Laryngopharyngeal Reflux (LPR) is caused by the backwards flow of digestive juices up from the stomach, through the esophagus and into the throat. These juices contain acid and enzymes that can injure the throat because it lacks the resistance of tissues in the digestive tract. LPR can be difficult to recognize because most people do not have associated heartburn or stomach discomfort. It is now being increasingly recognized and linked to other disorders including chronic fluid in the ears and sinus infections and nasal congestion. Many symptoms thought to be related to allergy are probably in fact caused or mimicked by laryngopharyngeal reflux. Typical symptoms of laryngopharyngeal reflux are chronic cough, post-nasal drip, throat clearing, liquid or water in the throat, a sour taste in the mouth, a foreign body sensation in the throat, hoarseness and voice weakness or cracking. Again, the majority of people do not have heartburn or indigestion, hence the name "silent acid reflux". New evidence has also linked LPR to chronic nasal congestion, chronic sinus infection, ear infections, fluid in the ears and even throat cancers. Some researchers have also found an association with tooth decay. In any event, it is an extremely common condition that in some studies, is estimated to affect up to thirty per cent of the population. The cause is thought to be related to a weak valve (sphincter) in the upper esophagus, but it can also be worsened by a leaky valve between the stomach and the lower esophagus. This usually accompanies a hiatal hernia, a condition where the stomach valve has slid above the diaphragm and is unable to completely close. Non-medical treatment may be as simple as avoiding caffeine, chocolate, cinnamon or carbonated beverages, sleeping elevated and avoiding food two hours before bedtime. Other people with more persistent symptoms require medication to turn off acid production, usually in doses that are higher than what is used to treat common "heartburn". LPR has also been associated with colic in infants and should be sought as a cause of treatment failure of sinus infections.
Nasal Polyps
are outgrowths of the lining of the nasal cavity or
sinuses. They appear as translucent, round, pale and gelatinous swellings
within the nasal cavity or in the bony recesses of the nose. Unlike
polyps that occur elsewhere, such as in the colon, there is no potential
for them to become malignant or cancerous. They are
associated with chronic sinus infection and allergy, although
their true cause is not known. Nasal polyps can be associated with
allergy to aspirin and with cystic fibrosis. Chronic nasal blockage that
does not improve with allergy therapy or with treatment of a sinus infection
may be due to undiagnosed nasal polyps. All patients with chronic nasal
obstruction or loss of sense of smell should have an endoscopic
examination to look for polyps or other anatomical problems.
Treatment usually requires a nasal steroid spray, oral steroids and
antibiotics. Response to medical therapy is usually fair and many people
ultimately require surgical removal if symptoms cannot be controlled
with medication. Recurrence of nasal polyps is common after surgery,
especially if underlying environmental allergies have not been
identified or adequately treated. Inverting papillomas are a more
serious nasal malady and can be confused with common polyps. They are
most common in children. There is
evidence to suggest they are caused by viruses. They tend to occur on
the wall of the nasal cavity but unlike common polyps, they may erode
into the sinuses and have the ability to undergo malignant
transformation. Surgical resection is necessary to rule out malignancy.
Recurrence rate is about fifteen per cent.
Post Nasal Drip is a term used by patients to describe the sensation of fluid draining into the back of the throat. The British term "water brash" is a more descriptive and less leading term for the problem. Post nasal drip may be related to allergies, sinus disorders or other factors, including digestive disorders. When related to allergies or chronic sinus infection, it is usually accompanied by a watery nasal discharge. In the absence of nasal drainage or congestion, post nasal drip is more likely to be caused by laryngopharyngeal reflux. Proper evaluation usually entails allergy testing and endoscopy of the nasopharynx to observe the origin of the discomfort and to visualize sinus drainage, if present. Treatment is successful in most cases once the cause is identified.
Eustachian Tube Dysfunction (ETD) refers to the inadequate opening of the tube that allows air pressure to equalize on both sides of the eardrum. Dysfunction can cause a sensation of fullness in the ears or of being underwater and hearing loss. It can be caused by allergies, inadequate movement of the muscle that opens the tube or anatomical blockage of the tube. When it occurs on one side, an endoscopic examination of the nasopharynx should be performed to exclude abnormal growths or tumors that can block the opening of the tube. Children are predisposed to ETD because of the short length of the tube and open angle of the tube. Prolonged dysfunction can lead to fluid accumulation in the inner ear and is called an effusion. This fluid may become infected and is called otitis media. Some researchers have suggested an association between laryngopharyngeal reflux and eustachian tube dysfunction.
Pressure must be equal on both sides of the eardrum or discomfort will occur.
Vocal Cord Dysfunction (VCD) is a cause of shortness of breath and wheezing that is often confused with asthma. It is caused by paradoxical movement of the vocal cords during inspiration and expiration. Normally the vocal cords separate or open during inspiration and expiration to allow air in or out of the lungs. With VCD, the vocal cords close with inspiration. This is associated with airway obstruction that can be measured with a spirometer. The results can be confounded with asthma, which also causes airway obstruction, but the flow-volume loop usually reveals the correct diagnosis. Since there is no lower airway obstruction, there is a poor response to treatment with asthma medications. Patients are usually labeled as severe, steroid resistant asthmatics when the the problem may ultimately be vocal cord dysfunction. There is is an intimate association of laryngopharyngeal acid reflux (LPR) with VCD. LPR may cause chronic laryngeal inflammation which cause the vocal cords to be hyper-reactive and possibly develop laryngeal spasm. The gold standard for diagnosing VCD is to visualize the paradoxical movement of the vocal vocal cords during the respiratory cycle with a rhinolaryngoscope. Unfortunately, the exam may be normal between attacks. VCD usually improves with antacid therapy, and in some cases , speech therapy.