See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/12598350

Diagnosis and management of chronic laryngitis associated with reflux

Article  in  The American Journal of Medicine · April 2000

DOI: 10.1016/S0002-9343(99)00349-6 · Source: PubMed

CITATIONS READS

62 131

2 authors, including:

Jack J Jiang
University of Wisconsin–Madison
279 PUBLICATIONS   4,814 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Aerodynamics assessment of phonation View project

Acoustic analysis View project

All content following this page was uploaded by Jack J Jiang on 23 October 2017.

The user has requested enhancement of the downloaded file.

Diagnosis and Management of Chronic Laryngitis
Associated with Reflux
David G. Hanson, MD, Jack J. Jiang, MD, PhD
Chronic laryngitis symptoms are commonly seen in
otherwise healthy people. This article reviews recent
progress in our understanding and effective treat-
ment of chronic laryngitis. Clinical experience and
prospective treatment and outcome studies have
demonstrated objective evidence of the efficacy of
treating patients with chronic laryngitis symptoms
with nocturnal antireflux precautions and acid-sup-
pressing medications. The role of pH testing and
most common errors in treatment are reviewed. Am
J Med. 2000;108(4A):112S–119S. © 2000 by Excerpta
Medica, Inc.
From the Department of Otolaryngology, Head and Neck Surgery,
Northwestern University Medical School, Chicago, Illinois, USA.
Requests for reprints should be addressed to David G. Hanson, MD,
Department of Otolaryngology, Head and Neck Surgery, Northwestern
University Medical School, 303 East Chicago Avenue, Searle 12-580,
Chicago, Illinois 60610.
112S © 2000 by Excerpta Medica, Inc.
All rights reserved.
amel et al1 reported treatment of chronic poste-
K
rior laryngitis with omeprazole in 1992, address-
ing the hypothesis that if chronic laryngitis were
related to reflux, it should substantially improve when
acid secretion was profoundly suppressed. That study
demonstrated that treatment with a proton pump inhib-
itor, along with lifestyle modifications, alleviates most
chronic laryngitis symptoms, as well as the visible evi-
dence of chronic inflammation.2 A prospective case study
subsequently examined the outcomes of a progression of
treatment—from antireflux precautions, to H2 blockers,
to proton pump inhibitors in progressively higher dos-
age—for chronic laryngitis symptoms. The study also as-
sessed degree of laryngeal inflammation and recurrence
rate in relation to the progressively more intense treat-
ment modalities.3 That study demonstrated that there is a
range of inflammation associated with chronic laryngitis
that responds to antireflux treatment and demonstrated
that for 50% of patients with chronic laryngitis symptom,
antireflux precautions alone are sufficient for resolution
of symptoms.
Our experience since that report has been substantially
greater, has not significantly changed our conclusions re-
ported in 1996, but has added some new insights, which
we will discuss in this overview. Our practices are situated
in an urban environment with a population of business
professionals who tend to work late, who usually eat later
in the evening, and who admit to notable stress. It seems
that this group of patients has a relatively high incidence
of chronic laryngitis symptoms.
LARYNGITIS
Symptoms of discomfort of the throat, change in voice,
cough, dysphagia, and secretion stasis can occur with any
cause of inflammation. Symptoms can be classified as
acute or chronic, and can occur from infection, from ex-
posure to toxic irritants, or from other factors that pro-
voke an inflammatory reaction. Patients who complain of
long-term chronic symptoms that relate to the throat
may have varying degrees of symptom intensity, dura-
tion, and visible inflammation of the structures in the
hypopharynx and pharynx. The signs of inflammation on
examination of the larynx and pharynx can vary from
subtle erythema of the posterior larynx to severe mucosal
changes with ulceration and formation of granulation tis-
sue. Historically, ulcerative changes with granulation for-
0002-9343/00/$20.00
PII S0002-9343(99)00349-6
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang

mation were the first manifestations of chronic laryngitis

to be recognized.

ULCERATION OF LARYNGEAL
EPITHELIUM
The most severe manifestation of chronic laryngeal irri-
tation is actual ulceration of the laryngeal epithelium with
granulation. Jackson4 first called attention to contact ul-
cers of the posterior larynx and attributed the injury to
mechanical trauma. Other authors also supported a pri-
marily traumatic etiology.5–10 Cherry and Margulies11
first identified acidification of the larynx as a probable
factor in contact ulcers, and Delahunty and Cherry12
demonstrated that ulcers could be produced experimen-
tally by application of gastric acid. Treatments for contact
ulcers and granulomas have included surgical excision,
“vocal reeducation,” and other forms of speech therapy,
but these therapies have had disappointing variations in
success.13–15 Ward et al16 in 1979 concluded after study of
28 patients with contact granulomas “that habitual throat
clearing . . . and most important, acid regurgitation sec-
ondary to hiatal hernia are the causal factors of contact
ulcers.” There developed a growing appreciation that gas-
troesophageal reflux could be associated with extrae-
sophageal disease.17 Jacob et al in 199118 reported that
chronic laryngitis symptoms and posterior laryngitis
without ulceration could be associated with evidence of
gastropharyngeal reflux documented by pH monitoring.
Koufman19 also reported in 1991 a large series of patients
with laryngeal inflammatory diseases that were associated
with pH monitoring evidence of reflux. He supplemented
the clinical experience with experimental evidence that
supports the concept that application of gastric juices
could cause laryngeal mucosal injury. It was with the ad-
vent of medications that profoundly suppress gastric acid
secretion that argument for a relationship between gastric
acid reflux and chronic laryngeal inflammation really
started to become convincing. Kamel et al2 reported the
elimination of symptoms and signs of chronic posterior
laryngitis during treatment with omeprazole in a pro-
spective study in 1994. Figure 1 reproduces data for a
symptom index that patients recorded before, during,
and after cessation of treatment with omeprazole.
Whereas contact ulcers that occur over the cartilage of
the vocal processes are painful and problematic because
they can form large granulomas, circumferential ulcer-
ative damage to the epithelium of the posterior and sub-
glottic larynx causes more severe damage to function. Lit-
tle et al20 reported in 1985 a case of acquired subglottal
stenosis associated with reflux and described an animal
experiment in which application of gastric juices to the
subglottal larynx produced stenosis. As discussed else-
where in this issue, reflux-related stenosis of the larynx
and subglottic area is now a well-recognized problem in
neonates. Acquired stenosis of the larynx in adults who
Figure 1. Kamel et al reported that laryngeal symptoms doc-
umented daily by patients with chronic laryngitis changed sig-
nificantly after 6 to 9 weeks of treatment with omeprazole with
antireflux precautions. Symptoms recurred to a smaller degree
after omeprazole was discontinued. (Adapted from Am J Med.2)
have no history of long-term intubation is less common
but does occur. We have been involved in the care of five
adults who developed subglottic or glottic stenosis in as-
sociation with reflux. Subglottal stenosis and posterior
glottic stenosis are the most difficult to treat of the com-
plications of supraesophageal reflux and, fortunately, are
rare.
Other manifestations of chronic supraesophageal re-
flux, some of which can be life-threatening, also have
been subjects of clinical interest in the past decade and are
discussed in other papers from this conference. The most
common forms of laryngitis that can be associated with
reflux can be present for months to years before the indi-
vidual seeks and finds effective treatment. The following
is a summary overview of our clinical experience over the
last decade with diagnosis and treatment of the more
common symptoms of chronic irritative laryngitis.
POSTNASAL DRIP AND SENSATION OF
SECRETIONS
Symptoms of chronic irritative laryngitis occur from in-
jury to the normal function of the epithelium and adja-
cent structures of the pharynx and larynx. The earliest
symptoms to manifest with mild injury (and the last to
resolve with treatment) are associated mainly with dam-
age to the ciliary clearance function of the ciliated respi-
ratory epithelium. Patients most often describe these
symptoms as postnasal drip. However, the symptoms of
constant secretions in the back of the throat usually are

March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A) 113S
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang
Figure 2. The posterior larynx and interarytenoid area of the posterior glottic wall lies directly above and adjacent to the opening
of the esophagus posteriorly. This area is red in patients with chronic laryngitis.
the result of ciliary dysfunction in the posterior larynx
and pharynx rather than the nose. In the normally func-
tioning larynx, the outflow of mucous secretion from
the entire tracheal bronchial tree is directed by normal
ciliary beating cephalad toward and through the poste-
rior wall of the glottic aperture. The epithelium of the
vocal folds is a stratified squamous epithelium that is
more suited to resist the vibratory effects of phonation,
and although better suited to mechanical vibration, the
vocal fold epithelium provides a barrier to effective mu-
cous transport. Therefore, the posterior larynx is partic-
ularly important in mucous flow out of the tracheobron-
chial tree. When the ciliary function of the posterior la-
ryngeal mucosa is damaged by chemical irritation, or by
mechanical trauma, mucous stasis at the outflow of the
trachea becomes an annoying and prominent symptom.
COUGH AND THROAT CLEARING
The neural organization of laryngeal sensory and motor
systems has an important life-saving role, represented by
cross brainstem reflexes, which protect the airway from
aspiration. Clumping of mucous in the posterior larynx
and strings of mucous across the vocal folds can provoke
cough and laryngospasm at an unconscious reflex level as
well as provoking throat clearing at a conscious level.
Cough and laryngospasm appear to be more likely if the
sensitivity of laryngeal sensory endings is upregulated by
local inflammation. Other articles in this supplement dis-
cuss important aspects of that sensory system.
Throat clearing behavior is directed at trying to remove
secretions from the larynx but also is traumatic to the
epithelium of the vocal process and the posterior glottic
114S March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威
wall. Physiologically, throat clearing is accomplished by
firm closure of the vocal folds and forcing of airflow
through the posterior aperture of the glottis behind the
vocal folds. This is the area of ciliated respiratory epithe-
lium where mucous is transported through the larynx.
However, repeated mechanical trauma associated with
frequent throat clearing appears, in itself, to cause dam-
age to the delicate ciliary function of the posterior larynx.
In patients who chronically clear their throats, this area of
mucosa can appear rough, thickened, and callous-like.
An unusual amount of throat clearing is commonly ob-
served in patients with posterior laryngitis. Often, this is a
habituated behavior that is done unconsciously. The la-
ryngeal structures are important articulators in speech,
and the neural control of these structures appears to be
susceptible to relatively rapid habituation of automatic
unconscious response to stimuli. This may explain why
throat clearing and cough so easily become habits.
Anatomically, this area of the larynx is directly in front
of the opening of the esophagus into the pharynx. Figure
2 shows a picture of how the larynx would appear in a
patient lying on the back and breathing quietly. It be-
comes apparent that very small amounts of refluxed ma-
terial, if only in the form of a bubble of liquid film, could
easily get to the posterior laryngeal wall. This is the area in
which we first see signs of inflammation in patients with
chronic laryngitis symptoms.
SORE THROAT
The second most common manifestation of irritative lar-
yngitis is sensation of discomfort that may be described as
a dry, scratchy feeling, tightness in the throat, or sore
Volume 108 (4A)
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang

