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Reflux Laryngitis Clinical Presentation: History, Physical, Causes

Physical
Visualization of the larynx and vocal cords for signs of laryngopharyngeal reflux
(LPR) requires a laryngoscopic examination. The most useful signs of GERDrelated laryngitis or laryngopharyngeal reflux (LPR) were reported to be erythema,
edema, presence of posterior commissure bar, and cobblestoning, while
pseudosulcus vocalis; ulcers; and ventricular obliteration, nodules, polyps, and
leukoplakia were reported to be less useful.[12]
Pseudosulcus vocalis (see below) was shown to be reported in as many as 90% of
laryngopharyngeal reflux (LPR) cases. In a separate study, pseudosulcus was
show to have a 70% sensitivity and 77% specificity in patients with
laryngopharyngeal reflux (LPR). This further supports that the presence of
pseudosulcus vocalis is suggestive of laryngopharyngeal reflux (LPR).[13]
Helicobacter pylori bacteria could enter and colonize the nasopharyngeal cavity by
gastroesophageal reflux and may elicit otitis, sinusitis, pharyngitis, or laryngitis.
Belfasky et al (2002) developed an 8-item clinical severity scale to document
laryngopharyngeal reflux (LPR) findings during fiberoptic laryngoscopy, which are
quantified as the reflux finding score (RFS; as seen in the image below). The
following 8 items are assessed to aid in the diagnosis of laryngopharyngeal reflux
(LPR):
1.
2.
3.
4.
5.
6.
7.
8.

Pseudosulcus vocalis
Ventricular obliteration
Erythema/hyperemia
Vocal fold edema
Diffuse laryngeal edema
Posterior commissure hypertrophy
Granuloma/granulation
Thick endolaryngeal mucus

The image below describes the reflux finding score in more detail.

Reflux Laryngitis Clinical Presentation

Author: Bardia Amirlak, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Updated: Mar 05, 2014

The reflux finding score (RFS) documents the presence and degree of eight laryngopharyngeal
reflux (LPR) findings during fiberoptic laryngoscopy; maximum score: 26.

See the list below:

Posterior laryngitis: The classic laryngeal physical findings of
laryngopharyngeal reflux (LPR) reported in the otolaryngology literature are
edema and erythema of the posterior commissure.
Pseudosulcus vocalis: The medial edge of the vocal cord appears to have a
linear indentation due to diffuse infraglottic edema.
Vocal cord granuloma
Subglottic stenosis - Subglottic stenosis is a significant complication
associated with chronic pharyngeal acid exposure.
Contact ulcer of larynx
Additional signs related to laryngopharyngeal reflux
Recurrent or refractory sinusitis: A recent study on the long-term
outcome of adult patients who underwent functional endoscopic
sinus surgery indicated that GERD predicted poor symptom relief.
Dental erosions: Patients have a smooth, glazed, dished-out
appearance of the dentin on the lingual surfaces of the teeth. The
deleterious effect of regurgitated gastric acid on the teeth has been
suggested in reports dating back to the early 1970s. These include
association of dental erosions with hiatal hernia, chronic vomiting,
rumination, alcoholic gastritis, and regurgitation, as well as anorexia
nervosa and bulimia. Dental erosions are defined as the loss of tooth
substance by a chemical process that does not involve bacteria.

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Dental erosions are hard dished-out areas with a smooth and
glistening base as opposed to the soft, dark, and jagged-edge
lesions of dental caries. The prevalence of dental erosions in patients
with GERD was reportedly 20-55%, in contrast to 2-18% in the
general population.
Sandifer syndrome: The unique neck posture in Sandifer syndrome is
a clue to acid reflux disease in infants or young children. This
posture is an anatomic defense mechanism against repetitive acid
reflux.

