Laryngeal Hypersensitivity in the Context of LPR and Burning Mouth Symptoms
Laryngeal hypersensitivity represents a distinct pathophysiologic entity that may coexist with or mimic laryngopharyngeal reflux, and should be considered as an alternative diagnosis when patients fail to respond to appropriate acid suppression therapy, potentially benefiting from neuromodulators or behavioral interventions rather than continued PPI therapy. 1, 2
Understanding Laryngeal Hypersensitivity
Laryngeal hypersensitivity manifests as heightened laryngeal responsiveness to normal stimuli, producing symptoms such as chronic throat clearing, cough, globus sensation, voice changes, and paradoxical vocal fold movement. 3, 4 This condition results from both local irritation (which can include refluxate) and heightened sympathetic tone that creates hyper-responsive laryngeal patterns. 4
Key Diagnostic Distinctions
The critical error in clinical practice is assuming all laryngeal symptoms represent acid reflux. 2, 5 The laryngeal mucosa is more sensitive to refluxate than esophageal tissue, requiring fewer reflux episodes to produce symptoms, but this does not mean all laryngeal symptoms are reflux-related. 6
Diagnostic Approach for Your Patient
Step 1: Mandatory Laryngoscopy
You must perform laryngoscopy before prescribing any antireflux medication for isolated laryngeal or burning mouth symptoms. 1, 2 Look specifically for:
- Erythema and edema of the vocal folds 2, 7
- Surface irregularities of the arytenoid mucosa 2
- Posterior commissure changes 2
Critical caveat: Laryngoscopic findings alone have sensitivity and specificity less than 50% for LPR diagnosis and may be present in healthy individuals. 2, 6, 7
Step 2: Assess for Typical GERD Symptoms
Determine if your patient has heartburn or regurgitation alongside the burning mouth symptoms. 2, 5 This distinction is crucial because:
With typical GERD symptoms: Aggressive lifestyle modifications plus high-dose PPI therapy is appropriate, with expected response in 4-8 weeks for GI symptoms and up to 3 months for laryngeal symptoms. 2, 5
Without typical GERD symptoms: Do NOT empirically prescribe PPIs, as multiple meta-analyses show no advantage over placebo for isolated laryngeal symptoms (relative risk 1.28; 95% CI 0.94-1.74). 5
Step 3: Consider Alternative Diagnoses
For burning mouth symptoms specifically, consider primary burning mouth syndrome, which may require gabapentin rather than acid suppression. 2 Laryngeal hypersensitivity should be strongly considered when:
- Symptoms persist despite 3 months of appropriate PPI therapy 2, 5
- No typical reflux symptoms are present 5
- Laryngoscopy shows minimal or non-specific findings 2, 6
Treatment Algorithm for Laryngeal Hypersensitivity
When to Suspect Laryngeal Hypersensitivity
After one failed 3-month trial of appropriate therapy (lifestyle modifications plus PPIs if GERD symptoms present), perform objective testing rather than trying additional PPIs. 2, 5 Consider laryngeal hypersensitivity as the primary diagnosis rather than refractory reflux. 2
Evidence-Based Treatment Options
Laryngeal Recalibration Therapy (LRT): Speech-language pathologist-directed therapy provides mechanical desensitization and cognitive recalibration to suppress hyper-responsive laryngeal patterns. 4 In a 2024 study, 85% of patients with chronic laryngopharyngeal symptoms experienced symptom response with LRT, regardless of whether they had proven GERD on objective testing. 4
Neuromodulators: Pharmacologic visceral analgesia through agents like gabapentin or baclofen may reduce symptoms contributed by laryngeal hypersensitivity and hypervigilance. 1 However, baclofen has a challenging side effect profile and is not routinely recommended as primary therapy. 1
Behavioral Interventions: Hypnotherapy and other cortical modulation approaches may help, though data are sparse. 1
Critical Pitfalls to Avoid
Do not continue empiric PPI therapy beyond 3 months without objective response. 2, 5 The most common error is repeatedly prescribing or escalating acid suppression for isolated burning mouth or laryngeal symptoms without documented reflux, exposing patients to unnecessary risks including impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease. 5
Do not add H2-receptor antagonists to twice-daily PPI therapy for refractory symptoms. 5 There is no evidence of improved efficacy, and this represents therapeutic escalation without diagnostic clarity. 5
Do not rely on symptom improvement while on PPI therapy as confirmation of GERD. 6 Symptom improvement may result from mechanisms other than acid suppression, including placebo effects. 6, 7
Practical Management for Your Patient
Given your patient's history of LPR and burning mouth symptoms:
Perform laryngoscopy immediately to document current laryngeal findings and exclude alternative diagnoses. 1, 2
If typical GERD symptoms are present: Implement weight loss (if BMI >25), head of bed elevation, avoiding meals within 3 hours of bedtime, and high-dose PPI therapy (e.g., esomeprazole 40 mg twice daily). 5
If typical GERD symptoms are absent: Consider primary burning mouth syndrome or laryngeal hypersensitivity as the primary diagnosis and refer for speech-language pathology evaluation for LRT. 2, 4
If already on appropriate therapy for 3 months without improvement: Perform objective pH-impedance monitoring and strongly consider referral for LRT rather than escalating acid suppression. 2, 5, 4
Consider trial of gabapentin for burning mouth symptoms if reflux has been adequately excluded or treated, as this may address neuropathic or hypersensitivity components. 1, 2