Clinical Consultation: Recognizing the laryngeal effects of reflux

What are the symptoms and signs of laryngopharyngeal reflux (LPR)?

LPR is the movement of gastric contents beyond the esophagus up to the laryngeal and pharyngeal area. In addition to pepsin and acid, gastric contents may contain bile acids and pancreatic enzymes; reflux can injure tissues not adapted to the presence of these noxious materials.

There is no clear consensus about the symptoms and clinical findings of LPR. This is partly because we do not know exactly how to define it. Patients who present to otolaryngologists with LPR do not usually complain of typical gastroesophageal reflux symptoms, such as heartburn and regurgitation.

A community survey of more than 1150 middle-aged women found that 6% had persistent globus (feeling of something in the throat) in the previous 3 months.¹ Throat clearing was experienced by 95% of 319 voice clinic attenders.² These symptoms, however, are nonspecific and may arise from additional and frequently unrelated causes: globus from psychological distress and adverse life events; hoarseness from voice misuse, voice overuse, and certain types of pulmonary inhalers; throat clearing from nasal discharge; and nonproductive cough from airway hyperresponsiveness.

Careful history taking and physical examination can aid the diagnosis. The patient's description of symptoms is particularly important. Damage by acid refluxate beyond the esophagus may produce pulmonary manifestations, such as pneumonia, chronic cough, asthma, and chest pain, and otorhinolaryngologic manifestations, such as globus pharyngeus, hoarseness, sore throat, posterior laryngitis, subglottic stenosis, otitis media, and sinusitis.

Reflux may be the cause in 23% to 60% of patients with globus symptoms.³ Other symptoms include dysphagia and chronic throat clearing.⁴ Upper respiratory tract symptoms are also thought to be frequent among persons with symptomatic reflux.⁵ Most of these studies are flawed, since the causal evidence linking throat symptoms to reflux comes from expert opinions and descriptive case series in which select patients have been subjected to different investigation schedules, each yielding different prevalence rates.

The examination findings in patients with LPR are equally nonspecific. The "Reflux Finding Score" includes inflammation at any or every laryngeal site--supraglottis, vocal cords, or subglottis.⁶ Such laryngitis may result from irritation by pulmonary or nasal secretions or inhaled pollutants, and mild variants are ubiquitous.

The laryngeal signs of reflux are said to be maximal in the posterior one third, because this is closest to the esophageal inlet. Of course, simple acid overflow may not be the only underlying mechanism; some persons may have referred sensations from the distal esophagus, leading to throat clearing and trauma to the arytenoid cartilages.

References:

REFERENCES

1. Deary IJ, Wilson JA, Kelly SW. Globus pharyngis, personality, and psychological distress in the general population.

Psychosomatics.

1995;36:570-577.
2. Wilson JA, Webb AL, Carding PN, et al. The Voice Symptom Scale (VoiSS) and the Voice Handicap Index (VHI): a comparison of structure and content.

Clin Otolaryngol Allied Sci.

2004;29:169-174.
3. Wilson JA, Pryde A, Piris J, et al. Pharyngoesophageal dysmotility in globus sensation.

Arch Otolaryngol Head Neck Surg.

1989;115:1086-1090.
4. Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery.

Otolaryngol Head Neck Surg.

2002; 127: 32-35.
5. Theodoropoulos DS, Ledford DK, Lockey RF, et al. Prevalence of upper respiratory symptoms in patients with symptomatic gastroesophageal reflux disease.

Am J Respir Crit Care Med.

2001;164:72-76.
6. Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS).

Laryngoscope.

2001;11:1313-1317.