Chronic throat clearing and cough can be frustrating. These symptoms interfere with a person's daily activities and make it hard to communicate. While usually attributed to allergies and infections, sometimes these symptoms can be due to some other underlying clinical conditions, which, if left untreated, can lead to various complications. One such condition may be laryngopharyngeal reflux (LPR). Studies reported that about 10-30% of people having throat symptoms are diagnosed with LPR.¹

To understand the link between these throat symptoms and LPR, you first need to know what LPR is. So, in this article, we will explore 

• What is LPR?
• How does LPR occur, and what are the specific causes that lead to LPR
• How LPR is diagnosed 
• What is the treatment of LPR

What is laryngopharyngeal reflux (LPR)?

LPR is a type of acid reflux where the contents of your stomach (acid and enzymes) travel up through your oesophagus (a tube that carries the food from your mouth to stomach, also known as the food pipe) into your throat and larynx (voicebox).^2,4,8

It is different from gastroesophageal reflux disease (GERD), which is when your stomach contents reach only up to the level of your lower oesophagus, causing symptoms like heartburn and indigestion.⁴ While in LPR, you usually do not feel such symptoms, which is why it is also known as silent reflux. It is often misdiagnosed due to this very reason, and many people do not even realise that they have LPR until it has already progressed to an advanced stage, leading to complications like cancer.²

How does LPR occur?

Throughout your digestive system, there are muscular rings called sphincters.³ These act as valves that allow the food and other fluids to pass in only one direction (downward). To prevent the reflux of stomach contents, your oesophagus has two such rings. One of the upper end, called the upper oesophageal sphincter (UES), is located between the pharynx (back of your throat) and the upper end of your oesophagus. The other one, called the lower oesophageal sphincter (LES), is located between the lower end of your oesophagus and the upper end of your stomach.

In some conditions, these muscular rings weaken, and the contents of your stomach move back up. So, LPR occurs when both your UES and LES do not function properly.² Your throat, unlike the oesophagus, lacks protection against the damaging effects of acid reflux. That is why, even two to three episodes of reflux can cause throat irritation and other symptoms.²

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

Several factors contribute to the development of LPR, including diet, lifestyle habits, and some medications.⁴ Let's talk about each of them separately.

Diet:

• Caffeine, chocolate, and alcohol can weaken your LES and increase the risk of causing reflux^5,6 
• Eating spicy or fatty meals can irritate your throat and oesophagus after reflux^4,5
• Fatty meals also delay the passage of food from the stomach to the intestines (gastric emptying). Therefore, they increase the bulk of refluxed stomach contents¹

Lifestyle habits:

• Most people have a habit of lying down or going to sleep immediately after eating, which increases the risk of acid reflux^4,5
• Wearing tight clothes around your waist applies pressure on your stomach, causing its contents to reflux 
• Smoking also weakens (relaxes) your oesophageal sphincters, making it easier for the acid to travel back from the stomach. A study found that smoking cessation caused visible improvement in symptoms in persons with LPR and also decreased the risk of reflux^4,7 

Medications:

Some medications also relax your oesophageal sphincters, causing LPR. These include

• Benzodiazepines
• Tricyclic antidepressants (TCAs)
• Calcium channel blockers 
• Non-steroidal anti-inflammatory drugs (NSAIDS) 

Others:

• During pregnancy, there is increased pressure on your stomach, which causes its acidic contents to reflux
• Obesity also increases your abdominal pressure, which can impair your LES over time
• In some people, a condition called hiatal hernia causes a part of their stomach to slip through an opening in their diaphragm. This can also pull their lower oesophageal sphincter (LES) upward, making it less effective in preventing the reflux
• A study showed that people with diabetes, asthma and chronic ear infections were more susceptible to LPR than those who did not have these diseases⁴

What are the symptoms of LPR?

There are no specific symptoms that can definitely indicate that you have laryngopharyngeal reflux. However, you might experience these symptoms:^4,8

• Repeated urge to clear your throat 
• Chronic sore throat 
• Chronic cough
• Hoarseness of voice 
• Irritation in your throat
• Difficulty in swallowing
• A feeling of mucus accumulation in the throat 
• A feeling of something stuck in your throat, but you cannot swallow it 
• Bitter taste in the mouth

Diagnostic methods

According to a study, there are no proper diagnostic methods for LPR.^2,8 However, if you experience any of the above symptoms, report to an otorhinolaryngologist (ear, nose and throat specialist) immediately, before the situation gets worse.

