What is laryngopharyngeal reflux (LPR)?

What is Laryngopharyngeal Reflux (LPR)?

Laryngopharyngeal reflux (LPR) is the backflow of gastric contents into the pharynx and larynx, causing throat and voice symptoms that occur without typical heartburn in up to 75% of cases. 1, 2

Core Definition and Pathophysiology

LPR is an extraesophageal variant of gastroesophageal reflux disease where gastroduodenal contents reflux beyond the esophagus to affect the laryngopharynx. 3, 4 The critical distinction from typical GERD is that the laryngeal mucosa is significantly more sensitive to refluxate than esophageal tissue, requiring fewer reflux episodes to produce symptoms. 5, 2

Clinical Presentation: The "Silent" Nature

The hallmark of LPR is that up to 75% of patients have no typical gastrointestinal symptoms like heartburn or acid regurgitation, earning it the designation "silent reflux." 2 This creates a diagnostic challenge since patients present with throat symptoms rather than esophageal complaints.

Primary Symptoms Include:

• Hoarseness/dysphonia (present in 100% of otolaryngology patients with LPR) 2
• Chronic cough (can be the sole manifestation in up to 75% of cases) 2
• Throat clearing 3, 6
• Globus sensation (feeling of a lump in the throat) 3, 7
• Dysphagia 3, 8
• Post-nasal drip sensation 3
• Throat pain 4, 7

The striking contrast: only 6% of otolaryngology patients with LPR report heartburn despite 100% having hoarseness. 2

Diagnostic Challenges and Pitfalls

A critical pitfall: LPR should NOT be diagnosed based on symptoms or laryngoscopic findings alone. 2 The American Academy of Otolaryngology-Head and Neck Surgery explicitly warns against this common error. 2

Why Diagnosis is Difficult:

• Laryngoscopic findings (erythema, edema, posterior commissure hypertrophy) have sensitivity and specificity less than 50% for diagnosing LPR and can be present in asymptomatic individuals. 5, 2
• There is currently no single gold standard diagnostic tool that can conclusively identify gastroesophageal reflux as the cause of LPR symptoms. 5
• Reflux monitoring (pH testing) has limited diagnostic value for extraesophageal reflux manifestations. 5

Diagnostic Tools Used in Practice:

• Reflux Symptom Index (RSI) - a questionnaire to quantify symptoms 6
• Reflux Finding Score (RFS) - laryngoscopic scoring system 6
• Dual-probe 24-hour pH testing with upper probe above the upper esophageal sphincter (considered gold standard when used) 3
• Laryngoscopy - primarily to exclude alternative diagnoses, not to confirm LPR 9, 1

Treatment Approach

The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends AGAINST empiric PPI therapy for isolated dysphonia or LPR symptoms without laryngoscopic confirmation. 1 Laryngoscopy should be performed first to confirm laryngeal inflammation and exclude alternative diagnoses. 1

For Patients WITH Heartburn or Regurgitation:

Initial treatment combines lifestyle/dietary modifications with twice-daily PPI therapy: 1

• Weight loss if BMI > 25 1
• Elevate head of bed 1
• Avoid eating within 2-3 hours of bedtime 1
• Avoid individualized trigger foods 1
• Twice-daily proton pump inhibitors 1

Important caveat: PPIs alone are ineffective without lifestyle changes. 1

Timeline Expectations:

• Gastrointestinal symptoms respond within 4-8 weeks 1
• LPR symptom improvement may take up to 3 months 1, 3
• Treatment duration typically requires 6 months for complete resolution 6

Evidence Quality Warning:

The evidence for PPIs in LPR is notably weak - only 3 out of 9 placebo-controlled trials showed improvement in voice symptoms, and meta-analyses found no advantage for PPIs over placebo for GERD-related chronic laryngitis. 1 Symptom improvement on PPIs may result from mechanisms other than acid suppression (placebo effect) and should not be regarded as confirmation of GERD as the underlying cause. 1, 5

When Treatment Fails

After one failed 3-month trial of appropriate therapy, perform objective testing (esophageal manometry and pH-metry) rather than trying additional PPIs. 1 This evaluates for alternative diagnoses including laryngeal hypersensitivity. 1

The presence of erosive reflux disease on endoscopy predicts good treatment response of LPR symptoms to PPI treatment. 1, 5

Key Clinical Pearls

• LPR is often multifactorial, requiring a multidisciplinary approach with gastroenterologists and otolaryngologists. 5
• A therapeutic trial of PPIs is often the most pragmatic approach for suspected reflux-related symptoms when objective testing is unavailable. 5
• Functional laryngeal disorders and laryngeal hypersensitivity can mimic LPR symptoms with or without actual gastroesophageal reflux disease. 7