throat. If there is ulceration of the epithelium, most com-

monly over the vocal processes and usually associated
with chronic throat clearing, there may be localized pain
that may radiate to the ear. Patients who have recurrent
severe sore throats without other typical symptoms of an
upper respiratory infection syndrome are likely to have
irritative laryngitis as an underlying cause. The complaint
of soreness, irritation, or pain usually is associated with
visible signs of inflammation on laryngeal examination.
The cardinal manifestation of this inflammation is ery-
thema and visible increase in surface vascularity. Hanson
et al21 recently reported a study of a large group of pa-
tients with chronic laryngitis symptoms in which video-
documented images of the laryngeal examination were
digitized and subjected to digital color analysis. Color
value for red, green, and blue was determined in multiple
5 ⫻ 5 pixel areas and averaged for measurement of the
degree of redness of the epithelium over the posterior
larynx and the epithelium on the vocal folds. The values
for red color were related as a percent to the overall values
Figure 3. Hanson et al reported that between patients with
for red ⫹ green ⫹ blue to define a red index
chronic laryngitis symptoms and normal individuals with no
冉 red index ⫽
red value
red ⫹ green ⫹ blue冊.
laryngeal complaints, there was a significant difference in red
value measured from digital color images of the larynx. Post ⫽
posterior; Voc ⫽ vocal. (Adapted from J Voice.21)
The study showed a significant difference in red index
between normal subjects and individuals who com-
plained of chronic laryngitis symptoms. Figure 3 repro-
duces data on difference in redness between patients with
laryngitis and normal subjects. In addition, during treat-
ment, serial examinations of the larynges of patients with
chronic laryngitis showed a significant treatment effect as
the larynges became significantly less red with antisecre-
tory and antireflux therapy. Figure 4 reproduces data on
change in redness during treatment with omeprazole.
Therefore, it appears that the visible inflammation man-
ifested by erythema is a hallmark of posterior irritative
laryngitis that responds to treatment for nocturnal reflux.
In some situations, it may be advantageous to recog-
nize the signs of laryngeal inflammation even when the
patient does not volunteer complaints. Ellis et al22 re-
ported on a prospective study of video-documented la-
ryngeal examinations in 75 patients who were scheduled
to have open heart surgery with prolonged intubation.
Blinded analysis of the pre- and postintubation laryngeal
examinations indicated that patients who had visible ev-
idence of inflammation of the larynx in the pre-intuba-
Figure 4. Change in redness of the vocal folds was docu-
tion examination were likely to have more severe postin- mented with treatment by Hanson et al. (Adapted from J
tubation injuries manifested by impressive edema, ulcer- Voice.21)
ation, granulation, and paresis. We now recommend that
patients who will have prolonged intubation be covered sively impaired voice quality may be the primary com-
with antisecretory acid suppression. plaint of posterior irritative laryngitis without soreness or
other symptoms. In order to examine the complaint of
HOARSENESS AND CHANGE IN VOICE hoarseness, Hanson et al23 studied patients with chronic
The third most common complaint of chronic laryngitis laryngitis symptoms as they were being treated with ome-
is deterioration in voice quality with voice use. Progres- prazole and antireflux precautions. Voice recordings

March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A) 115S
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang

Figure 5. Hanson et al reported that percent jitter and shimmer, and the ratio of clear signal to noise in the voice, changed
significantly during treatment with omeprazole for patients with hoarseness associated with chronic laryngitis. (Time in weeks).
(Adapted from Ann Otolol Rhinol Laryngol.23)

were made in a sound-protected room with a high-qual-
ity microphone and recording system. The recordings
were digitized, and representative segments from stable
mid phonation were analyzed blindly for perturbation of
the voice signal. Jitter is a measure of the cycle-to-cycle
variability in the period of the acoustic signal and detects
irregularity of frequency of cycles in the acoustic signal.
There was a significant decrease in jitter during treatment
in the voices of patients with chronic laryngitis who com-
plained of the symptom of hoarseness. Shimmer is a mea-
sure of cycle-to-cycle variation in the amplitude of the
acoustic signal envelope and is a measure of how much
intensity of the phonation is perturbed from cycle to cy-
cle. During treatment for reflux, there was a significant
decrease in the shimmer in the voices of patients who had
complained of hoarseness. Signal-to-noise ratio of the
acoustic signal is another measure of cycle-to-cycle regu-
larity or irregularity. The measure uses an autocorrela-
tion technique to compare how well the acoustic signal
matches from cycle to cycle versus random noise in the
signal. A significant improvement in signal-to-noise ratio
was demonstrated during antireflux and antisecretory
treatment for patients who had complained of vocal
hoarseness. Figure 5 shows data for percent jitter, percent
shimmer, and signal-to-noise ratio from that study.
TREATMENT
Prospective study of patients with chronic laryngitis com-
plaints has demonstrated that approximately 50% of such
patients will have symptoms resolve if they can be con-
vinced to reliably follow nocturnal antireflux precautions
(avoid food and liquids 2 to 3 hours before retiring and
sleep with head and shoulders consistently elevated dur-
ing sleep so that the throat area is elevated higher than the
stomach).3 Patient education is key to successful treat-
ment. Individuals are unlikely to make lifestyle changes
unless they are convinced that so doing is important to
resolution of symptoms. Most patients with mild chronic

