Reflux Laryngitis

Heartburn is the most common symptom associated with reflux laryngitis.

Reflux laryngitis is inflammation of the voice box (larynx) caused by stomach acid backing up into the esophagus (acid reflux, gastroesophageal reflux disease, GERD). Heartburn is the most common symptom of reflux laryngitis. Acid reflux can irritate and inflame the lining of the esophagus and cause signs and symptoms.

Other causes of reflux laryngitis include obesity, tight clothing, or a hiatal hernia.

Medical treatments for reflux esophagitis include medications (acid blockers or proton pump inhibitors), or surgery. Behavioral modifications such as weight loss, quitting smoking, sleeping with the head of the bed elevated, and dietary changes can decrease symptoms of reflux laryngitis.

Rarely, reflux laryngitis may be a risk factor for developing esophageal cancers.

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. Moreover, any increase in abdominal pressure (such as obesity or tight clothing, which can push acid back from the stomach up the esophagus) or a person with a hiatal hernia will have an increased risk for reflux.

When it causes symptoms or esophageal inflammation 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 irritate the lining of the esophagus, larynx, and throat, which can lead to the following:

• Erosion of the lining of the esophagus (erosive esophagitis)
• Narrowing of the esophagus (stricture)
• Chronic hoarseness
• Chronic throat clearing
• Discomfort swallowing food
• Foreign body sensation in the throat
• Asthma or cough
• Spasms of the vocal cords
• Sinusitis
• Growths on the vocal cords (granulomas)

Rarely, reflux can lead to cancers of the esophagus or larynx.

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). Considering the high prevalence of GERD, reflux laryngitis and its symptoms are uncommon.

Acid reflux can irritate and inflame the lining of the esophagus and cause signs and symptoms that may include:

• Chronic hoarseness
• Problems swallowing
• Constantly clearing the throat
• Cough
• Asthma
• The feeling of a foreign body stuck in the throat
• Sinusitis
• Vocal cord spasms
• Erosive esophagitis
• Esophageal strictures
• Granulomas (growths on the vocal cords).

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 include the following:

• Esophagram (an X-ray of the esophagus)
• Endoscopy
• Laryngoscopy
• Esophageal pH acid monitoring
• Esophageal motility studies

• 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 many diseases of the larynx as well as reflux can cause these signs.

There are difficulties with using symptoms to diagnose reflux. For example, a cough may occur when there is reflux in the esophagus. The refluxed liquid does not need to reach the larynx.

Finally, it is unclear whether refluxed liquid from the stomach that is not acidic 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.

There are several different types of medications available over the counter (OTC) or by prescription.

OTC antacids

Antacids neutralize stomach acid and give immediate relief. Popular choices include sodium bicarbonate (Alka Seltzer), calcium carbonate (Tums, Rolaids, Alka-Mints), and aluminum and magnesium antacids (Maalox, Mylanta, Riopan, Gaviscon). Use antacids 30 to 60 minutes after each meal and at bedtime because they are more effective at these times.

People on a low-sodium diet should avoid sodium bicarbonate. Calcium and aluminum can cause constipation, while magnesium antacids can cause diarrhea. Patients with kidney disease should avoid magnesium and aluminum antacids. Check with your pharmacist or doctor for any interactions with other medications you are taking.
Drugs such as nonsteroidal anti-inflammatory drugs (NSAIDS), theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin), anticholinergics, and calcium channel blockers should be avoided if feasible, but discuss discontinuing any medication with a doctor first.

Acid-blocking drugs (H2-blockers)

The acid-blocking drugs (famotidine [Pepcid], cimetidine [Tagamet], nizatidine [Axid], and ranitidine [Zantac]) are known as H2-blockers. These are available without a prescription. However, their strength may be inadequate.

Other medications

Other valuable medications include metoclopramide (Reglan), which helps to empty the stomach more rapidly; or proton pump inhibitors, such as omeprazole (Prilosec) and lansoprazole (Prevacid).

Surgery (fundoplication)

If conservative therapy and medical therapy fail, surgery may be necessary. Traditionally, fundoplication, a procedure that serves to strengthen or recreate the muscular valve (lower esophageal sphincter), requires significant surgical work and a hospital stay. Surgery or fundoplication also has been able to be done with an endoscope, which shortens the hospital stay and recovery.

Diet, home remedies, medications, and lifestyle changes to treat acid reflux, heartburn, and reflux laryngitis.

• Avoid large meals at dinner.
• Avoid eating before bedtime, and allow several hours after eating before lying down to allow the stomach to empty.
• Avoid spicy or fried foods, peppermint, citrus, tomatoes, onions, and chocolate, especially if these foods increase symptoms.
• The diet should be high-protein, high-carbohydrate, and low fat
• Avoid alcohol, caffeinated beverages, and tobacco.
• Elevate the head of the bed with wooden blocks under the bedposts to allow gravity to keep the acid in the stomach. Pillows under the head are not helpful, however, wedges that elevate the head and upper chest are effective.
• Lose weight to reduce reflux.
• If you smoke, stop.