ABSTRACT

In patients with laryngopharyngeal reflux (LPR), gastric contents exhibit retrograde flow into the upper aero-digestive tract, causing extraesophageal symptoms. It is apparent that the pathophysiology of LPR is different from that of classical gastroesophageal reflux disease (GERD). Head and neck disorders associated with extraesophageal reflux are postulated to occur via direct mucosal damage or a direct effect on mucociliary clearance from exposure to gastric contents; gastroesophageal reflux (GER) related distal esophageal damage that results in vagally mediated, referred symptomatology; and laryngeal reflexes mediated by the stimulation of distal esophageal afferents. Alteration of pH has a direct effect on mucociliary transport and may lead to increased viscosity of the mucus. A reduction in mucociliary transport may decrease resistance to infection and has been theorized to contribute to the pathogenesis of subglottic stenosis. The diagnosis of LPR is difficult with the current understanding of the pathophysiology and available tests. Laryngoscopy does not dependably predict who will respond to treatment, due to high interobserver variability. A 2-month treatment course of PPI is typically safe in those without accompanying warning symptoms. A trial of twice-daily PPI for evaluation and management, in addition to dietary and behavioral changes, should be emphasized. All PPI therapy should be tapered to the minimum dose of acid suppression to control patient symptoms. Future studies with oropharyngeal pH monitoring and salivary pepsin assay need to provide controlled outcome data to better understand their role in cases with difficulty in the diagnosis. Overall, there is currently no clear evidence that an empiric PPI trial results in a significant reduction in LPR symptoms or laryngoscopic findings over placebo. Therefore, its use as a diagnostic or therapeutic tool in the management of patients with ENT symptoms remains controversial. However, on the basis of outcomes of LPR studies to date and earlier experience with treatment of GERD and erosive esophagitis, a trial of 2-3 months should be used, with dose tapering if a symptomatic response is achieved. Given the unreliability of laryngoscopic findings, therapy should be based on symptoms. (JAREM 2014; 4: 85-7)

Keywords: Reflux, laryngopharyngeal reflux, gastroesophageal reflux, pepsin, bile acid