Voice and Swallowing Problems
Do you have hoarseness, frequent throat clearing, cough, or sensation like something is stuck in your throat? Then you may have Laryngopharyngeal Reflux (LPR) due to GERD (Gastroesophageal reflux disease). We can diagnose and treat you in office with Examination and pH probe.
Many of our patients include people who depend on their voices for their careers, such as teachers, actors and professional singers. The Maryland ENT Center has state-of-the-art specialized equipment that allows us to evaluate and treat patients who suffer from voice and swallowing disorders. This includes video laryngeal stroboscopy, which illuminates the vocal folds as they vibrate so that we can examine any changes in the vocal cord tissue that may account for hoarseness, persistent laryngitis or a change in vocal range and control.
One of the most common disorders that can affect the throat is Gastro-Esophageal Reflux Disease (GERD) affects up to 40% of adults in the US population. GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from refluxing or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid and other contents of the digestive tract to move up the esophagus. GERD is often characterized by the burning sensation known as heartburn. In some cases, reflux can be silent, with no heartburn. When the reflux goes all the way up to the throat and/or the nasal airway, this is called Laryngo-Pharygeal Reflux or LPR.
Who Gets GERD or LPR?
Women, men, infants, and children can all have GERD or LPR. These disorders may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters.
Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or something stuck (globus sensation).Some patients have hoarseness, difficulty swallowing, throat clearing, and difficulty with the sensation of drainage from the back of the nose (postnasal drip). Some may have difficulty breathing if the voice box is affected. Many patients with LPR do not experience heartburn. In infants and children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep-disordered breathing, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnea), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical.
How are GERD and LPR Diagnosed and Treated?
GERD and LPR are evaluated by a thorough ENT physical examination which includes a laryngoscopy\. A few additional tests may be recommended to confirm both the diagnosis as well as the seriousness of your condition. These may include a barium swallow, esophagoscopy, esophageal motility and an acid probe test. The Restech Dx probe is a novel a minimally invasive pH probe that measures the acidity of the pharynx. This device utilizes a 1.5-mm diameter catheter, a specially designed sensor, and a unique flashing LED light to guide the catheter into proper position in the posterior oropharynx above the upper esophageal sphincter.
The Restech Dx-pH Measurement System measures and records airway pH every half second for up to 48 hours, while the patient inputs clinically relevant information such as meals, symptoms, and supine position with the press of a button. The miniaturized antimony sensor and reference electrode are housed 0.002" apart in the tip of the Dx-pH Probe, enabling it to measure the aerosolized particles of refluxate in your patient's airway. All pH data from the catheter is digitized by the Dx-Transmitter and sent wireless to the Restech recorder where it is stored in non-volatile memory (SD data card). The system utilizes Zigbee based telemetry, which is the name of a specification for a suite of high level communication protocols using small, low-power digital radios based on the IEEE 802.15.4.
Examples of 24-hour pH Sample Cases
Notice how the two tracings shown below track along a pH in the mid 7 range +/- a half pH value. The amplitude is tight and no reflux events occur, even during meal periods (which can be considered artifact caused by the acidity of the meal). The red line across the bottom denotes the supine period, blue line denotes meal period, and pink lines are patient input of various symptoms.
Classic Nocturnal Reflux
This patient demonstrates a classic nocturnal / supine dip in pH - note how the acidity clears in the morning. Also note the nocturnal arousal subsequent to a fairly rapid decrease in pH. Very normal upright and seated daytime pH - absent any exaggerated amplitude. Mean pH is 7.2 - which is DeMeester's calculated normal oropharyngeal pH level. No co-occurring symptoms at 10% H2 blocker might relieve nocturnal acidity but does not appear to be a candidate for PPI's therapy because of the normal daytime pH levels. Note how tight the daytime upright amplitude is - very characteristic of a normal flat tracing.
Severe Nocturnal Reflux
This patient is an example of severe nocturnal pH reflux and acidic environment. Even after waking the pH is still very decreased and dips to a pH of 5. This patient should respond well to PPI's therapy.
Most people with GERD or LPR respond favorably to a combination of lifestyle changes and medication. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention.
Adult Lifestyle Changes to Prevent GERD and LPR
- Avoid eating and drinking within two to three hours prior to bedtime
- Do not drink alcohol
- Eat small meals and slowly
- Lose weight
- Quit smoking
- Wear loose clothing
- Limit problem foods including caffeine, carbonated drinks, chocolate, peppermint, tomato, citrus fruits, fatty and fried foods, alcohol.
Information regarding diet for GERD can be found on the following websites: