Interactive Approaches Help Control Reflux Disease
Laryngopharyngeal reflux (LPR) and Gastro- Esophageal Reflux Disease (GERD) cause some of the most common complaints in the ENT world. Up to 10 percent of patients may suffer from LPR, but they can be treated successfully.
It only makes sense that the patient has a consultation with a gastroenterologist right away, since many people have more than GERD: issues such as esophagitis, gastritis, ulcers, and neoplasms are not uncommon and may present with “upper throat” symptoms. The gastroenterologist can at least confirm, add to or modify the supposition.
“Proton-pump inhibitor therapy was considered the standard for LPR, but PPIs can have adverse effects, including malabsorption, which can lead to osteoporosis, an increase in cardiac events, increased incidence of enteric infections, dementia, pneumonia, colitis and other problems. Those adverse effects have led to increasing resistance to using PPIs. Fortunately, we have [there are] options.”
Potential options to PPIs include voice therapy, diet-based management, probiotics, acupuncture, stress reduction, and combination strategies.
One of the most obvious effects of LPR are vocal changes. Patients with LPR typically show hard glottal attack, glottal fry, restricted pitch range, a rough or hoarse sound, and other changes to the quality, loudness and clarity of their voice. PPI therapy often helps reduce vocal symptoms of LPR, but voice therapy can help even more.
Vocal techniques usually address hyperfunction through stretching exercises and identifying muscular over-achievers. Isolating and only using necessary muscles as well as neuromuscular re-education can break and replace habitual patterns that cause vocal symptoms. Multiple studies support the beneficial effects of voice therapy plus PPI treatment, and the use of voice therapy alone is currently under investigation.
Probiotics act by restoring more normal gut flora to reduce acid production. The most commonly used probiotics include Bacteroides fragilis, various Bifidobacterium and Lactobacillus species, Escherichia, Enterococcus, Bacillus, Streptococcus thermophiles and Saccharomyces boulardii (yeast). Patients can take oral probiotics or simply eat more fermented foods, such as yogurt, kefir, kimchi, tofu, kombucha, sauerkraut, tempeh, natto, and pickles.
On the herbal side, demulcent plants repair irrigated GI mucosa and are generally ingested before meals to coat and protect the stomach. Common herbals include aloe, marshmallow, slippery elm, licorice and deglycyrrhizinated licorice (DGL), plantains, coltsfoot, and Irish moss.
Traditional Chinese medicine is another well-developed alternative. “Hot” foods such as fried and fatty foods, spicy foods, onions, garlic, cheese, chocolate, refined sugars, coffee, and citrus can trigger reflux. “Cooling” foods such as melons, leafy green vegetables, soy, and bitter melon can reduce reflux. Reducing hot foods in the diet and increasing cooling foods can improve LPR symptoms.
So can reducing stress, which triggers reflux via the brain-gut axis. Relaxation techniques can help, as can acupuncture that targets both GI symptoms and stress.
For diet, not eating meals within three hours of bed time is helpful. Avoiding citrus, spicy and fried foods help many. For some, it is dairy that needs to be avoided.
One of the issues not described here is surgery. For the motivated patient, a consultation for surgical management of GERD (ie “fundoplication”) would be a reasonable option.
The bottom line is that there are treatment options for most patients, wether they can take medicine or not. By incorporating these alternatives, we can give patients new treatment options.