Understanding Reflux Laryngitis | Symptoms | Diagnosis | Treatment | Frontiers

Understanding the Disorder Print E-mail
glossary2Key Glossary Terms
Reflux Laryngitis
Voice disorder caused by backflow of stomach fluids to the throat and voice box area; a type of supra-esophageal GERDLaryngopharyngeal 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

Reflux
Backflow of stomach fluids which contain acid and enzymes

Gastro-Esophageal Reflux Disease (GERD)
Backflow of stomach fluids into the esophagus; associated with heartburn

Overview

The voice disorder caused by backflow of stomach fluids to the voice box is known as reflux laryngitis. Unlike the stomach, the voice box and throat are sensitive to the acid and enzymes in stomach fluids.

Exposure of the voice box to stomach acid and enzymes results in swelling and irritation (inflammation).

Patients with reflux laryngitis usually complain of hoarseness, feeling of a lump in the throat (globus pharyngeus), and frequent throat clearing. Patients with reflux laryngitis may or may not feel heartburn or discomfort after eating (dyspepsia) – which are typical in irritation of esophagus (esophagitis) caused by backflow stomach fluids, also known as gastroesophageal reflux disease (GERD).

Comparison of Reflux Laryngitis and GERD with Esophagitis
Reflux Laryngitis
or GERD with Laryngitis		 GERD with Esophagitis
Backflow Level Backflow of stomach fluids to the voice box Backflow of stomach fluids to the esophagus
Reflux Pattern Usually in upright position (awake) Usually in supine position (nighttime), especially after meals
Medical Term Laryngopharyngeal reflux – a type of supra-esophageal GERD not usually associated with esophagitis; sometimes called atypical GERD GERD with esophagitis
Inflammation Site Backflow of stomach fluids causes:

  • Inflammation in throat (pharyngitis)
  • Inflammation in voice box (laryngitis)

(For more information, see Anatomy & Physiology of Voice Production.)

 Backflow of stomach fluids causes:

  • Inflammation in esophagus (esophagitis)
Symptoms
  • Hoarseness
  • Feeling like as if there is a lump in throat
  • Frequent throat clearing
  • Heartburn
  • Indigestion
Notes
  • Both reflux laryngitis and esophagitis may be present at the same time
  • Patients with reflux laryngitis usually do not have inflammation of the esophagus (esophagitis) and therefore do not complain of heartburn
  • Terminology in flux: the term “GERD with throat and voice complications” has also been used instead of laryngopharyngeal reflux or LPR
What are the causes of reflux laryngitis?

Reflux laryngitis is a product of backflow of stomach fluids to the voice box, also known as laryngopharyngeal reflux (LPR), which occurs when there is:

  1. Too much acid produced in the stomach, or
  2. Abnormal function of the throat + food pipe (pharyngo-esophageal tract), or
  3. Combination of both 1 and 2
Key InformationKey Information
When there is a malfunction along the esophagus, even normal amounts of stomach acid can backflow into the esophagus.
Three Main Causes of Reflux Laryngitis

There are three main causes of over-secretion of stomach acid, and abnormal muscle function of the throat-food pipe tract (pharyngo-esophageal tract).

  1. abnormal function or structure of food pipe (esophagus) and/or stomach
  2. some lifestyle habits
  3. some medications

These causes often work in combination to result in reflux laryngitis.

1. Abnormal Function or Structure in the Esophagus and/or Stomach
Cause What’s Wrong How Blackflow Results
Hiatal HerniaLoose opening (hiatus) of the muscle separating the chest and abdomen (diaphragm) allows displacement (hernia) of lower esophageal sphincter Displaced lower “gate” or lower esophageal sphincter (LES)
  • The LES or “gate” between the esophagus and stomach is displaced above the diaphragm into the chest cavity
 Main “gate” or lower esophageal sphincter unable to prevent backflow

  • With the LES above the diaphragm, the LES pressure is lower resulting in increased risk for backflow
Note: Not all patients with hiatal hernia have reflux laryngitis or GERD with esophagitis
Low LES PressureLow pressure in lower esophageal sphincter “Weak” lower esophageal sphincter

