THE AMERICAN JOURNAL OF GASTROENTEROLOGY

© 1999 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.

Vol. 94, No. 10, 1999
ISSN 0002-9270/99/$20.00
PII S0002-9270(99)00477-3

CLINICAL REVIEWS

Reflux Laryngitis: Pathophysiology,
Diagnosis, and Management
Eric J. Ormseth, MAJ., M.C., and Roy K. H. Wong, COL., M.C.
Gastroenterology Service, Walter Reed Army Medical Center, Washington, D.C., and Uniformed Services
University of the Health Sciences, Bethesda, Maryland

ABSTRACT
Gastroesophageal reflux disease is felt to be associated with
a variety of laryngeal conditions and symptoms of which
“reflux laryngitis” is perhaps the most common. The most
likely mechanism for laryngeal injury and symptoms is
secondary to direct acid and pepsin contact, although studies
concerning the cause and effect between gastroesophageal
reflux disease and laryngeal disorders are conflicting. Likewise, the most effective method to diagnose such patients is
unclear. Empiric treatment of patients with reflux laryngitis
has been shown to be effective though none of the studies
are controlled. (Am J Gastroenterol 1999;94:2812–2817.
© 1999 by Am. Coll. of Gastroenterology)

INTRODUCTION
Dr. L. A. Coffin, in 1903, was one of the first to associate
gastroesophageal reflux (GER) with laryngeal disorders. He
speculated that the “eructation of gases from the stomach”
and hyperacidity were responsible for the symptoms in
many of his patients with “postnasal catarrh,” and stated that
this problem was overlooked because many patients had no
gastrointestinal symptoms. Years later, in 1968, Cherry and
Margulies (1) reported three patients with contact ulcers of
the larynx and gastroesophageal reflux disease (GERD)
diagnosed by acid barium studies. Treatment with antacids,
dietary modification, and elevation of the head of the bed
resulted in resolution of the contact ulcers. Ohman et al. (2),
in 1978, used 24-h pH monitoring to document GERD in 43
men with either a history of or current laryngeal contact
ulcers, and noted that 51% of their patients had abnormal
GER.
It is estimated that 4 –10% of patients presenting to an
otolaryngology practice will have symptoms and/or findings
related to GERD (3, 4). The most common symptoms associated with reflux laryngitis are hoarseness, vocal fatigue,
chronic throat clearing, excessive throat mucus, chronic
cough, dysphagia, and globus sensation. Though not the
focus of this article, several other laryngeal conditions (see
Table 1) have also been associated with GERD and some of
Disclaimer: The opinions and assertions expressed in this report contained herein
are the private ones of the authors and are not to be construed as official policy or
reflecting the views of the Department of Defense.

which are associated with significant morbidity. Several
studies have identified GERD as a potential risk factor for
the development of laryngeal carcinoma though a definitive
relationship remains to be proven (5, 6). The term esophagopharyngeal reflux (EPR) is used to describe esophageal
acid reflux into the laryngeal and pharyngeal areas. This
article reviews the literature concerning the pathophysiology, diagnosis, and management of patients with reflux
laryngitis.

PATHOPHYSIOLOGY
There are two schools of thought concerning how gastric
acid causes laryngeal pathology. The first implicates a direct
acid-peptic injury to the larynx and surrounding tissues via
EPR (7–10). Data to support this hypothesis come from
animal studies (7, 8, 11, 12). The second hypothesis suggests that acid in the distal esophagus stimulates vagally
mediated reflexes resulting in chronic throat clearing and
coughing which eventually lead to laryngeal lesions and
symptoms (13–16). Perhaps a combination of these mechanisms could be present in the same patient. Lastly, it may
be that EPR only results in laryngeal injury and symptoms
when acting in concert with other risk factors for laryngitis,
such as voice overuse and chronic throat clearing behavior.
The notion that significant laryngeal injury occurs with
only minute amounts of acid is based on the canine and
rabbit model where acid and pepsin are applied directly to
the laryngeal mucosa (4, 7). Because the laryngeal apparatus
is not continually coated by saliva, the gastric refluxate
cannot be neutralized, diluted, or mechanically washed off
of the mucosa, resulting in a greater propensity for injury
(17). Also, because laryngeal mucosa is not normally exposed to acid and pepsin, the intrinsic cellular mechanism to
protect against chemical injury may not be present, although
this has not been well studied. Kambic and Radsel (12)
biopsied the larynx of 44 patients with posterior laryngitis
and noted that the laryngeal epithelium was often thickened
due to hyperplasia of the prickle cell layer, and in some the
epithelium was keratinized. In patients with laryngeal ulcers, there were abundant lymphocytes and plasma cells
infiltrating the epithelium. These changes are similar to
esophageal biopsies of reflux esophagitis patients.