Contributor Information and Disclosures

Author
Bardia Amirlak, MD Assistant Professor of Plastic Surgery, Director of Residency Cosmetic Clinic, Director of
Plastic Surgery Global Health Program, University of Texas Southwestern Medical Center at Dallas; Chief of
Hand and Peripheral Nerve Surgery, Dallas Veterans Affairs Medical Center
Bardia Amirlak, MD is a member of the following medical societies: American College of Surgeons, American
Society of Plastic Surgeons, American Society of Reconstructive Transplantation, Kleinert Society
Disclosure: Nothing to disclose.
Coauthor(s)
Reza Shaker, MD
Reza Shaker, MD is a member of the following medical societies: American College of Gastroenterology,
American College of Physicians, American Federation for Medical Research, American Gastroenterological
Association, American Neurogastroenterology and Motility Society, American Physiological Society, American
Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
Pamela A Mudd, MD Attending Physician in Pediatric Otolaryngology, Children's National Medical Center
Pamela A Mudd, MD is a member of the following medical societies: American Academy of OtolaryngologyHead and Neck Surgery, American College of Physicians
Disclosure: Nothing to disclose.
Ramin Soraya, MD Chair, Department of Science, West Coast University, Dallas
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences,
State University of New York Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic
and Reconstructive Surgery, American Head and Neck Society, American Rhinologic Society, Triological
Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery,
American College of Surgeons, American Medical Association, Medical Society of the State of New York
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado
School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic
and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head
and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
Medvoy;Testappropriate;Cerescan;Empirican;RxRevu<br/>Received none from Allergy Solutions, Inc for board
membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder
and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest
from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee
from Carespan for advisor; Received consulting fee from Covidien for consulting.
Additional Contributors
Clark A Rosen, MD Director, University of Pittsburgh Voice Center; Professor, Department of Otolaryngology
and Communication Science and Disorders, University of Pittsburgh School of Medicine
Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and
Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of
Surgeons, American Medical Association, Pennsylvania Medical Society
Disclosure: Received consulting fee from Merz North America Inc for consulting; Received consulting fee from
Merz North America Inc for speaking and teaching.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors,
Ann L Edmunds, MD, PharmD, to the development and writing of this article.

