An ongoing debate in gastroenterology is whether objective reflux testing, rather than empiric treatment with a proton pump inhibitor (PPI), should be initial management for suspected laryngopharyngeal reflux (LPR). The issue is complicated by concerns about the limited benefit and potential complications of PPI therapy and the lack of an objective gold standard for diagnosing LPR.
A newer technology called hypopharyngeal–esophageal multichannel intraluminal impedance–pH (HEMII-pH) testing is being studied for diagnosis of LPR because it records full-column esophagopharyngeal reflux (“pharyngeal reflux”) events.
Sanjay Salgado, MD, a former physician in the Department of Medicine at Brigham and Women’s Hospital, Walter W. Chan, MD, PhD, director of the Center for Esophageal/Gastrointestinal Disorders, and colleagues recently found no correlation between suspected LPR symptoms and HEMII-pH results. Yet in Diseases of the Esophagus, they explain why they still suggest upfront objective testing for LPR.
The researchers retrospectively studied 133 adults (70% female, mean age 56) who presented with suspected LPR and were referred to HEMII-pH at the Brigham between March 2015 and October 2017. 62% had concomitant symptoms of gastroesophageal reflux disease and the others had throat or airway symptoms alone.
Within three months of the initial visit and symptom questionnaire completion, all patients underwent high-resolution manometry to aid proper placement of HEMII-pH catheters. Patients were asked to maintain normal activities and diet during a 24-hour monitoring period.
Two researchers blinded to patient-reported symptoms independently reviewed the HEMII-pH tracings. LPR, defined as more than pharyngeal reflux event during the monitoring period, was noted in 62% of patients.
The principal findings were that:
- Neither symptoms classically associated with LPR (hoarseness, throat clearing, cough, globus, dysphagia, dyspnea and throat discomfort) nor typical symptoms of GERD (heartburn, chest pain and regurgitation) correlated with the number of pharyngeal reflux events on HEMII-pH
- Neither laryngeal symptoms nor GERD symptoms predicted LPR on univariate or multivariable analyses
- Both a composite symptom questionnaire, the Reflux Symptom Index (RSI), and an individual symptom questionnaire, the Voice Handicap Index, failed to correlate with proximal esophageal or pharyngeal reflux events, although the mean RSI score was significantly higher in the LPR group than the non-LPR group (21 vs. 17; P=0.04)
- A significantly higher proportion of patients with GERD symptoms reported chronic cough compared with those who had no esophageal symptoms (58% vs. 36%, P=0.014); this association was not seen with any other symptoms of suspected LPR
Guidance for Clinicians
Clinical symptoms alone are not sufficient to make an LPR diagnosis. Given that finding, and considering the financial cost and suboptimal efficacy of PPI therapy, the value of empiric trials of PPI based on clinical symptoms alone is questionable.
Instead, when patients present with suspected LPR, clinicians should consider:
- Broad evaluation of differential diagnoses such as rhinosinusitis, asthma and visceral hypersensitivity
- Upfront objective testing to ascertain the quantity and severity of reflux burden before initiating PPI therapy