Hoarseness or loss of voice, frequent throat clearing without an apparent reason, and a persistent dry cough are common symptoms of laryngopharyngeal reflux. This less well-known condition, related to acid reflux, occurs when digestive juices irritate the throat and voice box. Although common treatments involve medications, dietary and lifestyle changes, certain breathing techniques and voice therapy can also help ease the symptoms. 

What is laryngopharyngeal reflux?

The majority of us experience heartburn in our lifetime after a huge meal, too spicy food or indigestion.¹ Heartburn is one of the common symptoms of acid reflux (or gastroesophageal reflux disease, GERD), when the digestive juices (acids) in the stomach enter the oesophagus and cause irritation or inflammation. Unlike GERD, laryngopharyngeal reflux (LPR) symptoms occur in the throat (pharynx) and the voice box (larynx), when the acids pass the lower part, and reach the upper area of the oesophagus. It is also called ‘silent reflux’ because it is not always paired with GERD symptoms such as heartburn or indigestion, but goes without them, and has more subtle signs.

These symptoms can be:

• Hoarseness
• Lump feeling in your throat
• Frequent throat clearing
• Chronic dry cough
• Excessive mucus or phlegm in the throat
• Difficulty swallowing
• Chronic sore throat
• Laryngitis (inflammation in your vocal cords)
• Wheezing
• Postnasal drip
• Frequent upper respiratory infections
• New or worsening asthma

Although next to GERD, the number of laryngopharyngeal reflux cases is smaller, it is still a common disease, and chronic hoarseness is diagnosed as LPR in more than 50% of the cases.

What happens in the oesophagus in LPR?

There are two barriers, called sphincters, that protect the oesophagus from the stomach juices. One of these muscular valves guards the border of the stomach and oesophagus (lower oesophageal sphincter (LES), and the other one stands between the oesophagus and the throat (upper oesophageal sphincter (UES). 

Someone can experience the symptoms of GERD when the lower muscular valve does not function properly, and allows acids to enter the oesophagus. LPR occurs when the upper part also struggles to close and the digestive juices can reach the throat. It is therefore a reasonable question to ask then: how can someone experience only LPR symptoms but not GERD?

The answer is that the oesophagus has developed with multiple layers in order to protect it from these aggressive components, but the throat and voice box did not. While a frequent, considerable amount of acid in the oesophagus will cause GERD, even a slight amount of acid is enough to trigger LPR.

What causes the sphincters to function inappropriately?

There are many factors and circumstances that affect the sphincters and eventually cause irritation in the oesophagus.

Behind the LES problems can stand medications, such as non-steroid anti-inflammatory drugs (or NSAIDs, e.g., ibuprofen, aspirin) or theophylline (a common asthma drug) (broader list is here). Some food and drinks can also negatively affect LES, such as coffee, chocolate, alcohol, mint, garlic, onion and strong spices (a broader list is here). Certain lifestyle habits also trigger inappropriate functioning in the LES, such as lying down after eating, sleeping on your back, eating large meals, or wearing tight belts and clothes.

When the acids pass the lower sphincter, the purpose of the UES is to protect the throat. But it can also have difficulty fulfilling its role. When someone is lying, it can make the sphincters more relaxed and allow some digestive juices to reach the throat. Frequent burping is also a risk factor because these gas bubbles can still carry a tiny amount of digestive juices. Average movements, such as bending over, exercising or singing, can increase the pressure on the UES, while smoking and drinking alcohol also negatively affect the upper muscular valve and irritate the sensitive throat.

How to treat LPR?

There are many efficient ways to ease the symptoms of LPR, but the most suitable treatment depends on how severe and how serious the disease is. On many occasions, dietary and lifestyle changes are enough to reach significant improvement, but sometimes medications (such as proton-pump inhibitors) are also needed. These drugs are designed to reduce the amount of acids produced by the stomach and can cure GERD and LPR, too. 