116S March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A)
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang

posterior laryngitis do not complain of significant are reluctant to have surgery if they can have their symp-
amounts of heartburn and do not have gastropharyngeal toms controlled with medication that seems to have rel-
reflux during the day; therefore, it is not intuitive that atively little side effect.
their symptoms might be caused by silent reflux episodes A small percentage of patients cannot tolerate proton
during sleep. Comparison of laryngeal examination data pump inhibitors or may not have acid production ade-
and demographic information with treatment outcome quately suppressed even on high dosage of inhibitors yet
data suggests that patients who are most likely to respond will usually have complete resolution of both symptoms
to nocturnal antireflux precautions alone are patients and laryngeal evidence of inflammation after fundoplica-
who are young, whose lifestyle and habits put them at risk tion.
for reflux. These patients also usually have relatively mild
evidence of inflammation on examination. Typical of this ROLE OF pH MONITORING STUDIES IN
group is an individual who eats late at night, has alcohol OUR PRACTICE
in the evening, and sleeps flat. The incidence of hiatal
Approximately 75% of the patients that we see with
hernia in this population is similar to that of the general
chronic laryngitis will achieve resolution of laryngitis
population, approximately 20%, and these patients usu-
symptoms by following nocturnal antireflux precautions
ally do not demonstrate any esophageal disease or any
with or without a relatively inexpensive H2 blocker.
reflux on barium swallow examination.
Therefore, we think that routine pH studies are not cost-
Another 25% of patients who complain of chronic lar-
effective for the diagnosis and management of posterior
yngitis symptoms require an H2 blocker, in addition to
laryngitis. This author’s personal experience with noctur-
observing nocturnal antireflux precautions. These tend
nal reflux and our clinical practice experience suggest that
to be patients who have mild to moderate changes on
the reflux associated with chronic irritative laryngitis may
laryngeal examination and who have had onset of symp-
occur very intermittently, as well as silently. Therefore,
toms in association with stress. These patients are more
pH monitoring studies suffer from a sampling problem.
likely to demonstrate increased episodes of reflux on pH
We have treated many patients who demonstrated “nor-
studies but may have “normal” pH monitoring patterns
mal” patterns of esophageal acidification during the pe-
at the time that they are studied.
riod that they had pH monitoring but who, nevertheless,
Approximately 25% of patients with chronic laryngitis
had complete resolution of symptoms and laryngitis with
symptoms require prolonged treatment with a proton
nocturnal antireflux precautions and acid suppression.
pump inhibitor in order to achieve acceptable improve-
Some degree of reflux occurs in most individuals, and
ment in their symptoms and signs of laryngitis. These
some reflux into the esophagus at night is normal. While
patients usually have evidence of more severe laryngeal
in a healthy condition, the laryngeal and esophageal mu-
inflammation on initial examination and may have evi-
cosa appear to tolerate some level of reflux. However, it
dence of inflammation of upper pharynx and nasophar-
seems that once there is some injury to the epithelium,
ynx. These patients are more likely to be aware of heart-
further exposure to gastric acid is not tolerated well. We
burn and gastropharyngeal reflux episodes during the day
find that patients who have had radiation to the larynx do
or night, and they are more likely to have relapse of symp-
not tolerate acid exposures that would fall within pH data
toms and evidence of inflammation when acid suppres-
expected for normal subjects. Therefore, although pH
sion is discontinued.
monitoring has had an important place in the under-
A few patients require high-dosage proton pump in-
standing of chronic irritative laryngitis and reflux, in
hibitor to suppress acid secretion. Monitoring of esoph-
most cases that have an appearance and symptoms char-
ageal pH while on medication can be helpful in patients
acteristic of chronic irritative type of laryngitis, we would
who do not appear to be responding to what should be
not withhold acid suppression simply based on a “nor-
adequate dosages of acid suppression medication. These
mal” pH study. Probe monitoring of esophageal acidifi-
patients may demonstrate repeated acidification of the
cation, therefore, is not obtained routinely for patients
upper esophagus, even though they are taking a dosage of
who present with only laryngitis symptoms. In our prac-
proton pump inhibitor that is usually adequate to pro-
tice, all patients who require long-term or high-dosage
vide effective suppression. This group of patients is more
proton pump suppression, and all patients who have
likely to have relapse of symptoms and recurrence of lar-
esophageal symptoms, are treated and observed in con-
yngitis when they stop taking medication and are more
junction with a gastroenterologist.
likely to have recurrent and prolonged problems. Patients
with reflux and acidity that is resistant to treatment with
usual dosage of proton pump inhibitors are probably
TREATMENT OF VOCAL GRANULOMAS
candidates for fundoplication. Successful fundoplication In an ongoing prospective study of patients presenting
is cost-effective in comparison with long-term high-dose with vocal process granulomas at Northwestern Univer-
proton pump inhibitor suppression, but many patients sity Medical School, treatment with antireflux precau-

