Laryngopharyngeal reflux (LPR) has pathophysiological mechanisms, signs, and symptoms distinct from those of classic gastroesophageal reflux disease, but no definition of LPR is universally accepted.

The non-specificity of symptoms and findings attributed to LPR and the poor effectiveness of empiric proton pump inhibitor therapy make the diagnosis challenging. Moreover, the role of various diagnostic tests continues to be debated.

In this climate of uncertainty, a multidisciplinary group of experts developed a consensus document about the definition and diagnosis of LPR. It’s been named the Dubai Definition and Diagnostic Criteria of LPR after the conference’s location where it was first presented.

Thomas L. Carroll, MD, a laryngeal surgeon and director of the Program for Voice, Swallowing and Upper Airway Health in the Division of Otolaryngology–Head and Neck Surgery at Brigham and Women’s Hospital, Walter W. Chan, MD, MPH, director of the Center for Gastrointestinal Motility in the Division of Gastroenterology, Hepatology and Endoscopy at the Brigham, Jerome R. Lechien, MD, PhD, MSc, of the University of Mons in Belgium, and colleagues published the consensus in The Laryngoscope.

Methods

48 experts from five continents (otolaryngologists, gastroenterologists, surgeons, and physiologists) participated in a modified Delphi process to revise statements about LPR. Three rounds of anonymous voting determined 38 statements to be acceptable.

A subgroup of eight physicians assessed the quality of evidence for each acceptable statement using the GRADE guidelines. Grade A denotes high-level evidence and the experts’ opinion that future investigations are unlikely to change their confidence in the estimated effect.

Key Position Statements

Clinically relevant statements that garnered at least 85% agreement and received grade A or grade B were:

Definition, pathophysiology, and differences from GERD

• LPR is a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological, and/or neurological changes in the upper aerodigestive tract. (93%, A)

• LPR and GERD share some common pathophysiological mechanisms but may present with different clinical pictures. (91%, A)

• The following may be factors that impair gastroesophageal function and be associated with the development of LPR: tobacco use; obesity; primary esophageal dysmotility; diets high in fat, salt, sugar, mint, or acidic content; diets low in protein. (92%, B)

Symptoms and signs

• LPR may be associated with the following nonspecific ear, nose, and throat symptoms: dysphonia, dysphagia, throat pain, globus sensation, throat clearing, postnasal drip or throat sticky mucus, troublesome cough, cough after lying down/eating, heartburn, and regurgitations. (90%, B)

• Typical esophageal symptoms of GERD, such as heartburn and digestive symptoms, may be present in some patients with LPR. (91%, A)

• No specific laryngeal signs are diagnostic of LPR. (89%, B)

Endoscopy and esophagoscopy

• The findings of upper gastrointestinal endoscopy or transnasal esophagoscopy may be normal in LPR patients. (91%, A)

• Upper GI endoscopy should be performed for all patients with LPR-related symptoms and concomitant “alarm” features, such as severe dysphagia, hematemesis, unexplained weight loss, or family history of upper GI tract cancer. (96%, A)

Impedance/pH monitoring

• Single-channel (esophageal) or dual-channel (esophageal–esophageal) pH probes are useful for diagnosing GERD but inadequate for diagnosing LPR because of lack of pharyngeal sensors and lack of consideration of non-acid events. (85%, A)

• Hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) can suggest the diagnosis of LPR when there is >1 hypopharyngeal reflux event in 24 hours. (90%, B)

• On HEMII-pH, a hypopharyngeal acid reflux event involves pH <4.0. A weakly acid reflux event involves a pH between 4.0 and 7.0. An alkaline reflux event involves a pH >7.0. (87%, A)

• HEMII-pH results may provide guidance as to the appropriate nature, dosing, and timing of medications for the specific patient according to the type of LPR (acid, weakly acid, or nonacid) and time of occurrence (upright and daytime and/or nighttime). (85%, B)

• HEMII-pH is promising as an objective tool for diagnosing LPR, but the correlation between its findings and treatment outcomes remains limited. Controlled studies are needed. (91%, A)

Pepsin saliva detection

• Pepsin saliva detection may prove to be a useful adjunctive diagnostic and/or screening test for LPR but requires further understanding of how diet and sampling frequency influence results. (85%, B)

A Caveat

The Dubai Statement has been endorsed by the International Federation of Oto-rhino-laryngological Societies, but it is based on expert opinion. The writing was not always guided by evidence from systematic reviews or randomized trials, so this work should not be considered a clinical guideline.