What is Laryngopharyngeal Reflux?
Laryngopharyngeal reflux (LPR) is a condition where gastric contents backflow into the larynx and pharynx, causing laryngeal inflammation and symptoms such as throat clearing, hoarseness, chronic cough, globus sensation, and dysphonia—typically without the heartburn or regurgitation seen in classic gastroesophageal reflux disease (GERD). 1, 2
Key Distinguishing Features from GERD
LPR differs fundamentally from typical GERD in several critical ways:
- Silent reflux: Up to 75% of LPR patients lack typical GI symptoms like heartburn or regurgitation, making it "silent" from a gastrointestinal standpoint 1, 3
- Tissue sensitivity: The laryngeal mucosa is far more sensitive to refluxate than esophageal tissue, requiring fewer reflux episodes to produce symptoms and damage 4
- Timing of reflux: LPR typically occurs while upright during daytime hours, whereas classic GERD often occurs when supine 5
- Symptom profile: Otolaryngology patients with LPR present with hoarseness (100%) and rarely heartburn (6%), while gastroenterology GERD patients show the opposite pattern—heartburn (89%) and no hoarseness 1
Clinical Presentation
The characteristic symptoms include:
- Throat clearing and excess mucus production in the throat 2, 6
- Hoarseness and dysphonia (voice changes) 2, 5
- Chronic cough without other obvious cause 1, 3
- Globus sensation (feeling of a lump in the throat) 2, 6
- Throat pain or soreness 2, 7
Pathophysiology
The mechanism involves:
- Small amounts of refluxate causing disproportionate damage to laryngeal tissues compared to the esophagus 5
- Both acid and non-acid reflux can contribute to symptoms, including gaseous refluxate 5
- Inflammation and narrowing of the posterior choanae in infants and children, potentially leading to nasal congestion and respiratory complications 1
Special Populations
In infants and children, LPR (also called pharyngonasal reflux) presents differently:
- Frequent choking and apneic spells 1
- Recurrent pneumonia from aspiration 1
- Nasal congestion from posterior choanal inflammation 1
- Associated with prematurity, neuromuscular disease, or cleft palate 1
Diagnostic Challenges
LPR diagnosis remains problematic because:
- No pathognomonic finding exists: There is no single symptom or test that definitively confirms LPR 5
- Laryngoscopic findings are unreliable: Erythema and edema have sensitivity and specificity both less than 50% 4, 8
- pH monitoring has limitations: Standard reflux testing has limited diagnostic value for extraesophageal manifestations 4
- Multichannel intraluminal impedance combined with pH monitoring improves detection of non-acid and gaseous reflux events that contribute to LPR 5