References
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16/9/2015

Reflux Laryngitis Clinical Presentation: History, Physical, Causes

1. Cherry J, Margulies SI. Contact ulcer of the larynx. Laryngoscope. 1968 Nov. 78(11):1937-40. [Medline].
2. Koufman JA. 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. Laryngoscope. 1991 Apr. 101(4 Pt 2
Suppl 53):1-78. [Medline].
3. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. 2005 Sep 28. 294(12):1534-40.
[Medline].
4. Vaezi MF. Benefit of acid-suppressive therapy in chronic laryngitis: the devil is in the details. Clin
Gastroenterol Hepatol. 2010 Sep. 8(9):741-2. [Medline].
5. Maronian NC, Azadeh H, Waugh P, Hillel A. Association of laryngopharyngeal reflux disease and
subglottic stenosis. Ann Otol Rhinol Laryngol. 2001 Jul. 110(7 Pt 1):606-12. [Medline].
6. Reavis KM, Morris CD, Gopal DV, Hunter JG, Jobe BA. Laryngopharyngeal reflux symptoms better
predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Ann
Surg. 2004 Jun. 239(6):849-56; discussion 856-8. [Medline].
7. Burton LK Jr, Murray JA, Thompson DM. Ear, nose, and throat manifestations of gastroesophageal reflux
disease. Complaints can be telltale signs. Postgrad Med. 2005 Feb. 117(2):39-45. [Medline].
8. Milstein CF, Charbel S, Hicks DM, Abelson TI, Richter JE, Vaezi MF. Prevalence of laryngeal irritation
signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible
laryngoscope). Laryngoscope. 2005 Dec. 115(12):2256-61. [Medline].
9. Gill GA, Johnston N, Buda A, Pignatelli M, Pearson J, Dettmar PW. Laryngeal epithelial defenses against
laryngopharyngeal reflux: investigations of E-cadherin, carbonic anhydrase isoenzyme III, and pepsin. Ann
Otol Rhinol Laryngol. 2005 Dec. 114(12):913-21. [Medline].
10. Andersson O, Moller RY, Finizia C, Ruth M. A more than 10-year prospective, follow-up study of
esophageal and pharyngeal acid exposure, symptoms and laryngeal findings in healthy, asymptomatic
volunteers. Scand J Gastroenterol. 2009. 44(1):23-31. [Medline].
11. Altman KW, Stephens RM, Lyttle CS, Weiss KB. Changing impact of gastroesophageal reflux in medical
and otolaryngology practice. Laryngoscope. 2005 Jul. 115(7):1145-53. [Medline].
12. Ahmed TF, Khandwala F, Abelson TI, et al. Chronic laryngitis associated with gastroesophageal reflux:
prospective assessment of differences in practice patterns between gastroenterologists and ENT
physicians. Am J Gastroenterol. 2006 Mar. 101(3):470-8. [Medline].
13. Belafsky PC, Postma GN, Koufman JA. The association between laryngeal pseudosulcus and
laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2002 Jun. 126(6):649-52. [Medline].
14. Malhotra A, Freston JW, Aziz K. Use of pH-impedance testing to evaluate patients with suspected
extraesophageal manifestations of gastroesophageal reflux disease. J Clin Gastroenterol. 2008 Mar.
42(3):271-8. [Medline].
15. So JB, Zeitels SM, Rattner DW. Outcomes of atypical symptoms attributed to gastroesophageal reflux
treated by laparoscopic fundoplication. Surgery. 1998 Jul. 124(1):28-32. [Medline].
16. Salminen P, Karvonen J, Ovaska J. Long-term outcomes after laparoscopic Nissen fundoplication for
reflux laryngitis. Dig Surg. 2010. 27(6):509-14. [Medline].
17. Cadiere GB, Houben JJ, Bruyns J, Himpens J, Panzer JM, Gelin M. Laparoscopic Nissen fundoplication:
technique and preliminary results. Br J Surg. 1994 Mar. 81(3):400-3. [Medline].
18. Chambers DW, Davis WE, Cook PR, Nishioka GJ, Rudman DT. Long-term outcome analysis of functional
endoscopic sinus surgery: correlation of symptoms with endoscopic examination findings and potential
prognostic variables. Laryngoscope. 1997 Apr. 107(4):504-10. [Medline].
19. Curran AJ, Barry MK, Callanan V, Gormley PK. A prospective study of acid reflux and globus pharyngeus
using a modified symptom index. Clin Otolaryngol Allied Sci. 1995 Dec. 20(6):552-4. [Medline].
20. Deveney CW, Benner K, Cohen J. Gastroesophageal reflux and laryngeal disease. Arch Surg. 1993 Sep.
128(9):1021-5; discussion 1026-7. [Medline].
21. Dobhan R, Castell DO. Normal and abnormal proximal esophageal acid exposure: results of ambulatory
dual-probe pH monitoring. Am J Gastroenterol. 1993 Jan. 88(1):25-9. [Medline].
22. el-Serag HB, Sonnenberg A. Comorbid occurrence of laryngeal or pulmonary disease with esophagitis in
United States military veterans. Gastroenterology. 1997 Sep. 113(3):755-60. [Medline].
23. Farkkila MA, Ertama L, Katila H, Kuusi K, Paavolainen M, Varis K. Globus pharyngis, commonly
associated with esophageal motility disorders. Am J Gastroenterol. 1994 Apr. 89(4):503-8. [Medline].
24. First multi-disciplinary international symposium on supraesophageal complications of gastroesophageal
reflux disease. Workshop consensus reports. Am J Med. 1997 Nov 24. 103(5A):149S-150S. [Medline].
25. Gallup Organizational National Survey. Heartburn Across America. Princeton, NJ: The Gallup
Organization Inc; 1988.
26. Graham DY, Smith JL, Patterson DJ. Why do apparently healthy people use antacid tablets?. Am J
Gastroenterol. 1983 May. 78(5):257-60. [Medline].
27. Grossman TW, Toohill RJ, Mushtag E, et al. Pharyngeal, laryngeal and tracheobronchial manifestations
of gastroesophageal reflux. Proceedings of the XXIV World Congress of Otolaryngology Head and Neck
Surgery. Berkley, Calif: Kugler and Ghedini Publishing;
28. Hanson DG. Diagnosis and management of chronic irritative laryngitis. Am J Med. 1999.
29. Hanson DG, Jiang JJ, Chen J, Pauloski BR. Acoustic measurement of change in voice quality with
treatment for chronic posterior laryngitis. Ann Otol Rhinol Laryngol. 1997 Apr. 106(4):279-85. [Medline].

