Reflux Laryngitis Workup

Updated: Sep 25, 2017
  • Author: Bardia Amirlak, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Imaging Studies

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  • Barium esophagography
    • A demonstration of a structural abnormality on barium contrast esophagraphy may supply useful clues to the presence of GERD (eg, the presence of hiatal hernia or distal esophageal narrowing or stricture). The former finding may be a clue; the latter is evidence of damage secondary to GERD.
    • Although reflux of gastric barium into the esophagus during fluoroscopy is not specific for diagnosing reflux disease, spontaneous frequent barium reflux to the aortic arch correlates well, in the authors' experience, with patients who have extensive esophageal acid exposure revealed by pH monitoring. Overall barium esophagography has a sensitivity of only 33% in diagnosing reflux. [7]
    • Pharyngeal reflux was noted in 25% of patients with globus who were evaluated with esophagraphy. However, the diagnostic yield of this technique in regard to pharyngolaryngeal complications of reflux disease is unacceptably low. Furthermore, the technique does not reveal intermittent reflux or provide assessment of the status of the fine mucosa.
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Procedures

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  • Laryngoscopy
    • The laryngoscopic examination is the primary procedure for diagnosing laryngopharyngeal reflux (LPR). As stated above, several signs of posterior laryngeal irritation are usually seen, with edema and erythema being the most useful for diagnosis. Pseudosulcus vocalis is also thought to be somewhat specific for laryngopharyngeal reflux (LPR).
    • Several signs suggestive of laryngopharyngeal reflux (LPR) have been shown to be present in a high percentage of asymptomatic individuals, raising questions about the diagnostic specificity of the laryngoscopic examination. Furthermore, pseudosulcus vocalis was found in up to 37% of asymptomatic individuals. One criticism of the following study was the inclusion of subclinical reflux disease. [8]
    • Laryngeal examination with the more commonly used flexible laryngoscopy is more sensitive but less specific than rigid laryngoscopy in revealing laryngeal tissue irritation in suspected laryngopharyngeal reflux (LPR). [8]
  • Endoscopic examination of the esophagus
    • Demonstrating signs of esophageal inflammation at endoscopic examination does not incriminate GERD as the possible etiology in a supraesophageal disorder. However, it does help to build a possible scenario for the role of acid reflux and alerts the clinician to a possible explanation for the patient's problems. Unfortunately, the presence of esophagitis revealed during endoscopic examination is not a constant finding in patients with suspected supraesophageal complications of GERD and has rarely been documented in patients with reflux laryngitis. Prior reports have shown that less than 30% of patients with extraesophageal manifestations of reflux show endoscopic evidence of esophagitis.
    • Although the absence of physical damage to the esophagus in most patients with suspected supraesophageal complications of GERD appears at first glance to be a paradox, most investigators in this field have come to accept this fact based on the assumption that the magnitude of acid reflux that reaches the pharynx may be adequate for causing pharyngolaryngeal lesions but inadequate for inducing esophageal damage. This is possibly caused by differences in tolerance to acid exposure between esophageal and pharyngeal mucosa.
    • Often, patients with suspected supraesophageal complications of GERD have been treated with antacids at doses acceptable for healing esophagitis but inadequate for treating the suspected supraesophageal complications. In these situations, the macroscopic peptic lesion of the esophageal lining may have disappeared. Subtle distal esophageal scars or pitting above the gastroesophageal junction is a hallmark of gastroesophageal reflux. Obviously, the presence of Barrett columnar lining, with or without associated esophageal inflammation, indicates the presence of acid reflux disease.
  • Ambulatory 24-hour pharyngoesophageal pH monitoring
    • Ambulatory pharyngoesophageal pH monitoring was once considered the criterion standard for diagnosing reflux. However, this diagnostic modality is less sensitive in those with extraesophageal manifestations of GERD such as reflux laryngitis. Studies have shown that the distal proximal and hypopharyngeal pH monitoring are only 70%, 50%, and 40% sensitive in detecting reflux. [14] Furthermore, recent data suggest that abnormal findings of pH monitoring do not predict response to therapy.
    • In esophageal pH monitoring, a distal pH probe is located 5 cm above the lower esophageal sphincter (LES) by tradition, and the proximal pH probe is usually placed 20 cm above the LES, just below the upper esophageal sphincter. A third pH probe is placed in the pharynx to simultaneously record changes associated with acid escape into the pharynx. The pH readings are recorded for 24 hours while the patient indicates onset and end of meals, sleep, and symptoms events. Information provided by this test includes the frequency, duration, and site of reflux events.
    • The reference range of total acid exposure when the pH probe is positioned beneath the upper esophageal sphincter is approximately 0-1% over a 24-hour period. However, a significantly greater percentage of distal reflux episodes reached the proximal esophagus in a group of patients with laryngitis compared with control groups, and the number of pharyngeal reflux episodes and acid exposure time were also significantly greater in the laryngitis group.
    • Overall proximal esophageal and pharyngeal reflux events are short-duration events. Given the sensitivity of the supraesophageal regions to acid exposure, comparable acid exposure time to the esophagus may not be necessary for the development of lesions. Consequently, the number of reflux events may be a better diagnostic clue than acid exposure time.
    • The most meaningful computed values are those that indicate the total time of esophageal exposure to a pH level of less than 4.0 and a differentiation of total acid exposure in the upright versus the supine position. Laryngopharyngeal reflux (LPR) is confirmed if the total time of exposure is greater than 1% over 24 hours.
    • The reference range of values for the proximal probe varies between various centers and currently lacks standardization. Such lack of standardization remains a significant concern with regard to the diagnostic accuracy of this modality.
    • Intraluminal combined pH monitoring and impedance testing may be used to detect nonacid or gas causes of reflux in patients with atypical symptoms that have not responded to proton pump inhibitors. [16]
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Histologic Findings

Posterior laryngitis is characterized by hyperplasia of the squamous epithelium with a chronic inflammatory infiltrate in the submucosa. Disease progression leads to the epithelium becoming atrophic and ulcerated with deposits of fibrin, granulation tissue, and fibrosis in the submucosa.

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