Evaluation and management of laryngopharyngeal reflux.
BACKGROUND
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.


METHODS
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.


RESULTS
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 sphincter.


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.
Ford
Charles N
CN
Department of Surgery, Division of Otolaryngology, University of Wisconsin, Madison, USA. ford@surgery.wisc.edu
D000465:Algorithms; D004791:Enzyme Inhibitors / Q000627:therapeutic use; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000503:physiopathology / Q000628:therapy; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007827:Laryngitis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D007828:Laryngoscopy; D007830:Larynx / Q000473:pathology; D018670:Monitoring, Ambulatory; D054328:Proton Pump Inhibitors
D004791:Enzyme Inhibitors; D005765:Gastrointestinal Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors