GOI Standard Treatment Guidelines for Laryngopharyngeal reflux (LPR)

1. Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Laryngopharyngeal reflux (LPR). Dr. J M Hans Ex-HOD Dept. of Otorhinolaryngology Dr.RML Hospital New Delhi has prepared these guidelines for Government of India.

Laryngopharyngeal reflux (LPR), is a disease commonly diagnosed in otorhinolaryngologic practice in the presence of a set of nonspecific laryngeal signs and symptoms. It refers to the retrograde flow of gastric contents to the upper aerodigestive tract, which causes a variety of symptoms, such as a cough, hoarseness, and asthma, among others.

Although heartburn is a primary symptom among people with gastroesophageal reflux disease (GERD), heartburn is present in fewer than 50% of the patients with LPR. Other terms used to describe this condition include atypical reflux and supraesophageal (or supra-esophageal) reflux.

Following are the major recommendations:

Signs and symptoms :

Extraesophageal symptoms are the result of exposure of the upper aerodigestive tract to the gastric juice. This causes a variety of symptoms, including hoarseness, postnasal drip, sore throat, difficulty swallowing, indigestion, wheezing, chronic cough, globus pharyngis and chronic throat-clearing.

Diagnosis :

As there are multiple potential etiologies for the respiratory and laryngeal symptoms, establishing LPR as the cause based on symptoms alone is unreliable. Further laryngoscopic findings such as erythema, edema, laryngeal granulomas, and interarytenoid hypertrophy have been used to establish the diagnosis; but these findings are very nonspecific, and have been described in the majority of asymptomatic subjects undergoing laryngoscopy. Response to acidsuppression therapy has been suggested as a diagnostic tool for confirming a diagnosis of LPR, but studies have shown that the response to empirical trials of such therapy (as with protonpump inhibitors) in these patients is often disappointing.

Treatment :

Management of symptoms for patients within this subgroup of the GERD spectrum is difficult. Several studies have emphasized the importance of measuring proximal esophageal, or, ideally, pharyngeal acid exposure in patients with clinical symptoms of LPR, to document reflux as the cause of the symptoms. Once these patients are identified, Nissen fundoplication should be offered to the patients in the early phase of the disease, as medical treatments often don't provide any benefit, and a delay in referring patients for surgical treatment is associated with poor outcome.