Reflux Laryngitis Research Articles

PH Monitoring in Patients with Benign Voice Disorders

The aim of this study was to compare oesophageal pH-metry with laryngeal signs and symptoms in patients suspected of laryngeal reflux disease. A total of 60 patients with voice disorders, who were suspected of laryngeal reflux, were tested by single probe oesophageal pH monitoring. Thirty-two suffered from reflux laryngitis. A comparison of symptoms in patients with proven reflux with patients with no reflux was made. The symptoms were more frequent in the patients in the reflux group than in the non-reflux group. There was a significant difference between the groups with regard to dysphonia, sore throat, thick mucus and heartburn. Clinical signs appeared more frequently in the reflux group than in the non-reflux group. A significant difference was found between the groups regarding oedema of the vocal cords and hyperaemia and oedema of the posterior commisure, contact granuloma, posterior wall granulation and increased muscle tension. The patients in the reflux group were given medical treatment using omeprazole, and 76% logopedic voice training program. More than 50% of the laryngeal reflux patients were treated for more than 4 months before their voice problems had resolved. It is important to realize that signs of reflux laryngitis are not confined to the posterior commisure.

Reflux laryngitis: pathophysiology, diagnosis, and management.

Gastroesophageal reflux disease is felt to be associated with a variety of laryngeal conditions and symptoms of which "reflux laryngitis" is perhaps the most common. The most likely mechanism for laryngeal injury and symptoms is secondary to direct acid and pepsin contact, although studies concerning the cause and effect between gastroesophageal reflux disease and laryngeal disorders are conflicting. Likewise, the most effective method to diagnose such patients is unclear. Empiric treatment of patients with reflux laryngitis has been shown to be effective though none of the studies are controlled.

Laryngeal mucosal histology in laryngomalacia: the evidence for gastro-oesophageal reflux laryngitis

Objective: To describe the histopathological changes of the mucosa in laryngomalacia; look for any relationship with gastro-oesophageal reflux and to describe the histological changes of reflux laryngitis in laryngomalacia. Methods: We examined serial histological sections from nine cases of laryngomalacia, who had aryepiglottoplasty and compared the histopathological features with five cases of postintubation inflammatory laryngitis and five age-matched autopsy specimens of normal larynx. Results: Five of the cases of laryngomalacia had mild inflammation in the form of basal cell hyperplasia and chronic inflammation close to the basement membrane. Deeper subepithelium was oedematous. Two cases had moderate and two cases severe inflammation. The latter showed ulceration and a dense band of chronic inflammation in the immediate subepithelium with underlying oedema. Three of the cases had gastro-oesophageal reflux proven by barium swallow. Two of these showed intraepithelial eosinophils. Conclusions: A band of inflammation of variable intensity just beneath the epithelium with oedema deep to it is the most important histological feature of laryngomalacia. The presence of intraepithelial eosinophils appears to be a histological indication for reflux aetiology of the inflammation.

THROAT DISORDERS

Recent advances in our understanding of the pathophysiology of pharyngitis and reflux laryngitis have changed the treatments for these disorders. New diagnostic and treatment strategies for head and neck lymphadenopathy, snoring, and sleep apnea are discussed, as well as the changing indications for tonsillectomy and uvulopalatoplasty.

Secondary esophageal peristalsis is preserved in patients with posterior laryngitis

