I have been a laryngologist for almost 40 years, and I was one of the very first to specialize in this field. Laryngology is a medical specialty that focuses on patients with voice disorders and diseases of the larynx (voice box), throat and airway. Quite possibly, I have examined more larynges (plural of larynx) than anyone in the history of civilization, approximately 250,000 of them.
When I look at the larynx, I see things that other doctors don’t see. In particular, I recognize the subtle findings of acid reflux and vocal cord weakness; those being the most common and important underlying causes of hoarseness. The larynx talks to me. It tells the patient’s medical history and it tells me the whole story. I am the larynx whisperer.
How did my story begin? In 1969 I went to medical school with the idea of becoming a general surgeon. I attended Boston University, and during my third-year electives, I had the opportunity to work with three creative visionaries (Drs. Strong, Vaughn and Jako), who were pioneering laser surgery of the larynx.
Imagine my excitement and awe when in 1972 I first saw one-inch-long vocal cords grow to the size of gigantic salamis on a large-screen TV. The images were incredible. The tiny blood vessels looked like a NY subway map. Through the operating microscope, small growths could be removed with precision using laser light. And this was all done through the mouth with no incisions, while the patient slept. It was brilliant. I signed up on the spot.
I finished my residency in 1978, and became the 4th surgeon in the United States to work with the CO2 laser. My very first business cards declared, “Specializing in Laryngology and the Voice.” I appealed to my medical colleagues: “Just send me the patients with laryngeal and voice disorders that you don’t want, and the ones that you can’t fix.” I got busy very quickly.
In 1981, I began to notice that some of my patients had unexplained laryngeal inflammation that was severe and causing complications. I removed vocal cord polyps from one patient with precision only to find that she subsequently developed excessive scarring. In another case, I successfully removed a small vocal cord cancer, which healed poorly (unexpectedly) resulting in another bad outcome.
Patients who had surgical complications seemed to show a similar pattern, and some had symptoms of heartburn. Eureka! I figured it out—they had reflux. I began to explore all that was known about reflux in the medical literature, and I found little on how it might affect the larynx and throat. With careful documentation of my observations, I began to be able to describe the reliable findings of reflux laryngitis. Around that same time (1982-83), I got the idea to do reflux testing in the throat using a specially designed pH (acid) monitoring device. For the next 20 years ( as both clinician and scientist), I would spent my career studying reflux as it affected the larynx.
It has taken me all these years to become the larynx whisperer; it has been a personal journey, an evolution of experience and thought. Now it is clear and now I can teach others much of what I know.
For years I had believed that people either had airway or esophageal reflux (not both) with different symptoms, different patterns of reflux and different manifestations; however, that is not the case. Reflux is reflux and why some people develop predominant airway or esophageal symptoms is still unclear, but most people with esophageal reflux also show manifestations of airway reflux even if they deny having airway symptoms. The converse is less true, that is, many people with airway reflux do not have esophageal disease, because much less reflux in the airway can cause trouble
I developed a reflux scoring system for airway (laryngeal) reflux long ago. Unfortunately most physicians are unaware of it; however, I have scored every examination of every patient at every visit for 25 years. Now, I know that most people with reflux, regardless of their symptoms (airway or esophageal reflux) have laryngeal findings of reflux. A look at the larynx tells everything about the status of the entire reflux system; the reflux finding score is a reliable barometer of the whole system.
The Larynx as Barometer of the Reflux System
I used to think that airway reflux (LPR) and esophageal reflux (GERD) were fundamentally dissimilar, that the mechanisms and patterns of reflux were different, which explained why each group of patients had different symptoms.
I thought that the mechanism in LPR was related to a faulty upper esophageal valve (UES, upper esophageal sphincter) and that’s why reflux got into the throat. Similarly, the mechanism in GERD was a leaky the lower valve (LES, lower esophageal sphincter). As it turns out, both valves are dysfunctional in almost all people with reflux regardless of their symptoms. This is a paradigm shift, even for me, and I have been professionally immersed in reflux every day for decades. I thought I understood reflux, but I was wrong.
Here’s why. As a laryngologist, until I wrote Dropping Acid: The Reflux Diet Cookbook and Cure, I was almost exclusively seeing patients with airway reflux. After the book, I began to see just as many patients with primary esophageal reflux who wanted my advice on diet, lifestyle, and treatment in general. As a matter of fact, I began seeing the worst of the worst, people with Barrett’s esophagus, a reflux-caused precancerous condition.
In other words, patients with severe GERD were consulting me. To my surprise, all of them looked like they had airway reflux (LPR) when I examined their throats. Maybe they looked less inflamed (red), but they all looked swollen (edematous) in a pattern that I recognized to be exclusively related to reflux. That’s right, not allergies, infections, or post-nasal drip causes a larynx to look like reflux. To me, only reflux looks like reflux.
Now, with a lot of experience taking care of patients with “GERD,” I am finding that all refluxers have signs and symptoms of reflux in the larynx. And I now believe that by varying degrees, the entire system is affected by reflux. In other words, almost all patients with reflux, regardless of their symptoms, will have characteristic findings of airway reflux. And when the larynx becomes healthy, the system is healthy … and that is my job, to make that happen.
These before- and after-treatment photographs show the larynx of a 40-year-old woman with airway reflux who presented with severe hoarseness, chronic cough, and “asthma”; she was a silent refluxer. [Before (top photo) and after (bottom photo). The V-like structures are the vocal cords; the pre-treatment (upper) is very swollen (blimp-like) by comparison with the photo on the bottom. Also, the back of the larynx (top of the photos) is very much thicker and redder in the before-treatment (upper) photo.]
Specialization: When Being the Best Isn’t Good Enough
Neither gastroenterologists (GIs) nor otolaryngologists recognize and treat airway (laryngeal) reflux; neither have a reliable test for it. And unfortunately, for the most part, ENT doctors do not know what they are looking at when they do examine the larynx. And lung doctors? They still have no idea that reflux accounts for up to 70% of lung disease. Pulmonologists think of reflux last, and when they do, they consult GIs.
When it comes to reflux, the medical establishment has missed the boat by a mile. (You are probably asking yourself how could this happen? Maybe I could be wrong?) Consider this: I recently showed the “reflux laryngitis” photo, the “before treatment” one (above), at a national convention of ENT doctors where I lectured on reflux. I asked for a show of hands to the question, “Is this larynx abnormal?” No hands went up. Then, I asked, “Okay, is this larynx normal?” Again, no hands went up. Hundreds of otolaryngologists in the audience looking at a photo that unequivocally showed reflux, and all I could hear was crickets. Not one of the doctors even dared to venture a guess.
Dear reader — and silent reflux sufferer — that is the sad state of the art!