Finding the best treatment of laryngopharyngeal reflux (LPR) for you is a challenge. There are many treatment options, but only a few have been shown in studies to work. One crucial aspect of treatment success is to remove the cause of the reflux instead of merely suppressing symptoms.
There are three recognized treatment methods for LPR: medication, dietary and lifestyle changes, and surgery.
Medications: Limited Effectiveness
Medications, particularly acid-suppressing drugs, are commonly used for the treatment of LPR. Unfortunately, most medications are either not effective or cause unacceptable side-effects. This has been shown in multiple studies.
Proton-Pump Inhibitors
Proton-pump inhibitors (PPIs) are effective against classic acid reflux (GERD) but do not work any better than a placebo for LPR treatment.[1] The reason why I mention them here is that they are the most frequently prescribed medications for silent reflux. Most physicians who prescribe them are still not aware how poorly their outcome is according to studies.
See more about PPIs for LPR in this article.
Gaviscon Advance
Gaviscon Advance is one of the few medications that have been shown in studies to improve LPR symptoms. It forms a foam layer above the stomach contents, thereby preventing them from rising towards the esophagus.
One study tested the efficacy of Gaviscon Advance and assessed the symptoms before and after treatment with the help of the reflux symptom index (RSI). The RSI is a questionnaire to determine the severity of nine different LPR symptoms. The highest score is 45, which denotes extreme symptoms, while a score of 0 means that the patient is free of symptoms.[2] Most patients are somewhere in the middle.
With Gaviscon Advance, the symptoms of patients with LPR improved from a mean RSI score of 23.9 to a mean score of 11.2 within 2 months, meaning that the symptoms were roughly halved.[3]
It is important not to confuse Gaviscon Advance with the Gaviscon sold in the US. Gaviscon is quite confusing in the way in which they market products with widely different formulas in different countries. The US formulas aremore of an antacid and not well suited to treating LPR.
Read more about the difference between US and UK Gaviscon in this article. I also tell you where to get UK Gaviscon, even if you do not live in the UK.
Diet & Lifestyle Changes
Dietary changes can effectively relieve symptoms in most LPR patients. Nutritional adaptations can reduce the reflux and thereby minimize pepsin reaching the throat and airways. Furthermore, avoiding acidic foods and drinks can also decrease the activity of the remaining pepsin.
In one study, a low-acid, low-fat diet improved LPR symptoms within a few weeks. The mean RSI score fell from 14.9 to 8.6, meaning that symptoms were almost halved.[4]
You can find out more about diet approaches for LPR in my specialized article.
Surgery
Surgery can be effective at reducing LPR symptoms, but it always bears the risk of complications. Surgical approaches are only recommended when other measures fail to provide adequate relief.
Nissen Fundoplication
The Nissen fundoplication is the most established surgery for LPR. During this procedure, the upper part of the stomach is wrapped around the esophagus. This tightens the lower esophageal sphincter (LES), a valve that helps to keep stomach contents within the stomach.
Nissen fundoplication is not always effective, but it improves symptoms in about 75% of LPR patients.[5] One study carefully quantified the improvement and showed that symptoms reduced from an average RSI score of 31.7 to 10.[6]
As regards side-effects, Nissen fundoplication can cause bloating, swallowing difficulties, and vagus nerve damage. The vagus nerve is a long cranial nerve that controls digestion, and damage to this nerve can result in digestive problems.
It is important to know that due to the nature of LPR, the outcomes of the Nissen fundoplication can vary wildly. GERD, with symptoms such as heartburn, is liquid reflux, which is relatively easy to stop by tightening the lower esophageal sphincter. LPR, on the other hand, is gaseous reflux. Gas is more difficult to stop than liquid, which is why the fundoplication fails more often for LPR than for GERD.
You can get more information about fundoplication in this article.
Stretta procedure
The Stretta procedure is usually mentioned together with surgical options, even though it’s technically not surgery. It is merely electrical stimulation of the lower esophageal sphincter, which is less invasive, safer, and an alternative to surgical approaches.
The procedure works by sending radiofrequency energy to the muscles of the LES with the help of special needles, thereby stimulating and strengthening the muscles. Stronger muscles tighten the LES and consequently reduce the leakage of reflux.
The procedure is much newer than the fundoplication. However, a number of studies have been carried out that show good results.[7],[8],[9] It is important to know that it takes up to 12 months to see the full results of the procedure; it is not a quick fix.
Summing It Up
LPR is much more difficult to treat than classical reflux symptoms.
The most critical difference is that simply taking a pill rarely works well for LPR, while it is usually quite effective for heartburn. LPR is mostly caused by the stomach enzyme pepsin, and for that reason, acid-suppressing medication does not help much with LPR.
However, there are different effective approaches to controlling the disease with changes in diet and lifestyle. For extreme cases, surgery can be an effective approach to gain relief.
References
[1] Reimer C, Bytzer P. Management of laryngopharyngeal reflux with proton pump inhibitors. Ther Clin Risk Manag. 2008;4(1):225–33.
[2] Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002;16(2):274–7.
[3] McGlashan JA, Johnstone LM, Sykes J, Strugala V, Dettmar PW. The value of a liquid alginate suspension (Gaviscon Advance) in the management of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2009;266(2):243–51.
[4] Koufman JA. Low-acid diet for recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Ann Otol Rhinol Laryngol. 2011;120(5):281–7.
[5] van der Westhuizen L, Von SJ, Wilkerson BJ, et al. Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms. Am Surg. 2011;77(7):878–82.
[6] Carroll TL, Nahikian K, Asban A, Wiener D. Nissen fundoplication for laryngopharyngeal reflux after patient selection using dual ph, full column impedance testing: a pilot study. Ann Otol Rhinol Laryngol. 2016;125(9):722–8.
[7] Dughera L, Rotondano G, De Cento M, Cassolino P, Cisarò F. Durability of Stretta radiofrequency treatment for GERD: Results of an 8-year follow-up. Gastroenterol Res Pract. 2014;2014:531907.
[8] Meier PN, Nietzschmann T, Manns MP. The Stretta procedure for reflux disease: 1 year follow-up in 40 patients. Gastrointestinal Endoscopy 2005;61(5):AB137.
[9] Triadafilopoulos G. Stretta: A valuable endoscopic treatment modality for gastroesophageal reflux disease. World J Gastroenterol. 2014;20(24):7730–8.
