Voice disorder caused by backflow of stomach fluids to the throat and voice box area; a type of supra-esophageal GERD
Laryngopharyngeal Reflux (LPR)
Backflow of stomach fluids to the laryngopharynx (voice box + lower back of throat)
Esophagus or Food Pipe
Muscular “tube” that connects throat to stomach; actively moves swallowed food/drinks into the stomach
Backflow of stomach fluids which contain acid and enzymes
Gastro-Esophageal Reflux Disease (GERD)
Backflow of stomach fluids into the esophagus; associated with heartburn
How is reflux laryngitis treated?
There are two main methods of treating voice disorder from stomach fluid backflow (reflux laryngitis), both of which depend on an accurate identification of the cause of backflow.
- Decrease production and secretion of stomach acid with medicine
- Improve the barrier function of the lower food pipe sphincter (lower esophageal sphincter, LES) through surgery
Current Clinical Recommendation
Effective medical treatment of voice disorders from backflow of stomach fluid (reflux laryngitis) involves medicines that decrease stomach acid production . These medicines, called proton pump inhibitors or PPIs, are taken twice daily from three to six months.
Expectation from Effective Treatment
- Improvement of voice disorder
- Improvement of associated complaints (e.g., frequent throat clearing, sensation of lump in throat)
- Improvement in surface appearance of voice box and throat:
- Decreased swelling in throat and voice box
- Decreased redness in throat and voice box
- Decreased mucus production
Some physicians prescribe medications in addition to proton pump inhibitors (PPIs) to increase the power of a treatment plan. Antacids, H2 blockers, and pro-kinetic (motility-promoting) drugs are all used to varying degrees.
Evaluation of Medical Treatment
After three to six months, the response to medical therapy is checked.
If Treatment Successful
“No-meds” trial: After a period of success on medications, they are decreased to determine whether the body can suppress the backflow (reflux) on its own. The outcome of this “test” will influence the type of further treatment you receive.
No more backflow: In some patients symptoms will not return after discontinuing or decreasing medication (proton pump inhibitors). This has been observed most often in mild cases of reflux laryngitis.
Return of backflow after months or years: In some patients the voice disorder and accompanying complaints return. These patients are placed on another round of proton pump inhibitors.
Immediate return of voice disorder: Other patients experience an immediate return of the voice disorder as soon as medications are stopped. In these cases, long-term treatment with PPIs may be necessary to keep symptoms in check.
Fortunately, current studies of patients on high dose PPI therapy suggest that PPIs can be taken safely by many patients for long periods of time (such patients show no ill effects even after 10 years), and PPIs appear to be quite successful at controlling symptoms over the course of many years.
If Treatment Not Successful
If the three-to-six month treatment trial is not successful, the patient is re-evaluated. Possible explanations for treatment failure are given below.
- The cause of the voice disorder may not be due to backflow of stomach fluids as originally suspected.
- There may be multiple causes for the patient’s voice disorder; all will need to all be identified and managed for meaningful improvement in voice function.
- The patient has a particularly “tough case” of reflux which needs a “stepped-up” treatment strategy, which usually involves two steps:
- Dosage of PPIs are increased or different PPIs are tried until an effective medial treatment regimen is found
- Surgical treatment is performed to reinforce the lower esophageal sphincter (LES) to make it function effectively as the main barrier against backflow of stomach fluid (reflux).
Surgery Versus Lifetime Medical Treatment
Surgery is most likely recommended for younger patients who would need to take PPIs for the remainder of their lives to counteract reflux laryngitis or who find the lifestyle changes associated with PPI treatment to be too demanding.
- Current Most Effective Surgical Procedure: Nissen fundoplication
Currently, the most effective surgical treatment for backflow of stomach fluid (reflux) is the Nissen Fundoplication. Briefly, this surgery tightens the lower food pipe sphincter (lower esophageal sphincter, LES) so it can perform better as a barrier to stomach fluid backflow.
Minimally Invasive Surgery
Nissen fundoplication can now be performed through several small holes in the abdomen (laparoscopically) or through a tube inserted down the throat (endoscopically) – rather than the traditional method of operating through an open incision in the abdomen. Postsurgical recovery is much faster with these minimally invasive techniques
- Note: Despite proven success in treating GERD, no conclusive studies have yet been reported to quantify the success of using fundoplication surgery to treat stomach fluid backflow to the voice box (laryngopharyngeal reflux, LPR).
- Theoretically at least, if less acid is able to backflow into the esophagus, less is then able to travel beyond the upper esophageal sphincter (UES) and into the voice box (larynx).
- More studies must be completed to judge the long-term success and complications of fundiplication for patients with voice disorders due to stomach fluid backflow.
Possible Multiple Causes When Patients Do Not Respond to Medical or Surgical Treatment for Reflux
When both medical and surgical treatments for stomach fluid backflow (reflux) do not improve the voice disorder and associated complaints – despite all tests confirming that stomach fluid backflow does occur – an additional cause of the persisting voice disorder might be present and must also be investigated and treated.
These many-cause voice disorders (multifactorial voice disorders) contribute to the challenges in the investigation and treatment of voice disorders.
Patient education material presented here does not substitute for medical consultation or examination, nor is this material intended to provide advice on the medical treatment appropriate to any specific circumstances.
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