Context Laryngopharyngeal reflux (LPR) is a major cause of laryngeal inflammation
and presents with a constellation of symptoms different from classic gastroesophageal
Objective To provide a practical approach to evaluating and managing cases of
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
Conclusions Laryngopharyngeal reflux should be suspected when the history and laryngoscopy
findings are suggestive of the diagnosis. Failure to respond to a 3-month
trial of behavioral change and gastric acid suppression by adequate doses
of proton pump inhibitor medication dictates need for confirmatory studies.
Multichannel intraluminal impedance and pH-monitoring studies are most useful
in confirming LPR and assessing the magnitude of the problem.