Secondary peristalsis not only helps volume clearance of refluxate from the esophagus, it may help prevent entry of refluxate into the pharynx and its complications such as reflux laryngitis. Previous studies have documented abnormalities of esophageal secondary peristalsis in patients with peptic esophagitis (Schoeman MN, Holloway RH; Gut 1995;36:499-504). However, secondary esophageal peristalsis in patients with supraesophageal complications of reflux disease has not been systematically studied. Aims: To study the frequency stimulation and parameters of esophageal secondary peristalsis in patients with posterior laryngitis (PL). Methods: We studied 14 PL (45_ 5 yrs) documented by stroboscopy and 11 healthy age matched controls (46 -+ 6 yrs). Controls and PLs underwent transnasal unsedated EGD and did not exhibit any esophageal abnormalities. Upper esophageal sphincter (UES) pressure was monitored by a sleeve assembly incorporating an injection port 7cm distal to the sleeve. Esophageal body and LES pressures were measured by a LES sleeve assembly incorporating recording sites at 0, 3, 6, 9 and 15cm proximal to the sleeve. Secondary peristalsis was induced by abrupt injection of incrementally increased volumes of air (5mL) into mid esophagus. Intraluminal pressures were recorded using a minimally compliant pneumohydraulic perfusion system (Arndorfer Specialties, Greendale, WI). Results: Secondary peristalsis could not be elicited by injection of any volume (up to 60mL) in 3 patients (ages 57, 63, and 72 yrs) and 2 normal controls (ages 69 and 76 yrs). These 5 had normal primary peristalsis. The threshold volume of air required to stimulate secondary peristalsis in PL (15_+2.5mL, SE) was similar to that of controls (11.6_+2.5mL, SE). Threshold volume did not induce belching. The parameters of secondary peristalsis were similar in both groups (Table). In both groups, parameters of secondary peristalsis were similar to primary peristalsis induced by swallowing 5mL of water. UES response to the injection of threshold volume that induced secondary peristalsis in PL was contraction in 58% of the trials, partial relaxation in 3% and no response in 39%. Findings were similar for the controls. Lower esophageal sphincter response to injection of threshold volume resulted in complete relaxation in both patients and controls.

Long-term, follow-up of patients with reflux laryngitis

Long-term, follow-up of patients with reflux laryngitis

Anti-reflux therapy improves symptoms in patients with reflux laryngitis

Anti-reflux therapy improves symptoms in patients with reflux laryngitis

Elevated upper esophageal sphincter (UES) pressure is associated with reflux laryngitis

Elevated upper esophageal sphincter (UES) pressure is associated with reflux laryngitis

Quantitative color analysis of laryngeal erythema in chronic posterior laryngitis.

The purpose of this study was to quantitatively analyze the degree of erythema visible in the larynges of normal subjects and of patients with symptoms of chronic posterior laryngitis. Video-documented examinations of laryngoscopy were digitized and then analyzed using computer image analysis software that allowed quantification of average color values, hue, saturation, and brightness from digitized color images. Documented laryngoscopic images from 7 normal subjects and 64 patients complaining of chronic laryngitis symptoms were examined, and additional patient examinations which were obtained and documented during treatment for reflux laryngitis were analyzed. Analysis was made of five different areas of each laryngeal image: the right and left vocal folds, the right and left vocal processes, and the posterior arytenoid mucosa. Data analysis showed that average color value ratings of redness for the patients with chronic laryngitis were significantly (p <0.0561) greater than the average values for normal subjects for the vocal folds. Color values for redness of the posterior laryngeal structures and vocal folds in the patients who were treated for reflux laryngitis were significantly (p <0.05) reduced over time and correlated with the clinical response to treatment. The data suggest that computer color analysis of documented video-laryngoscopic examinations can provide quantitative data on degree of erythema and may be useful as a quantitative means of diagnosis and documentation of treatment outcome for reflux laryngitis.

Laryngeal manifestations of gastroesophageal reflux before and after treatment with omeprazole.

Laryngeal manifestations of gastroesophageal reflux disease are thought to be prevalent in our society. In general, diagnosis has been primarily based on symptoms. Historically, additional testing has included laryngoscopy, barium swallow, manometry, and single and double probe pH monitoring. We assessed 96 patients who had symptoms suggestive of reflux laryngitis. We administered surveys grading their symptoms. All patients had standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then received a uniform regimen of dietary restrictions and omeprazole (a proton pump inhibitor) for 12 weeks, after which they were retested. Using the new laryngoscopic grading system, we found that this regimen produced statistically significant improvement in all symptoms except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measurements of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement. We conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if the patient is hoarse, acoustic analysis are useful techniques to aid diagnosis and monitor therapy. Antireflux therapy with omeprazole is effective, and improvement can be objectively shown with the techniques described.

Role of Refluxed Acid in Pathogenesis of Laryngeal Disorders

The neuroanatomic proximity of the larynx to the hypopharynx and proximal esophagus make it particularly vulnerable to diseases that occur in those 2 areas. This is particularly true of gastroesophageal reflux disease (GERD). There is increasing awareness of this relationship, and dysphonias from gastroesophageal reflux (GER) are far more common than previously realized. The symptoms and findings of reflux laryngitis, vocal nodules, Reinke’s edema, contact ulcer and granuloma, laryngeal stenosis, and paroxysmal laryngospasm are presented, and diagnostic protocols for each disorder are suggested. The treatment varies with the severity of each problem. Conservative lifestyles and dietary control are helpful, but long-term medical therapy with H 2, H 1, and prokinetic drugs are usually needed. Surgical therapy may be indicated for such life-threatening problems as laryngeal stenosis and paroxysmal laryngospasm. The need for physician and patient awareness, research, and improved and less expensive therapy are discussed.

