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Laryngopharyngeal reflux

Ramon A Franco, Jr, MD
Section Editor
Daniel G Deschler, MD, FACS
Deputy Editor
Daniel J Sullivan, MD, MPH


Laryngopharyngeal reflux (LPR) is the retrograde movement of gastric contents (acid and enzymes such as pepsin) into the laryngopharynx, leading to symptoms referable to the larynx/hypopharynx [1,2]. Typical LPR symptoms include dysphonia/hoarseness, globus pharyngeus, mild dysphagia, chronic cough, and nonproductive throat clearing [3].

Most patients are relatively unaware of LPR, with only 35 percent reporting heartburn. There are no unequivocal criteria that reliably demonstrate a causal link between acid reflux and laryngeal symptoms; results of esophageal pH testing, and response to proton pump inhibition therapy in controlled trials, are variable. (See 'Diagnosis' below.)

In fact, the validity of reflux as a cause of symptoms attributed to LPR, in the absence of esophageal symptoms associated with gastroesophageal reflux disease (GERD), has been called into question. Guidelines issued by specialty societies in laryngology [1] and gastroenterology [4] present differing perspectives. Both groups acknowledge that interpretation of existing studies is confounded by uncertain diagnostic criteria for LPR, differing measures of treatment response, and a significant placebo treatment effect.

Thus, it is likely that some patients are mistakenly diagnosed with LPR, and investigation of other causes of laryngeal symptoms (allergy, sinus, or pulmonary disease) should be considered for patients who fail to respond to LPR measures.

The clinical manifestations, diagnosis, and treatment of LPR are discussed here. GERD is discussed separately. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and "Medical management of gastroesophageal reflux disease in adults" and "Surgical management of gastroesophageal reflux in adults".)

