Photo Rounds

Hoarseness and chronic cough

A 52-year-old man complained to his family physician (FP) about hoarseness and a chronic cough that had been bothering him for the past 6 months. He told his FP that he occasionally got reflux and took an over-the-counter H2 blocker as needed. He denied any recent upper respiratory infections and did not smoke. The FP performed flexible fiberoptic laryngoscopy and viewed the vocal cords during phonation.

What's your diagnosis?


The FP diagnosed laryngopharyngeal reflux (LPR) based on the edema and visible mucus. The vocal cords showed no masses or lesions.

LPR symptoms include hoarseness, throat clearing, “postnasal drip,” chronic cough, dysphagia, globus pharyngeus, and sore throat. LPR must be differentiated from gastroesophageal reflux disease (GERD), in which acid reflux is more likely to cause heartburn, indigestion, and regurgitation and does not necessarily reach the larynx or upper aerodigestive tract.

In this case, the FP recommended that the patient avoid acidic and greasy foods, limit alcohol and caffeine, consider losing some weight, and avoid meals shortly before lying down. Medical therapy consisted of twice daily proton pump inhibitors 30 to 60 minutes before meals, which can often be weaned after several months of therapy. Some patients benefit from adding an H2 blocker, such as ranitidine 300 mg, at bedtime.

Photos courtesy of Blake Simpson, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Matrka L, Simpson CB, King JM. The larynx (hoarseness). In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:220-226.

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