|
Understanding Reflux Laryngitis
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).
Comparison of Reflux Laryngitis Versus Normal Larynx
| 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).
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
|
|
| 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:
- Too much acid produced in the stomach, or
- Abnormal function of the throat + food pipe (pharyngo-esophageal tract), or
- Combination of both 1 and 2
 Key Information
When there is a malfunction along the esophagus, even normal amounts of stomach acid can backflow into the esophagus.
Diagram of Stomach Acid Backflow Path Causing Voice Disorders
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).
- abnormal function or structure of food pipe (esophagus) and/or stomach
- some lifestyle habits
- 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 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).
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).
|
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 Caused by Backflow of Stomach Acids/Enzymes
- Aspirin
- Potassium tablets
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Tetracycline
- Iron salts
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.
|
) into the esophagus (lower 
), then up the esophagus (
), through the upper esophageal sphincter and into the throat and voice box area (laryngopharynx) (upper 
) 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.
