Laryngopharyngeal Reflux Disease (LPRD): A Comprehensive Overview
Laryngopharyngeal reflux disease (LPRD) is a condition affecting the upper aerodigestive tract, resulting from the direct or indirect effects of gastroduodenal content reflux. This reflux induces morphological and neurological changes in the upper aerodigestive tract, leading to a range of non-specific symptoms and clinical findings. Unlike gastroesophageal reflux disease (GERD), LPRD has distinct pathophysiological and clinical characteristics, necessitating a unique approach to diagnosis and treatment.
Laryngopharyngeal Reflux Disease (LPRD): Definition and Pathophysiology
LPRD is defined as a disease caused by the reflux of gastroduodenal content, including pepsin, bile acids, elastase, and trypsin, into the upper aerodigestive tract. This reflux leads to inflammation of the mucosa and the development of related symptoms. Recent studies have highlighted the role of bile acids, elastase, and trypsin in the pathophysiology of LPRD, which were previously overlooked in clinical research. The detection of these enzymes in the saliva of LPRD patients supports the occurrence of dysmotility mechanisms in the upper digestive tract, involving reflux processes from the duodenum to the stomach and further to the esophagus and pharynx.
The dysmotility associated with LPRD is believed to be linked to autonomic nerve dysfunction, which can be exacerbated by anxiety, stress, or depression. The presence of gastroduodenal enzymes in regions beyond the larynx and pharynx, such as the sinonasal regions, middle ear, tracheobronchial tube, or even tears, has sparked a debate about renaming LPRD to “airway reflux” to better reflect its widespread impact.
Laryngopharyngeal Reflux Disease (LPRD): Diagnosis
The gold standard for diagnosing LPRD is the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring. This method detects the backflow of gastroduodenal content into the pharynx and is crucial for confirming the diagnosis. The IFOS-Dubai consensus established that more than one pharyngeal reflux event during the 24-hour HEMII-pH monitoring is indicative of LPRD.
Oropharyngeal-pH monitoring is considered an adjunctive tool in cases where HEMII-pH is unavailable. However, it is not regarded as a gold standard due to its limitations in detecting pseudo-reflux events and its inability to identify proximal esophageal events before detecting pharyngeal reflux events. Future studies are needed to evaluate the accuracy of oropharyngeal-pH monitoring in comparison to HEMII-pH.
Laryngopharyngeal Reflux Disease (LPRD): Empirical Treatment Diagnosis
In the absence of HEMII-pH or oropharyngeal-pH monitoring, a clinical diagnosis of LPRD can be made based on symptoms, findings, and their evolution during an empirical therapeutic trial. This approach is cost-effective for patients with mild-to-moderate LPRD. Experts recommend a minimal duration of two months for empirical treatment, as most symptoms are relieved within this period. The effectiveness of the treatment should be evaluated using patient-reported outcome questionnaires and validated clinical tools, such as the reflux symptom score (RSS) and reflux sign assessment (RSA).
Laryngopharyngeal Reflux Disease (LPRD): Treatments
There is currently no international consensus for treating LPRD. However, the IFOS-Dubai consensus proposed practical management strategies, focusing on diet, lifestyle changes, medical treatment, and surgery.
Diet and Lifestyle Changes:
Diet plays a crucial role in managing LPRD. A low-acid, low-fat, high-protein diet has been shown to reduce symptoms by neutralizing pepsin activity in the upper aerodigestive tract mucosa. Fatty meals and raw vegetables can increase gastric emptying time, leading to more reflux events, while proteins can increase the tonicity of the lower and upper esophageal sphincters. Lifestyle changes, including stress management, addressing anxiety and depression, and improving sleep quality, are also essential for effective LPRD management.
Medical Treatment:
Medical treatment for LPRD should be personalized based on the reflux profile identified during 24-hour HEMII-pH monitoring. Proton pump inhibitors (PPIs) are not always effective in LPRD due to its weakly acid or alkaline profile. Instead, alginates and antacids are recommended for their ability to form a barrier above the gastric content and neutralize acid, respectively. Future randomized controlled studies are needed to determine the best empirical pharmaceutical combination for LPRD.
Recalcitrant Reflux, Weaning, and Surgery:
For recalcitrant LPRD, changing drug classes rather than increasing doses is recommended. Weaning off medication is possible in 66-69% of LPRD patients, and reducing medication doses can help minimize adverse effects and healthcare costs. Fundoplication is only recommended for patients with GERD findings, as its success in LPRD patients without GERD is unpredictable.
Conclusion
The IFOS-Dubai consensus provides a comprehensive framework for the diagnosis and management of LPRD. By adopting common management approaches, collaborative research can be improved, leading to better patient outcomes. Future clinical studies using the recommendations of this consensus are essential to validate its accuracy and further advance evidence-based medicine for LPRD.
In summary, LPRD is a complex condition requiring a multifaceted approach to diagnosis and treatment. Understanding its unique pathophysiology and clinical presentation is crucial for effective management and improving the quality of life for patients affected by this disease.
Reference
- Lechien JR, Chiesa-Estomba CM, et al. European clinical practice guideline: managing and treating laryngopharyngeal reflux disease. Eur Arch Otorhinolaryngol 2024 Dec 24.