Usually, the doctor uses a combination of different approaches to get to a diagnosis. These are:

History:

The doctor will ask some questions related to your condition and assess your symptoms.

Examination: 

• Laryngoscopy: The doctor will pass a small camera (laryngoscope) to visualise the inside of your throat. It is a small, clinic-based test and is basically done to look for any signs of inflammation or redness in your throat.⁸ However, these signs are nonspecific and can be due to a number of diseases, for example, allergies, infections, etc.
• In another examination called esophagogastroduodenoscopy (EGD), the camera is passed further down your oesophagus (food pipe) to your stomach. It evaluates the strength of your lower oesophageal sphincter⁸

Acid detection test (pH monitoring): 

It is carried out in two ways. In one method, the doctor passes a soft, thin tube through your nose into your food pipe, where it stays for 24 hours. It is connected to a small recorder (which you wear or on your waist) that records your acid levels the whole time.⁸

The other method measures your acid levels for a more prolonged period.⁸ It is performed by placing a small capsule in your food pipe, and the measurements are recorded in the same way as in the 24-hour test

During these tests, you can perform your daily activities as usual, so you do not need to stay in the hospital.

Oesophageal manometry:

It is a test that checks how well the muscles of your food pipe are working.

How to treat LPR?

Even after a number of studies, scientists could not find a specific treatment for LPR.² However, following different strategies can help reduce your symptoms.^1,8

Dietary changes:

For people having mild to moderate throat symptoms, some changes in their diet are enough to control their symptoms and prevent the reflux.¹ That means you should try to avoid foods that can trigger your reflux. For instance, spicy and fatty meals, carbonated drinks, caffeine and chocolate.

Eating more alkaline foods, such as fruits and vegetables, can help reduce acidity in your body. Research shows that people who consume more vegetables show a significant improvement in their symptoms.⁹

Lifestyle changes:

• Eat at least two to three hours before bedtime
• Elevate the head of your bed and sleep on your left side⁸
• Do regular exercise
• Quit smoking and alcohol
• Avoid wearing tight clothes around your waist 

Medications:

Medications usually play a limited role in the treatment of LPR. But they can help you recover faster when combined with healthy eating habits and changes in daily routine.  Most commonly used over-the-counter medications are alginates, sold under the trade name ‘gaviscon’.^2,8 They work by stopping stomach acid from moving back up into your food pipe.

If your symptoms continue, your doctor may suggest stronger options such as proton pump inhibitors (PPIs) or H2 receptor blockers to control your reflux.^2,8 They decrease the amount of acid secreted by your stomach, which ultimately decreases the reflux.

Surgical treatment:

Most people get treated by lifestyle changes along with medications. Therefore, surgery is not usually recommended. However, it is done in rare cases when your condition does not improve even after these management strategies.

The procedure that is commonly done is Nissen fundoplication, in which the surgeon tightens the valve between your stomach and your oesophagus.⁸,¹⁰ It is mostly done in people who have laryngopharyngeal reflux due to a hiatal hernia.

What is the prognosis of LPR?

Accurate and early diagnosis of LPR is very important in determining the way your disease progresses. If you get diagnosed timely, only dietary and lifestyle changes can prove effective in preventing your reflux.¹ Although for some people, it might take several weeks to feel improvement in their symptoms after these modifications. 

However, if LPR is not diagnosed accurately and timely manner, it can cause various complications.² You might get repeated infections as the mucus accumulated in your throat does not clear out microorganisms that might get trapped in it.

Acid present in your throat might go down the larynx into your airways, causing respiratory complications. 

Chronic throat irritation and voice changes can cause inflammation of your larynx (laryngitis), which can progress to laryngeal cancer.²

Ear infections can also occur due to problems in the eustachian tube (a tube which connects your ear to the back of your throat).

Summary

If you have a chronic cough or find yourself constantly clearing your throat, you might be dealing with laryngopharyngeal reflux (LPR). Unlike GERD, LPR doesn't usually cause the typical symptoms of acid reflux like heartburn or indigestion, which is why it often goes undiagnosed or misdiagnosed. It happens when the oesophageal sphincters become weak, allowing stomach contents to reach the throat and voice box.

Since its symptoms are often vague or silent, many people don’t realise they have LPR. While there is no single definitive test for diagnosis, a detailed medical history, physical examination, and certain specialised tests can help identify it. Treatment typically involves lifestyle and dietary changes, and although medications may be prescribed, they aren’t specifically targeted for LPR.