Reflux laryngitis (RL) is a condition involving the irritation and inflammation of the voice box, or larynx, caused by the backflow of stomach contents. This inflammatory response occurs when gastric material travels up the esophagus and reaches the delicate tissues of the throat and larynx. This disorder, known as Laryngopharyngeal Reflux (LPR), is often described as “silent reflux” because, unlike classic heartburn, it frequently presents with symptoms located solely in the throat and voice box area.
The Mechanism of Laryngopharyngeal Reflux
The backflow of stomach contents (acid and digestive enzymes) is typically prevented by two muscular valves, or sphincters, along the esophagus. Gastroesophageal Reflux Disease (GERD) happens when the lower esophageal sphincter (LES) fails, allowing contents to splash back into the lower esophagus, causing the familiar chest pain of heartburn. LPR, in contrast, involves a failure of both the LES and the upper esophageal sphincter (UES). This failure permits the gastric material to travel all the way up to the pharynx and larynx.
The laryngeal tissue is significantly more vulnerable to damage than the lining of the esophagus, which possesses more robust defense mechanisms. Even a small number of reflux episodes can cause substantial irritation to the larynx. A primary culprit in this damage is the digestive enzyme pepsin, which is produced in the stomach.
Pepsin attaches to the laryngeal tissue during a reflux event and can remain dormant within the cells. Subsequent exposure to any acidic substance, even a weakly acidic one, can reactivate the enzyme, causing further damage to the cell’s protective proteins. This process of damage can occur even when the refluxate is not highly acidic. The damage is a result of both the direct chemical insult from the gastric contents and a secondary inflammatory reaction.
Identifying Non-Classic Symptoms
The symptoms associated with reflux laryngitis are often different from the classic burning sensation associated with GERD, making self-diagnosis challenging. One of the most common complaints is chronic throat clearing, an attempt to dislodge excess mucus or clear the persistent sensation of a foreign object. This frequent clearing can itself contribute to further irritation and inflammation of the vocal cords.
Another defining symptom is persistent hoarseness, medically termed dysphonia, which occurs due to the swelling of the vocal cords. This hoarseness is often worse in the morning because reflux events tend to be more frequent when a person is lying flat during sleep. Individuals may also develop a sensation of a lump in the throat, known as globus pharyngeus, even though no physical mass is present. This feeling results from muscle tension and inflammation in the throat area caused by the reflux.
A chronic, dry cough that does not seem related to a cold or allergy is also frequently linked to RL. This cough can be triggered by the direct irritation of the laryngeal tissue or by a vagally mediated reflex originating from the lower esophagus. Excessive mucus or phlegm in the throat is a separate, yet related, symptom. The body attempts to produce more protective secretions to coat the irritated tissues.
Medical Confirmation and Diagnostic Tests
A diagnosis of reflux laryngitis is typically made by a physician, often an otolaryngologist, based on a detailed patient history and a physical examination. The physician will assess the patient’s symptoms using validated tools like the Reflux Symptom Index (RSI), which scores the severity of common LPR complaints. The primary tool for physical examination is a laryngoscopy, which involves inserting a flexible or rigid scope through the nose or mouth to view the larynx.
During the laryngoscopy, the doctor looks for specific physical changes, or “findings,” that suggest reflux damage, which are graded using the Reflux Finding Score (RFS). These findings include redness (erythema) and swelling (edema) of the vocal cords and surrounding structures, particularly in the posterior larynx. Another common sign is pseudosulcus, a subtle swelling or thickening just below the vocal cords.
Because these visual findings can sometimes be present in healthy individuals or be caused by other conditions like allergies or vocal abuse, diagnosis is not always straightforward. Advanced diagnostic tests may be used to confirm the presence of refluxate. These include a 24-hour pH monitoring test (sometimes with two probes to measure acid levels in the esophagus and pharynx) or oropharyngeal pH monitoring. In some cases, a physician may initiate an empirical treatment trial, prescribing anti-reflux medication to see if the symptoms improve.
Comprehensive Treatment and Lifestyle Adjustments
Management of reflux laryngitis requires a multi-pronged approach that combines significant lifestyle adjustments with medical intervention. Since reflux is often triggered by what a person eats and when they eat it, dietary changes are foundational to treatment. Avoiding common reflux triggers is recommended, including high-fat foods, chocolate, caffeine, alcohol, citrus fruits, and tomatoes.
Positional and behavioral changes are equally important for reducing the frequency of reflux episodes. Patients are advised to elevate the head of their bed by six to eight inches using blocks or a wedge, allowing gravity to assist in keeping stomach contents down. Timing meals correctly is also helpful, specifically avoiding food intake for at least three hours before lying down to sleep.
Medical treatment usually involves acid-suppressing medications, most commonly Proton Pump Inhibitors (PPIs) and H2 blockers. PPIs reduce the amount of acid the stomach produces; H2 blockers suppress acid production by blocking histamine receptors. Treatment for RL often requires a longer duration of medication, typically two to six months, and sometimes higher doses than those used for standard GERD. This prolonged therapy is necessary to allow the highly sensitive laryngeal tissues adequate time to heal from the chemical damage caused by the reflux.