Should a patient with hoarseness and gastroesophageal reflux disease (GERD) symptoms see a gastroenterologist (GI) or an ear, nose, and throat (ENT) specialist first?

Should a Patient with Hoarseness and GERD Symptoms See Gastroenterology or ENT First?

A patient with hoarseness and GERD symptoms should start with gastroenterology for initial evaluation and management, as extraesophageal GERD manifestations require objective testing off PPI therapy rather than empiric treatment, and gastroenterologists can coordinate the necessary diagnostic workup before determining if ENT involvement is needed. 1

Why Gastroenterology First

The key issue is that hoarseness with GERD represents extraesophageal reflux (EER), which has fundamentally different diagnostic requirements than typical GERD. Unlike classic heartburn and regurgitation that respond well to empiric PPI trials, isolated extraesophageal symptoms like hoarseness have poor response rates to PPIs and require upfront objective testing. 1

• Patients with isolated extraesophageal symptoms should undergo objective reflux testing off medication rather than an empiric PPI trial, as recommended by the American Gastroenterological Association. 1
• The American Gastroenterological Association specifically states that after one failed trial (up to 12 weeks) of PPI therapy for extraesophageal symptoms, patients should be referred to gastroenterology for objective testing. 1
• There is no single diagnostic tool that can conclusively identify reflux as the cause of hoarseness—diagnosis requires a global clinical impression incorporating symptoms, endoscopy findings, and ambulatory reflux monitoring. 1

The Multidisciplinary Reality

However, the optimal approach is actually multidisciplinary from the start, not sequential. The American Gastroenterological Association emphasizes that extraesophageal manifestations are often multifactorial and require input from multiple specialties. 1

• Hoarseness has numerous non-GERD causes including postnasal drip, laryngeal allergy, functional dysphonia, muscle tension dysphonia, vocal cord paralysis, and vocal cord polyps. 1
• A multidisciplinary approach with communication between gastroenterology and otolaryngology results in the best outcomes for suspected EER patients. 1
• Results from ENT diagnostic testing (such as laryngoscopy) should be incorporated when gastroesophageal reflux is considered as a cause for extraesophageal symptoms. 1

Practical Algorithm

Start with gastroenterology who can:

1. Perform upper endoscopy to evaluate for erosive esophagitis (Los Angeles classification), hiatal hernia, Barrett's esophagus, and alternative diagnoses. 1

2. Arrange prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or rule it out entirely. 1

3. Coordinate with ENT for laryngoscopy to evaluate laryngeal findings and exclude non-reflux causes of hoarseness. 1

4. Interpret results collectively rather than treating empirically, since PPI response does not predict the contribution of reflux to hoarseness. 1

Critical Pitfalls to Avoid

• Do not start an empiric PPI trial for isolated hoarseness. This is explicitly discouraged by guidelines because the likelihood of non-response is high and it provides no diagnostic information. 1

• Do not assume hoarseness is due to GERD without objective testing. Many conditions mimic EER, and causation (versus association) is difficult to establish. 1

• Do not refer to ENT alone. While ENT can identify laryngeal pathology, they cannot perform the reflux testing needed to establish GERD as the cause. The gastroenterologist must coordinate this workup. 1

• Recognize that lack of heartburn does not exclude GERD. Patients with extraesophageal reflux may not complain of typical symptoms, yet reflux may still be contributing. 1

If PPI Trial Already Started

If the patient has already been on PPIs without adequate response:

• Refer to gastroenterology immediately rather than continuing different PPI trials, which are low yield. 1
• Testing should be performed off acid suppression to accurately assess reflux burden. 1
• Consider pH-impedance monitoring on PPI only if GERD has already been objectively proven and symptoms persist despite therapy. 1

When ENT Becomes Primary

ENT should take the lead if:

• Laryngoscopy reveals structural pathology (polyps, paralysis, papilloma) requiring ENT-specific intervention. 1
• Objective reflux testing is negative and alternative laryngeal diagnoses need evaluation. 1
• Multidisciplinary evaluation confirms a non-reflux etiology such as muscle tension dysphonia or functional voice disorder. 1