Diagnosis of Reflux Laryngitis
How is reflux laryngitis identified by physicians?
As with most diseases, a step-wise process of investigation is necessary to identify reflux laryngitis.
This investigation can be "tricky" and a bit of challenge since many of
the complaints and findings are also present in other voice disorders
from other causes.
Step 1: Initial Identification
Although physicians may use different investigative approaches,
initial identification is aimed at collecting three main clusters of
clues that suggest that voice disorder is caused by backflow of stomach
fluid into the voice box. (For more information, see Overview of Diagnosis, Treatment & Prevention.)
These clusters of clues are:
- Patient risk factors
- Patient observations
- Physical findings
1. Patient Risk Factor Clues
Physicians obtain these clues through a complete medical history
with focus on determining whether risk factors for backflow exist.
These factors include certain lifestyle habits – intake of certain food
and drinks, smoking – and use of certain medications. Levels of patient
voice usage in daily life or profession is also an important clue.
2. Patient Observation Clues
Through a complete medical history, physicians will review whether
patient observations or complaints are consistent with the patterns
observed in most cases of reflux laryngitis. If the review of patient
risk factors and patient complaints are consistent reflux laryngitis,
an alert level is raised which guides the next steps of investigation
of voice function and the voice box.
3. Physical Finding Clues
Examination of the throat and voice box for visible changes
consistent with reflux laryngitis can be done in the outpatient visit
by:
Changes Consistent with Reflux Laryngitis
(one or more may be present) |
- Swelling and redness in the back of the larynx; sometimes with prominent blood vessels (inflammation of larynx / laryngitis)
- Swelling of the vocal folds
- Swelling of the false vocal folds may also be present
- Thickening of the tissues between the vocal folds at the back of the larynx (pachyderma)
- Abnormal amount of mucus present in and around the voice box (larynx)
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Combined with suggestive patient risk factor(s) and observation
clues, the presence of the changes listed above present a convincing
case that the patient's voice disorder is most likely reflux laryngitis.
 Key Information
Complete Head and Neck Exam
As
part of the investigation, physicians perform a complete head/neck
examination to check for any swollen glands, growths or lesions that
might suggest that a condition other than reflux laryngitis is
affecting your voice.
Step 2: Confirmation of Initial Identification Through Treatment Trial
With first step findings suggestive of reflux laryngitis, a trial of
anti-reflux treatment is done – to begin treatment as well as to
confirm the suggestive identification of reflux laryngitis.
A favorable response to the anti-reflix treatment trial indicates
that the voice disorder is most likely caused by backflow of stomach
fluids to the voice box (reflux laryngitis).
A treatment trial (empiric therapy) involves a three to six month
period of treatment on anti-reflux medications and precautions. If the
voice disorder and/or accompanying complaints decrease or go away with
treatment, the identification of reflux laryngitis becomes clear.
There are two main components of empiric therapy.
- Altering dietary/lifestyle habits to reduce contributing risk factors
- Taking
prescription medications to reduce the production of acid within the
stomach to reduce the likelihood of acid backflow to the voice box area.
Key Information
Treatment Trial Response Usually Robust
Recent research suggests that this therapy will successfully treat 90 percent of patients with reflux laryngitis.
Some People Require Longer Treatment Trials
If
there is no improvement with the treatment trial, and investigation for
other causes does not identify any other cause, a case with clues
consistent with a voice disorder caused by backflow of stomach fluids
may need a more intense treatment trial with higher doses of medicine
or a longer observation period.
Component 1: Dietary/Lifestyle Modifications
Anti-reflux treatment involves elimination of dietary and lifestyle
habits known to contribute to backflow of stomach fluids (reflux), such
as:
- Avoid fatty foods, chocolate, mints, caffeinated beverages, carbonated drinks
- Avoid alcohol, especially in the evening and/or before bedtime
- Avoid overeating
- Avoid eating or drinking within three hours of going to bed
- Stop smoking
- Avoid tight-fitting clothing
- Lose weight if overweight
- Elevate the head of the bed 4-6 inches [*see below]
Key Information
Daytime Backflow Different From Nighttime Backflow
- Elevating the head of the bed has been shown to reduce the help that gravity gives to backflow of stomach fluid when lying down.
