Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease

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Key points

  • •

    Extraesophageal reflux syndromes represent a significant economic health care burden in the United States owing to delay in recognition of the diagnosis, lack of a gold standard diagnostic test, and lack of effective therapies.

  • •

    The reflex theory describes the most likely underlying pathophysiology. There is emerging evidence for the role of autonomic nerve dysfunction and neuronal hyperresponsiveness in disease.

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    Current diagnostic modalities, specifically laryngoscopy, esophagogastroduodenoscopy,

Pathophysiology

Controversy exists over the underlying physiologic mechanism linking esophageal reflux to extraesophageal symptoms. The reflux theory postulates that esophagopharyngeal reflux through microaspiration of acid, bile acids, and pepsin results in direct injury to the larynx.8 An alternative mechanism, the reflex theory, proposes that acidification of the distal esophagus induces laryngeal symptoms through a vagally mediated reflex.9,10 In examining the pathophysiology of reflux-induced cough,

Diagnostic modalities

The diagnosis of laryngopharyngeal reflux proves to be more difficult than typical GERD because of the lack of a definitive testing methodology.21 There is much uncertainty on how best to diagnose LPR, with most testing methodologies, such as laryngoscopy, upper endoscopy, and pH monitoring, all showing poor sensitivity in detecting in whom reflux may be the cause of laryngeal symptoms. There are currently no diagnostic tests that unequivocally link any extraesophageal symptoms to GERD.

Medical Therapy

Empiric acid suppression with 2 months of a PPI is the first step in treatment of patients with suspected LPR. There have been numerous studies investigating the efficacy of PPI therapy in this cohort of patients, and there is a lack of evidence in support of its use. In a systematic review of 14 uncontrolled studies and 6 randomized controlled trials that used PPI as empiric therapy for LPR, the uncontrolled studies showed positive results, but the randomized controlled trials (RCTs) reported

Summary

A gold standard test for the diagnosis of extraesophageal GERD remains elusive. Laryngoscopy and EGD have poor predictive value for diagnosing GERD as the cause of laryngeal symptoms. Ambulatory pH-impedance monitoring and oropharyngeal pH monitoring are also limited and novel tests and biomarkers need further controlled trials before they can be recommended for diagnostic evaluation. The lack of a gold standard test for diagnosis, in addition to the variable response to PPI, has undoubtedly

Disclosure

The authors have no relevant conflicts of interest pertaining to this article.

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