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Laryngopharyngeal reflux — Clinical Guidelines

Overview

Laryngopharyngeal reflux (LPR) involves the backflow of gastric contents into the larynx and pharynx, causing a range of upper aerodigestive symptoms without always presenting with typical esophageal reflux signs 1 2.

Diagnosis

Clinical Symptoms: Globus sensation, chronic cough, hoarseness, throat clearing, and dysphonia 1 2 9 29.

Reflux Symptom Index (RSI): Validated tool for assessing LPR symptoms 26 19.

Dual pH with Multichannel Intraluminal Impedance (MII) Testing: Emerging tool for evaluating LPR symptoms 22.

Endoscopy: May reveal laryngeal or pharyngeal mucosal changes, though not always specific 2 24.

pH Monitoring: Gold standard but interpretation can be complex 33 30.

Management

First-Line Treatments:

- Proton Pump Inhibitors (PPIs): Effective for healing and symptom relief 8 34. - Alginates: Commonly used for symptom management 4.

Adjunctive Treatments:

- Vonoprazan Fumarate: Shows promise for rapid symptom relief 3. - Dietary Modifications: Reducing refluxogenic foods as per clinical tools 15.

Special Populations

Elderly Patients: Diagnostic and therapeutic approaches may need adaptation due to altered presentation and outcomes 10.

Pediatrics: Assessment and management remain controversial; otolaryngologists play a crucial role in evaluation 24.

Pregnancy: Specific considerations and management strategies are needed, though detailed guidelines are limited 21.

Key Recommendations

Utilize the Reflux Symptom Index (RSI) for diagnosing LPR symptoms in clinical practice (Evidence: Moderate) 19 26.

Initiate treatment with proton pump inhibitors (PPIs) for managing LPR, considering their efficacy in healing and symptom relief (Evidence: Strong) 8 34.

Consider dual pH with multichannel intraluminal impedance (MII) testing for patients with atypical or refractory symptoms (Evidence: Moderate) 22.

Implement dietary modifications guided by refluxogenic potential scores to complement pharmacological treatment (Evidence: Expert opinion) 15.

Tailor management strategies for elderly patients due to potential differences in therapeutic response and symptomatology (Evidence: Moderate) 10.