- New
research, however, suggests that in many patients with reflux
laryngitis with no heartburn, the backflow occurs in the upright
position – usually called "daytime" or "upright" refluxers.
- Therefore, bed elevation probably does not help majority of patients with reflux laryngitis.
Component 2: Prescription Medications
There are several medicines which inhibit the secretion of stomach
acid – a key culprit causing voice disorders due to reflux. Currently,
the group of medicines known as proton-pump inhibitors (PPIs) seems to provide the best results.
Because they reduce the secretion of stomach acid at the source,
these drugs are also typically prescribed for patients with
"heartburn-type" backflow (gastroesophageal reflux disorder or GERD).
Medicines that Reduce Stomach Acid
(Proton-Pump Inhibitors (PPIs))
| Brand Name |
Generic Name |
Prilosec |
omeprazole |
Prevacid |
lansoprazole |
Protonix |
pantoprazole |
Aciphex |
rabenazole |
 Red Flag
No Official Recommendation
The
Website does not recommend the use of any pharmaceutical product.
Patients must consult with physicians and pharmacists prior to use of
any medication.
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The twice-daily dose of stomach acid reducers (proton-pump
inhibitors or PPIs) that physicians generally recommend for treatment
trial for laryngopharyngeal reflux (LPR) is higher than that typically given to patients with heartburn- or dyspepsia-type gastroesophageal reflux disease (GERD).
As a treatment trial, drug dose starts at the high end in order to
assure a response to the medication in the shortest possible time,
rather than slowly increasing the dose over time with a wait-and-see
attitude until a response to the medicine is observed. Current
physician observations indicate that LPR usually needs higher doses of
anti-reflux medication than GERD.
A Response to Treatment Trial Indicates Reflux as Cause
If the treatment trial results in improvement of patient symptoms
and/or decrease of swelling and irritation of the voice box,
identification that the voice disorder is due to stomach fluid backflow
or becomes quite certain.
Long-Term Treatment Strategy Differs From Treatment Trial
With identification of the reflux laryngitis, a long-term management
plan – using the optimal (lowest effective) dose of medicine along with
continuing lifestyle changes – is then mapped out.
Non-Response to Treatment Trial May Be Due to Several Reasons
Some patients fail to improve with treatment trials. Failure of
treatment trials to improve voice function, patient complaints, and/or
voice box swelling and irritation could be explained by one or more of
the reasons listed below.
- PPIs not included in treatment trial: Clinical experience has found that proton pump inhibitors (PPIs) are
the ideal drugs to use for treatment trials. Although effective at
treating occasional heartburn, other medicines – over the-counter acid
suppressants like Maalox or H2 blockers like Zantac, Pepcid AC, or
Tagamet – have not been observed to be as effective in treating reflux
laryngitis.
- PPIs not taken at the right time: Even
when PPIs are used, the time patients take them and how long between
doses can affect the success of the PPI treatment trial. In particular,
because the effects of PPIs lasts only about 12 to 16 hours, they
should be taken twice daily to achieve maximum effectiveness.
Additionally, proton pump inhibitors should be taken 30 minutes to an
hour before a meal to reach the stomach before acid secretion.
- Dietary lifestyle changes not followed: Success of treatment trials relies on patient cooperation with the
anti-reflux precautions such as lifestyle changes as much as it does on
the anti-reflux medications. Oftentimes, patients who fail to cut down
on caffeine intake and smoking, for example, may continue to experience
voice problems and accompanying complaints (symptoms) despite receiving the right medical therapy.
Red Flag
Impact of "Less than Perfect" Treatment Trial
- Patients must cooperate fully with their physicians during a treatment trial.
- "Less
than perfect" treatment trials can lead to a delay in the
identification of backflow of stomach fluid (reflux) as the cause of
the voice disorder.
-
Backflow may not be the cause of the voice disorder or throat complaints: Finally, a non-response to the treatment trial could indicate that the
cause of the voice disorder is most likely not stomach fluid backflow.
Additional exams investigating other possible causes of voice
dysfunction are indicated.
