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How Often Is GERD the Cause of Suspected Laryngopharyngeal Reflux?

Acid-suppressive agents were no more beneficial than placebo in patients with suspected reflux laryngitis.

The standard approach to patients with laryngopharyngeal reflux (LPR) is acid-suppressive therapy with proton-pump inhibitors (PPIs). However, studies to support this practice are either uncontrolled or small. In this industry-supported, prospective, placebo-controlled multicenter study, researchers in Florida examined the effect of acid suppression in 145 patients who had experienced signs of LPR (hoarseness, repetitive throat clearing, excessive pharyngeal mucus, globus, and voice changes) for 3 consecutive months or longer. Patients with moderate-to-severe heartburn on 3 or more days weekly were excluded.

Researchers randomized patients to receive twice-daily esomeprazole (40 mg; 95 patients) or placebo (50 patients) for 16 weeks. The primary symptom resolved in 14.7% of esomeprazole recipients and in 16% of placebo recipients. No differences were evident between groups in symptoms or objective laryngoscopic evaluation (based on a laryngoscopic scoring system developed by the investigators). Ambulatory pharyngoesophageal pH monitoring showed abnormal distal pH in 25% of esomeprazole recipients and in 36% of placebo recipients; abnormal proximal pH in 8% and 12%, respectively; and pharyngeal acid reflux in 13% and 16%. Pharyngeal acid reflux did not predict treatment response.

Comment: These patients, who presented to otolaryngologists with signs or symptoms of laryngopharyngeal reflux, did not benefit from PPI treatment with esomeprazole. However, patients with moderate-to-severe heartburn were excluded, as evidenced by the low percentage of patients with abnormal pH. Although GERD certainly can cause laryngeal signs and symptoms, such signs and symptoms are not specific enough to diagnose LPR. The percentage of patients with true "silent reflux" who do not have any associated GERD symptoms (heartburn, regurgitation) probably is lower than previously thought. Empirical PPI therapy is reasonable in such patients but, in the absence of a clinical response, should be continued only for 2 to 3 months. The yield of diagnostic pH impedance testing is low in patients who do not respond to empirical PPI treatment.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology March 14, 2006

Citation(s):

Vaezi MF et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006 Feb; 116:254-60.

• Medline abstract (Free)

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