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Diagnosis and Management of Laryngopharyngeal Reflux

Am Fam Physician. 2006 Mar 15;73(6):1099.

Laryngopharyngeal reflux (LPR) occurs in up to 10 percent of patients who consult an ear, nose, and throat subspecialist. It can account for more than 50 percent of patients presenting with hoarseness. LPR is caused by reflux into the larynx and often occurs in the absence of typical gastroesophageal reflux disease (GERD) symptoms, such as heartburn. Symptoms of LPR can include throat clearing, cough, and globus pharyngeus. Findings on laryngoscopy are nonspecific but can include redness, thickening, and edema in the posterior larynx. A medial edge concavity in the vocal fold, called pseudosulcus, is found in up to 90 percent of patients with LPR. Diagnosis can be confirmed by response to treatment, endoscopic observation of the injury, or through impedance and pH monitoring studies. However, pH monitoring is less reliable in detecting LPR than in detecting GERD. Ford analyzed key articles, journals, and reference lists to determine a practical method for assessing and managing LPR cases.

LPR patients should begin treatment with behavior and dietary changes. Where applicable, patients should stop smoking, stop drinking alcohol, and lose weight. Restricting chocolate, fats, citrus fruits, carbonated beverages, spicy foods, red wine, caffeine, and late-night meals also could be beneficial. There are four types of drugs used to treat LPR: proton pump inhibitors (PPIs), histamine H2 blockers, prokinetic agents, and mucosal cytoprotectants. PPIs are the medical therapy of choice and should be taken 30 to 60 minutes before each meal.

Longer and more aggressive treatment is required for LPR than for GERD. If an H2 blocker is used in treatment, ranitidine (Zantac) is preferred over cimetidine (Tagamet). If a prokinetic drug is used, tegaserod (Zelnorm) is the drug of choice because it decreases reflux and esophageal sphincter relaxation. Sucralfate (Carafate) may be used as an adjunct treatment to protect injured mucosa. However, antacids should not be used to treat LPR.

Surgical intervention with partial or complete fundoplication is an option for patients resistant to medical management. Surgery is more effective than medical treatment in preventing Barrett’s syndrome. If the patient has not improved after aggressive medical management for three months, ambulatory pH monitoring or esophagoscopy should be performed to make a definitive diagnosis. The author concludes that because LPR is associated with aerodigestive malignancy, patients whose symptoms persist should be monitored closely.

Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. September 28, 2005;294:1534–40.


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