Voiceproblem.org: Reflux Laryngitis: Understanding the Disorder

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).

Reflux Laryngitis

Normal Larynx – Open Position

Irritation from reflux of stomach fluids into the voice box causes: redness and swelling (indicated with white arrows) in vocal folds (vf) and false vocal folds (f vf) as well as pachyderma (indicated with yellow arrow) or thickening of tissue in between the focal folds.

Note: This patient also has a granuloma (gr), which can also be caused by laryngopharyngeal reflux. (For more information, see Vocal Fold Granuloma.)

In contrast, a normal voice box does not exhibit redness or swelling or any thickening of the surface cover.

(click photos for larger images)

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).

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

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:

Diagram of Stomach Acid Backflow Path Causing Voice Disorders

Laryngopharyngeal reflux (LPR) results from backflow of stomach fluids from the stomach () into the esophagus (lower ), then up the esophagus (), through the upper esophageal sphincter and into the throat and voice box area (laryngopharynx) (upper ). Stomach fluids are irritating to the surface lining of the esophagus, nose and throat area (naso-oropharynx ) and voice box area. This results in swelling of exposed areas. Vocal folds (), especially the back part, can get irritated and swollen when exposed to stomach fluid backflow.

(click for larger image)

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

Cause	What's Wrong	How Blackflow Results
Hiatal Hernia Loose 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 Pressure Low 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 Clearance Abnormal 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 Dysmotility Abnormal 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 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).

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).

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).

Key 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.