Role of Confirmatory Tests in Non-Response to Treatment Trial
When there is no clear-cut response to the treatment trial the
patient's work-up that identified reflux laryngitis will be revisited
and confirmatory tests for acid backflow will be performed, such as a
test that directly measures the levels of acid in the throat and
esophagus throughout a routine patient day (ambulatory prolonged double probe pH monitoring).
This test can determine if acidic stomach fluids backflow, when
backflow occurs, how many times the backflow occurs during the day, and
with what activity the backflow occurs.
Key Information
The use of confirmatory tests is best determined by the physician as
each patient's case presents different specific problems and scenarios.
Tests to Confirm Identification of Reflux
Four tests are used to confirm the diagnosis of backflow of stomach
fluid (reflux) as the cause of voice disorder or throat complaints.
- 24-hour dual channel or double-probe pH monitoring
- Barium swallow esophagram
- Esophagoscopy
- Esophageal manometry
| Questions Addressed |
Tests |
Is there backflow? |
- 24-hour dual channel or double-probe pH test
- Barium swallow esophagram
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Is there injury to the lining of the food pipe? |
- Barium swallow esophagram
- Esophagoscopy
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Are there segments of the food pipe with abnormal muscle function that contributes to backflow? |
- Barium swallow esophagram
- Esophageal manometry
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Note: These tests each have their limitations.
1. Prolonged 2-site Acid Level Test (Prolonged Double-Probe pH Monitoring)
This test measures the acid level at the site where the sensors are
placed since stomach acidic fluids have much lower pH levels compared
to saliva, food, or drinks. This test can measure:
- Presence or absence of acid in the esophagus or in back of throat above food pipe opening (hypopharynx)
- How many times acid backflow happens throughout the test period (usually a whole day)
- How symptoms correlate with time of day and patient activity
A small tube is placed through the nose into the food pipe with two sensors (located at the tip) that measure acid levels (pH levels).
- Lower Sensor: A sensor is placed in the esophagus above the lower esophageal sphincter (LES) (#3 in diagram) to check for backflow of stomach acid into the food
pipe. (Note: This position is also where a probe would be placed to
determine whether "classic" gastroesophageal reflux is present.)
- Upper Sensor: Another sensor is placed near the upper esophageal sphincter (UES) (#2 in diagram). Since stomach acid backflow must reach this level to
cause reflux laryngitis, measurement of acid level at this site is
important. (Note: some physicians may place a sensor in the lower back
of the pharynx or hypopharynx (#1).)
- 24-hour record: To accurately measure levels of acid over a 24-hour period, information
from the sensors is sent to a small recording device clipped to the
patient's belt. The catheter running through the nose and down the
throat must be kept in place the entire 24-hour period.
- 24-hour patient journal: During this study, the
patient keeps a journal of complaints, time they were felt, as well as
time and type activities performed (lying down, eating, upright
positions).
- Routine OK: The probe placements do not
disturb breathing, swallowing, talking – so the patient may carry on a
routine day, and should do so for maximum benefit of the testing.
- Minor side effects: Although uncomfortable, prolonged double-probe pH monitoring is usually
well tolerated by patients. The most noticeable side effect can be some
loss of sleep due to throat and nasal irritation from the small
catheter.
Difficulties Interpreting Results from Double-Probe pH Monitoring – Test Has Limitations
Although double-probe pH monitoring is considered the confirmatory test for reflux laryngitis, the test has its limitations.
- Meaning of positive results clear: Detection of acid backflow to the level of the upper probe (above the upper esophageal sphincter or (UES)) indicates that the voice disorder is caused by backflow of stomach fluid with a high degree of certainty.
- Meaning of negative results less clear: However, non-detection of acid (negative results on pH monitoring) does
not eliminate the possibility that the voice disorder is caused by
reflux. The reasons for this cloudy view are:
- On-off backflow: Some patients can experience
laryngopharyngeal reflux on a sporadic or intermittent "on-off" basis.
Therefore, the relatively short 24-hour pH probe may fail to pick up
any acid backflow.
- An "off day": Some patients do
not live a "normal" day during the 24-hour pH probe test–for example,
not experiencing normal stress or eating the foods they typically do.