http://emedicine.medscape.com/article/864864-clinical#b4

3/5

16/9/2015

Reflux Laryngitis Clinical Presentation: History, Physical, Causes

30. Hanson DG, Kamel PL, Kahrilas PJ. Outcomes of antireflux therapy for the treatment of chronic laryngitis.
Ann Otol Rhinol Laryngol. 1995 Jul. 104(7):550-5. [Medline].
31. Helm JF, Shaker R, Dodds WJ. Revelations about ambulatory esophageal pH monitoring.
Gastroenterology. 1988. 94(5):A421.
32. Hill J, Stuart RC, Fung HK, et al. Gastroesophageal reflux, motility disorders, and psychological profiles
in the etiology of globus pharyngis. Laryngoscope. 1997 Oct. 107(10):1373-7. [Medline].
33. Howden GF. Erosion as the presenting symptom in hiatus hernia. A case report. Br Dent J. 1971 Nov 16.
131(10):455-6. [Medline].
34. Jacob P, Kahrilas PJ, Herzon G. Proximal esophageal pH-metry in patients with 'reflux laryngitis'.
Gastroenterology. 1991 Feb. 100(2):305-10. [Medline].
35. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC, Anvari M. Laparoscopic Nissen fundoplication.
Ann Surg. 1994 Aug. 220(2):137-45. [Medline].
36. Jarvinen V, Meurman JH, Hyvarinen H, Rytomaa I, Murtomaa H. Dental erosion and upper gastrointestinal
disorders. Oral Surg Oral Med Oral Pathol. 1988 Mar. 65(3):298-303. [Medline].
37. Jindal JR, Milbrath MM, Shaker R, Hogan WJ, Toohill RJ. Gastroesophageal reflux disease as a likely
cause of "idiopathic" subglottic stenosis. Ann Otol Rhinol Laryngol. 1994 Mar. 103(3):186-91. [Medline].
38. Jones NS, Lannigan FJ, McCullagh M, et al. Acid reflux and hoarseness. J Voice. 1990. 4(4):355-58.
39. Kambic V, Radsel Z. Acid posterior laryngitis. Aetiology, histology, diagnosis and treatment. J Laryngol
Otol. 1984 Dec. 98(12):1237-40. [Medline].
40. Kamel PL, Hanson D, Kahrilas PJ. Omeprazole for the treatment of posterior laryngitis. Am J Med. 1994
Apr. 96(4):321-6. [Medline].
41. Katz PO. Ambulatory esophageal and hypopharyngeal pH monitoring in patients with hoarseness. Am J
Gastroenterol. 1990 Jan. 85(1):38-40. [Medline].
42. Katzka DA, Paoletti V, Leite L, Castell DO. Prolonged ambulatory pH monitoring in patients with
persistent gastroesophageal reflux disease symptoms: testing while on therapy identifies the need for
more aggressive anti-reflux therapy. Am J Gastroenterol. 1996 Oct. 91(10):2110-3. [Medline].
43. Lazarchik DA, Filler SJ. Effects of gastroesophageal reflux on the oral cavity. Am J Med. 1997 Nov 24.
103(5A):107S-113S. [Medline].
44. Locke GR 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3rd. Prevalence and clinical spectrum of
gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology.
1997 May. 112(5):1448-56. [Medline].
45. Luostarinen M, Isolauri J, Laitinen J, et al. Fate of Nissen fundoplication after 20 years. A clinical,
endoscopical, and functional analysis. Gut. 1993 Aug. 34(8):1015-20. [Medline].
46. Lussi A, Schaffner M, Hotz P, Suter P. Dental erosion in a population of Swiss adults. Community Dent
Oral Epidemiol. 1991 Oct. 19(5):286-90. [Medline].
47. Mair IW, Natvig K, Maurer HJ, Odegaard HI. The globus symptom. ORL J Otorhinolaryngol Relat Spec.
1973. 35(2):104-10. [Medline].
48. McNally PR, Maydonovitch CL, Prosek RA, Collette RP, Wong RK. Evaluation of gastroesophageal reflux
as a cause of idiopathic hoarseness. Dig Dis Sci. 1989 Dec. 34(12):1900-4. [Medline].
49. Metz DC, Childs ML, Ruiz C, Weinstein GS. Pilot study of the oral omeprazole test for reflux laryngitis.
Otolaryngol Head Neck Surg. 1997 Jan. 116(1):41-6. [Medline].
50. Meurman JH, Toskala J, Nuutinen P, Klemetti E. Oral and dental manifestations in gastroesophageal
reflux disease. Oral Surg Oral Med Oral Pathol. 1994 Nov. 78(5):583-9. [Medline].
51. Miko TL. Peptic (contact ulcer) granuloma of the larynx. J Clin Pathol. 1989 Aug. 42(8):800-4. [Medline].
52. Moloy PJ, Charter R. The globus symptom. Incidence, therapeutic response, and age and sex
relationships. Arch Otolaryngol. 1982 Nov. 108(11):740-4. [Medline].
53. Moser G, Vacariu-Granser GV, Schneider C, et al. High incidence of esophageal motor disorders in
consecutive patients with globus sensation. Gastroenterology. 1991 Dec. 101(6):1512-21. [Medline].
54. Ott DJ, Ledbetter MS, Koufman JA, Chen MY. Globus pharyngeus: radiographic evaluation and 24-hour
pH monitoring of the pharynx and esophagus in 22 patients. Radiology. 1994 Apr. 191(1):95-7. [Medline].
55. Peters JH, Heimbucher J, Kauer WK, Incarbone R, Bremner CG, DeMeester TR. Clinical and physiologic
comparison of laparoscopic and open Nissen fundoplication. J Am Coll Surg. 1995 Apr. 180(4):385-93.
[Medline].
56. Pindborg JJ. Chemical and physical injuries. Pindborg JJ, ed. Pathology of the Dental Hard Tissues.
Philadelphia, Pa: WB Saunders Co; 1970. 312-25.
57. Richter JE. Ambulatory esophageal pH monitoring. Am J Med. 1997 Nov 24. 103(5A):130S-134S.
[Medline].
58. Ruth M, Carlsson S, Mansson I, Bengtsson U, Sandberg N. Scintigraphic detection of gastro-pulmonary
aspiration in patients with respiratory disorders. Clin Physiol. 1993 Jan. 13(1):19-33. [Medline].
59. Schroeder PL, Filler SJ, Ramirez B, Lazarchik DA, Vaezi MF, Richter JE. Dental erosion and acid reflux
disease. Ann Intern Med. 1995 Jun 1. 122(11):809-15. [Medline].
60. Shaker R, Milbrath M, Ren J, et al. Esophagopharyngeal distribution of refluxed gastric acid in patients
with reflux laryngitis. Gastroenterology. 1995 Nov. 109(5):1575-82. [Medline].
61. Shaw GY, Searl JP, Young JL, Miner PB. Subjective, laryngoscopic, and acoustic measurements of
laryngeal reflux before and after treatment with omeprazole. J Voice. 1996 Dec. 10(4):410-8. [Medline].

