What type of specialist treats laryngopharyngeal reflux (LPR)?

Specialist Management of Laryngopharyngeal Reflux

Laryngopharyngeal reflux requires a multidisciplinary team approach, with otolaryngology (ENT) and gastroenterology serving as co-primary specialists, though the initial point of contact depends on whether typical GERD symptoms are present. 1

Primary Specialist Selection Algorithm

Start with Gastroenterology if:

• Patient has concomitant typical GERD symptoms (heartburn, regurgitation) along with laryngeal symptoms 1
• Patient requires objective reflux testing with pH monitoring or impedance studies, which gastroenterologists perform and interpret 2
• Upper endoscopy is needed to evaluate for erosive esophagitis, hiatal hernia, Barrett's esophagus, or alternative diagnoses like eosinophilic esophagitis 1, 2
• Patient has already failed one trial of PPI therapy (up to 12 weeks) for isolated extraesophageal symptoms, as they require objective testing rather than additional empiric trials 2

Start with Otolaryngology (ENT) if:

• Patient presents with isolated laryngeal symptoms (hoarseness, throat clearing, globus, dysphonia) without typical GERD symptoms 1
• Laryngoscopy is needed to visualize the larynx and exclude structural pathology such as vocal cord paralysis, polyps, papillomas, or malignancy 1
• Dysphonia persists beyond 4 weeks or a serious underlying cause is suspected, requiring direct laryngeal visualization 1
• Suspected laryngeal pathology requires ENT-specific intervention such as botulinum toxin for spasmodic dysphonia or surgery for benign vocal fold lesions 1

Why Both Specialists Are Essential

The 2023 AGA guidelines explicitly state that LPR management requires a multidisciplinary approach because these conditions are multifactorial, and optimal outcomes depend on communication between gastroenterology and otolaryngology. 1

Gastroenterology's Role:

• Performs objective reflux testing (96-hour wireless pH monitoring preferred) off medication to confirm or rule out GERD as the causative factor 2
• Conducts upper endoscopy to identify reflux-related mucosal damage and exclude alternative diagnoses 1, 2
• Manages acid suppression therapy and determines if reflux burden justifies treatment escalation 1
• Coordinates pH-impedance monitoring to detect both acid and non-acid reflux events that may contribute to laryngeal symptoms 2

Otolaryngology's Role:

• Performs diagnostic laryngoscopy to document laryngeal findings and communicate results to the speech-language pathologist or gastroenterologist 1
• Identifies non-reflux causes of laryngeal symptoms including postnasal drip, laryngeal allergy, functional dysphonia, muscle tension dysphonia, vocal cord paralysis, and laryngeal papilloma 1
• Provides surgical intervention for conditions amenable to surgery such as suspected malignancy, symptomatic benign vocal fold lesions unresponsive to conservative management, or glottic insufficiency 1
• Offers specialized treatments like botulinum toxin injections for laryngeal dystonia 1

Additional Specialists in the Multidisciplinary Team

The 2023 AGA guidelines identify several other specialists who may contribute to LPR management depending on the clinical presentation: 1

• Allergy/Immunology: For laryngeal allergy, vocal cord dysfunction, or asthma-related symptoms 1
• Speech-Language Pathology: For functional dysphonia, muscle tension dysphonia, and voice therapy 1
• Pulmonology: When chronic cough, asthma, or pulmonary fibrosis coexist with suspected reflux 1
• Behavioral Psychology: For muscle tension dysphonia and functional voice disorders 1
• Primary Care: For coordinating initial evaluation and managing comorbid conditions 1

Critical Pitfalls to Avoid

Do not refer to ENT alone without gastroenterology involvement, as ENT can identify laryngeal pathology but cannot perform the reflux testing needed to establish GERD as the cause. 2

Do not start empiric PPI therapy for isolated hoarseness without objective testing, as the 2023 AGA guidelines explicitly discourage this approach due to high non-response rates and lack of diagnostic information. 2

Do not assume hoarseness is due to GERD without objective testing, as up to 50-60% of patients with extraesophageal symptoms do not have GERD as the underlying cause, and many conditions mimic LPR. 2, 3

Do not prescribe antireflux medications to treat isolated dysphonia based on symptoms alone without visualization of the larynx, as this is a strong recommendation against in the 2018 AAO-HNS guidelines. 1

Do not continue multiple PPI trials after one failure; instead, refer to gastroenterology for objective testing, as the yield from additional empiric trials is extremely low. 2

Practical Coordination Strategy

The optimal approach involves simultaneous or sequential evaluation by both gastroenterology and otolaryngology, with results interpreted collectively rather than in isolation. 1, 2

• Gastroenterology performs upper endoscopy and arranges prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or rule it out entirely 2
• Otolaryngology performs laryngoscopy to evaluate laryngeal findings and exclude non-reflux causes of hoarseness, with results communicated to gastroenterology 1, 2
• Both specialists collaborate to determine if reflux is contributory, the sole cause, or unrelated to the laryngeal symptoms 1, 2