Tip of the Month

What is Silent Reflux?

Reflux refers to the flow of stomach contents or acid back into the esophagus. Normally, two valves (called sphincter muscles) at the top and bottom of the esophagus prevent this backflow. In some people, for a variety of reasons, these valves allow acid to reach all the way up into the throat and voice box.

Many people with silent reflux or LPR do not experience heartburn, hence the term "silent." This is because the material that is refluxed does not usually stay in the esophagus for very long and does not have enough time to irritate the esophagus and cause heartburn. While a person may not experience heartburn, there may still be injury and irritation to the sensitive tissues of the throat and voice box. Even small amounts of refluxed acid present for short periods of time can irritate the throat and voice box tissues causing a variety of symptoms.

LPR patients usually experience reflux during the daytime but it may also occur at night. LPR can occur even if a person hasn't eaten and can be aggravated by certain foods, certain patterns of eating, as well as stress.

Symptoms of LPR:

Hoarseness, dysphagia (trouble swallowing), a "lump" sensation in the throat, too much phlegm or mucus, chronic cough or throat clearing, chronic sore throat or burning in the throat. Some or all of these symtoms may occur frequently or intermittently and may also be accompanied by heartburn.

Evaluating LPR:

First, a Otolaryngologist (Ear, Nose and Throat doctor) will look at your throat to determine if you have signs of reflux. The most common signs are red, swollen tissues and thick mucus. If necessary, some tests may be ordered to help confirm the diagnosis.

Some tests include 24 hour pH monitoring and a barium swallow. A barium swallow involves swallowing a chalky white substance while an x-ray is taken of your throat, esophagus and stomach. This shows how you swallow as well as any other abnormality in the throat or esophagus. A 24-hour pH test is a special test that involves wearing a small, flexible tube through your nose and into your esophagus overnight. The tube is connected to a small computer that measures the acid in your esophagus and throat. This test is often very helpful in determining the amount and frequency of acid reflux events and is sometimes used to determine how effective the medications are at stopping acid.

Treating LPR:

Sometimes, dietary and lifestyle changes that are known to aggravate reflux symptoms are recommended. In most cases, however, dietary and lifestyle changes are not enough and must be combined with medications to control reflux. In severe cases, surgery may be recommended to prevent reflux.

There are various medications used to treat reflux. Acid neutralizers such as Mylanta, Maalox, and Tums are designed to neutralize the stomach acid to some degree and are thought to be minimally effective in controlling the symptoms long-term. H2 blockers such as Zantac, Axid and Pepcid, which can be bought over the counter or prescribed by your doctor, are considered more effective than neutralizers as they work to limit the production of stomach acid. Finally, proton pump inhibitors such as Nexium, Prevacid, Prilosec, Protonix and Aciphex are considered the most effective class of medicines for reflux. These medicines also work to limit the production of stomach acid. A combination of these medicines may be prescribed to best control your symptoms.

Dietary restrictions and lifestyle changes to reduce reflux and control symptoms :

• Avoid caffeine in coffee, tea, or soda
• Quit smoking (Smoking makes you reflux. After every cigarette you may have some LPR)
• Avoid alcoholic beverages, particularly in the evening
• Aim to eat a low-fat diet, limit your intake of red meat and butter; avoid fried foods, chocolate, cheese, eggs
• Avoid mints
• Avoid Aspirin, Motrin, Ibuprofen which may aggravate the stomach lining
• Do not lie down just after eating. Try not to eat within 2-3 hours of bedtime
• If you are overweight, weight loss is recommended
• Avoid wearing clothes that fit tightly across the mid-section of the body such as tight belts or girdles
• You may try elevating the head of your bed by 4-6 inches with cinder blocks or books
• Do not skip meals. Try eating at least 3 or 4-6 smaller meals per day

How long is treatment needed?

The answer to this question is different for everyone. It often takes a number of months for injury to the throat and voice box to heal once acid has been suppressed. In many cases, increasing the dosage or frequency of the medication for an extended period of time may be necessary for a person to get relief. Many people with LPR require treatment indefinitely to control symptoms. Some people require treatment intermittently. That is, a person may recover completely for months or years and not require medications, then they may have a recurrence of symptoms and again require treatment.

In severe cases, aggressive, prolonged treatment of the reflux with medications and routine monitoring of the throat is recommended. Further testing may also be necessary to test the strength of the lower stomach valve. In some cases, a type of "anti-reflux" surgery (called fundoplication) is recommended to "tighten" the lower stomach valve.

Taking your Reflux Medications :

Most commonly, proton pump inhibitors (e.g., Prilosec, Prevacid) are prescribed for reflux. The role of this drug is to limit the production of stomach acid before it starts. For the drug to be most effective, it is important to take the medication 1/2 hour to 1 hour BEFORE eating a meal. If you are prescribed once a day dosing, take the medication 1/2-1 hour BEFORE breakfast or the first meal of the day. If you are prescribed twice a day dosing, take the second dose 1/2 to 1 hour BEFORE your supper meal. If you take the medicine after you eat, you've already produced some stomach acid. Also, if you take the pill but do not eat, the medicine will not be as effective.

Compliance and consistency with taking your medications are extremely important. If you frequently skip dosages or take the medication sporadically, you are not likely to improve. Remember, only small amounts of acid experienced intermittently may be enough to continue irritation and inflammation of the throat and voice box.

(*some information adapted from Patient Information Sheet on Laryngopharyngeal Reflux, J. Koufman, www.bgsm.edu/voice)