All of the studies that have looked at pharyngeal acid exposure have noted EPR to occur much more frequently in those with reflux laryngitis than in controls. and new environmental conditions that contain synthetic materials. (27) found that at least secondary peristalsis is preserved in those with posterior laryngitis versus healthy controls.AJG – October. halitosis. that although patients with reflux laryngitis as well as those with typical GER symptoms experience proximal esophageal acid reflux. however. such as the hypopharynx. 30). Furthermore. suggesting an abnormality in the afferent sensory limb of the pharyngo-UES contractile reflex (24). Some authors have attempted to identify whether patients with reflux laryngitis experience more acid reflux in the proximal esophagus than controls with only typical GERD symptoms. Likewise. Koufman (30) speculates that GERD plays a contributing role in approximately 55% of patients seen with the complaint of hoarseness. the gastric contents must reflux proximally from the distal and proximal esophagus and through the upper esophageal sphincter (UES) into the laryngeal area. history of upper respiratory tract infections with coughing. To gain a better understanding of the pathophysiology of reflux laryngitis. 2) during postprandial belching. It seems. frequent throat clearing. It may be that in some patients with posterior laryngitis. Shaker et al. Wo et al. or in those who responded to therapy. In one of the studies that found normal resting UES pressures. Laryngeal Conditions Associated With GERD Reflux laryngitis Subglottic stenosis Carcinoma of the larynx Contact ulcers and granulomas Endotracheal intubation injury Paroxysmal laryngospasm Arytenoid fixation Globus pharyngeus Vocal nodules Laryngomalacia Pachydermia laryngis Recurrent leukoplakia To implicate acid-induced laryngeal damage. therefore. postnasal drip. a careful history is imperative. in reflux laryngitis patients compared to controls. we may have to look elsewhere than the proximal esophagus. only infrequent and small Reflux Laryngitis 2813 amounts of EPR are required to cause damage whereas in others. Some have postulated that a defective UES is present in reflux laryngitis patients and have looked manometrically at the UES to determine if it differs from normal controls. The significance of these findings with respect to reflux laryngitis. Waring et al. Some investigators have speculated that esophageal dysmotility plays a role in reflux laryngitis patients noting abnormal acid clearance times and an increase in the prevalence of nonspecific motility (26). found that there were no significant differences in the amount of proximal reflux in a large group of patients with atypical reflux symptoms. the distribution of these reflux episodes may be different. 24). however. (20) found that proximal esophageal reflux had no predictive value in identifying patients with atypical reflux symptoms. 21. Because the differential diagnosis of the symptoms of reflux laryngitis is broad. on the other hand. others have found normal resting UES pressures (17. a significantly higher percentage of distal reflux episodes reached the proximal esophagus compared to both normal controls and those with typical GERD symptoms. Jacob et al. remains unknown. including hoarseness. 22). and 3) during appropriate decrements of UES pressure associated with swallowing when gastric contents pooled in the proximal esophagus overflow into the posterior pharynx especially during nocturnal supine state (25). and prolonged vocal warm-up. though the question of how much and how often EPR occurs in normal healthy controls remains unanswered. chronic idiopathic cough. Risk factors associated with these symptoms include frequent voice use. (17) noted that. pets. and hence prevent EPR. EPR has been well documented to occur in those with suspected reflux laryngitis (17. Early in the evaluation of patients with laryngitis and . chronic cough. 22). others found no significant difference in esophageal clearance times in patients with laryngitis compared to a control group of GERD patients (28). 1999 Table 1. globus sensation. concurrent tobacco use. allergic type symptoms. including hoarseness. EPR has been noted to occur in three circumstances: 1) during spontaneous drops in UES pressure. though this prevalence has not been verified in any studies. but the differential diagnosis of hoarseness is broad. EPR also occurs in normal healthy controls with a prevalence of 16 –21% (17. (18) found that a subset of patients who experience laryngeal symptoms had significantly more proximal esophageal acid exposure compared to a control group of GERD patients. some have studied pharyngeal acid reflux or EPR. Though one study (23) noted elevated UES pressures in reflux laryngitis patients. but patients may deny associated heartburn as has been mentioned. Hoarseness is noted in 92% of patients (29. researchers noted that it takes significantly larger volumes of refluxate to trigger UES contraction. However. compared to a group with typical reflux symptoms. DIAGNOSIS Patients with reflux laryngitis most commonly present with hoarseness. Given that reflux laryngitis probably results from direct exposure of the hypopharynx and larynx to acid and pepsin. (19). Patients with refractory chronic or intermittent symptoms are often referred to an otolaryngologist. Ulualp et al. recent air conditioner. frequent sore throats. although proximal esophageal acid exposure time was not increased in patients with reflux laryngitis. frequent and copious amounts of pharyngeal acid reflux may occur and not be associated with laryngeal injury or symptoms. A reflux history is important to obtain.