http://emedicine.medscape.com/article/864864-clinical#b4

4/5

16/9/2015

Reflux Laryngitis Clinical Presentation: History, Physical, Causes

62. Sognnaes RF, Wolcott RB, Xhonga FA. Dental erosion. I. Erosion-like patterns occurring in association
with other dental conditions. J Am Dent Assoc. 1972 Mar. 84(3):571-6. [Medline].
63. Thompson WG, Heaton KW. Heartburn and globus in apparently healthy people. Can Med Assoc J. 1982
Jan 1. 126(1):46-8. [Medline].
64. Ulualp SO, Toohill RJ, Hoffmann R, Shaker R. Pharyngeal pH monitoring in patients with posterior
laryngitis. Otolaryngol Head Neck Surg. 1999 May. 120(5):672-7. [Medline].
65. Ulualp SO, Toohill RJ, Hoffmann R, Shaker R. Possible relationship of gastroesophagopharyngeal acid
reflux with pathogenesis of chronic sinusitis. Am J Rhinol. 1999 May-Jun. 13(3):197-202. [Medline].
66. Ulualp SO, Toohill RJ, Kern M, Shaker R. Pharyngo-UES contractile reflex in patients with posterior
laryngitis. Laryngoscope. 1998 Sep. 108(9):1354-7. [Medline].
67. Ulualp SO, Toohill RJ, Shaker R. Pharyngeal acid reflux in patients with single and multiple
otolaryngologic disorders. Otolaryngol Head Neck Surg. 1999 Dec. 121(6):725-30. [Medline].
68. Vaezi MF, Schroeder PL, Richter JE. Reproducibility of proximal probe pH parameters in 24-hour
ambulatory esophageal pH monitoring. Am J Gastroenterol. 1997 May. 92(5):825-9. [Medline].
69. Weusten BL, Akkermans LM, vanBerge-Henegouwen GP, Smout AJ. Spatiotemporal characteristics of
physiological gastroesophageal reflux. Am J Physiol. 1994 Mar. 266(3 Pt 1):G357-62. [Medline].
70. Wiener GJ, Koufman JA, Wu WC, Cooper JB, Richter JE, Castell DO. Chronic hoarseness secondary to
gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring. Am J
Gastroenterol. 1989 Dec. 84(12):1503-8. [Medline].
71. Wilson JA, Heading RC, Maran AG, Pryde A, Piris J, Allan PL. Globus sensation is not due to gastrooesophageal reflux. Clin Otolaryngol Allied Sci. 1987 Aug. 12(4):271-5. [Medline].
72. Wo JM, Grist WJ, Gussack G, Delgaudio JM, Waring JP. Empiric trial of high-dose omeprazole in
patients with posterior laryngitis: a prospective study. Am J Gastroenterol. 1997 Dec. 92(12):2160-5.
[Medline].
73. Woo P, Noordzij P, Ross JA. Association of esophageal reflux and globus symptom: comparison of
laryngoscopy and 24-hour pH manometry. Otolaryngol Head Neck Surg. 1996 Dec. 115(6):502-7.
[Medline].

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