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What is Laryngopharyngeal Reflux (LPR)?
Laryngopharyngeal reflux (LPR) is a condition in which the contents of the stomach travel back up beyond the esophagus and reach the throat, specifically the larynx and pharynx. It is technically distinct from the better-known gastroesophageal reflux disease (GERD), in which acid backflow is limited to the esophagus (the muscular tube connecting the throat to the stomach that allows food to pass after swallowing).
The most commonly reported symptom among patients with LPR is hoarseness, caused by irritation of the vocal cords from acidic gastric material. Other frequently reported symptoms include:
- A sensation of a lump in the throat (globus sensation)
- Persistent need to clear the throat
- Heartburn
- Acid regurgitation
- Chronic cough
- Sore throat
The prognosis is generally favorable. LPR tends to respond well to lifestyle modifications; when these are insufficient, pharmacological therapy may be required, and surgery is considered only in rare cases.
It is worth noting that, according to some authors, the prevalence of reflux-related diseases has been increasing at a rate of approximately 4% per year since 1976, highlighting the growing public health significance of this condition.
Causes
Several physiological mechanisms normally prevent the development of laryngopharyngeal reflux. These include:
- The lower esophageal sphincter (LES), a valve between the esophagus and stomach, should only open to allow food to pass downward.
- The esophageal clearance mechanisms, which rely on:
- Esophageal peristalsis (involuntary muscular contractions of the esophagus).
- Saliva.
- Gravity.
- The upper esophageal sphincter (UES), a valve separating the throat from the esophagus.
When these protective barriers fail, gastric contents come into contact with the laryngopharyngeal tissue, causing significant damage to the mucosal epithelium. It is important to understand the chemical dimension of this injury: the pharynx has a neutral pH of approximately 7, while gastric acid has a pH ranging from 1.5 to 2. The damage is therefore caused not only by the abrupt drop in pH but also by exposure to digestive substances such as:
- Pepsin
- Bile salts
- Pancreatic enzymes
While up to 50 episodes of acid reflux per day confined to the esophagus are considered physiologically normal, gastric contents reaching the throat even just three times per day can already produce measurable tissue damage.
Physical Causes
- Dysfunction of the lower esophageal sphincter, which fails to prevent upward flow of acid
- Hiatal hernia
- Esophageal spasms
- Delayed gastric emptying
- Use of certain medications (such as aspirin and NSAIDs)
Lifestyle-Related Risk Factors
- Overweight and obesity increase abdominal pressure, which promotes reflux
- Smoking weakens sphincter function and impairs mucosal defense
- Eating large meals or eating shortly before lying down
- Excessive consumption of fatty or fried foods
- Drinking alcohol and coffee
Pregnancy can also cause temporary reflux episodes, both due to physical reasons (pressure from the expanding uterus) and hormonal changes that relax the lower esophageal sphincter.
Symptoms
LPR presents with a wide range of symptoms. The most characteristic symptom, and the one that helps distinguish it from classic GERD, is dysphonia (reduction or alteration in voice quality).
Importantly, many patients with LPR do not experience the typical heartburn associated with gastroesophageal reflux. This can lead to delayed diagnosis, as patients and clinicians may not immediately associate throat symptoms with a reflux disorder.
Common Symptoms in Adults
- Heartburn
- Persistent belching
- Regurgitation of stomach contents
- Frequent need to clear the throat and/or persistent cough
- Excess mucus production and postnasal drip
- Bitter or sour taste in the mouth
- Burning sensation or sore throat
- Sensation of a foreign body in the back of the throat (globus sensation)
- Difficulty swallowing (dysphagia)
- Choking episodes (sometimes causing nocturnal awakening)
- Breathing difficulties
Symptoms in Infants and Children
Signs in newborns and children can differ significantly from adults and may include:
- Respiratory problems such as cough, hoarseness, noisy breathing (stridor), or asthma
- Breathing pauses (apnea) or snoring during sleep
- Feeding difficulties (excessive and frequent regurgitation)
- Episodes of cyanosis (bluish discoloration of the face, lips, or fingernails)
- Growth delay and poor weight gain
Complications
If left untreated over a long period, LPR can lead to chronic and irreversible vocal cord lesions. Additionally, the complications associated with GERD may co-occur. The most clinically significant is Barrett’s esophagus, a precancerous change in the esophageal lining that is associated with an increased risk of esophageal adenocarcinoma.
Other potential complications include:
- Recurrent laryngitis
- Bronchopulmonary infections
- Chronic sinusitis
- Otitis media (middle ear infection)
- Contact ulcers and granulomas of the larynx
- Subglottic stenosis (narrowing of the airway below the vocal cords) in severe or prolonged cases
When to See a Doctor
You should consult your primary care physician, an otolaryngologist (ENT specialist), or a gastroenterologist if you experience unexplained and persistent symptoms involving the upper respiratory or digestive tract, including:
- Hoarseness lasting more than two to three weeks
- Difficulty breathing
- Persistent sore throat without other apparent cause
- Continual need to clear your throat (sometimes not noticed by the patient themselves, but observed by family members or friends)
- Difficulty swallowing
- Unexplained chronic cough
Important: Any persistent change in voice, unexplained swallowing difficulty, or throat symptoms lasting more than 2–3 weeks should prompt prompt medical evaluation to rule out serious underlying conditions.