hypopharyngeal reflux has been documented in normal healthy controls. reliance on the results of pharyngeal probe monitoring has the potential to decrease the diagnostic yield when evaluating patients with suspected reflux laryngitis. THE ROLE OF THE GASTROENTEROLOGIST IN PATIENTS WITH SUSPECTED REFLUX LARYNGITIS Most of the patients seen by a gastroenterologist with the diagnosis of suspected reflux laryngitis will have been evaluated by an otolaryngologist and referred for either upper endoscopy or pH monitoring to document the presence of abnormal GER. some patients with normal 24-h pH studies have been shown to have EPR. During pharyngeal pH monitoring. Furthermore. In a group of 46 patients with the diagnosis of reflux laryngitis based on symptoms of hoarseness and/or an abnormal laryngeal examination. The prevalence of esophagitis in those with typical GERD symptoms ranges from 48% to 79% (35. Pharyngeal pH monitoring has been used to study patients with suspected EPR to identify the culprit at the scene of the crime. Indirect laryngoscopy may be used as a screening tool. only 28% had evidence of endoscopic esophagitis. which can easily be missed because both indirect mirror and fiberoptic laryngoscopy may not identify this lesion. Pharyngeal pH monitoring may be the best modality to establish EPR and GER as the cause of laryngeal disease. For example. the most common laryngeal findings were: edema. 87%. Table 2 lists some of the laryngeal findings associated with GERD. Rather. certain foods are associated with false–positive results such as citric acid-containing beverages including orange juice and carbonated soft drinks. AJG – Vol. some have speculated that the presence of a probe in the posterior pharynx may actually precipitate acid reflux secondary to irritation (39) resulting in possible false– positive results. (34) noted that only 19% of a group of 16 patients with posterior laryngitis refractory to H2RA treatment had endoscopic esophagitis. Koufman (38) found that 23% (28 of 122) of reflux laryngitis patients with a normal 24-h pH test had evidence of EPR with the addition of a hypopharyngeal probe. (33) noted that although 61. erythema. The reported prevalence of abnormal GER by 24-h pH monitoring in patients with suspected “acid laryngitis” ranges from 17. patients with reflux laryngitis have a low prevalence of endoscopic esophagitis. and the technology is limited to modern voice laboratories. loss of mucosal contact between the pH probe and the cavernous posterior pharynx may occur with subsequent abnormal pH recordings resulting in “pseudoreflux. and ulceration. or proximal esophagus. 36). Katz (21) found that three of 10 patients would have been diagnosed as normal had only a single distal esophageal probe been used. Abnormalities. 37). 18. which is able to identify subtle mucosal abnormalities enhancing the ability to evaluate laryngeal pathology and function. Laryngeal Findings Associated With GERD Reflux laryngitis Vocal cord nodules Reinke’s edema Contact ulcers and granulomas Laryngeal stenosis Paroxysmal laryngospasm associated symptoms. 1999 In addition. No. The term “reflux laryngitis” refers to a constellation which includes classic “posterior laryngitis” with red arytenoids and piled-up interarytenoid mucosa but is not seen in the majority of patients with reflux laryngitis (31). This variability probably relates to patient heterogeneity and methodology concerning whether the pH probe is placed in the hypopharynx. Patients with reflux laryngitis may well deny any associated heartburn symptoms of GER. Also. 94. There are several different instruments used by laryngologists to evaluate the hypopharynx and larynx. 30.2814 Ormseth and Wong Table 2. Taking these issues into consideration along with the fact that GER and EPR are intermittent phenomena.5% of laryngitis patients with chronic hoarseness had abnormal pH values. Because patients with the diagnosis of reflux laryngitis have a low prevalence of endoscopic esophagitis. distal.5% to 70% (17. 2% (30). laryngeal edema is the most common finding. 10. Likewise. which is in fact lower than the rate of positive Bernstein tests for patients with typical GERD symptoms (range 32–100%. which may relate to its proximity to the esophagus and hence may be most exposed to acid-peptic refluxate. granuloma/granulation. videostroboscopy is expensive. such as erythema and edema. Interestingly. the decision to perform upper endoscopy should be based on whether there are other indications to do the procedure. Kamel et al. most patients will undergo laryngoscopic examination. and several authors have documented a low prevalence of heartburn (6 – 43%) in those with reflux laryngitis (2. Documentation of abnormal GER by pH monitoring may be appropriate in some patients.” A gradual drop in pH with a rapid recovery that is not associated with a preceding drop in pH measured in the more distal probes may represent . Wiener et al. 30). 89%. although some (26) have noted a decreased esophageal mucosal sensitivity to acid in patients with reflux laryngitis based on their finding of a high incidence of acid reflux on pH monitoring combined with a low incidence of positive Bernstein acid tests (5%). 21. mean 78%) (32). Unfortunately. such as Barrett’s screening in patients with a long duration of heartburn symptoms. 26. as mentioned. The explanation of this finding is unclear. yet pharyngeal acid reflux was detected with the addition of a hypopharyngeal probe. are more often seen on the posterior aspect of the larynx. although caution must be exercised in the interpretation of these results. 19%. ranging from indirect mirror laryngoscopy to the more sophisticated videostroboscopy. but videostroboscopy is considered to be the best technique to study the larynx.

