What is the treatment for laryngoesophageal reflux?

Treatment of Laryngopharyngeal Reflux (LER)

The most effective treatment for laryngopharyngeal reflux includes a combination of lifestyle modifications and proton pump inhibitors (PPIs) for 8-12 weeks, with twice-daily dosing recommended for patients with both LER and typical GERD symptoms. 1

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• Laryngoscopy should be performed to confirm laryngeal inflammation and rule out alternative diagnoses 1
• Consider objective testing (pH monitoring, impedance testing) for patients who fail initial therapy 1
• Distinguish between LER and typical GERD, as treatment approaches may differ 1

First-Line Treatment: Lifestyle Modifications

Lifestyle modifications are foundational and should be implemented before or alongside medication:

• Dietary changes:

  • Avoid food intake at least 2-3 hours before recumbency 1, 2
  • Limit fat intake to no more than 45g in 24 hours 2
  • Avoid trigger foods on an individualized basis (common triggers: coffee, tea, chocolate, mints, citrus, alcohol) 1, 2
  • Consider food sensitivity testing for refractory cases 3

• Positional therapy:

  • Elevate head of bed on 6-8 inch blocks 1, 2
  • Sleep in left lateral decubitus position 1, 2

• Other lifestyle measures:

  • Weight loss for overweight/obese patients 1, 2
  • Smoking cessation 2
  • Avoid late evening meals 2
  • Limit vigorous exercise that increases intra-abdominal pressure 2

Pharmacologic Management

For patients with both LER and typical GERD symptoms:

• First-line medication: Proton pump inhibitors (PPIs)

  • Twice-daily dosing for 8-12 weeks 1
  • Example: Lansoprazole 30mg twice daily 4
  • Higher response rates with twice-daily vs. once-daily dosing 1

• Adjunctive therapy:

  • Alginate-containing antacids may provide additional benefit 1
  • H2-receptor antagonists (H2RAs) may help with nighttime breakthrough reflux 1

For patients with LER symptoms alone (without typical GERD symptoms):

• Caution with empiric PPI therapy - evidence for benefit is limited 1
• Consider objective testing before initiating long-term medication 1

Treatment Duration and Follow-up

• Initial treatment period: 8-12 weeks 1, 5
• Response to treatment may be delayed - improvement in laryngeal symptoms can take up to 3 months 2, 5
• If no response after 12 weeks of appropriate therapy, consider:
  1. Objective testing for pathologic reflux 1
  2. Alternative diagnoses 1
  3. Non-acid reflux as a potential cause 1

Alternative Treatment Options

For patients who fail standard therapy:

• Non-PPI treatment options:

  • Neuromodulators for laryngeal hypersensitivity 1
  • Cognitive behavioral therapy 1
  • External upper esophageal sphincter compression devices 1, 5, 6

• Surgical options (for patients with objectively defined GERD):

  • Anti-reflux surgery may be considered after shared decision-making 1
  • Important caveat: Lack of response to PPI therapy predicts poor response to surgery 1

Common Pitfalls to Avoid

1. Overuse of PPIs in patients without documented GERD or with LER symptoms alone 1, 2
2. Inadequate treatment duration - laryngeal symptoms may take longer to resolve than typical GERD symptoms 2
3. Failure to implement comprehensive lifestyle modifications before or alongside medication 2
4. Empiric PPI treatment without laryngoscopy - may lead to missed diagnoses 1
5. Ignoring potential side effects of long-term PPI use - including impaired cognition, bacterial gastroenteritis, pneumonia, drug interactions, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease 1

Remember that LER is a complex syndrome with multiple potential causes beyond acid reflux. A systematic approach to diagnosis and treatment is essential for optimal outcomes.