LARYNGOPHARYNGEAL REFLUX DISEASE (LPR) is recurrent movement of stomach acid in the larynx and throat. Symptoms of LPR may include laryngitis, hoarseness, a sensation of a lump in the throat, post-nasal drip, chronic throat clearing, excessive throat mucous, sore throat, cough, laryngospasm (muscle spasm of the throat), and/or throat pain (Gaynor, 2000). In particular to singers and other professional voice users, other symptoms may include increased time necessary to achieve adequate vocal warm-ups, restricted vocal tone placement ad decreased pitch range (Ross, Noordzji & Woo, 1998). (photo)

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LPR IS DIFFERENT THAN GERD (Gastroesophageal Reflux Disease), some important differences include the following:

Laryngo-Pharyngeal Reflux (LPR) is DIFFERENT from Gastro-Esophageal Reflux Disease (GERD ) . The "CLASSIC" Symptoms of GERD in a typical ESOPHAGITIS patient are HEARTBURN - 83%, COUGH - 47%, DYSPHAGIA - 40%, REGURGITATION - 23% (1). On the contrary, the typical symptoms of LPR in the typical ENT patient are HOARSENESS - 71%, CHRONIC COUGH - 51%, DYSPHAGIA - 51% GLOBUS - 47%, THROAT CLEARING - 42%, HEARTBURN and/or REGURGITATION - 10%-33%.

The reflux pattern in the typical GERD patient is a supine, nocturnal reflux (patient
refluxing while lying flat at night) while the LPR patient generally refluxes while upright
during the day.

LPR may not have any perceivable symptoms the way GERD usually does (i.e. heartburn or indigestion, increased belching or flatus, pain in the stomach/chest). Stomach acid in the esophagus may cause heartburn or even chest pain; however, not all individuals will experience heartburn as the esophagus is capable of withstanding a certain amount of acid exposure.  On the other hand, the throat and larynx (voicebox) are not meant to withstand any exposure to acid.  If acid actually refluxes into the lungs, chronic cough and pulmonary conditions can result, such as pneumonia or bronchitis. Other conditions, such as asthma or vocal cord dysfunction, are exacerbated by LPR.

Testing for GERD may find negative results of unusual activity in the esophagus, but the patient may still have positive results at the level of the larynx. In fact, a recent article cited that “laryngoscopy is superior to endoscopy in diagnosing LF GERD [LPR]. ” (Laimas Jonaitis,, Ruta Pribuisiene, Limas Kupcinskas, Virgilijus Uloza, “ Laryngeal examination is superior to endoscopy in the diagnosis of the laryngopharyngeal form of gastroesophageal reflux disease”, Scandinavian Journal of Gastroenterology, Taylor & Francis, Volume 41, Number 2 / February 2006, pp 131 – 137.) Your voice specialists at Performance Voice Solutions are trained in videostroboscopy, a method of visualizing the larynx that allows for screening and assessment of LPR.

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HOW DO I REDUCE my risk of acid reflux?

The following are standard recommendations for reducing the recurrence of LPR and GERD. Remember, your stomach can tolerate the food you eat, it’s the level of gastric acid in your stomach at any given time that increases the likelihood of reflux activity. Therefore, posture remains important and reducing the amounts of caffeine, alcohol and mint (these tend to relax the lower esophageal sphincter and thereby allow acid to reflux more easily) are priorities in managing LPR.

1. No eating or drinking within three hours of bedtime or lying down to rest.    This includes lying down anytime, such as an afternoon nap.  Individuals suffering from reflux may have delayed emptying of the stomach in the lower intestinal tract, leaving increased amounts of food in the stomach. The more food there is in the stomach, the higher the potential for more acid to be refluxed (Gaynor, 1991).  As a result, added time will be needed to allow for gastric emptying. If circumstances dictate that one must eat late, the lighter and lower in fat the food, the quicker the stomach will empty into the intestinal tract.
2. Avoid overeating. Overfilling the stomach increases the likelihood of reflux.  It is better to eat several small meals each day than to eat one or two big meals. 
3. Avoid intra-abdominal pressure.  Avoid tight-fitting clothing, bending over, or straining after eating (especially working out and lifting weights).
4. Reduce your intake of foods that increase stomach acid production.     These include fatty, fried, spicy, or acidic foods, chocolate, caffeine, carbonated beverages, peppermint/ spearmint, and alcohol.
5. Elevate the head of your bed.   Place cinder blocks under the legs at the head of your bed.  This will put the bed at an incline of at least 5 inches.
6. Lose weight.   You should lose weight if you are overweight; excess weight puts pressure on gastric contents.
7. Stop the use of any tobacco products.   Good for you all around.
8. Take your medication.   You may be placed on a medication to control your acid production.  It is important to take these medicines as instructed; however, it has been shown that the medications most commonly prescribed for acid reflux, called proton pump inhibitors, are most effective if taken 30 - 60 minutes prior to your most substantial meal (usually dinner).
9. Use over-the-counter antacids.   Over-the-counter antacids may be appropriate, especially if you will be singing or eating close to bedtime.  If you are advised to take antacids, chewable antacids such as Rolaids and Tums are not recommended because they do not neutralize enough stomach acid to be effective.  You may add a medication called an H2 blocker to your daily routine, such as Zantac or Pepcid, before singing or exercising and before bed.  You may also use liquid antacids such as Maalox, Mylanta, Geluscil, Amphogel, or Gaviscon.  Take these as instructed.
10. Chew your gum!   New research from Great Britain shows post-meal gum chewing appeared to reduce acid in the esophagus and quell heartburn symptoms among people with chronic reflux problems.  Why does it work?  Gum stimulates saliva production, which theoretically works to neutralize acid remaining in the larynx and esophagus. 
11. Sleep on your left side.   The esophagus enters the stomach on your right side.  Sleeping on your left side may help to prevent any food remaining in your stomach from pressing on the opening to the esophagus, which could cause reflux.

For further information, please visit the voiceproblem.org the voice problem website, or www.gbmc.org/voice/refluxchanges.cfm

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