Friday, March 22, 2013

“ Silent Reflux – Do You Hear the Throat Clears?”


By: Carleen F. Ozley, MS, CCC-SLP
ExcelENT of Alabama
Ever been in a crowd of people, shopping at the mall, standing in line at a fast food restaurant and heard someone constantly clearing their throat? Ever listen to a friend talk and suddenlynotice that between every few words or sentences that they are clearing their throat? Ever had anyone ask YOU the question, “What’s wrong – you keep clearing your throat?”

            Chronic throat clears is a major symptom of laryngopharyngeal reflux or LPR. It is a most misunderstood and disturbing symptom for the sufferer. Laryngopharyngeal reflux is a condition in which stomach acid leaks out of the stomach and into the esophagus and throat. The acid irritates the throat and the vocal cord area. It may result in voicing/swallowing difficulties and sinus infections. Some people with LPR may experience quite a bit of heartburn, but most people with LPR report little or no heartburn and therefore, it is often referred to a “silent reflux.” The laryngeal area, compared to the esophagus, is much more sensitive to irritation and injury from stomach acid. LPR is present in up to 50% of patients with voice disorders.

            Reflux more often occurs at night when we are sleeping. When we sleep, the stomach muscles and the esophagus relax and open slightly. Gravity is no longer working to our advantage to keep the acid inside the stomach. This supine position can allow acid in the stomach to travel up through the esophagus and irritate the back of the throat where the vocal cords are located.

            It may take up to 8-12 weeks of daily usage of medication along with diet and lifestyle modifications before reduction/resolution of symptoms occurs.

The most common symptoms of LPR are listed below:

1. Chronic throat clearing (increases after eating)

2. Sensation of “lump or something stuck in the throat” that does not clear with repeat swallows.

3. Dry cough

4. Hoarseness of voice loss

5. Swallowing difficulties and feeling that “solids won’t go down”

6. Sore throat

7. Aspiration – choking while eating because food enters the airway

8. Excessive mucus production

9. Reddening/swelling of and around the vocal chords observed during a LaryngealVideoEndoStrobscopy

10. Postnasal drip
In addition to a proton pump inhibitor or other reflux meds your ENT physician may prescribe, the following strategies for diet and lifestyle are recommended to assist in reducing the symptoms of LPR and especially the “nagging throat clears:”
1.      Avoid spicy, acidic, tomato based, fatty foods, chocolate, citrus fruits and citrus fruit juices and peppermints.
2.     Reduce weight around mid section that increases abdominal pressure that can aggravate reflux.
3.     Eat small, frequent meals/ no large meals.
4.     Wait at least 1-2 hours after eating before exercising.
5.     Do not wear tight, restrictive clothing around your waist. Be careful about assuming body positions that exert pressure against your waist. For example: gardening, lifting weights, bending over at waist.
6.     Limit your intake of coffee, tea, colas (caffeine) and alcohol.
7.     Stop smoking.
8.     Wait at least 2 -3 hours after eating before lying down.
9.     Elevate the head of your bed with a foam wedge or use bricks under head of bed for 2-4 inch elevation.  Be sure your chest and neck is higher than your stomach. A 45 degree angle is best.
10.            Take your reflux medicine exactly as prescribed. Be sure it is at least 30 minutes prior to eating.
**Be sure to drink the required number of oz. of water daily. Body weight divided by 2.2 = oz. needed.
Take this simple test to determine if you may be experiencing LPR.
Within the last MONTH, how did the following problems affect you?
Circle the number that best represents the severity of the symptom
0 = No Problem 5 = Severe Problem
1. Hoarseness or a problem with your voice                         0 1 2 3 4 5
2. Clearing your throat                                                                 0 1 2 3 4 5
3. Excess throat mucous or postnasal drip                             0 1 2 3 4 5
4. Difficulty swallowing food, liquids or pills                          0 1 2 3 4 5
5. Coughing after you ate or after lying down                      0 1 2 3 4 5
6. Breathing difficulties or choking episodes                          0 1 2 3 4 5
7. Troublesome or annoying cough                                          0 1 2 3 4 5
8. Sensations of something sticking in your                           0 1 2 3 4 5
throat or a lump in your throat
9. Heartburn, chest pain, indigestion, or                                0 1 2 3 4 5
stomach acid coming up

If you require an antacid or taking an OTC PPI more that 2x week on a weekly basis and scored 13 points or higher, perhaps you need to have a LaryngealVideoEndoStrobscopy to further visualize the damage that may be caused by untreated LPR. Remember, those throat clears may be sign of something more serious that just a “nagging throat clear.” 
1 Belafsky PC, Postma GN, and Koufman JA. Validity and reliability of the reflux symptom index (RSI). Journal of Voice. 2002. 16(2): 274-277.

Submitted by Carleen F. Ozley, MS, CCC-SLP
Voice and Swallowing Therapist
ExcelENT of Alabama

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