Laryngopharyngeal Reflux (LPR)

What is laryngopharyngeal reflux (LPR)?

Laryngopharyngeal (“la-Ring-go-fa-Rin-jee-al”) reflux, or LPR, is a special type of acid reflux. Acid reflux occurs when stomach juices (including acid) rise from your stomach into your esophagus (swallowing tube). Symptoms of acid reflux usually affect your lower esophagus, within your chest. But if you have LPR, the reflux has a habit of creeping higher up, into your larynx (voice box) and pharynx (throat).

LPR is also called “extraesophageal” reflux, because the reflux passes beyond your esophagus. This causes different symptoms from typical acid reflux — so different that you might not realize it’s a type of reflux at all. Instead of causing heartburn and indigestion, LPR tends to irritate your voice, throat and sinuses. Because you can have LPR without other reflux symptoms, it’s sometimes called “silent reflux.”

LPR vs. GERD — what’s the difference?

GERD stands for gastroesophageal reflux disease, otherwise known as chronic acid reflux. This is what we call it when stomach acid routinely rises into your esophagus, which runs from your throat down to your stomach. GERD more often affects your lower esophagus, while LPR reaches higher up in your throat. Some people have LPR in addition to GERD, but other people only have LPR symptoms.

How common is laryngopharyngeal reflux?

Healthcare providers estimate that more than half of people who complain of chronic hoarseness have laryngopharyngeal reflux. About 10% of people who visit a throat specialist are diagnosed with LPR.

What are LPR symptoms?

Laryngopharyngeal reflux symptoms include:

• Hoarseness and/or lowering of your voice register.
• A lump or a feeling of something stuck in your throat.
• Throat clearing.
• Chronic cough.
• Excessive mucus or phlegm.
• Difficulty swallowing.
• Chronic sore throat.
• Laryngitis (inflammation of your vocal cords or losing your voice).
• Wheezing.
• Postnasal drip.
• Frequent upper respiratory infections.
• New or worsening asthma.

What is the main cause of LPR?

For gastric juices to travel from your stomach all the way up through your esophagus and into your throat, they have to get past two important guards. These are your upper and lower esophageal sphincters — the muscular valves that seal off your esophagus at the top and bottom. The lower one separates your esophagus and stomach, while the upper one separates your esophagus and throat.

Normal acid reflux happens when something weakens your lower esophageal sphincter (LES), allowing stomach juices to flow back up into your esophagus. LPR happens when your upper esophageal sphincter (UES) also relaxes inappropriately. This allows reflux that’s already in your esophagus to creep up higher into your throat. Different things can affect these two sphincters and cause them to relax.

What are some specific causes that can lead to laryngopharyngeal reflux?

A lot of things can affect how well your esophageal sphincters close to keep substances out. Some of these factors weaken the muscles gradually over time, while other factors can affect them temporarily. Most people have more than one factor affecting them. Healthcare providers don’t always know exactly which ones caused LPR, but they often find that if you reduce these factors, your reflux reduces.

1. Breaching your LES

Your lower esophageal sphincter (LES) is the first guard against acid reflux from your stomach into your esophagus. Frequent, substantial acid reflux will cause symptoms of GERD, but you can have a small amount of reflux in your esophagus without feeling it. Your esophagus has many layers of protection against acid reflux, so it takes a lot to wear it down. Your throat doesn’t have the same protection.

Common factors that may weaken your LES temporarily include:

Medications. Certain medications can have a relaxing effect on your LES, including:

• Benzodiazepines, a type of sedative.
• Calcium channel blockers, which treat high blood pressure.
• Tricyclic antidepressants, which treat depression and pain.
• NSAIDs (nonsteroidal anti-inflammatory drugs) like aspirin and ibuprofen.
• Theophylline, a common asthma medication.
• Hormone therapy (HT) medications for menopause.

Foods and drinks. Foods and drinks that may have a relaxing effect on your LES include:

• Coffee.
• Chocolate.
• Alcohol.
• Mint.
• Garlic.
• Onions.

Lifestyle habits. Simple things can temporarily weaken your LES by increasing abdominal pressure against it, or by taking away the advantage of gravity, which helps keep it closed.

• Lying down or reclining too soon after eating.
• Sleeping on your back, which submerges your LES inside your stomach contents.
• Eating larger meals, which expands your abdomen and increases digestion time.
• Wearing tight clothes or belts around your abdomen, especially when sitting.

Common factors that may weaken your LES progressively over time include:

• Hiatal hernia. When your stomach bulges up through a hole in your diaphragm, your LES also moves above your diaphragm and loses some of its muscle support system.
• Pregnancy. Lots of people get temporary acid reflux during pregnancy when abdominal pressure pushes against your diaphragm and LES. Hormones also contribute.
• Obesity. Obesity is another cause of constant abdominal pressure that can weaken your LES over time. It can also affect your hormone levels.
• Smoking. Tobacco smoke has a relaxing effect on your LES. It’s also associated with coughing, which can put chronic pressure on your LES. It’s a common cause of hiatal hernia.

2. Breaching your UES

Once stomach juices are in your esophagus, it’s up to your upper esophageal sphincter (UES) to keep them out of your throat. You may only have a small, unnoticeable amount of reflux in your esophagus, but it doesn’t take much to irritate your throat tissues. They don’t have the same protective lining as your esophagus, and they also don’t have the same mechanisms that wash reflux out, so it stays longer.

Common factors that may weaken or relax your UES include:

• Lying down. Some people have LPR during the night because their esophageal sphincters both relax a little when they lie down.
• Burping. Burping is one reflex that can trigger both your LES and your UES to open. Gas bubbles can carry small amounts of stomach juices into your throat.
• Bending over, exercising or singing. These activities build pressure under your UES, which may weaken it.
• Smoking and alcohol use. These substances have a relaxing effect on both of your esophageal sphincter muscles.

What are the complications of LPR?

Laryngopharyngeal reflux may cause:

• Excessive mucus and frequent infections. Stomach acid interferes with the normal mechanisms that clear mucus and infections out of your throat and sinuses. Mucus exists to trap infections and help clear them out. When mucus doesn’t get cleared out, infections don’t, either.
• Chronic voice and throat irritation. Chronic voice and throat irritation can interfere with your ability to speak and swallow. Over time, it can cause vocal cord lesions (growths) to develop. Long-term vocal inflammation (laryngitis) is also a risk factor for developing laryngeal cancer.
• Respiratory complications. Acid in your larynx may pass through your trachea (windpipe) into your bronchial tubes and lungs. You can inhale tiny acid particles without realizing it, especially in your sleep (silent aspiration). This can cause bronchial inflammation and infections.

How can you tell if you have LPR?

If you have chronic hoarseness, there’s a 50% chance you have LPR. Look out for other related symptoms, as well. Most people with LPR are unaware of having acid reflux. You might think that you have allergies or an endless cold. Actually, many people develop their first symptoms of LPR shortly after an infection that irritated their throat. This irritation set the stage for reflux to do its own damage.

How is LPR diagnosed?

An otolaryngologist — an ear, nose and throat doctor — typically diagnoses LPR. They’ll listen to your symptoms, then take a look inside your throat for signs of inflammation or tissue damage. A flexible laryngoscopy is a simple, in-office procedure they can use to look inside your throat. They pass a laryngoscope, a tiny, lighted camera on the end of a slim tube, through your nose into your throat.

Based on what they find, your provider might feel confident enough to guess that you have LPR. They might take the approach of treating it with medication to see if your symptoms improve and confirm your condition that way. Or they might want to run additional tests to confirm their suspicions or rule out other possible causes. Additional tests for laryngopharyngeal reflux (LPR) may include:

• Upper endoscopy. This is another type of endoscopic exam that looks further down into your upper gastrointestinal tract. The endoscope passes from your mouth through your throat, esophagus and stomach. This can show what’s going on with both your esophageal sphincters.
• Esophageal pH test. A healthcare provider places one or several sensors in your throat and/or esophagus to monitor acid levels. The sensor stays in place for 24 hours, then your provider collects and reads the data. Different acid levels in different places indicate GERD and/or LPR.
• Esophageal manometry. This test measures the muscle activity in your esophagus, using pressure sensors embedded in a nasogastric tube. It can measure the activity and strength of both your esophageal sphincters, as well as the muscles that clear acid from your esophagus.

How do I get rid of LPR?

The approach to treating LPR depends on how severe it is and how serious the cause is. In many cases, there’s no serious problem with your esophageal sphincter muscles, and diet and lifestyle changes can make a real difference in reducing LPR reflux. Medication can help heal your tissues as these adjustments begin to take effect. But some people do need more extensive treatment than others.

Can you treat LPR naturally?

Some people can solve their LPR with lifestyle adjustments alone. In general, LPR is more likely than GERD to improve without medication, because LPR may be caused by only a small amount of reflux. It takes time for LPR to heal, though, so it may be several months before you can tell if your adjustments are working. Medications called proton pump inhibitors (PPIs) can help speed up the healing process.

What is the medical treatment for laryngopharyngeal reflux?

Treatment for laryngopharyngeal reflux begins with addressing the cause. Often, there’s no one obvious cause, so healthcare providers focus on diet and lifestyle adjustments to reduce all possible contributing causes. This might mean addressing habits like smoking, drinking alcohol or coffee, or adjusting the way you eat and sleep. Some people might need treatment for an underlying condition, like an esophageal disorder.

Medication

Medication usually plays a limited role in treating laryngopharyngeal reflux. For example, your provider might prescribe proton pump inhibitors for several months while you aim to reduce your reflux with lifestyle changes. These neutralize the acid in your reflux and also coat and protect the tissues in your throat while they heal. If this approach works, you’ll be able to discontinue medication after a while.

If you continue to have symptoms, you might need to use an acid-blocking medication or another medication long-term. Acid blockers like proton pump inhibitors and H2 blockers can help when you continue to have reflux despite efforts to reduce it. These medications reduce the acid content in your reflux. Medications called alginates can help protect against other irritants in your reflux, like enzymes.

Surgery

Surgery isn’t typical for laryngopharyngeal reflux unless you have an obvious defect affecting your esophageal sphincter muscles, like a hiatal hernia. A minor procedure called a Nissen fundoplication can repair a hiatal hernia and reinforce your lower esophageal sphincter, which is your first guard against acid reflux. If your upper esophageal sphincter also needs reinforcing, similar procedures are possible.

What's the outlook with laryngopharyngeal reflux (LPR)?

Getting an accurate diagnosis, discovering the contributing causes and targeting them with the right treatment can be a process. But once the way is clear, treatment for LPR is usually brief and effective. Most people won’t need long-term prescription medications or other interventions. The key to recovery lies in making helpful lifestyle changes and taking care to protect your throat and voice while they heal.

What diet and lifestyle changes help with LPR?

Healthcare providers suggest that you:

• Eat smaller meals. Try five to six mini meals instead of three bigger ones.
• Avoid rich, spicy and acidic foods. These can increase the acid and other irritants in your reflux.
• Eat dinner earlier. Try not to recline or lie down for three hours after eating.
• Sleep on your left side. This positions your lower esophageal sphincter in an air pocket above your stomach contents, which reduces reflux while you sleep.
• Avoid excessive burping. Avoid carbonated beverages and eat slowly so you don’t swallow air. If you have chronic burping, you might have a digestive disorder that needs treating.
• Reduce abdominal pressure. Wearing loose clothes around your waistline is a start. Reducing abdominal volume is better. A healthcare provider can discuss weight loss options with you.
• Quit smoking. Ask your healthcare provider about resources to help you quit.
• Reduce alcohol. Talk to your healthcare provider if you think you have alcohol use disorder.

How can I take care of my throat and voice to help them heal?

Healthcare providers suggest that you:

• Use your voice gently. Avoid speaking for long periods, like a long phone conversation or formal presentation. Try to minimize shouting, whispering, coughing and clearing your throat.
• Stay hydrated. Drink lots of water and avoid drying substances, like caffeine, alcohol and menthol cough drops. Herbal teas with marshmallow or honey can be soothing.
• Avoid smoke. Whether it’s you or someone around you who’s smoking, exposure to smoke will irritate your throat and vocal cords. It also makes reflux worse.

A note from Cleveland Clinic

Symptoms affecting your throat, vocal cords and sinuses can have many causes. Most are temporary, like infections and allergies. When these symptoms continue for a long time without any obvious cause, it can be frustrating, as well as confusing. Most people don’t think of acid reflux as a possible cause of these symptoms, especially when they aren’t aware of having it. But that can be the case with LPR.

It only takes a small amount of acid reflux — which includes erosive enzymes like pepsin and stomach acid — to affect your sensitive throat and voice. An even smaller amount may escape through your throat into your respiratory system and do damage there. Fortunately, this also means that small adjustments are often enough to manage it. Treatment for LPR is usually successful and short-term.