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Literature review current through: Nov 2017. | This topic last updated: Jun 20, 2017.
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  1. Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002; 127:32.
  2. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005; 294:1534.
  3. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991; 101:1.
  4. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1392.
  5. Hicks DM, Ours TM, Abelson TI, et al. The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers. J Voice 2002; 16:564.
  6. Merati AL, Lim HJ, Ulualp SO, Toohill RJ. Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 2005; 114:177.
  7. Ozturk O, Oz F, Karakullukcu B, et al. Hoarseness and laryngopharyngeal reflux: a cause and effect relationship or coincidence? Eur Arch Otorhinolaryngol 2006; 263:935.
  8. Aviv JE, Liu H, Parides M, et al. Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia. Ann Otol Rhinol Laryngol 2000; 109:1000.
  9. Altman KW, Haines GK 3rd, Hammer ND, Radosevich JA. The H+/K+-ATPase (proton) pump is expressed in human laryngeal submucosal glands. Laryngoscope 2003; 113:1927.
  10. Roussa E, Thévenod F. Distribution of V-ATPase in rat salivary glands. Eur J Morphol 1998; 36 Suppl:147.
  11. Roussa E, Thévenod F, Sabolic I, et al. Immunolocalization of vacuolar-type H+-ATPase in rat submandibular gland and adaptive changes induced by acid-base disturbances. J Histochem Cytochem 1998; 46:91.
  12. Basseri B, Conklin JL, Mertens RB, et al. Heterotopic gastric mucosa (inlet patch) in a patient with laryngopharyngeal reflux (LPR) and laryngeal carcinoma: a case report and review of literature. Dis Esophagus 2009; 22:E1.
  13. Chong VH, Jalihal A. Heterotopic gastric mucosal patch of the esophagus is associated with higher prevalence of laryngopharyngeal reflux symptoms. Eur Arch Otorhinolaryngol 2010; 267:1793.
  14. Cobeta I, Pacheco A, Mora E. The role of the larynx in chronic cough. Acta Otorrinolaringol Esp 2013; 64:363.
  15. Bucca CB, Bugiani M, Culla B, et al. Chronic cough and irritable larynx. J Allergy Clin Immunol 2011; 127:412.
  16. Norris BK, Schweinfurth JM. Management of recurrent laryngeal sensory neuropathic symptoms. Ann Otol Rhinol Laryngol 2010; 119:188.
  17. Campbell R, Kilty SJ, Hutton B, Bonaparte JP. The Role of Helicobacter pylori in Laryngopharyngeal Reflux. Otolaryngol Head Neck Surg 2017; 156:255.
  18. Sivarao DV, Goyal RK. Functional anatomy and physiology of the upper esophageal sphincter. Am J Med 2000; 108 Suppl 4a:27S.
  19. Wiener GJ, Koufman JA, Wu WC, et al. Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring. Am J Gastroenterol 1989; 84:1503.
  20. Axford SE, Sharp N, Ross PE, et al. Cell biology of laryngeal epithelial defenses in health and disease: preliminary studies. Ann Otol Rhinol Laryngol 2001; 110:1099.
  21. Johnston N, Bulmer D, Gill GA, et al. Cell biology of laryngeal epithelial defenses in health and disease: further studies. Ann Otol Rhinol Laryngol 2003; 112:481.
  22. Koufman JA. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease. Ear Nose Throat J 2002; 81:7.
  23. Dagli E, Yüksel A, Kaya M, et al. Association of Oral Antireflux Medication With Laryngopharyngeal Reflux and Nasal Resistance. JAMA Otolaryngol Head Neck Surg 2017; 143:478.
  24. Cherry J, Margulies SI. Contact ulcer of the larynx. Laryngoscope 1968; 78:1937.
  25. Delahunty JE, Cherry J. Experimentally produced vocal cord granulomas. Laryngoscope 1968; 78:1941.
  26. Chodosh PL. Gastro-esophago-pharyngeal reflux. Laryngoscope 1977; 87:1418.
  27. Bortolotti M. Laryngospasm and reflex central apnoea caused by aspiration of refluxed gastric content in adults. Gut 1989; 30:233.
  28. Chung JH, Tae K, Lee YS, et al. The significance of laryngopharyngeal reflux in benign vocal mucosal lesions. Otolaryngol Head Neck Surg 2009; 141:369.
  29. Bain WM, Harrington JW, Thomas LE, Schaefer SD. Head and neck manifestations of gastroesophageal reflux. Laryngoscope 1983; 93:175.
  30. Little FB, Koufman JA, Kohut RI, Marshall RB. Effect of gastric acid on the pathogenesis of subglottic stenosis. Ann Otol Rhinol Laryngol 1985; 94:516.
  31. Jindal JR, Milbrath MM, Shaker R, et al. Gastroesophageal reflux disease as a likely cause of "idiopathic" subglottic stenosis. Ann Otol Rhinol Laryngol 1994; 103:186.
  32. Ward PH, Hanson DG. Reflux as an etiological factor of carcinoma of the laryngopharynx. Laryngoscope 1988; 98:1195.
  33. Morrison MD. Is chronic gastroesophageal reflux a causative factor in glottic carcinoma? Otolaryngol Head Neck Surg 1988; 99:370.
  34. Hickson C, Simpson CB, Falcon R. Laryngeal pseudosulcus as a predictor of laryngopharyngeal reflux. Laryngoscope 2001; 111:1742.
  35. Qadeer MA, Swoger J, Milstein C, et al. Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux. Laryngoscope 2005; 115:1947.
  36. Book DT, Rhee JS, Toohill RJ, Smith TL. Perspectives in laryngopharyngeal reflux: an international survey. Laryngoscope 2002; 112:1399.
