Ever ended up with a sore throat after binging on deep fried-food, chocolates or durian? You probably attributed this to eating too much “heaty” food.
However, there's actually a medical reason behind this. All these "heaty foods" cause acid reflux, which exacerbates a very common condition I see amongst Singaporeans known as Laryngopharyngeal Reflux (LPR).
Here's all you need to know about LPR:
1. What is Laryngopharyngeal Reflux (LPR)?
LPR is a condition where acidic stomach contents travel from your stomach, back up the food pipe (oesophagus) to the level of the voice box (larynx).
You may be wondering how it's different from Gastroesophageal Reflux Disorder (also known as GERD, the more widely known type of acid reflux).
Both LPR and GERD are similar, but not the same. In GERD, stomach contents travel up the food pipe (oesophagus), but do not reach the throat.
Hence, the predominant symptoms of GERD are in the stomach and chest regions (bloatedness, burping, indigestion), rather than in the throat as with LPR.
2. What are the symptoms of Laryngopharyngeal Reflux?
Symptoms I commonly see in patients with LPR include:
- Sore throat or an itchy throat. Some also describe a choking sensation
- Frequent throat clearing, cough and/or phlegm in your throat
- A hoarse or rough voice
- A sour or bitter taste in your mouth (usually worse in the mornings)
The majority of cases do not cause long-term complications. However, in severe cases, it can cause:
- Non-cancerous growths that can worsen the quality of your voice (vocal process contact ulcers and granulomas)
- Worsening of asthma and sinusitis
Severe LPR may also play a role in the development of cancer of the voice box and food pipe.
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3. What causes Laryngopharyngeal Reflux?
LPR is mainly caused by physical and lifestyle causes.
Lifestyle causes include:
- Diet (eg. alcohol, oily and spicy food, chocolate)
- Poor lifestyle choices (eg. alcohol abuse, over-eating, sleeping or lying down too soon after a meal)
Physical causes include:
- Obesity, which causes malfunctioning of the upper and lower oesophageal sphincters
- Hiatus hernia (outpouching of the stomach)
- Slow emptying of the stomach
4. Why does Laryngopharyngeal Reflux occur?
In a normal person, the oesophagus has 2 ring-like muscles:
- One in the upper part of your food pipe (upper oesophageal sphincter)
- One in the lower part of your food pipe (lower oesophageal sphincter)
These muscles act as gatekeepers to prevent stomach contents from travelling up the oesophagus.
If you have LPR, both these sphincters are weak or relaxed, allowing backflow (reflux) of acidic stomach contents into your food pipe and throat.
Unlike the stomach, your food pipe and voice box have little defence against the strong acid from the stomach.
Because your voice box is more sensitive than the food pipe to acid, just a small amount of acid reflux once or twice a week is enough to cause significant problems in your throat.
5. How is Laryngopharyngeal Reflux diagnosed?
Diagnosis of LPR is made based on:
- A suggestive clinical history
- Nasoendoscopy findings, which involves the passage of a small tube into the nose and back of your throat
This procedure is done in the clinic setting, after application of topical anaesthesia and decongestant.
Common findings of LPR include swelling and redness at the back part of the larynx (voice box), caused by inflammation from acid reflux.
Sometimes when the reflux is very severe, I also find non-cancerous ulcers and growths.
Occasionally, additional tests may be required to confirm the presence of acid reflux. These include:
- Barium swallow - After drinking some dye, a series of X-rays is taken to outline part of your digestive tract (mouth, throat, oesophagus, and stomach)
- Gastroscopy - A scope is passed through your food pipe and stomach to look for signs of acid reflux, or to look for growths and strictures
- Double probe 24-hour pH monitoring (acid test) - A probe is inserted down your food pipe to determine the acidity level
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6. How do you prevent LPR?
I always advise my patients to tweak their diet and lifestyle as a first step and then instruct them on how to protect their throat. This helps the majority of my patients.
Dietary modifications include:
- Taking small meals (stop eating when about three-quarters full). You can instead have multiple meals spread throughout the day.
- Avoiding food or drink 3 hours before sleeping, including water.
- Avoiding consumption of food that may aggravate LPR, such as oily and spicy food, alcohol, chocolates, coffee and tea, carbonated soft drinks, tomatoes, and citrus fruits (eg. lemon, oranges).
Lifestyle modifications include:
- Losing weight if you are overweight or obese.
- NOT exercising immediately after eating.
- Wearing loose clothing during sleep, and NOT sleeping on your abdomen.
- Sleeping slightly more upright by raising the head of the bed (eg. by placing a wedge under your pillow). This allows gravity to prevent stomach contents from going back up your food pipe.
Tips on protecting your throat include:
- Avoid throat clearing as it worsens the inflammation in the voice box region. Try swallowing to clear the throat instead, and exhale forcefully rather than coughing.
- Practise good vocal hygiene, such as avoiding prolonged use of your voice. Take frequent breaks and sips of water to keep your throat hydrated.
7. How is LPR treated?
The treatment of LPR is targeted at:
- Preventing reflux of stomach contents into the food pipe
- Reducing acid production
- Providing a protective barrier against the acid
Medications therefore fall under 1 of the 3 categories:
1. Medication to reduce acid production - the main type of medication used to treat LPR
- Proton pump inhibitors (eg. Omeprazole, Esomeprazole, and Dexlansoprazole)
- Histamine receptor antagonist (eg. Ranitidine, Famotidine, Cimetidine)
2. Medication to promote gastric emptying
- Prokinetic agents (eg. Domperidone)
3. Medication to form a protective layer
- Antacids (eg. Gaviscon and Mylanta)
Any medication often requires between 2 - 6 months of treatment before significant improvement can be seen.
Surgery is reserved for very severe cases of LPR that has failed medical treatment. The surgery is known as gastric fundoplication, whereby part of the stomach is used to wrap around the lower food pipe, hence tightening the lower oesophageal sphincter.
So the next time someone blames his or her sore throat on heatiness after a durian binge, feel free to share this article!
Dr Gan Eng Cern is an ENT Specialist at Mount Elizabeth Novena Specialist Centre (A Specialist Centre for Sinus, Snoring & ENT), and is also a Senior Clinical Lecturer at the National University of Singapore. He obtained Subspecialty training in Nose and Sinuses, and has a passion for the treatment of snoring and Obstructive Sleep Apnoea (OSA). Dr Eng Cern enjoys jogging regularly to keep his spare tyres under control.
Fraser-Kirk K et al. Laryngopharyngeal reflux: A confounding cause of aerodigestive dysfunction. Aust Fam Physician. (2017)
Salihefendic N et al. Laryngopharyngeal Reflux Disease - LPRD. Med Arch. (2017)