Yet One More Question From Dr. Park

[Steven Y Park, MD]

How many of you have any or all of the following:

Chronic cough,
Hoarseness
post-nasal drip,
mucous
throat clearing
lump sensation
tightening
throat pain
difficulty swallowing
or burning?

[Lulu54]

Could LPRD be misdiagnosed as Nutcracker esophagus or is that part of the constrictive action- a lot of us have heard that one! And a whole bunch of us have undergone esophogeal motility tests and videoscoping.

How about Barrett's - although that is confirmed by a pathology report, could stage one also be a misdiagnosis?

Why don't all doctors explain this stuff to their patients instead of giving a one sentence diagnosis if we're lucky and then dismissing us with a pat on the head?  sorry, I know you can't answer that one but we're not feeling so friendly toward doctors here today.  

[Steven Y Park, MD]

Laryngopharyngeal reflux disease, or LPRD is probably one of the most common conditions that ENTs see, but treated in isolation, results are less than ideal. The textbook explanation is that it's a dysfunction of the upper esophageal sphincter so acid leaks up into the larynx, causing inflammation and all the other throat symptoms that I listed above. LPRD is different from GERD in that you don't have to feel anything in the stomach.

The standard recommended course of treatment is TWICE daily of any of the proton pump inhibitors (Prilosec, Aciphex, Nexium, Prevacid, Protonix, etc.) to be taken BEFORE breakfast and dinner. Once daily is not good enough. It also has to be taken for a long time. Our academy recommends months. You also have to address the typical dietary changes such as not eating before bedtime, avoiding alcohol before bedtime (within 3-4 hours for both), avoiding spicy or citrusy foods, etc. It's similar to the GERD diet. Not eating late before bedtime is probably the single most important thing that you can do (alcohol is #2), even more important than the medication.

This regimen works most of the time to various degrees, but the symptoms usually come back weeks, months, or years later. There are a few problems with this approach: although you're lowering the acidity of your stomach juices, it's still somewhat acidic. Your stomach contents also include bile, digestive enzymes and bacteria. Microscopic amounts of these substances can wreak havoc on your very delicate voice box structures. These materials have also been shown to reach the lungs, ears, and sinuses. This can cause inflammation in these areas which can present as your typical "infections."

The other reason for the lump sensation and the tightening that many people feel in their throats is probably due to spasming of the cricopharyngeus muscle. This is part of the upper esophageal sphincter and is the muscle that wraps around the esophagus behind the voice box. When irritated or if aggravated by other stress factors that can cause muscle spasm, you can get the classic "lump" sensation with difficulty swallowing, or a tightening sensation.

So who do these juices come up to the throat in the first place? As I more fully describe in my book, many people have jaw narrowing and dental crowding that predisposes the tongue to fall back more when lying flat. Then during deep sleep along with muscle relaxation, the tongue falls back completely and begin to obstruct. Most people wake up very quickly (less than a few seconds) so it's not an apnea. People with these issues know not to sleep on their backs. The problem is that despite sleeping on their sides of stomachs, it's not good enough. When you obstruct, but before you wake up and turn over, a tremendous vacuum effect is created in the chest and throat which suctions up microscopic amounts of stomach juices into your throat. Sometimes you'll be fine until you get a simple cold or an allergy attack and a vicious cycle happens, where due to swelling, the tongue falls back easier and more juices are brought up, causing more inflammation. When the inflammation spreads to your nose, this makes your nose more congested, causing more of a vacuum effect downstream, causing your tongue to collapse even easier.

This is why taking an acid reflux medicine doesn't help consistently (since it does nothing for the reflux—it only lower the acid content). When it does work, it probably works by promoting less irritation and inflammation of the throat.

Furthermore, since your upper molars are more narrow, the side walls of your nasal cavity is more narrow, since the side walls follow the upper jaw. So if there's any inflammation in the nose, it gets stuffy faster. Also since the angle between your septum and your nostril is more narrow, your nostrils will cave in more during inspiration.

So the overall effect is that if you have this condition (UARS), you'll never feel refreshed in the morning because you're unable to get any deep sleep. This can create a physiologic stress response that can wreak havoc on your nervous system (makes it hypersensitive), your immune system (also makes it more hypersensitive), and affects almost every hormone in your body.

I also see what can be described as "migraine" attacks in various parts of the body. But we can talk about that another time.

[Lulu54]

Dr. Park,
I did order your book and it arrived today - in the very first chapter you have given me an explanation of why I have this choking happen where I literally can't breathe.  LPRD fits me to a tee and like Shell I now want to know how its treated. I sure hope its in the book.    My GI doc decided it was anxiety that was causing me to choke.  Thank you, thank you, thank you for making this problem clear.  Perhaps I will give him your book after I am done reading it!

Laura

[sllowe]

Dr. Park,

Thank you once again.  So what is the treatment for laryngopharyngeal reflux -  and does the cause matter? How is it dx'd? I'm sorry if this question belongs in your forum.  Just wondering if there would be a different course when and if it's found to be MS related.  

I did not have the problems I have now pre-MS.

This thread is incredibly educational....
-Shell

[hbananas]

Me, the TM lady..
I have been told I have hiatal hernia, and I have reflux.  Hardly ever happens anymore, since I don't eat late at night, and gave up alcohol.  I did have a little "burf" (cross between burping and barfing) the other night, first time since starting CPAP.  Kinda scary, wondering if you're going to pollute your mask.

Chronic cough-, Have had, not for a few years.  Esp when I was on an ACE inhibitor.
Hoarseness- no
post-nasal drip-, Always a little something trickling back there
mucous -Not much since severe allergies successfully treated
throat clearing- ditto.  I sort of learned not to do it because it irritates my husband, and because I sing and the director says it's bad for the voice--swallow a lot and drink water instead.
lump sensation- Yes.  Sometimes I get esophagus spasms, if I eat too quickly, then even drinking a lot of water doesn't get it totally relaxed.
tightening -ditto
throat pain -ditto.  Kind of mid-chest
difficulty swallowing -sometimes
or burning? When there is reflux.  Chocolate is a big contributor.

[Steven Y Park, MD]

Thanks for the information and sharing your story.

A thought just came up for another question....