March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A) 117S
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang
tions and suppression of gastric acid secretion with pro-
ton pump inhibitors has been uniformly successful in the
complete resolution of vocal process ulcers and granulo-
mas. This study, which represents a notable departure
from the generally unsuccessful experience with surgical
excision and speech therapy as primary treatments for
vocal granulomas, will be completed and reported in the
near future. To date, 12 patients have been followed for at
least a year after resolution of their granuloma. The treat-
ment period averaged 5 months to resolution of the le-
sions. Duration of treatment required to reach resolution
appears related to the size of the granuloma and the de-
gree to which throat clearing behavior can be eliminated.
TREATMENT FAILURES
The most common error of chronic laryngitis symptom
treatment that is observed in our tertiary referral practice
is treatment of the sore throat with antibiotics alone. Pa-
tients with chronic laryngitis usually do feel better on
antibiotics. Unfortunately, the symptoms recur as soon as
antibiotic is discontinued. The second most common er-
ror is failure of physicians to explain adequately the ratio-
nale for treatment to patients, with the result that patients
do not follow antireflux precautions. Patient education is
a key factor in inducing patients to change significant
sleeping, eating, and drinking aspects of their lifestyle.
Although acid suppression clearly has an important role
in the treatment of chronic irritative laryngitis, acid sup-
pression alone may not be adequate to achieve long-term
resolution of laryngeal inflammation and symptoms.
Therefore, precautions to minimize the likelihood of
nocturnal reflux appear to be important in the preven-
tion of further laryngeal injury and also may be the only
treatment needed for the majority of patients with mild
symptoms and signs of inflammation.
The third most common error of treatment that we see
is inadequate length of treatment. It is not unusual for
patients to take medication and follow precautions for 2
to 3 weeks but then to stop treatment because they do not
feel significant improvement. It is important that patients
understand that the injury to the epithelium of the larynx
and hypopharynx that is associated with reflux is a chem-
ical burn. Antireflux precautions and acid suppression do
not reverse injury to the laryngeal epithelium. Rather,
prolonged prevention of further injury is needed to allow
healing of the tissues and eventual resolution of symp-
toms. Some vocal granulomas in our currently ongoing
series have required 9 months of preventive treatment.
Once injured, refluxed materials may further irritate the
laryngeal epithelium even if pH is relatively high. Neither
acid suppression nor antireflux precautions completely
controls the possibility of intermittent reflux of gastric
material up into the hypopharynx. It seems that once
chronically inflamed, the epithelium of the larynx may be
injured by very episodic small amounts of reflux. In con-
118S March 6, 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A)
trast, we know from 24-hour pH monitoring data that
some degree of reflux is tolerated without evidence of
injury by patients who do not have laryngeal symptoms.
Commonly chronic laryngeal symptoms can be traced
back to an episode of severe coughing, vomiting, or other
trauma to the laryngeal epithelium. This may suggest that
the laryngeal mucosa tolerates some degree of reflux until
it is injured by some other form of trauma, but once in-
jured, subsequent episodes of reflux on the inflamed ep-
ithelium cause progressive damage. Once evidence of lar-
yngitis has healed, many patients may resume their pre-
vious lifestyle habits without recurrence of symptoms for
prolonged periods of time.
LONG-TERM FAILURE OF TREATMENT
AND LARYNGEAL CANCER
In 1988, Ward and Hanson reported a retrospective study