  37. Branski RC, Bhattacharyya N, Shapiro J. The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. Laryngoscope 2002; 112:1019.
  38. Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001; 111:1313.
  39. Belafsky PC, Postma GN, Koufman JA. Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope 2001; 111:979.
  40. Reichel O, Dressel H, Wiederänders K, Issing WJ. Double-blind, placebo-controlled trial with esomeprazole for symptoms and signs associated with laryngopharyngeal reflux. Otolaryngol Head Neck Surg 2008; 139:414.
  41. Lien HC, Wang CC, Hsu JY, et al. Classical reflux symptoms, hiatus hernia and overweight independently predict pharyngeal acid exposure in patients with suspected reflux laryngitis. Aliment Pharmacol Ther 2011; 33:89.
  42. Noordzij JP, Khidr A, Desper E, et al. Correlation of pH probe-measured laryngopharyngeal reflux with symptoms and signs of reflux laryngitis. Laryngoscope 2002; 112:2192.
  43. Reichel O, Keller J, Rasp G, et al. Efficacy of once-daily esomeprazole treatment in patients with laryngopharyngeal reflux evaluated by 24-hour pH monitoring. Otolaryngol Head Neck Surg 2007; 136:205.
  44. Vaezi MF, Schroeder PL, Richter JE. Reproducibility of proximal probe pH parameters in 24-hour ambulatory esophageal pH monitoring. Am J Gastroenterol 1997; 92:825.
  45. Reichel O, Issing WJ. Impact of different pH thresholds for 24-hour dual probe pH monitoring in patients with suspected laryngopharyngeal reflux. J Laryngol Otol 2008; 122:485.
  46. Muderris T, Gokcan MK, Yorulmaz I. The clinical value of pharyngeal pH monitoring using a double-probe, triple-sensor catheter in patients with laryngopharyngeal reflux. Arch Otolaryngol Head Neck Surg 2009; 135:163.
  47. Golub JS, Johns MM 3rd, Lim JH, et al. Comparison of an oropharyngeal pH probe and a standard dual pH probe for diagnosis of laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 2009; 118:1.
  48. Eckley CA, Michelsohn N, Rizzo LV, et al. Salivary epidermal growth factor concentration in adults with reflux laryngitis. Otolaryngol Head Neck Surg 2004; 131:401.
  49. Birchall MA, Bailey M, Gutowska-Owsiak D, et al. Immunologic response of the laryngeal mucosa to extraesophageal reflux. Ann Otol Rhinol Laryngol 2008; 117:891.
  50. Ylitalo R, Thibeault SL. Relationship between time of exposure of laryngopharyngeal reflux and gene expression in laryngeal fibroblasts. Ann Otol Rhinol Laryngol 2006; 115:775.
  51. Thibeault SL, Smith ME, Peterson K, Ylitalo-Moller R. Gene expression changes of inflammatory mediators in posterior laryngitis due to laryngopharyngeal reflux and evolution with PPI treatment: a preliminary study. Laryngoscope 2007; 117:2050.
  52. Reichel O, Issing WJ. Should patients with pH-documented laryngopharyngeal reflux routinely undergo oesophagogastroduodenoscopy? A retrospective analysis. J Laryngol Otol 2007; 121:1165.
  53. http://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/ucm122561.htm (Accessed on February 29, 2012).
  54. Powell J, O'Hara J, Wilson JA. Are persistent throat symptoms atypical features of gastric reflux and should they be treated with proton pump inhibitors? BMJ 2014; 349:g5813.
  55. Lam PK, Ng ML, Cheung TK, et al. Rabeprazole is effective in treating laryngopharyngeal reflux in a randomized placebo-controlled trial. Clin Gastroenterol Hepatol 2010; 8:770.
  56. Havas T, Huang S, Levy M, et al. Posterior pharyngolaryngitis: double-blind randomised placebo-controlled trial of proton pump inhibitor therapy. Aust J Otolaryngol 1999; 3:243.
  57. Steward DL, Wilson KM, Kelly DH, et al. Proton pump inhibitor therapy for chronic laryngo-pharyngitis: a randomized placebo-control trial. Otolaryngol Head Neck Surg 2004; 131:342.
  58. Vaezi MF, Richter JE, Stasney CR, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006; 116:254.
  59. Wo JM, Koopman J, Harrell SP, et al. Double-blind, placebo-controlled trial with single-dose pantoprazole for laryngopharyngeal reflux. Am J Gastroenterol 2006; 101:1972.
  60. Noordzij JP, Khidr A, Evans BA, et al. Evaluation of omeprazole in the treatment of reflux laryngitis: a prospective, placebo-controlled, randomized, double-blind study. Laryngoscope 2001; 111:2147.
  61. Oridate N, Takeda H, Yamamoto J, et al. Helicobacter pylori seropositivity predicts outcomes of acid suppression therapy for laryngopharyngeal reflux symptoms. Laryngoscope 2006; 116:547.
  62. Youssef TF, Ahmed MR. Treatment of clinically diagnosed laryngopharyngeal reflux disease. Arch Otolaryngol Head Neck Surg 2010; 136:1089.
  63. Halum SL, Sycamore DL, McRae BR. A new treatment option for laryngeal sensory neuropathy. Laryngoscope 2009; 119:1844.
  64. Swoger J, Ponsky J, Hicks DM, et al. Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study. Clin Gastroenterol Hepatol 2006; 4:433.
  65. Catania RA, Kavic SM, Roth JS, et al. Laparoscopic Nissen fundoplication effectively relieves symptoms in patients with laryngopharyngeal reflux. J Gastrointest Surg 2007; 11:1579.
  66. Ogut F, Ersin S, Engin EZ, et al. The effect of laparoscopic Nissen fundoplication on laryngeal findings and voice quality. Surg Endosc 2007; 21:549.