Reflux laryngitis is a voice disorder that results from irritation and swelling of parts of the voice box due to the backflow of stomach fluids into the voice box area.
This backflow is called laryngopharyngeal reflux.Stomach fluids contain acids and enzymes that help digest food in the stomach, but cause problems elsewhere in the food pipe [esophagus, throat, and voice box].
Reflux is caused by weakness in the muscle at the junction of the esophagus with the stomach. Normally, this muscular valve, or sphincter, functions to keep food and stomach acid from moving upward from the stomach to the esophagus and larynx.
This valve opens to allow food into the stomach and closes to keep the stomach’s contents from coming back up. The backward movement of stomach contents (gastric contents) up into the esophagus is called gastroesophageal reflux.
Additionally, any increase in abdominal pressure (such as obesity or tight clothing), which can push acid back from the stomach up the esophagus, or a patient with a hiatal hernia, will have an increased risk for reflux.
When it causes symptoms, it is referred to as gastroesophageal reflux disease (or GERD). When the acid backs up into the voice box (larynx), the condition is referred to as reflux laryngitis.
Stomach acid can cause irritation of the lining of the esophagus, larynx, and throat. This can lead to:
- erosion of the lining of the esophagus (erosive esophagitis),
- narrowing of the esophagus (stricture),
- chronic hoarseness,
- chronic throat clearing,
- difficulty swallowing,
- foreign body sensation in the throat,
- asthma or cough,
- spasms of the vocal cords,
- sinusitis, and
- growths on the vocal cords (granulomas).
People with reflux laryngitis usually complain of hoarseness, frequent throat clearing, sensation of lump in the throat (globus pharyngeus), cough, or sore throat.
These patients do not commonly experience heartburn, which is a typical complaint in backflow of stomach fluids to the esophagus causing inflammation in the esophagus, also known as gastroesophageal reflux disease (GERD).
What are the typical symptoms of reflux laryngitis?
Heartburn is the most common symptom associated with reflux. The American College of Gastroenterology estimates that more than 60 million Americans experience heartburn at least once a month and some studies suggest that more than 15 million people experience heartburn symptoms each day.
The incidence of GERD is on the rise, and the rise in obesity is believed to be a contributing factor.
In addition to heartburn, reflux severe enough to cause laryngitis can cause chronic hoarseness, asthma, or a foreign body sensation in the throat (globus phenomenon).
How is reflux laryngitis evaluated?
In most patients, the presumptive diagnosis of reflux laryngitis is based on the typical history of heartburn and hoarseness.
Testing usually is reserved for those patients who do not respond to conservative therapy (as explained below) or drug therapy. Diagnostic tests includes an:
- esophageal pH monitoring, and
- esophageal motility studies.
What types of medications are used to treat reflux?
There are several different types of medications available over the counter (OTC) or by prescription.
The acid-blocking drugs (famotidine [Pepcid], cimetidine [Tagamet], nizatidine [Axid], ranitidine [Zantac]) are known as H2-blockers. These are available without a prescription. However, their strength may be inadequate.
Other valuable medications include: metoclopramide (Reglan), which helps to empty the stomach; or the proton pump inhibitors, such as omeprazole (Prilosec) and lansoprazole (Prevacid).
If conservative therapy and medical therapy fail, surgery may be necessary. Traditionally, the fundoplication procedure, which serves to strengthen the muscular valve (lower esophageal sphincter), required significant surgical work and hospital stay.
Recently, the surgery also has been able to be performed endoscopic fundoplication. This has shortened both hospital stay and recovery.
What are the difficulties in diagnosing reflux laryngitis?
In some patients it appears clear that the laryngeal symptoms – hoarseness, cough, sore throat – are due to reflux, for example, in patients with marked heartburn and regurgitation of acid.
In most patients with laryngeal symptoms – those with milder heartburn and no regurgitation who comprise the majority of patients in whom reflux laryngitis is considered – it is not as clear.
Examination of the larynx may reveal redness and swelling, but these signs can be caused by many diseases of the larynx as well as reflux.
There are difficulties with using symptoms to diagnose reflux. For example, cough may occur when there is reflux into the esophagus. Refluxed liquid does not need to reach the larynx.
Finally, it is unclear whether or not refluxed liquid from the stomach that is not acid can cause reflux laryngitis, and there is no way of testing whether or not non-acid liquid is reaching the larynx.
Many physicians use a trial of potent acid-suppression with PPIs to try to prove that acid reflux is the cause of the laryngeal symptoms.
The problem with a trial of PPIs is that some symptoms such as cough and throat clearing can be caused by habit, and the PPIs may have a placebo effect. Thus, a response to PPIs may not be proof that reflux is the cause of symptoms.
Role of Surgery in Treatment
In most cases of clearly demonstrated reflux, surgical treatment is indicated when there is no improvement of the voice disorder, the voice box swelling and irritation, and/or throat pain despite adequate anti-reflux treatment and precautions, and other conditions causing voice dysfunction have been eliminated.
In some cases, surgery may be indicated earlier in the treatment management.
Elements of Successful Treatment
For treatment to be successful, the patient must do the following:
- Take the proper amount of medicine
- Take the medicine regularly
- Take the medicine for the proper period of time
- Follow physician advice to prevent backflow of stomach fluids (reflux precautions)
- Go for follow-up check-ups with the physician