Treatment of laryngopharyngeal reflux disease (LPR)—the retrograde flow of gastroduodenal contents into the larynx and pharynx—is challenging. The most common approach is empiric anti-reflux therapy, but most patients don’t respond. Moreover, the role of laparoscopic Nissen fundoplication, although well-established for gastroesophageal reflux disease (GERD), is inconclusive for LPR.
Thomas L. Carroll, MD, section chief of Laryngology and director of the Voice Program in the Division of Otolaryngology–Head and Neck Surgery at Brigham and Women’s Hospital, and colleagues recently completed a Delphi process to develop guidance about the treatment of LPR. They report their consensus in Digestive Diseases and Sciences.
15 recognized specialists in GERD participated in the Delphi panel: five gastroenterologists, eight otolaryngologists, and two general surgeons from four countries (the U.S., France, Italy, and New Zealand). They considered the importance, scientific acceptability, usability, and feasibility of various LPR treatment strategies in a four-round approach.
In the end the expert panel agreed on 17 statements, which are paraphrased below.
Modification of diet and other lifestyle behaviors is recommended:
- Along with medical therapy for patients with suspected, presumed, or demonstrated LPR
- As the sole initial approach if the patient has suspected LPR with mild symptoms
Laryngopharyngoscopy should be part of the workup when a patient has LPR symptoms but no classic GERD complaints.
If voice complaints in a patient with suspected or presumed LPR do not improve with anti-reflux therapy, referral for laryngoscopy and/or laryngeal videostroboscopy is indicated.
For patients with presumed LPR who cannot be weaned from acid suppression, titrate to the lowest dose of a proton pump inhibitor (PPI) or H2 antagonist needed for long-term reflux control or consider other options for long-term control.
If PPI therapy has improved symptoms in a patient with presumed or demonstrated LPR, provide information about the reported risks of long-term use and offer alternative treatment if the patient does not want to use a PPI long-term.
When PPIs are chosen for use in LPR treatment:
- They should be dosed 30 to 60 minutes before meals
- The risks and benefits should be carefully reviewed with the patient before use
Endoscopic treatment and surgery
A patient being considered for endoscopic or surgical reflux treatment should undergo evaluation of esophageal function as part of treatment planning.
When fundoplication is considered for a patient with LPR symptoms and not GERD, otolaryngologic evaluation is warranted before surgery to assess whether non-reflux etiologies contribute to the symptoms.
A patient being considered for endoscopic treatment of LPR should be counseled that its efficacy in patients is not completely understood.
For a patient with LPR who experiences good symptom control with medications, a surgical anti-reflux procedure, with supportive objective reflux and motility testing, may be considered as an alternative to continued medication.
Philosophy and/or empiric treatment
For a patient with presumed LPR who has reached a therapeutic plateau with reflux treatment:
- If symptoms persist—Objective testing such as pH-impedance reflux testing can be pursued to help identify refractory reflux; also consider evaluation of non-reflux etiologies for common complaints that had previously been attributed to LPR
- If symptoms are adequately controlled—Objective testing can suggest whether non-reflux etiologies for patient complaints need to be considered
If a patient is sent for objective reflux testing, the referring physician should think critically about testing on-therapy versus off-therapy relative to the interpretation of results.
If a patient with suspected LPR does not respond to an adequate empiric trial of antacid medication, then objective testing such as pH-impedance and high-resolution esophageal manometry testing can be pursued to identify refractory non-acidic or weakly acidic reflux or to suggest that non-reflux etiologies need to be considered.
Treatment choices for LPR should consider factors such as symptom severity and patient-related factors such as age, health status, and comorbidities.
Advantages Over Previous Guidance
Last year the American College of Gastroenterology updated its guidelines on diagnosing and treating GERD, which now incorporate more detail about managing extra-esophageal manifestations of the disease. Still, a literature gap remained on specifically how to treat LPR.
The new consensus statements address that gap and have the advantage of being based on the votes and discussion of a multidisciplinary expert group, not literature review alone.