Diagnosis
The diagnosis of LPR is often first suspected clinically, based on the patient’s reported symptoms and risk factors collected during the medical history (anamnesis). Physical examination can provide further evidence; an otolaryngologist can use minimally invasive procedures such as laryngoscopy (a direct visual inspection of the larynx) to identify characteristic mucosal changes and inflammation.
Diagnostic Tools
- Laryngoscopy / Nasolaryngoscopy: direct visualization of the larynx and vocal cords
- 24-hour pH monitoring: measures acid levels in the esophagus and/or pharynx over time
- Impedance-pH monitoring: detects both acid and non-acid reflux episodes
- Esophageal manometry: assesses the function of esophageal sphincters and muscular contractions
- Upper endoscopy (esophagogastroduodenoscopy) evaluates the esophageal and gastric mucosa
Empirical Treatment as a Diagnostic Tool
In uncertain cases, empirical treatment is a valid diagnostic strategy: proton pump inhibitors (PPIs) are prescribed for 2–3 months, after which:
- A favorable response to treatment confirms the diagnosis
- No improvement suggests an alternative diagnosis should be considered
Differential Diagnosis
LPR must be distinguished from globus hystericus (or globus pharyngeus), a psychosomatic condition characterized by the subjective sensation of a foreign body in the throat in the absence of organic pathology. Other differential diagnoses include laryngeal carcinoma, thyroid disease, and infectious causes of laryngitis.
Treatment
1. Lifestyle Modifications (First-Line Approach)
Lifestyle changes represent the essential first step in managing LPR and can significantly reduce symptom severity:
- Weight loss if indicated: reducing abdominal pressure decreases reflux episodes
- Adopt a pattern of frequent, small meals rather than large ones
- Wait at least 3 hours after eating before lying down
- Follow a diet low in fat (which delays gastric emptying) and low in acidic foods
- Avoid carbonated or caffeinated beverages
- Avoid spicy foods, chocolate, mint, citrus fruits, and tomatoes
- Quit smoking
- Avoid tight-fitting clothing around the waist
- Reduce alcohol consumption
- Elevate the head of the bed by 15–20 cm (6–8 inches) to use gravity to reduce nocturnal reflux
2. Pharmacological Therapy
When lifestyle modifications alone are insufficient, medication is the next step:
- Proton pump inhibitors (PPIs), the most effective class of drugs for reducing gastric acid production (for example, omeprazole, pantoprazole, esomeprazole). Clinical evidence suggests treatment should last a minimum of 3 months, administered twice daily, taken 30–60 minutes before meals (typically breakfast and dinner)
- H2 receptor antagonists (H2 blockers): such as famotidine. These are less potent than PPIs but useful in mild cases or as add-on therapy.
- Antacids: for symptomatic relief; not a primary treatment for LPR
- Alginates form a physical barrier over stomach contents, reducing reflux
It is important to remember that pharmacological therapies require at least 2–4 weeks to exert their full effects. Premature discontinuation of treatment almost always leads to recurrence of symptoms.
3. Surgical Treatment
Surgery is reserved for severe, refractory cases that do not respond to lifestyle and medical management. The most established procedure is Nissen fundoplication, in which the upper part of the stomach is wrapped around the lower esophagus to reinforce the sphincter and prevent reflux. This can be performed laparoscopically with minimal invasiveness.
Diet and Alkaline Water
Researcher Koufman proposed an important hypothesis: pepsin, a digestive enzyme deposited in laryngeal tissue during reflux episodes, can be reactivated by acids from various sources, not exclusively from the stomach. Based on this, Koufman suggested that patients who do not respond adequately to standard medications might benefit from an alkaline (non-acidic) diet.
An alkaline diet for LPR consists of foods and beverages with a pH of 5 or higher. This approach also incorporates alkaline water with a pH of 8.8, which has been shown in laboratory studies to irreversibly denature pepsin, potentially reducing its damaging effects on laryngeal tissue.
Principles of an Alkaline Diet for LPR
- Emphasize vegetables, whole grains, lean proteins, and low-acid fruits
- Avoid or strictly limit: tomatoes, citrus fruits, vinegar, carbonated drinks, alcohol, coffee, chocolate, and mint
- Drink alkaline water (pH ≥ 8.8) as part of daily hydration
- Avoid processed foods and fast food
Results from studies applying this approach have been encouraging, though limited by small sample sizes. Larger randomized controlled trials are needed to confirm these findings at a population level. Patients are encouraged to discuss dietary modifications with their physician before making significant changes.
Sources and Bibliography
- Laryngopharyngeal Reflux – Jens Brown; Carl Shermetaro. StatPearls, NCBI
- ENThealth – American Academy of Otolaryngology: GERD and LPR
- Il reflusso laringofaringeo – Associazione Otorinolaringologi Ospedalieri Italiani (AOOI)
- Boston Medical Center – Laryngopharyngeal Reflux (LPR)
- Koufman JA et al. – Laryngopharyngeal reflux: a review at a decade’s end. Laryngoscope, 2010. PubMed
- Reflux disease prevalence – Epidemiology and natural history. PubMed
- Johnston N et al. – Pepsin in nonacidic reflux can damage hypopharyngeal epithelial cells. Annals of Otology, Rhinology & Laryngology, 2004. NCBI
- Amin MR, Postma GN, Johnson P, et al. – Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2001.
- Belafsky PC, Postma GN, Koufman JA – The validity and reliability of the reflux finding score (RFS). Laryngoscope. 2001.