Besides these approaches, studies show that diaphragmatic breathing and voice therapy have advantages. They can not only help reduce GERD symptoms, but also have positive effects on LPR, by easing the pressure on the UES, improving airflow and vocal control, and relaxing the laryngeal muscles.^2,3,4,5,6

Diaphragmatic breathing is an effective breathing exercise in LPR

Diaphragmatic breathing (or abdominal breathing) focuses on the exercise of the diaphragm, which is located under your lungs in the shape of a dome. This technique’s purpose is to learn to use this muscle correctly and strengthen it. Its daily practice has several benefits, including lowering blood pressure and heart rate, reducing breathing rate, and improving relaxation. Diaphragmatic breathing is proven to be useful in the treatment of anxiety, asthma, COPD, and stress. Studies also suggest that regular exercise can ease the symptoms of GERD and LPR, too.^2,3,7,8

Fortunately, it is an exercise that is easy to practice even at home, you just need to follow these steps:

• Lay down on a flat surface (in the bed or on a mat), with your knees bent
• Put one of your hands on the upper chest and the other one right below the rib cage around the diaphragm
• Breathe slowly in through your nose and allow your hand on your belly to move up with your stomach, while the other hand remains as still as possible
• Tighten the stomach muscles and breathe out through your mouth and feel your belly moving in with your hand on top

If there is no opportunity to practice lying down, there is also an option to do diaphragmatic breathing while sitting. The steps are similar, but while sitting, the back needs to be straight, and the head, neck and shoulders relaxed. In this way, even in an office, it is possible to practice this breathing technique. As a start, five to 10 minutes are recommended three to four times a day, and later this amount can be increased or hardened (for example, by placing a book on the abdomen).

Important to note, that like any exercise, diaphragmatic breathing also takes time and needs practice. In the beginning, it can be difficult and tiring, which over time becomes easier and more natural. But continuous practice is crucial to ease the LPR symptoms.

Voice therapy to ease LPR symptoms

Voice therapy is designed to help restore the function of the vocal cords caused by voice disorders. These problems have different causes (from infection to paralysis) but all of them affect the quality, pitch or loudness of someone’s voice. Multiple studies prove that this therapy is also useful in LPR, and combined with medications, provides a more effective treatment.^9,10

Voice therapy is usually taught by a speech-language pathologist, respiratory therapist or a voice coach and has multiple aspects to it:

• Breathing exercises, like the previously mentioned diaphragmatic breathing
• Tension release, which includes massage or stretching to ease the tension in the throat
• Voice-building exercises, which focus on strengthening the vocal cords, like humming, or lip trills
• Semi-occluded vocal tract exercises, such as straw phonation, when one puts a straw into their mouth and then trying to make different sounds

Summary

Laryngopharyngeal reflux is a type of acid reflux that affects the throat and the voice box, occurring with symptoms such as hoarseness, lump feeling in the throat, dry cough, and frequent throat clearing. Because its cause is the inappropriate relaxation of sphincters in the lower and upper part of the oesophagus, its main therapy focuses on fixing these muscular valves’ functions. This treatment involves dietary and lifestyle changes and medications, but other approaches also exist. One of them is diaphragmatic breathing, which helps to strengthen the diaphragm and has many health benefits in general. The other one is voice therapy, which is usually taught by a specialist, and includes breathing practices, tension release in the throat, voice building and semi-occluded vocal tract exercises. These can help to reduce the symptoms in the throat and restore the function of the vocal cords.

FAQs

Is there any other breathing exercise that is worth trying if I have LPR?

Yes, like box breathing. Although this practice is not confirmed by studies, it is suggested that it can also help to ease the symptoms of LPR. It is also called 4-4-4-4 breathing, because of its 4 steps with each of them lasting for 4. Someone who wants to practice can relax their bodies as much as possible (it can happen sitting, standing or lying down, too). First, you need to breathe in slowly and count up to 4. Second, hold your breath for another 4 seconds. Third, breathe out slowly while you are counting again to 4. Fourth, wait with another breath for 4 seconds. You can repeat the process as long as you wish. 

Is there any other voice exercise that I can practice at home to ease my LPR symptoms?
Besides the previously mentioned humming, there are many other smaller exercises. These are also not confirmed by research, but used in general amongst singers and teachers to restore their vocal cords function. One of them is lip trill exercises, for example, when you try to blow air through your loosely closed lips to create a vibrating sound (like an engine). Another one is vocal function exercises (VFEs) that include a series of tasks such as sustaining as long as possible, or gliding from low to high pitch and back. It is important to note though that if you feel worsening symptoms, irritation or pain, stop the exercises and look for medical/specialist help.