Pilot study of the oral omeprazole test for reflux laryngitis

BACKGROUND: Gastroesophageal reflux disease occasionally presents with laryngeal symptoms. Such patients are often referred for a gastroenterology evaluation. This study was designed to determine whether an empiric trial of high-dose omeprazole therapy could reliably identify patients with reflux laryngitis and thus obviate the need for a gastroenterology workup. METHODS: Patients were evaluated with a history, physical examination, esophageal manometry, upper endoscopy, and 24-hour pH-metry for determination of the presence or absence of underlying gastroesophageal reflux disease and then received an empiric trial of oral omeprazole therapy (20 mg twice daily for 1 month). A positive omeprazole test result was defined as resolution of all laryngeal symptoms on completion of the empiric trial of therapy. RESULTS: Two patients were classified as having no reflux, and eight were classified as having reflux. Omeprazole test results were positive in six patients. Five of six had reflux, but one patient had no evidence for reflux. Omeprazole test results were negative in four patients. Three of four had reflux, and one did not. Despite the absence of antisecretory therapy, laryngeal symptoms did not recur in either patient without reflux during follow-up. Laryngeal symptoms were managed in two of the three patients with reflux who had negative omeprazole test results and who were using inhalers in combination with histamine H 2 receptor antagonist therapy for their reflux disease. One patient with reflux who had a negative omeprazole test result responded to higher doses of omeprazole, and the five patients with reflux who had positive omeprazole test results all responded to continuation of omeprazole. CONCLUSIONS: The omeprazole test may be useful in confirming the suspicion of reflux laryngitis in patients suspected of having this disease after an otolaryngology evaluation. However, there is a potential for false-positive and false-negative test results. A gastroenterology evaluation may aid in the identification of false-positive test results by documenting the absence of reflux in certain responders. (Otolaryngol Head Neck Surg 1997;116:41-6.)

Pilot Study of the Oral Omeprazole Test for Reflux Laryngitis

BACKGROUND: Gastroesophageal reflux disease occasionally presents with laryngeal symptoms. Such patients are often referred for a gastroenterology evaluation. This study was designed to determine whether an empiric trial of high‐dose omeprazole therapy could reliably identify patients with reflux laryngitis and thus obviate the need for a gastroenterology workup.METHODS: Patients were evaluated with a history, physical examination, esophageal manometry, upper endoscopy, and 24‐hour pH‐metry for determination of the presence or absence of underlying gastroesophageal reflux disease and then received an empiric trial of oral omeprazole therapy (20 mg twice daily for 1 month). A positive omeprazole test result was defined as resolution of all laryngeal symptoms on completion of the empiric trial of therapy.RESULTS: Two patients were classified as having no reflux, and eight were classified as having reflux. Omeprazole test results were positive in six patients. Five of six had reflux, but one patient had no evidence for reflux. Omeprazole test results were negative in four patients. Three of four had reflux, and one did not. Despite the absence of antisecretory therapy, laryngeal symptoms did not recur in either patient without reflux during follow‐up. Laryngeal symptoms were managed in two of the three patients with reflux who had negative omeprazole test results and who were using inhalers in combination with histamine H2 receptor antagonist therapy for their reflux disease. One patient with reflux who had a negative omeprazole test result responded to higher doses of omeprazole, and the five patients with reflux who had positive omeprazole test results all responded to continuation of omeprazole.CONCLUSIONS: The omeprazole test may be useful in confirming the suspicion of reflux laryngitis in patients suspected of having this disease after an otolaryngology evaluation. However, there is a potential for false‐positive and false‐negative test results. A gastroenterology evaluation may aid in the identification of false‐positive test results by documenting the absence of reflux in certain responders.