of all patients in the UCLA/Wadsworth Veterans Affairs
tumor registries over a 30-year period who had developed
carcinoma of the laryngopharynx and who never had
smoked.24 Long history of reflux was the common unify-
ing risk factor identified in these patients. Some of the
patients had been followed with chronic laryngitis for 8 to
12 years before they developed cancer. Subsequent to
those observations, we have frequently identified irrita-
tive laryngitis that responds to antireflux and antisecre-
tory therapy during the follow-up of patients whom we
have successfully treated for laryngeal carcinoma. Postra-
diation patients may be much more susceptible to muco-
sal injury from reflux, and it has been our experience that
antireflux treatment may be important in such patients
even if they have normal pH studies. Individual patients
who have had normal pH studies, nevertheless, have
demonstrated evidence of severe ongoing chronic in-
flammation, which did respond to acid suppression and
antireflux precautions. Although a causative relationship
between chronic irritative laryngitis from reflux and can-
cer has not been established experimentally, it seems
likely that chronic laryngeal irritation from reflux may be
a risk factor for carcinoma. Olson5 recently reviewed ev-
idence that reflux of gastric contents outside of the stom-
ach might be related to development of cancer in the
esophagus, larynx, or lungs.
Finally, we would insert a word about terminology.
Laryngitis, or inflammation of the larynx, can be caused
by infection with viruses, with other organisms, by
trauma or thermal injury, or by exposure to toxic mate-
rials. Infectious acute laryngitis, usually from virus infec-
tion, rarely lasts more than 10 to 14 days at the most.
Acute bacterial infection, supraglottitis, is also not a
chronic condition. Generally, chronic infections, with tu-
berculosis, Candida, or exotic infections are rare and usu-
ally occur in association with other evidence of disease.
Therefore, chronic laryngitis that lasts more than a few
weeks and is not associated with systemic disease usually
 A Symposium: Chronic Laryngitis Associated with Reflux/Hanson and Jiang
is associated with recurrent exposure of the larynx to an
irritant. Tobacco smoke is the most commonly inhaled
irritant, but laryngitis can occur with cannabis smoking
and other inhaled smoke sources. For patients with
chronic laryngitis who do not smoke, it appears that the
most common source of irritant is reflux of gastric con-
tents. Historical evidence suggests that this most com-
monly occurs during sleep and usually is silent at the time
the exposure occurs. Symptoms of chemical burn injury
may vary from very mild to severe, but usually the expo-
sure does not awaken patients. In its most common and
mild form, reflux causes injury isolated to the posterior
part of the larynx, but any part of the upper respiratory
tract epithelium will become inflamed if exposed to suf-
ficient gastric liquids to cause injury. Because the visible
evidence of mucous membrane injury (specifically red-
ness, loss of surface mucous layer, granularity, and ulcer-
ation) is not specific for a cause of the inflammation, we
prefer to use the term chronic laryngitis, which may be
mainly confined to the posterior larynx . After a careful
history, assessment for other causes of irritation, success-
ful treatment trial, or positive pH study, we may deter-
mine that the chronic irritative laryngitis is the result of
reflux. Only then is the term “reflux laryngitis” accurate.
In summary, it is our experience that chronic laryngi-
tis, which may or may not be confined to the posterior
larynx, and which usually responds to treatment aimed at
reducing nocturnal reflux of acid containing gastric
juices, is a very common cause of throat and voice com-
plaints. The large majority of patients with chronic laryn-
gitis complaints can be adequately evaluated and treated
based on history of symptoms and a simple examination