Restricting reflux-inducing activities during a 24-hour pH test may
result in a pseudo-negative (false-negative) result.
2. X-ray Imaging of Food Pipe During Swallowing (Barium Swallow Esophagram)
Current observations indicate that barium swallow esophagrams have not been very helpful in the identification of reflux laryngitis.
A barium swallow esophagram is an X-ray study that can demonstrate reflux, abnormal narrowings along the food pipe (esophageal strictures).
During an X-ray a patient swallows a contrast fluid, containing barium (barium swallow)
which appears densely white on X-ray. The food pipe walls appear gray,
and any air in the food pipe appears black. On X-rays during
swallowing, the barium-white cocktail stands out against the tissue and
air, giving an overview picture of the food pipe structure and function.
- By following what happens to the barium-white cocktail after it is swallowed, backflow can be confirmed.
- By checking the outline of the inner wall of the esophagus, the test can detect:
- narrowings along the esophagus (strictures)
- bulges along the food pipe caused by any mass – such as tumors
- By
checking where the stomach connects to the esophagus, the test can also
identify abnormal junction between the food pipe and stomach or (hiatal hernia)
This test allows direct inspection of the inner surface of the food pipe and stomach.
A viewing tube-scope is passed into the esophagus and stomach.
- Abnormalities affecting or on the surface of the esophagus
- Inflammation and irritation along the food pipe (erosive esophagitis)
- Narrowings (strictures)
- Abnormal surface features (Barrett's esophagus)
- Abnormal junction between the food pipe and stomach (hiatal hernia)
- Site for a biopsy: A small sample (biopsy) of the food pipe lining can be taken to investigate any abnormality at the cell level.
This test measures the pressures generated along the esophagus and at the upper esophageal sphincter (UES) and lower esophageal sphincter (LES).
A pressure-sensitive catheter is placed into the food pipe and
measures the pressures generated by both upper and lower sphincters of
the food pipe, as well as along the food pipe as food is moved into the
stomach through sequence of muscle contractions along the food pipe (peristalsis).
Manometry, which measures pressure generated along the esophagus, can be useful in identifying how backflow occurs.
- If the pressure at the UES is low (normal UES pressure is about +100 units), any acid that has
found its way into the food pipe can easily get into the throat and
voice box area (laryngopharyngeal reflux).
Note: Likewise, air in the throat can easily get into the esophagus.
- If the pressure at the LES is low (normal LES pressure is about +20 units), stomach acid can
easily backflow into the food pipe since the pressure in the stomach
(usually + 5 units) is 10 times higher than the pressure along he food
pipe (usually -5 units since it is in the chest cav
The information about esophageal pressure gathered in manometry has been found to be helpful in predicting treatment outcomes.
Key Information
- For barium swallow esophagram, esophagoscopy, and manometry, a gastroenterologist is usually involved.
- Depending on results, referral to a general surgeon may be advised for surgical treatment of GERD.
What are new trends/issues in identifying reflux laryngitis?
1. Stomach Enzyme ( Pepsin) Testing
- Pepsin is the stomach enzyme that (along with
stomach acid) helps digest foods in the stomach. Pepsin may cause
problems in patients with backflow (reflux).
- As
with a crime scene investigation, testing for stomach fluid backflow
looks for "fingerprints" – the fingerprints of reflux are stomach acid
and stomach enzymes. A test for measuring stomach acid exists, the pH
probe test. A test for measuring stomach enzymes (pepsin) is being
developed.
This test measures whether a key stomach enzyme (pepsin) is present
at the level of the upper and lower esophageal sphincters (UES and LES).
Possible Added Value of Test
If this new technique is perfected and proves valid, the
identification of voice disorders from backflow of stomach fluid
(reflux laryngitis) may be easier since only a saliva sample would be
necessary for testing.
B. Normal Levels for Acid Balance
During a 24-hour dual-probe pH test, the acidity of your throat and
larynx is measured along a pH scale of 1 to 14. Individuals with no (or
only minimal) reflux present would score around a 7 – meaning the pH
level of their LES and UES areas is balanced. Some disagreement exists
over the level at which a patient's pH would suggest backflow to the
voice box area (laryngopharyngeal reflux or LPR) is present.
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