The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD): A Clinical Investigation of 225 Patients Using Ambulatory 24‐Hour pH Monitoring and an Experimental Investigation of the Role of Acid and Pepsin in the Development of Laryngeal Injury

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Proximal esophageal pH-metry in patients with ‘reflux laryngitis’

Fiberoptic laryngoscopic examinations were performed on 40 patients with gastroesophageal reflux disease, 25 of whom had persistent laryngeal symptoms (dysphonia, cough, globus sensation, frequent throat clearing, or sore throat) and 15 without laryngeal symptoms who served as disease controls. Ten patients with laryngeal symptoms but none of the controls had laryngoscopic findings consistent with reflux laryngitis. Dual-site ambulatory pH recordings were obtained with the pH electrodes spaced 15 cm apart and with the proximal sensor positioned just distal to the upper esophageal sphincter. Patients in the three groups (disease controls: group 1; patients with symptoms but without laryngoscopic findings: group 2; and patients with both laryngeal symptoms and findings: group 3) were comparable in terms of age, smoking habit, the presence of esophagitis, and distal esophageal acid exposure. Proximal esophageal acid exposure was, however, significantly increased in groups 2 and 3, and nocturnal proximal esophageal acidification occurred in over half of these patients but in none of the group 1 patients. We conclude that the subset of reflux patients who experience laryngeal symptoms show significantly more proximal esophageal acid exposure (especially nocturnally) and often have laryngoscopic findings of posterior laryngitis not observed in control reflux patients.

Videolaryngoscopy after endotracheal intubation: Part II. A critical care perspective of lesions affecting voice

<h2>Summary</h2> In a Critical Care setting, videolaryngoscopic techniques document nearly universal vocal fold lesions in patients after endotracheal intubation. A miniaturized, moderately priced, transportable system, utilizing rigid and flexible fiberoptic laryngoscopes, coupled with a compact 8-mm camcorder, is featured. Laryngeal damage begins within 1 h of placement of an endotracheal tube. Posterior erosions at the level of the vocal processes appear within 24 h, characteristic "key-hole" lesions in the posterior glottis appear within 48 h, granulations are seen within 72 h, and granulomatous polyps occur by 144 h after endotracheal intubation. Nasogastric intubation promotes gastroesophageal reflux laryngitis. Acute dysphonia, permanent voice problems, and airway obstruction occur with greater frequency than previously suspected. Early tracheostomy, within 6 days of endotracheal intubation, appears to prevent permanent vocal fold damage and provides comfortable, effective airways toilette

Reflux laryngitis and its sequelae: The diagnostic role of ambulatory 24-hour pH monitoring

Summary Ambulatory 24-h intraesophageal pH monitoring was performed in 32 patients with hoarseness, documented laryngeal pathologic findings or lesions, globus, and/or chronic cough. The laryngeal lesions included granulomas, stenoses, and carcinomas. Twenty-two (68.8%) of the patients had no symptoms specific for reflux. One-half of the patients underwent pH monitoring with a double probe, one probe being placed in the distal esophagus and the second being placed in the hypopharynx just behind the laryngeal inlet. Twenty-four (75%) of the patients had abnormal studies, i.e., significant reflux. Of those, 17 (70.8%) had upright reflux, 13 (54.2%) had supine nocturnal reflux, and 10 (41.7%) had both types. Seven of the 16 patients undergoing double-probe-type monitoring had reflux into the pharynx (43.8%). These data suggest that occult gastroesophageal reflux may be involved in the pathogenesis of many conditions commonly encountered in otolaryngologic practice.

Professional singers: The science and art of clinical care

Voice complaints of serious singers are usually not imaginary, and rational diagnosis and treatment can be achieved through systematic inquiry and analysis based on anatomy, physiology, psychology and psychoacoustics of voice production. Good vocal habits should be encouraged from childhood. Measures to aid in voice conservation include avoiding singing in noisy, dry, dusty, and smoky environments and learning to control the voice in circumstances in which auditory monitoring of the intensity of vocalization cannot be done effectively. The dangers of cheerleading, choir-conducting, and other forms of abuse of the speaking voice for the serious singer are emphasized. Young singers should be enthusiastically encouraged to sing music suitable for their ages and voices, and should be discouraged from taking on difficult roles prematurely. Smoking must be avoided. Thorough training and regular practice are essential for maintenance of a healthy singing voice. Close cooperation among laryngologist, speech pathologist and voice teacher is emphasized. Treatments for reflux laryngitis, anxiety, muscle spasm, voice abuse, vocal nodules, and infectious laryngitis in the professional singer are detailed.