Chronic Laryngitis Caused by Chronic-Throat-to-Voice-Box-Reflux

          Whenever anything but air is aspirated from the throat into the voice box it causes cough and throat irritation.  What is aspirated could be food, saliva, mucus from the nose or sinuses, allergic or infected secretions from the throat or nose or sinuses, acidic secretions from the stomach, yellow bile from the liver, certain irritating gases such as smoke, and all kinds of dust or annoying particles such as pollens or animal dander or insects.  The voice box (larynx) only likes to conduct moist, clean air into the windpipe (trachea); anything else besides moist, clean air causes voice box irritation (laryngitis), which in turn may cause the five cardinal symptoms of chronic-throat-to-voice box-reflux, namely:a) cough,  b) throat clearing,  c) hoarseness,  d) throat irritation, and e) feeling of a false lump in the throat.         
          The current medical term for chronic-throat-to-voice box-reflux (chronic, laryngo-pharyngeal reflux) is a misnomer because it indicates that the reflux occurs from the voice box (larynx) into the throat (pharynx) instead of the opposite.  The causes behind this chronic-throat-to-voice-box-reflux are complex, poorly understood, and are not directly related to the reflux of stomach secretions into the esophagus (chronic, gastro-esophageal reflux).  For example, in a series of about 900 patients, throat clearing occurred in 87% of those with chronic-throat-to-voice box-reflux in contrast to 3% of those with chronic, stomach-to-esophagus reflux.  Moreover, only 20% of those with chronic-throat-to-voice box-reflux had heartburn in contrast to 83% of those with chronic, stomach-to-esophagus reflux.
          A post-infectious presentation of this inscrutable, chronic laryngitis is very common.  Typically, one suffers a viral respiratory infection with cough and congestion, which endures the usual 2 to 3 weeks and then resolves leaving in its wake the symptoms of chronic-throat-to-voice box-reflux such as cough, throat clearing, throat irritation, and hoarseness.  When these symptoms continue for several weeks and are often made worse by eating or reclining, one seeks medical attention and is first treated with antibiotics to no avail.  Then one is referred to an Ear-Nose-Throat subspecialist, who after scoping and x-raying the patient makes the diagnosis of chronic, laryngo-pharyngeal reflux and treats the patient with a stomach-acid-pump inhibitor such as Nexium for three months.  If this treatment fails, the patient is told to return for further follow-up and investigation.  It is not uncommon for patients to continue suffering from this type of chronic laryngitis for a year or longer regardless of the treatments provided.
          Several diseases may mimic this type of chronic laryngitis and should be ruled out before the diagnosis of chronic-throat-to-voice box reflux is made.  Chronic sinus infections, upper and lower airway allergies, voice box tumors, vocal cord nodules, voice box tuberculosis, chronic stomach-to-esophagus reflux, cigarette smoke irritation, work environment irritations, and neurological conditions that interfere with proper swallowing—should all be considered in the differential diagnosis.  This is necessary because the diagnosis of chronic-throat-to-voice-box-reflux is ultimately a diagnosis of elimination since there are no specific diagnostic findings that are pathognomonic and that do not overlap with other diseases.  In several studies, laryngoscopic findings in asymptomatic participants were similar to those seen in chronic-throat-to-voice-box-reflux patients.                            
          Because the causes of this type of chronic laryngitis are poorly understood, the treatments for this chronic-throat-to-voice-box-reflux are not always effective and could take up to 3 to 6 months to show benefit.  Consequently, seasoned clinicians have developed their own theories and methods of treatment that circumvent the shortcomings of our current scientific uncertainties.  When deemed appropriate, a therapeutic trial that produces quick results (after months or years of suffering) is readily welcomed by most patients.  I tend to provide this therapeutic trial after a thorough history and physical examination and before I embark on extensive investigations.  If patients improve within two weeks, further investigations will have been avoided.  However, if patients do not improve, then appropriate investigations become mandatory.
         My current therapeutic regimen involves taking together the following four, daily, over-the-counter medications—which are safe, inexpensive, and highly effective.
a)   Famotidine (Pepsid) 20 mg with breakfast and at bedtime.
b)   Omeprazole (Prilosec) 20 mg with breakfast and dinner.
c)   Loratadine (Claritin) 10 mg with breakfast.
d)   Cetirizine (Zyrtec) 10 mg at bedtime.
If by taking this regimen patients improve within two weeks, I ask them to stay on the treatment until they are totally well and then to try to stop it when their body allows and to use it intermittently to control seasonal or episodic symptoms.  The logic behind this treatment has to do with obstructing stomach acid secretion while simultaneously blocking the airways’ histamine-1 and histamine-2 receptors, which reduces airway secretions and allergic inflammations.

Evaluation & Management of Laryngopharyngeal Reflux. Charles N. Ford, MD. JAMA, Sep. 28, 2005-Vol. 294, No. 12