PRACTICE RECOMMENDATIONS
• Recommend dietary and behavioral modifications as a first step in treating patients with symptoms suggestive of laryngopharyngeal reflux disease (LPRD). C
• When medications are needed, prescribe a high-dose proton-pump inhibitor, a histamine-2 blocker at bedtime, and prophylactic antacids for reflux-inducing activities, such as exercising and eating. B
• Avoid the rebound effect associated with abrupt cessation of medications prescribed for LPRD with a gradual, 16-week taper. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE When Joan C, a 35-year-old patient whom you’ve known for years, comes in for a physical, you notice that she’s coughing frequently. Upon questioning, Joan says she first noticed the cough several months ago; she also reports that she’s frequently hoarse, but has no other symptoms. Joan is a former smoker, and quit 4 years ago.
If Joan were your patient, would you suspect that she had an upper respiratory infection and prescribe an antibiotic such as azithromycin? Would you include laryngopharyngeal reflux disease in the differential diagnosis?
Laryngopharyngeal reflux disease (LPRD) is a common condition that most primary care physicians encounter frequently. It is also frequently misdiagnosed by clinicians who are unfamiliar with the differences between LPRD and gastroesophageal reflux disease (GERD).
The American Academy of Otolaryngology–Head and Neck Surgery defines laryngopharyngeal reflux as the retrograde movement of gastric contents into the laryngopharynx.1 Common symptoms include hoarseness/dysphonia, chronic throat clearing, dysphagia, globus pharyngeus, and chronic cough, as well as postnasal drip, paroxysmal laryngospasm, odynophagia, excessive throat mucus, and a strange taste in the mouth.2
The diversity and vagueness of these symptoms, as well as the lack of a gold standard diagnostic test for LPRD, make it difficult to estimate its prevalence. In addition, signs of gastroesophageal reflux can be found in the laryngopharynx of up to 86% of healthy individuals, further complicating the clinical picture.3 To avoid missing this often overlooked reflux disease, you need to know how it develops, what signs and symptoms to look for, and which distinguishing features to keep in mind.
Pathophysiology and distinguishing features
The precise way in which LPRD develops is not known, but there are 2 proposed means of laryngeal injury—direct and indirect. In the first case, chemical irritants in the gastric refluxate enter the laryngopharynx and cause local mucosal injury. In the second, gastric reflux irritates the esophageal tissue enough to evoke laryngeal reflexes without ever reaching the larynx—a vagally mediated response associated with symptoms such as chronic cough, throat-clearing sensations, and bronchoconstriction.4
Unlike the esophageal lining, laryngeal epithelium is not protected against chemical injury from gastric acid, as it lacks both the stripping motion of esophageal peristalsis and the neutralizing bicarbonate in saliva.4 Thus, while far smaller amounts of gastric reflux make it into the laryngopharynx, the acid remains there longer and may cause greater injury.5 In some cases, this occurs as often as 50 times a day, although as few as 3 episodes per week have been known to cause LPRD.5
Heartburn is not the rule
Heartburn is a primary complaint of patients with GERD. It is reported by little more than a third (35%) of those with LPRD,5,6 however, (which is why it is sometimes called the “silent” reflux disease). This is because heartburn is caused by esophagitis due to esophageal dysmotility and lower esophageal sphincter dysfunction,3 while most patients with LPRD have normal esophageal motor function and upper esophageal sphincter dysfunction. The fact that only a minimal amount of reflux enters the laryngopharynx may be part of the reason heartburn is less likely in patients with LPRD.
Onset of symptoms. When reflux occurs is another thing that distinguishes LPRD and GERD. Symptoms of GERD typically worsen when the individual is supine, while laryngopharyngeal reflux usually occurs when he or she is upright.7 The frequency with which these 2 conditions overlap is debatable, as there are few studies differentiating LPRD and GERD based on standardized signs and symptoms.7
Making sense of signs and symptoms
Most patients with LPRD seek treatment from their primary care physician, typically reporting symptoms that they don’t associate with gastric reflux, such as hoarseness, a chronic cough or sore throat, or the sensation of a lump in the throat (TABLE 1). Less common manifestations include “water brash”—excessive mucus in the mouth caused by a release of salivary bicarbonate to help neutralize acidity8—otitis media, sinus disease, and dental caries.5