Every time i eat my throat hurts

Ever had lots of deep fried food, chocolates or durian and end up getting a sore throat in a few hours or the next day? Well, some would say that this is due to the “heaty” food that you took. However, there is a likely medical reason for this. According to Dr Gan, these foods are actually acid-reflux causing foods. These foods exacerbate a very common condition known as Laryngopharyngeal Reflux (LPR). In the following article, Dr Gan Eng Cern, an ENT Specialist in Singapore,  answers commonly asked questions about LPR.

What is Laryngopharyngeal Reflux (LPR)?

LPR is a medical condition where stomach contents (acidic) have passed from the stomach back up to the food pipe (esophagus) and to the level of the voice box (larynx)

Why does Laryngopharyngeal Reflux occur?

The esophagus (food pipe) has 2 ring-like muscles, one in the upper part of the food pipe (upper esophageal sphincter) and one in the lower part of the food pipe (lower esophageal sphincter) that act as gatekeepers to prevent stomach contents from travelling up the esophagus. In a patient with LPR, both these sphincters are weak or relaxed, allowing reflux (backflow) of acidic stomach contents into the food pipe and throat (Figure 1a). Unlike the stomach, the food pipe and voice box has little defense mechanism against the strong acid from the stomach. It is thought that the voice box is more sensitive than the food pipe to acid. Hence just a small amount of acid reflux once or twice a week is sufficient to cause significant problems in the throat.

Figure 1a – What happens in LPR

How is this different from Gastroesophageal Reflux Disorder (GERD)?

GERD and LPR are similar but not exactly the same. In GERD, the stomach contents travel up the food pipe (esophagus) but does not reach the throat (Figure 1b). Therefore, most of GERD symptoms are in the stomach and chest regions (e.g. bloatedness, burping, indigestion)

Figure 1b – What happens in GERD

Who gets Laryngopharyngeal Reflux?

Anyone can get LPR. Women, men, infants, children, adults and the elderly can get LPR. It is mainly caused by physical causes and lifestyle causes. Amongst the physical causes of LPR include a malfunctioning of the upper and lower esophageal sphincters due to obesity and  hiatus hernia (outpouching of the stomach)  as well as slow emptying of the stomach. Lifestyle causes include diet (e.g. alcohol, oily and spicy food, chocolate) and poor lifestyle choices (e.g. alcohol abuse, over-eating, sleeping or lying down too soon after a meal)

What are the symptoms of Laryngopharyngeal Reflux?

Unlike GERD, many patients with LPR may not necessarily experience bloatedness, burping or indigestion. Common symptoms of LPR include:

• Feeling of something stuck in the throat (Globus sensation)
• Choking sensation in the throat
• Itchy throat and frequent throat clearing
• Hoarse or rough voice
• Sorethroat or throat discomfort
• Cough
• Sour or bitter taste in the mouth (usually worse in the morning)
• Phlegm in the throat

How is Laryngopharyngeal Reflux diagnosed?

Diagnosis of LPR is usually made based on a combination of suggestive clinical history and findings from nasoendoscopy (passage of a small lighted tube with a camera into the nose and back of throat done under local anaesthesia)(Figure 2). On nasoendoscopy, common findings of LPR include swelling and redness at the back part of the larynx (voice box), indicating inflammation from acid reflux (Fig 3a &b). Sometimes when the reflux is very severe, it can cause non-cancerous ulcer and growth called vocal process contact ulcer and granuloma (Fig 3c).

Figure 2 – Flexible nasoendoscope is inserted in the nasal cavity and is guided to the posterior nasal space (back of nose) and to the level of the larynx (voice box). The procedure is done in the clinic setting after application of topical anaesthesia (numbing agent)  and decongestant

Figure 3 – a)Normal voice box b) Swelling and redness on the back part of the voice box in patients with LPR (yellow arrows) c) Non-cancerous growth (vocal process contact ulcer and granuloma – yellow arrow) in patients with severe LPR 

Occasionally, additional tests may be required to confirm the presence of acid reflux or to rule out other causes that may mimic symptoms of LPR. These include:

1. Barium swallow

This involves drinking a dye and taking a series of X-rays to outline part of the digestive tract (mouth, throat, esophagus and stomach)

2. Gastroscopy

This involves the passage of a scope through the food pipe and stomach to look for signs of acid reflux or to look for growths and strictures

3. Double probe 24-hour pH monitoring (acid test)

This involves insertion of a probe (small tube) from the nose down to the food pipe just above the lower esophageal sphincter to determine the level of acid in the food pipe and throat

How do I treat or prevent LPR?

The treatment of LPR is targeted at prevention of reflux of stomach contents into the food pipe, reduction of acid production and provision of a protective barrier against the acid. These include:

a) Lifestyle modifications

• Avoiding or minimizing the consumption of food that may aggravate LPR such as oily and spicy food, alcohol, chocolates, coffee and tea, carbonated soft drinks, citrus fruits (e.g. lemon, oranges), tomatoes etc. (Figure 4)
• Taking small meals (stop eating when about ¾ full). One can have multiple meals spread out during the day but never eat too full
• Do not take any food or drink (including water) 3 hours before sleeping
• Sleep slightly more upright by raising the head of the bed (e.g. by placing a blocks or a wedge under the head end of the mattress). This allows gravity to prevent stomach contents from going back up the food pipe. Do not sleep on your abdomen as this worsens LPR. Also it is best to wear loose clothing during sleep.
• Lose weight if you are overweight or obese. Anything that puts extra pressure on your abdomen can worsen LPR. This includes tight clothing and exercising immediately after eating.
• Avoid throat clearing as it worsens the inflammation in the voice box region. Try swallowing to clear the throat and exhale forcefully rather than cough
• Good vocal hygiene such as avoiding prolonged use of voice. Take frequent breaks and sips of water to keep the throat hydrated

Figure 4 – “Heaty” or acid-reflux causing diet

b) Medications

Medications to reduce the effects of the acid include:

1.Medication to reduce acid production (This is the main group of medication used to treat LPR. It often takes about 2-6 months of treatment before significant improvement can be seen):

• Proton pump inhibitors (E.g. omeprazole, rabeprazole, esomeprazole and dexlansoprazole)(Figure 5)
• Histamine receptor antagonist (e.g ranitidine, famotidine, cimetidine)

2. Medications to promote gastric emptying

• Prokinetic agents (e.g. domperidone)

3. Medications to produce a protective layer that shields the stomach and foodpipe lining from the caustic effects of acid

• Antacids (e.g Gaviscon and Mylanta)

Figure 5- Common proton pump inhibitors for the treatment of LPR

Surgery for LPR

This is rarely indicated and 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 to tighten the lower esophageal sphincter.

Why bother about LPR?

Majority of cases of LPR does not cause long term complications. However, in severe cases, it can cause ulcers (contact ulcers) and non-cancerous ulcers and growths (vocal process contact ulcers and granulomas) that can worsen the quality of the voice. Severe LPR has also been associated with worsening of asthma, sinusitis and may play a role in the development of cancer of the voice box and food pipe.

Best wishes,

Dr Gan Eng Cern

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