Symptoms classically attributed to laryngopharyngeal reflux correlate poorly with pharyngeal reflux events on multichannel intraluminal impedance testing

Abstract

Summary Laryngopharyngeal reflux (LPR) is thought to be a common etiology of throat and airway symptoms. Diagnosis of LPR is challenging, given the variable symptomatology and response to therapy. Identifying symptoms that better correlate with LPR may inform management strategies. We aimed to examine the association between patient-reported symptoms and objectively identified LPR on ambulatory reflux monitoring. This was a retrospective cohort study of consecutive adults with suspected LPR undergoing combined hypopharyngeal–esophageal multichannel intraluminal impedance–pH testing (HEMII-pH) at a tertiary center. All patients completed standardized symptom surveys for presenting symptoms, reflux symptom index (RSI), and voice handicap index (VHI). LPR was defined as >1 full-column pharyngeal reflux event on HEMII-pH over 24 hours. Univariate and multivariable analyses were performed. A total of 133 patients were included (mean age = 55.9 years, 69.9% female). Of this 83 (62.4%) reported concomitant esophageal symptoms. RSI and VHI did not correlate with proximal esophageal or pharyngeal reflux events (Kendall’s tau correlations P > 0.05), although the mean RSI was higher in the LPR group (21.1 ± 18.9 vs. 17.1 ± 8.3, P = 0.044). Cough, but not other laryngeal symptoms, was more common among patients with esophageal symptoms (58% vs. 36%, P = 0.014). Neither laryngeal symptoms nor esophageal symptoms of reflux predicted LPR on univariate or multivariable analyses (all P > 0.05). Neither laryngeal symptoms classically attributed to LPR nor typical esophageal symptoms correlated with pharyngeal reflux events on HEMII-pH. Clinical symptoms alone are not sufficient to make an LPR diagnosis. Broad evaluation for competing differential diagnoses and objective reflux monitoring should be considered in patients with suspected LPR symptoms.

Review article: Diagnosis and management of laryngopharyngeal reflux

“…9 In addition to imparting a tremendous healthcare burden, it can also have a significant impact on quality of life, and further research demonstrates that patients with chronic laryngeal symptoms experience heightened levels of anxiety and depression compared to controls. 10 As previously alluded to, LPR presents a significant diagnostic dilemma as classic LPR symptoms are not diagnostic of LPR, 11 and a wide variety of conditions can lead to laryngeal symptoms. 12 Unfortunately, despite this knowledge, 80% of patients with laryngeal symptoms will be diagnosed with LPR based solely on symptoms.…”

“…As previously alluded to, LPR presents a significant diagnostic dilemma as classic LPR symptoms are not diagnostic of LPR, 11 and a wide variety of conditions can lead to laryngeal symptoms 12 . Unfortunately, despite this knowledge, 80% of patients with laryngeal symptoms will be diagnosed with LPR based solely on symptoms 4 .…”

Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date

“… 23 , 24 In more than 50% of cases, patients do not report GERD. 25 The gaseous nature of events and the lack of GERD have led to a clinical picture characterized by otolaryngological symptoms without heartburn or abdominal findings.…”

Update on extraesophageal manifestations of gastroesophageal reflux

“…Identifying patients with LPR based on presenting symptoms also proved to be challenging. A recent cohort study of 133 adults found that laryngeal symptoms traditionally attributed to LPR did not correlate with pharyngeal reflux on objective testing, suggesting that symptoms alone are insufficient to diagnose LPR [14 ▪ ]. Laryngoscopic evaluation of the airway, even with previously developed scoring systems (Reflux Finding Score), also showed significant interobserver variability and suboptimal specificity [15,16].…”