References

1 Yadlapati R, Weissbrod P, Walsh E, Carroll TL, Chan WW, Gartner-Schmidt J et al.. The San Diego Consensus for Laryngopharyngeal Symptoms and Laryngopharyngeal Reflux Disease. The American journal of gastroenterology 2026. link 2 Lechien JR, Chiesa-Estomba CM, Hans S, Nacci A, Schindler A, Bohlender JE et al.. European clinical practice guideline: managing and treating laryngopharyngeal reflux disease. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2026. link 3 Bian C, Shen P, Zang Y, Liu W, Zhou P. Vonoprazan Fumarate: A Promising Therapeutic Option for the Rapid Relief of Laryngopharyngeal Reflux Disease. Journal of voice : official journal of the Voice Foundation 2025. link 4 Tsilivigkos C, Papantoniou K, Vitkos EN, Ferekidis E, Warnecke A. Alginates and laryngopharyngeal reflux: where we stand. A systematic review. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2025. link 5 Chen H, Ma X, Rives H, Serpedin A, Yao P, Rameau A. Trust in Machine Learning Driven Clinical Decision Support Tools Among Otolaryngologists. The Laryngoscope 2024. link 6 O'Banion LAA, Shao MY, Ali A, Kochubey M, Yan Y, Fallentine J et al.. Type IV Hypersensitivity Reaction after Cyanoacrylate Venous Closure. Annals of vascular surgery 2023. link 7 Lechien JR, Rameau A, De Marrez LG, Le Bosse G, Negro K, Sebestyen A et al.. Usefulness, acceptation and feasibility of electronic medical history tool in reflux disease. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2023. link 8 Jin X, Zhou X, Fan Z, Qin Y, Zhan J. Meta-analysis of Proton Pump Inhibitors in the Treatment of Pharyngeal Reflux Disease. Computational and mathematical methods in medicine 2022. link 9 Lechien JR, Perazzo PS, Ceccon FP, Eckley CA, Lopes KC, Maunsell R et al.. Management of laryngopharyngeal reflux in Brazil: a national survey. Brazilian journal of otorhinolaryngology 2022. link 10 Lechien JR. Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date. Clinical interventions in aging 2022. link 11 Jia J, Zhang J, Xiao S. Clinical Effects of Radiofrequency Coblation for Adult Laryngopharyngeal Vascular Lesions. The Laryngoscope 2021. link 12 Young VN, Jordan KM, Schneider SL, Lazar A, Dwyer CD, Rosen CA. Laryngology Quality of Life Questionnaire Associations: Towards Reducing Survey Burden. The Laryngoscope 2021. link 13 Xiao S, Li J, Zheng H, Yan Y, Li X, Zhang L et al.. An epidemiological survey of laryngopharyngeal reflux disease at the otorhinolaryngology-head and neck surgery clinics in China. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2020. link 14 Lechien JR, Mouawad F, Mortuaire G, Remacle M, Bobin F, Huet K et al.. Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux. The Annals of otology, rhinology, and laryngology 2019. link 15 Lechien JR, Bobin F, Mouawad F, Zelenik K, Calvo-Henriquez C, Chiesa-Estomba CM et al.. Development of scores assessing the refluxogenic potential of diet of patients with laryngopharyngeal reflux. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2019. link 16 Beckett D, Dos Santos SJ, Dabbs EB, Shiangoli I, Price BA, Whiteley MS. Anatomical abnormalities of the pelvic venous system and their implications for endovascular management of pelvic venous reflux. Phlebology 2018. link 17 Badham GE, Dos Santos SJ, Lloyd LB, Holdstock JM, Whiteley MS. One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux. Phlebology 2018. link 18 Whiteley MS, Lewis-Shiell C, Bishop SI, Davis EL, Fernandez-Hart TJ, Diwakar P et al.. Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience. Phlebology 2018. link 19 Gelardi M, Silvestri M, Ciprandi G. Relieving laryngopharingeral reflux (RELIEF) survey in otolaryngology - II the viewpoint of the patient. Journal of biological regulators and homeostatic agents 2018. link 20 Gelardi M, Silvestri M, Ciprandi G. Relieving laryngopharingeral reflux (RELIEF) survey in otolaryngology - the viewpoint of the otorhinolaryngologist. Journal of biological regulators and homeostatic agents 2018. link 21 Dos Santos SJ, Holdstock JM, Harrison CC, Whiteley MS. The effect of a subsequent pregnancy after transjugular coil embolisation for pelvic vein reflux. Phlebology 2017. link 22 Cumpston EC, Blumin JH, Bock JM. Dual pH with Multichannel Intraluminal Impedance Testing in the Evaluation of Subjective Laryngopharyngeal Reflux Symptoms. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2016. link 23 Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian Vein Diameter Cannot Be Used as an Indicator of Ovarian Venous Reflux. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2015. link 24 Galluzzi F, Schindler A, Gaini RM, Garavello W. The assessment of children with suspected laryngopharyngeal reflux: An Otorhinolaringological perspective. International journal of pediatric otorhinolaryngology 2015. link 25 Beech TJ, Campbell G, McDermott AL, Batch AJ. The effect of anti-reflux treatment on subjective voice measurements of patients with laryngopharyngeal reflux. The Journal of laryngology and otology 2013. link 26 Printza A, Kyrgidis A, Oikonomidou E, Triaridis S. Assessing laryngopharyngeal reflux symptoms with the Reflux Symptom Index: validation and prevalence in the Greek population. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2011. link 27 Goldmann K, Dieterich J, Roessler M. Laryngopharyngeal mucosal injury after prolonged use of the ProSeal LMA in a porcine model: a pilot study. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2007. link 28 Kelchner LN, Horne J, Lee L, Klaben B, Stemple JC, Adam S et al.. Reliability of speech-language pathologist and otolaryngologist ratings of laryngeal signs of reflux in an asymptomatic population using the reflux finding score. Journal of voice : official journal of the Voice Foundation 2007. link 29 Karkos PD, Benton J, Leong SC, Karkanevatos A, Badran K, Srinivasan VR et al.. Trends in laryngopharyngeal reflux: a British ENT survey. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2007. link 30 Senders CW. Should otolaryngologists perform pH probe studies?. Current opinion in otolaryngology & head and neck surgery 2006. link 31 Leone CA, Mosca F. Multicentric study: statistical correlation between clinical data and instrumental findings in laryngo-pharyngeal reflux: proposal for a new ENT classification of reflux. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale 2006. link 32 Selby JC, Gilbert HR, Lerman JW. Perceptual and acoustic evaluation of individuals with laryngopharyngeal reflux pre- and post-treatment. Journal of voice : official journal of the Voice Foundation 2003. link00017-1) 33 Postma GN, Belafsky PC, Aviv JE, Koufman JA. Laryngopharyngeal reflux testing. Ear, nose, & throat journal 2002. link 34 Postma GN, Johnson LF, Koufman JA. Treatment of laryngopharyngeal reflux. Ear, nose, & throat journal 2002. link 35 Heman-Ackah YD, Sataloff RT, Goldstein S, Heman-Ackah SE, Ghabra M. Multifocal tracheal chondromata. Journal of voice : official journal of the Voice Foundation 2002. link00134-0) 36 Ross JA, Noordzji JP, Woo P. Voice disorders in patients with suspected laryngo-pharyngeal reflux disease. Journal of voice : official journal of the Voice Foundation 1998. link80078-7)

Laryngopharyngeal reflux