” Although the issue of “pseudoreflux” has not been well studied. outcome parameters studied. b. the majority of patients underwent fundoplication (20). All studies except for one included a baseline laryngeal examination. dose and duration variable PPI or Nissan 40 mg/d variable duration PPI 40 mg/d 4 wk symptoms and laryngoscopic exam symptoms and laryngoscopic exam PPI 40 mg/d 4 wk PPI 40 mg/d 12 wk PPI 40 mg/d 8 wk Percent of Patients With Improvement in Symptoms 50% by voice analysis. 43). but there was a lot of variability. Of the studies which included upper endoscopy as part of the evaluation. Table 3 summarizes the results of eight studies. 43).AJG – October. The incidence of “pseudoreflux” with pharyngeal pH monitoring is felt to occur much less than previously reported with the use of newer multielectrode catheters (40. throat specialist and then referred to a gastroenterologist. and in the two which mentioned the prevalence of abnormal GERD. research methods. NA ⫽ not available. PPI or surgery. “pseudoreflux. This gradually disrupts the bipolar circuit. 41). laryngeal abnormalities were not uniformly described between the studies. ANTIREFLUX TREATMENT FOR LARYNGITIS Treatment of patients with suspected “reflux laryngitis” with antireflux medications. Subjective improvement in symptoms and improvement in follow-up laryngeal exams were the most common outcome parameters followed in the studies. In one study. 12 wk symptoms. In addition.i. heartburn ranged from 55– 60% (42. PPI therapy was used though the dose ranged from 20 mg p.d. and laryngoscopic exam symptoms. Three of the studies used pH monitoring (20.o. 45). When the patient swallows or changes position. 50% got worse 92% 96% symptoms 80% symptoms and laryngoscopic exam symptoms 100% symptoms.i. to 40 mg q HS. In all of the studies except for one (42). Three of the eight studies followed patients after . two studies included computerized voice analysis (42. † No baseline laryngeal exam. Overall improvement in symptoms in these eight studies ranged from 50 –100%.d. nose. 42. 1999 Reflux Laryngitis 2815 Table 3. The treatment duration ranged from 4 wk up to 24 wk (34). Hoarseness and throat burning are the most common symptoms studied. the patients were initially evaluated by an ear. such as histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) has been shown to be effective although no controlled studies have been performed. laryngoscopic exam 60% 60% 67% * Not placebo controlled. PPI ⫽ proton pump inhibitor. however. the pathophysiology of the pH pattern is most likely an artifact resulting from the probe either drying up or moving away from the pharyngeal mucosa. Results of Studies in the Treatment of Patients With Suspected Reflux Laryngitis No. The degree of GERD varied between the studies with the prevalence of heartburn ranging between 39 –100%. associated esophagitis ranged from 19% (34) to 100% (44). of Patients Percent of Patients With Heartburn Percent of Patients With Esophagitis McNalley ’89 11 82% 55% yes/55% Kamel ’94 12 83% 19% no Hanson ’95 182 NA NA no Waring ’95† 27 100% 59% Jasperson ’96 21 100% 100% Metz ’97 10 50% 20% Shaw ’97 96 39% NA no Wo ’97 22 55% NA no Study* pH Testing/ Percent With Positive Results yes/no mention of % with ⫹ pH test no yes/60% Rx/Dose and Duration Outcome Parameters H2RA 150 mg b. voice parameters prior H2RA-PPI 40 mg/d up to 24 wk H2RA. this then restores the bipolar nature of the system. as well as pharmacological agents and regimens used. causing a graded rather than precipitous drop in pH. acoustic voice analysis. In seven of the eight studies. Most studies are not comparable because of differences in patient selection. H2RA ⫽ histamine-2 receptor antagonist.

