Reflux Laryngitis Clinical Presentation

The most common symptoms used by ENT physicians to diagnose GERD-related laryngitis or laryngopharyngeal reflux (LPR) included globus, throat clearing, cough, and hoarseness; sore throat and dysphagia were considered less useful. ^[16]

The typical symptoms of laryngopharyngeal reflux (LPR), as listed above, can be caused by chronic irritation of the vocal cords due to overuse, smoking, alcohol, infection, and allergies and other environmental irritants.

Furthermore, history alone is often insufficient to elicit clues that suggest acid reflux as a cause of these symptoms. Most patients with suspected laryngeal complications of GERD may have no esophageal symptoms.

Most ENT physicians reported that they relied significantly more on symptoms, rather than on laryngoscopic signs, in diagnosing laryngopharyngeal reflux (LPR).

Belfasky et al (2002) published the self-administered 9-item reflux symptom index (RSI) to assist clinicians in documenting the presence and degree of laryngopharyngeal reflux (LPR) symptoms, both before and after treatment. ^[17] The reflux symptom index is depicted in the image below.

The RSI documents the presence and degree of nine laryngopharyngeal reflux (LPR) symptoms both before and after treatment; maximum score: 45.

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See the list below:

• Supraesophageal

  • Globus (This was the primary symptom in 4% of visits and was unrelated to the severity of reflux symptoms in a large cohort of more than 4000 general otolaryngology clinic patients. Globus was not associated with any specific psychometric parameters in 88 gastroenterology clinic patients.)

  • A history of persistent throat clearing

  • Chronic cough

  • Halitosis

  • Recurrent or persistent hoarseness, especially in the morning

• Esophageal symptoms associated with laryngopharyngeal reflux (LPR)

  • Regurgitation: A history of regurgitation, particularly at nighttime, associated with cough or with symptoms suggesting aspiration is the most significant clue to the possibility of supraesophageal complications of GERD. Unfortunately, this symptom complex occurs in a minority of patients.

  • Heartburn: The presence of heartburn symptoms can be a significant indication, but it should be defined appropriately in terms of the specific location and description of these symptoms. In a study of a large number of patients with suspected otolaryngologic complications of GERD, only 43% had classic symptoms of heartburn, regurgitation, or dysphagia. Heartburn was reported by 72% of 50 patients with idiopathic hoarseness and normal laryngoscopic findings who were refractory to speech therapy. Overall, GERD was demonstrable in 40% of patients by either esophagraphy or a 24-hour ambulatory pH study.

  • Other classic GERD-related history findings: These include patient symptoms related to the intake of tomato-based and/or spicy foods. These types of questions are important screening tools. Patients should also be asked about the frequency of using over-the-counter antacids. Often, patients deny having heartburn but then respond positively to questioning regarding problems with specific food types and/or frequent use of antacids.

Visualization of the larynx and vocal cords for signs of laryngopharyngeal reflux (LPR) requires a laryngoscopic examination. The most useful signs of GERD-related laryngitis or laryngopharyngeal reflux (LPR) were reported to be erythema, edema, presence of posterior commissure bar, and cobblestoning, while pseudosulcus vocalis; ulcers; and ventricular obliteration, nodules, polyps, and leukoplakia were reported to be less useful. ^[16]

Pseudosulcus vocalis (see below) was shown to be reported in as many as 90% of laryngopharyngeal reflux (LPR) cases. In a separate study, pseudosulcus was show to have a 70% sensitivity and 77% specificity in patients with laryngopharyngeal reflux (LPR). This further supports that the presence of pseudosulcus vocalis is suggestive of laryngopharyngeal reflux (LPR). ^[17]

Helicobacter pylori bacteria could enter and colonize the nasopharyngeal cavity by gastroesophageal reflux and may elicit otitis, sinusitis, pharyngitis, or laryngitis.

Belfasky et al (2002) developed an 8-item clinical severity scale to document laryngopharyngeal reflux (LPR) findings during fiberoptic laryngoscopy, which are quantified as the reflux finding score (RFS; as seen in the image below). The following 8 items are assessed to aid in the diagnosis of laryngopharyngeal reflux (LPR):

1. Pseudosulcus vocalis

2. Ventricular obliteration

3. Erythema/hyperemia

4. Vocal fold edema

5. Diffuse laryngeal edema

6. Posterior commissure hypertrophy

7. Granuloma/granulation

8. Thick endolaryngeal mucus

The image below describes the reflux finding score in more detail.

The reflux finding score (RFS) documents the presence and degree of eight laryngopharyngeal reflux (LPR) findings during fiberoptic laryngoscopy; maximum score: 26.

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• Posterior laryngitis: The classic laryngeal physical findings of laryngopharyngeal reflux (LPR) reported in the otolaryngology literature are edema and erythema of the posterior commissure.

• Pseudosulcus vocalis: The medial edge of the vocal cord appears to have a linear indentation due to diffuse infraglottic edema.

• Vocal cord granuloma

• Subglottic stenosis - Subglottic stenosis is a significant complication associated with chronic pharyngeal acid exposure.

• Contact ulcer of larynx

• Additional signs related to laryngopharyngeal reflux

  • Recurrent or refractory sinusitis: A recent study on the long-term outcome of adult patients who underwent functional endoscopic sinus surgery indicated that GERD predicted poor symptom relief.

  • Dental erosions: Patients have a smooth, glazed, dished-out appearance of the dentin on the lingual surfaces of the teeth. The deleterious effect of regurgitated gastric acid on the teeth has been suggested in reports dating back to the early 1970s. These include association of dental erosions with hiatal hernia, chronic vomiting, rumination, alcoholic gastritis, and regurgitation, as well as anorexia nervosa and bulimia. Dental erosions are defined as the loss of tooth substance by a chemical process that does not involve bacteria. Dental erosions are hard dished-out areas with a smooth and glistening base as opposed to the soft, dark, and jagged-edge lesions of dental caries. The prevalence of dental erosions in patients with GERD was reportedly 20-55%, in contrast to 2-18% in the general population.

  • Sandifer syndrome: The unique neck posture in Sandifer syndrome is a clue to acid reflux disease in infants or young children. This posture is an anatomic defense mechanism against repetitive acid reflux.

See the list below:

• Retrograde reflux of gastric acid or other contents (ie, pepsin) or both into the supraesophageal aerodigestive tract with mucosal injury from direct contact

• Damage to cilia from refluxate that leads to mucous stasis and chronic throat clearing and cough, with consequent symptoms of laryngeal inflammation and irritation

• Gastroesophageal reflux that leads to neurally mediated chronic cough and throat clearing with consequent symptoms with or without tissue injury

• A defect in carbonic anhydrase isoenzyme III

• Deglutitive pharyngolaryngeal abnormalities that lead to abnormal laryngeal exposure to contents transported in antegrade direction (possible role of defective airway protective defense mechanisms)