Asymmetric Laryngopharyngeal Reflux Findings Following Sleep in the Lateral Recumbent Position

Laryngopharyngeal reflux (LPR) causes hoarseness, excessive mucous, or phlegm in the throat, throat clearing, globus pharyngis, sore throat, dry throat, cough, water brash, postnasal drip, and other symptoms. Laryngopharyngeal reflux is implicated as a risk factor for laryngeal cancers, also.

Diagnosis and treatment requires a reliable method for quantifying LPR symptoms and signs. Reflux Symptom Index and Reflux Finding Score (RFS) have been validated for this purpose, although they remain controversial. ¹ Laryngoscopy is the most widely used tool for evaluating LPR, although its ability to detect subtle changes on the mucosal surfaces has been called into question. ² The best objective method to measure LPR at present is 24-hour pH impedance testing with a proximal sensor. We describe a consistent pattern of laryngoscopically observed asymmetric arytenoid erythema in patients presenting with a positive (>7) RFS. ¹

In the majority of cases, when asymmetry of arytenoid erythema is present, our prediction of which side the patient slept on the previous night has been correct. One such patient, a 41-year-old male vocal instructor, presented initially with dysphonia and the diagnoses included LPR. The patient failed twice-daily proton pump inhibitor with H₂ blocker at night, and he underwent a laparoscopic Nissen fundoplication 17 months after initial presentation. Following surgery, LPR findings and corresponding symptoms had not resolved fully as evidenced by rigid strobovideolaryngoscopy. A dual sensor 24-hour pH impedance test confirmed persistent LPR. Findings on morning strobovideolaryngoscopy included bilateral arytenoid erythema; however, this finding was more pronounced on the left side (Figure 1). Following this observation, the patient was asked in what position he had slept during the previous night and confirmed that it was on the left side. This is merely one example of a phenomenon observed across multiple patients. It is hypothesized that reflux events during the night while the patient is lying on one side can lead to pooling of gastric contents on the gravity-dependent arytenoid and piriform sinus. The observed correlation further reinforces the relationship between LPR and arytenoid erythema. Also, while the RFS has been validated and remains a useful clinical tool, it lacks sufficient sensitivity to detect subtle differences between examinations, such as the asymmetric erythema observed in this patient.

Figure 1.

Asymmetric laryngeal erythema observed on strobovideolaryngoscopy (left > right) with the vocal folds adducted (A) and abducted (B).

When pronounced unilateral laryngeal erythema and edema is discovered without a clear explanation for asymmetry, the patient’s sleep habits should be considered as a possible etiology.