Laryngoscope 1988.e. 9. M. Harmon JW. although two studies suggested that improvement in symptoms occurred more commonly with more mild laryngeal abnormalities (45. Wiener GJ. 42. et al. 47). Clinical relevance..92:276 – 84. 5. there was no good correlation between the degree of symptomatic improvement and abnormal 24-h pH scores (20. such as voice overuse. Bartual J. Experimental esophagitis in a rabbit model. et al. Little FB. 12. Based on a review of the studies listed in Table 3.92:228 –30.C. Surgery 1982. 49. SUMMARY Reflux laryngitis is a common disease and is probably only one of several laryngeal manifestations associated with GERD. Room 7F47. Proceedings of XIV World Congress of Otololaryngology— head and neck surgery. the optimal dose and duration of treatment remain unknown. none of the trials to date have been placebo-controlled. In the three studies that included pH monitoring. 4. 46. Laryngoscope 1988. Most of the studies did not identify factors suggestive of a favorable outcome. If pharyngeal pH monitoring is not available or undertaken. empiric treatment with PPIs has been shown to be effective in the majority of patients though as mentioned. Ann Otol Rhinol Laryngol 1978.2:78 –9. Whether this may benefit those with reflux laryngitis. In the two studies assessing computerized voice analysis. patients with other risk factors for chronic laryngitis. COL.W. In any case. 1999. In many patients. the cause of laryngeal symptoms may well be multifactorial. Kohut RI. although not without limitations. 5. In: Sacristan T. Reflux laryngitis and its sequela: The diagnostic role of ambulatory 24-hour monitoring. Walter Reed Army Medical Center. accepted May 21. 10.(Suppl)8: 26 – 44. particularly those with xerostomia is intriguing. may be the optimal method to evaluate such patients in terms of documenting the presence of EPR. 3) Incomplete acid suppression requiring higher doses of medications such as PPIs for extended periods of time.” “Pachydermia laryngeus” is characterized by thickening of the laryngeal epithelium (hyperkeratosis).27:127–31.. Ohman L. Otolaryngol Head Neck Surg 1998. 7. treatment with high dose PPIs (i. Koufman JA. J Otololaryngol 1998.C. Correlation of laryngeal and pharyngeal carcinomas and 24-hour pH monitoring of the esophagus and pharynx.98: 972–9. Gaynor EB. 1999. The use of other classes of drugs other than antiacid secretory drugs such as H2RAs and PPIs in the treatment of reflux laryngitis has not been studied. et al. 47). Role of the components of the gastrodudenal contents in experimental acid esophagitis. 2) The multifactorial nature of laryngitis in some reflux laryngitis patients in whom GER may only be playing a minor role or none at all. 3. et al. 25). Pharyngeal pH probe monitoring. Chief. These changes may produce refractory symptoms despite adequate antireflux therapy. cisapride has been shown to increase significantly salivary secretion including bicarbonate output (48). Building #2. Johnson LF. Chen MY.. may benefit from concomitant voice therapy. Olofsson J. 1990:3005–9. whether PPI treatment is initiated based on the results of pharyngeal pH monitoring or begun empirically.78:1937– 40. 1999 gitis is to first perform simultaneous esophageal and pharyngeal pH monitoring. Esophageal dysfunction in patients with contact ulcer of the larynx. Reprint requests and correspondence: Roy K. Lastly. Hanson DG. Ott DJ. . Kambic V. 2. 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