaryngoscopy.
The most valuable method in diagnosis and accepted as the gold standard is double probe 24-hour acid (pH) monitoring. In this examination, 24-hour acid changes in the esophagus can be monitored by placing 2 acid meters 5 cm and 15 cm above the lower valve in the esophagus.
Why is laryngopharyngeal reflux important and should it be treated? Which diseases do LPR pave the way for?
Unfortunately, LPR is a disease that is difficult to diagnose and cannot receive regular treatment. In recent years, medical LFR will be a disease that will become more popular in the coming years, as dizzying developments and technological transformation accompany it. The incidence of this disease will increase as a result of intense stress added to faulty diets and lifestyles.
It is blamed for the formation of many diseases: The most important of these are;
- Asthma
- Microaspiration (escape of acid and stomach contents into the respiratory tract),
- Lung diseases,
- Airway narrowing (laryngeal stenosis) ,
- Obstructive sleep apnea, which manifests itself with cessation of breathing during sleep,
- Laryngospasm with attacks,
- Laryngeal cancer,
- Sudden infant death syndrome ,
- Chronic sinusitis,
- Chronic pharyngitis. Chronic pharyngitis should not be considered as an incurable disease, the presence of reflux should be questioned in these patients.
What are the approaches to treatment? Does diet have a place in the treatment of this disease?
Diet regulation has a very important place not only in the treatment of this disease, but also in preventing its recurrence. In today's modern lifestyle, we need to adopt the right diet as our own lifestyle instead of temporary, weekly, monthly, seasonal diets. These recommendations are;
- Not eating/drinking any food (except water) 3 hours before going to bed,
- Avoiding overeating and eating immediately after meals. It can be summarized as not going to bed,
- Staying away from fried foods,
- Avoiding alcohol, coffee, tea, chocolate and acidic drinks,
- Not consuming foods that are known to bother you.
Do lifestyle changes have a place in the treatment of this disease?
Lifestyle changes are also one of the important parts that support drug treatment in LPR. These;
Elevating the head of the bed by 10-15 cm while lying down. The aim here is not to sleep on two pillows, but to raise the head of the bed. Tight clothing and tight belts should be avoided. Smoking and alcohol should not be consumed, ideal weight should be maintained. Additionally, clothes that are too tight on the abdominal area should be avoided. Additionally:
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- Avoiding lying down and bending over immediately after meals,
- Not using drugs that affect the stomach, such as aspirin, unless necessary,
- Avoiding intense stress or learning the art of coping with stress,
- Doing abdominal breathing,
- Eating frequent and small meals,
- Staying away from caffeine and nicotine,
- Consuming tomatoes and foods containing tomato sauce, spicy foods, pineapple, vinegar and citrus fruits in moderation,
- Chocolate, nuts, menthol and alcoholic beverages impair the lower esophageal sphincter and stay away from them,
- Avoiding fatty foods,
- Preferring reduced-fat or fat-free milk and dairy products instead of full-fat milk.
I would like to remind one point here to our patients who read this long list of suggestions. Of course, “It is essential that we remove all of the foods listed above from our lives.” Inferring that would be a heavy request and would probably never be complied with. The best thing to do is to consume the mentioned foods in limited and small amounts. One of my patients was not getting better despite 4 months of treatment. He later told me that he followed a detox cure and consumed 2 kilograms of grapefruit every day. Of course, drug treatment must be supported by these recommendations.
How often should patients go to the doctor for check-ups?
Our practice is to re-examine the patient in the 2nd month of treatment and in the 4th month after the end of treatment.
Are there patients who do not respond to treatment?
Unfortunately, the success rate with the most appropriate and optimal treatment with medication is 70%. Patients who do not respond to this treatment may require further examinations such as gastric endoscopy and biopsy.
Can you give information about your research on laryngopharyngeal reflux?
One of these is a study evaluating the effects of reflux disease on voice quality. was. With this study in which we conducted voice analysis, we demonstrated that laryngopharyngeal reflux negatively affects voice quality and criteria (1). In our second study, we investigated the mechanisms and clinical forms of reflux (2).
When should surgical treatment be used?
Surgical treatment options are used when we do not respond to treatment or when there are structural problems. It is a valuable option in patients with IPR.
Finally, do you have anything to add regarding LPR?
LPR is common and can be confused with GER. Making the correct diagnosis is difficult and important. If left untreated, it can lead to serious complications.
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