  • Decreased resting tone of LES
  • LES is unable to maintain closure of the gate between stomach and esophagus
 Pressure from stomach able to overcome weak “gate” or LES

  • Backflow of stomach fluids into esophagus occurs every time pressure in stomach becomes greater than pressure in LES
Abnormal Function of Upper Esophageal Sphincter (UES) Upper “gate” or upper esophageal sphincter not functioning properly

  • *research into cause of malfunction not done
 Stomach fluids in esophagus able to backflow beyond upper “gate” or UES into throat and voice box

  • Research into mechanism of backflow not done
Impaired Esophageal ClearanceAbnormal emptying or clearance of esophagus “Lazy” esophagus

  • Esophageal muscle contractions (peristalsis) move swallowed food/liquids into the stomach
  • When esophageal muscle contraction is weak or uncoordinated, moving the food into the stomach is delayed (delayed esophageal clearance)
 Delayed clearance worsens backflow

  • Any delay in esophageal clearance or emptying results in worsening of problems from backflow by:
    • keeping stomach fluids longer in the esophagus
    • increasing risk of backflow to throat and voice box
    • increasing risk of irritation and swelling
Gastric DysmotilityAbnormal contraction of stomach muscles “Lazy” stomach

  • When stomach muscles malfunction (lazy, low tone, weak, or uncoordinated), movement of stomach contents (including acids, enzymes) out of the stomach and into the small intestine is delayed (delayed emptying).
 Delayed emptying increases risk of backflow

  • Acids and enzymes that remain longer in the stomach due to delayed emptying have a higher risk of backflow
Key InformationKey Information
Upper Esophageal Sphincter (UES) Function
  • Most medical research has focused on the lower esophageal sphincter (LES). Currently, physicians are not certain how upper esophageal sphincter (UES) malfunctions occur.
  • Physicians believe that both the upper and lower esophageal sphincters (UES and LES) act very similarly.
  • Though more research must be completed, general risk factors of sphincter dysfunction apply to both the upper and lower esophageal sphincters (UES and LES).
2. Lifestyle Habits

There are a number of lifestyle behaviors that contribute to reflux. These habits must be changed or stopped to gain relief. More importantly, failure to change these habits can hinder the success of any treatment for backflow of stomach fluids into the throat and voice box (reflux laryngitis).

Lifestyle Habits That Increase Risk of Stomach Fluid Reflux
Particular Common Foods and Drinks
  • Fats, especially fried foods
  • Chocolates
  • Mints
  • Alcohol
  • Any beverage with caffeine (tea, coffee)
  • All soda/pop
  • Tobacco
  • In addition, certain foods and drinks can worsen mucosal irritation from backflow of stomach acids/enzymes:
    • Spicy foods
    • Citrus products
    • Tomato products
Going to Bed on a Full Stomach
  • Your stomach takes an average of three hours to empty after eating.
  • Lying down too soon increases risk of backflow (reflux).
Tight-Fitting Clothing
  • Wearing clothing that puts pressure on your stomach increases risk of backflow (reflux).
Overeating
  • Eating large quantities of food such that abdominal pressure is increased can increase risk of backflow (reflux).
Stress
  • High levels of stress, nervousness and/or anxiety has been shown to increase the secretion of stomach acid in some people.
Obesity
  • Being very overweight increases risk of backflow (reflux).
3. Medications

The medications listed below are associated with worsening reflux.

  • Progesterone
  • Theophylline
  • Anticholinergic agents
  • Beta-adrenergic agonists
  • Alpha-adrenergic antagonists
  • Diazepam
  • Meperidine
  • Nitrates
  • Calcium channel blockers
Drugs Which Can Worsen Lining (Mucosal) Irritation CausedbyBackflowofStomachAcids/Enzymes
  • Aspirin
  • Potassium tablets
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Tetracycline
  • Iron salts
Key InformationKey Information
Notes on Drugs That May Worsen Voice Disorders from Backflow of Stomach Fluids (Reflux Laryngitis)

Different People, Different Side Effects

Not everyone taking these medications will have a worsening of reflux laryngitis.

Need to Report Medications for Other Conditions

Patients with reflux laryngitis who are prescribed any of these types of medications should inform their physicians of their condition.

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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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