of their larynx. Although many patients with mild laryn-
gitis will recover by following simple life-style precau-
tions, the availability of potent acid-suppressing medica-
tions has greatly expanded our ability to treat successfully
chronic irritative laryngitis that is associated with reflux.
ACKNOWLEDGMENT
This review of experience in the diagnosis and treatment of
chronic irritative laryngitis at Northwestern University Medical
School has benefited from collaboration of several colleagues
who have shared in studies related to reflux and laryngitis. Par-
ticularly, we acknowledge the important contributions of Peter
Kahrilas and Perry Kamel in gastroenterology, Jack Jiang, Emily
Lin, Barbara Pauloski, and Jerilynn Logemann in speech sci-
ence, and the valuable participation of the patients who have
provided the basis of our experience.
REFERENCES
1. Kamel PL, Karhilas PJ, Hanson DG. A prospective study of
posterior laryngitis treatment with omeprazole. Gastroen-
terology. 1992;102:A93. Abstract.
2. Kamel PL, Hanson DG, Kahrilas PJ. Omeprazole for the
March 6, 2000
View publication stats
treatment of posterior laryngitis. Am J Med. 1994;96:321–
326.
3. Hanson DG, Kamel P, Kahrilas P. Outcomes of anti-reflux
therapy for the treatment of chronic laryngitis. Ann Otol
Rhinol Laryngol. 1995;104:550 –555.
4. Jackson C. Contact ulcer of the larynx. Ann Otol Rhinol
Laryngol. 1928;37:227–230.
5. Olson NR. Aerodigestive malignancy and gastroesophageal
reflux disease. Am J Med. 1997;103:97S–99S. Review.
6. Woodruff GH. Contact ulcers of the larynx. JAMA. 1936;
106:1562–1569.
7. Peach G, Holinger P. Contact ulcer of the larynx: II. The role
of vocal re-education. Arch Otolaryngol 1947;46:617– 623.
8. New GB, Devine KD. Contact ulcer granuloma. Ann Otol
Rhinol Laryngol. 1949;58:548 –558.
9. Baker DC Jr. Contact ulcer of the larynx. Laryngoscope.
1954;64:73–78.
10. von Leden H, Moore P. Contact ulcer of the larynx: exper-
imental observations. Arch Otolaryngol. 1960;72:746 –752.
11. Cherry J, Margulies SI. Contact ulcer of the larynx. Laryn-
goscope. 1968;73:1937–1940.
12. Delahunty JE, Cherry J. Experimentally produced vocal
cord granulomas. Laryngoscope. 1968;78:1941–1947
13. Jackson C. Contact ulcer granuloma and other laryngeal
complications of endotracheal anesthesia. Anesthesiology.
14:425– 436.
14. Snow GC, Arano M, Balogh K. Post intubation granuloma
of the larynx. Anesth Analg. 1966;45:425– 436.
15. Holinger PH, Johnston KC. Contact ulcer of the larynx.
JAMA. 1960;172:511–515.
16. Ward PH, Zwitman D, Hanson D, Berci G. Contact ulcers
and granulomas of the larynx: new insights into their etiol-
ogy as a basis for more rational treatment. Otolaryngol
Head Neck Surg. 1980;88:262–269.
17. Gaynor EE. Otolaryngologic manifestations of gastro-
esophageal reflux. Am J Gastroenterol. 1991;86:801– 808.
18. Jacob P, Kahrilas PJ, Herzon G. Proximal esophageal pH-
metry in patients with “reflux laryngitis.” Gastroenterology.
1991;100:305–310.
19. Koufman JA. The otolaryngologic manifestations of gastro-
esophageal 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. Laryngoscope. 1991;
101(suppl 53):1–78.
20. Little FB, Koufman JA, Kohut RI, Marshall RB. Effect of
gastric acid on the pathogenesis of subglottic stenosis. Ann
Otol Rhinol Laryngol. 1985;94:516 –519.
21. Hanson DG, Jiang J, Chi W. Quantitative color analysis of
laryngeal erythema in chronic posterior laryngitis. J Voice.
1998;12:78 – 83.
22. Ellis S, Pollak AC, Hanson DG, Jiang JJ. Videolaryngo-
scopic evaluation of laryngeal intubation: incidence and
predictive factors. Otolaryngol Head Neck Surg. 1996;114:
729 –731.
23. Hanson DG, Jiang JJ, Chen J, Pauloski B. Acoustic mea-
surement of change in voice quality with treatment for
chronic posterior laryngitis. Ann Otolol Rhinol Laryngol.
1997;106:279 –285.
24. Ward PH, Hanson DG. Reflux as an etiological factor of
carcinoma of the laryngopharynx. Laryngoscope. 1988;98:
1195–1199.
THE AMERICAN JOURNAL OF MEDICINE威 Volume 108 (4A) 119S