Evaluation and Management of Laryngopharyngeal Reflux

• Published in: JAMA : the journal of the American Medical Association 2005-09, Vol.294 (12), p.1534-1540
• Main Author: Ford, Charles N
• Format: Article
• Language: English
• Subjects: Algorithms; Biological and medical sciences; Disease management; Enzyme Inhibitors - therapeutic use; Fundoplication; Gastroesophageal Reflux - physiopathology; Gastroesophageal Reflux - therapy; Gastrointestinal Agents - therapeutic use; Gastrointestinal diseases; General aspects; Histamine H2 Antagonists - therapeutic use; Humans; Hydrogen-Ion Concentration; Laryngitis - diagnosis; Laryngitis - etiology; Laryngitis - therapy; Laryngoscopy; Larynx - pathology; Medical diagnosis; Medical sciences; Monitoring, Ambulatory; Proton Pump Inhibitors
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.294.12.1534

CONTEXT Laryngopharyngeal reflux (LPR) is a major cause of laryngeal inflammation and presents with a constellation of symptoms different from classic gastroesophageal reflux disease. OBJECTIVE To provide a practical approach to evaluating and managing cases of LPR. EVIDENCE ACQUISITION The PubMed database and the Ovid Database of Systematic Reviews were systematically searched for laryngopharyngeal reflux, laryngopharyngeal reflux fundoplication, laryngopharyngeal reflux PPI treatment, and gastroesophageal reflux AND laryngitis. Pertinent subject matter journals and reference lists of key research articles were also hand-searched for articles relevant to the analysis. EVIDENCE SYNTHESIS Reflux of gastric contents is a major cause of laryngeal pathology. The pathophysiology and symptom complex of LPR differs from gastroesophageal reflux disease. Laryngeal pathology results from small amounts of refluxate—typically occurring while upright during the daytime—causing damage to laryngeal tissues and producing localized symptoms. Unlike classic gastroesophageal reflux, LPR is not usually associated with esophagitis, heartburn, or complaints of regurgitation. There is no pathognomonic symptom or finding, but characteristic symptoms and laryngoscopic findings provide the basis for validated assessment instruments (the Reflux Symptom Index and Reflux Finding Score) useful in initial diagnosis. There are 3 approaches to confirming the diagnosis of LPR: (1) response of symptoms to behavioral and empirical medical treatment, (2) endoscopic observation of mucosal injury, and (3) demonstration of reflux events by impedance and pH-monitoring studies and barium swallow esophagram. While pH monitoring remains the standard for confirming the diagnosis of gastroesophageal reflux, the addition of multichannel intraluminal impedance technology improves diagnostic accuracy for describing LPR events. Ambulatory multichannel intraluminal impedance assessment allows for identification of gaseous as well as liquid refluxate and detection of nonacid reflux events that are likely significant in confirming LPR. Although some patients respond to conservative behavioral and medical management, as is the case with gastroesophageal reflux, most require more aggressive and prolonged treatment to achieve regression of symptoms and laryngeal tissue changes. Surgical intervention such as laparoscopic fundoplication is useful in selected recalcitrant cases with laxity of the gastroesophageal