Severe laryngeal hyperkeratosis secondary to laryngopharyngeal reflux.

A 53-year-old man, a smoker, presented to our office with a 1-year history of hoarseness. The hoarseness had first manifested following a severe upper respiratory infection. The patient's voice was rough and breathy. His Voice Handicap Index-10 score was 23 and his Reflux Symptom Index score was 24. Laryngeal examination detected diffuse laryngeal erythema and edema, and posterior laryngeal mucosal ulceration, as well as keratosis and generalized surface irregularity of the laryngeal mucosa. The patient was treated empirically for laryngopharyngeal reflux (LPR). He was prescribed 40 mg/day of pantoprazole (taken 60 min prior to dinner), 300 mg of ranitidine every night, and behavior modification for gastroesophageal reflux disease (GERD). (1,2)

Two months later, the patient returned for a follow-up evaluation. His voice had improved somewhat, but it was still raspy and deep. Laryngoscopic examination detected some crusting, surface irregularity, and keratosis of both vocal folds (figure, B). We performed microlaryngoscopy and biopsy of the larynx to evaluate for possible malignancy. The pathologist reported several areas of mild to moderate dysplasia and two areas of severe dysplasia. The dose of pantoprazole was increased to 40 mg twice a day, and ranitidine and GERD behavior modification were continued. Serologic tests to identify possible autoimmune or rheumatologic causes of the ulcerated vocal folds were all negative.

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At the 4-month follow-up visit, strobovideolaryngoscopy revealed a significant reduction in laryngeal crusting, but posterior glottic inflammation, pachydermia, and mild leukoplakia persisted. The patient was encouraged to maintain his current treatment.

At the 6-month follow-up visit, the hoarseness had resolved. Strobovideolaryngoscopy showed a great deal of improvement, including an absence of keratosis and vocal fold inflammation (figure, C).

LPR is common among patients with voice disorders. Medical therapy with a proton-pump inhibitor and ranitidine, as well as initiation of lifestyle modifications, has been shown to alleviate the disease. In the case described herein, a severe laryngeal hyperkeratosis secondary to LPR completely resolved with this treatment.

References

(1.) Park W, Hicks DM, Khandwala F, et al. Laryngopharyngeal reflux: Prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response. Laryngoscope 2005; 115:1230-8.

(2.) Steward DL, Wilson KM, Kelly DH, et al. Proton pump inhibitor therapy for chronic laryngo-pharyngitis: A randomized placebo-control trial. Otolaryngol Head Neck Surg 2004; 131:342-50.

Isabel Garcia, MD; Priya Krishna, MD; Clark A. Rosen, MD, FACS

From the Department of Otolaryngology, Hospital Universitario Ramon y Cajal, Madrid (Dr. Garcia), and the Department of Otolaryngology--Head and Neck Surgery, University of Pittsburgh School of Medicine (Dr. Krishna and Dr. Rosen).