When Chronic Hoarseness Isn’t Reflux Disease
David A. Johnson, MD
April 15, 2015

Medscape 21 April 2015

Gerry Gajadharsingh writes:

I see a lot of patients with throat related problems. Many of these will have been prescribed a PPI (proton pump inhibitor) for gastroesophageal-reflux. Often it makes little difference in their symptoms. Almost universally there is a breathing pattern disorder occurring in the patient, often over recruiting the accessory muscles of respiration, leading to a lot of muscle and fascial tension around the throat. Osteopathic Manual treatment and breathing re-education can make a real difference to these patients. The article from gastroenterologist Dr David Johnson below goes a little way to support this view, apart from the bit about good breathing behavior!

Refractory Laryngeal Symptoms

Hello. I’m Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Today I want to talk about the very challenging problem of patients with refractory laryngeal symptoms.

These patients come in and complain about hoarseness, voice changes, or a sensation here

[in the throat], and they invariably are referred to an ear, nose, and throat (ENT) specialist. The ENT specialist performs a laryngoscopy and says, “Aha, it’s a red larynx. You need to go see the gastroenterologist because, of course, this is gastroesophageal-reflux related.”

The gastroenterologist then sees the patient and perhaps prescribes a medication; we may prescribe a proton pump inhibitor (PPI). We may order a pH study or endoscopy, which are rarely helpful. I typically have pH studies performed during therapy to see whether the patient has ongoing reflux (acidic or nonacidic) and try to correlate it with the patient’s symptoms. The gastroenterologist says, “No, you don’t have reflux.”
If the patient didn’t improve with a PPI, what happens to these people?

Understanding Habituation

I want you to understand a key concept, and hopefully this will serve you well. It’s called habituation. I learned this in dealing with these patients for a long time.
These patients come in, and I’ll be listening to them as they talk, and their symptoms are frequently a gravelly voice, voice change, or sensation in the throat. The patient will say, “Well, doc, [clears throat] um, [clears throat] um, [clears throat].”
What you pick up right away is that there is some perpetuation of a behavior here known as habituation. What we are learning is that these patients may get into a cycle that they just can’t get out of.

These patients may truly have had gastroesophageal or laryngopharyngeal reflux. As the reflux improves, the patients, however, have learned to deal with it in the way that they clear their throats or inflect their voices, and that can actually incite an ongoing inflammatory response.

So I take a good voice history. I listen to these patients when they start talking about hoarseness or laryngeal symptoms.
As we are discussing this in the clinic, I listen in particular for habituation-type behavior. I also listen to their stories and ask questions. Are you a singer? Do you talk on the phone a lot? Do you talk in public? Are you a mom or dad who goes to sports games and yells and screams? Have you had voice fatigability over the course of a day? Do you find that your voice gets a little bit tired and strained? A lot of these answers come back as “yes.”
You find an avenue to say not just “you don’t have reflux disease,” but you may be able to develop a way to break this habituation.

Is It Repetitive Habituation-Type Behavior?

To help them understand, I use the analogy of clapping your hands together. If you clap your hands together, they get red and swollen. That is analogous to what the vocal cords are doing. I tell patients that as they clear their throats or have a dry cough or try to cough because of a sensation in their throats, it has the same effect. It perpetuates the inflammatory response.
First of all, you want to make sure that if the patient has reflux symptoms, the reflux is controlled, so it is reasonable to have a trial of a PPI. If the patient has a postnasal drip, you take care of the postnasal drip. If the patient has other modifiable environmental exposures that may make it difficult to control the patient’s postnasal drip or any allergies, you address those factors.

In between are the patients who don’t seem to get any better, and that’s why I want you to learn this habituation evaluation.
I ask these patients a couple of questions. I ask about their voice and their patterns of speech. Do they find that people tell them they don’t sound the same as they used to?

When patients start to have voice fatigability, they will change their pace of speech. They may speak more loudly to overcome what is perceived as a voice weakness. They may change the pitch of their speech. All of these efforts take them out of what I call the quiet, restful voice and induce an inflammatory response, so they perpetuate this behavior. They perpetuate the habituation with repetitive throat clearing and coughing, and it just never goes away.

Breaking the Cycle

After I get a good perspective that this sounds like repetitive habituation-type behavior, I talk with the patients about that and then look at a variety of things that they can do to help themselves.

One thing I insist on is having them carry a bottle of water, and every time they feel that sensation of thick secretions or a swelling-type feeling in the back of their throats, they take water rather than trying to clear it with phonation. If they have to clear it, I ask them to clear it without phonating. They should try to clear their throats softly, rather than harshly, and try to minimize the number of attempts to clear it.

Make sure that patients understand that this is going to be a process, and it’s an education. They need to recognize that they need to throttle back on using their voices if they find that their voices start to become hoarse or tired. They need to cut back on their telephone calls, yelling and screaming at games or parties, or whatever they do to overuse their voices. In social situations, they need to use their quiet voices, rather than projecting their voices, to get the inflammatory response under control.

If the patient can’t carry a bottle of water, I recommend carrying lemon drops, which help the parotid salivary secretions to flow more easily. When they are out and about, these are things they can carry with them. Emphasize hydration, and tell patients to minimize substances that dehydrate them such as caffeine and alcohol. If these patients are smokers, try to get them to stop smoking.

Make sure that the laryngologist has looked at their vocal cords, or do so if you perform an endoscopy. Make sure that all aspects of the problem have been taken care of.
If cough is the primary complaint and the patient is a nonsmoker with no evidence of postnasal drip or allergies, has a clear chest x-ray, and is not taking an angiotensin-converting enzyme inhibitor, you should be able to solve many of these issues just by addressing the habituation response and understanding why the patient is really coughing.

Habituation is very important, and you need to understand how to ask the right questions because these patients are very frustrated. They don’t improve. They see their ENT specialists and their gastroenterologists, and they don’t come back any better. They are stuck in a continual response cycle, even though whatever started that response may now be under control. Habituation perpetuates the problem.

Voice Retraining

I have also found it very helpful to engage with a voice specialist—a physical therapist who is uniquely trained in voice. This is not just a standard speech rehabilitation specialist. It has to be somebody who understands the complexity of voice retraining. They use phonation and exercises to help with pitch and expressions, and they get the patient back down to a more restful voice.
If you have one of those specialists, you should refer to that person. This is not a standard referral. There are very different perspectives among physical therapists and speech therapists with respect to voice retraining.
It’s important, with patients who aren’t improving, to think about habituation, take a good voice history, and do something to help these people because they are in a never-ending cycle.
Hopefully, this gives you some insight with your next patient who presents with similar complaints.