Laryngopharyngeal reflux: a diagnostic and therapeutic challenge for the otolaryngologist and gastroenterologist.

Abstract

Laryngopharyngeal reflux disease (LPRD) is an entity separate from GERD in which the refluxate (acid, pepsin, bile salts, etc.) crosses the upper esophageal sphincter and irritates the particularly sensitive pharyngeal and laryngeal mucosa, resulting in symptoms such as hoarseness, coughing, and grunting, frequently without the typical heartburn or esophageal erosions. The diagnosis cannot rely solely on the laryngoscopic appearance or the RSI/RFS scales (Reflux Symptom Index/Reflux Finding Score). The reference standard is hypopharyngeal-esophageal multichannel intraluminal impedance with pH monitoring (HEMII-pH), which documents the extent of reflux (acidic, non-acidic, gaseous) reaching the pharynx and allows for LPRD phenotyping and treatment selection. Gastroscopy is reserved mainly for alarm symptoms and complications of GERD. The treatment should be personalized and multidirectional, including lifestyle and diet modification as well as pharmacotherapy targeting the type of reflux. In weak acid/non-acid reflux, an important part is played by alginates (exerting mechanical action within the stomach to reduce postprandial and nocturnal reflux) and topical barrier preparations with hyaluronic acid that form a bioadhesive protective film on the mucosa and promote its regeneration. Prokinetic agents should be considered, especially in patients with motility disorders or distal reflux. Proton pump inhibitors should be used selectively, mainly with documented acid exposure or concomitant typical GERD symptoms. Effective care requires collaboration between an otolaryngologist and a gastroenterologist, with diagnostic and therapeutic decisions being based on the phenotype of reflux as well as the patient's preferences. This personalized approach reduces the risk of over-suppression of gastric acid and increases the clinical response rate.