Skip to main content
Log in

Beyond Laryngoscopy: Current Objective Diagnostic Testing and Interpretation for LPR

  • Laryngopharyngeal Reflux (T. Carroll, Section Editor)
  • Published:
Current Otorhinolaryngology Reports Aims and scope Submit manuscript


Diagnosis of laryngopharyngeal reflux (LPR) has traditionally been based on clinical symptoms and laryngoscopy findings. More recent applications of dual pH multichannel intraluminal monitoring (dual pH-MII), high-resolution esophageal manometry (HRM), and salivary pepsin testing may allow for a more comprehensive assessment of patients with suspected LPR. The limitations of empiric proton pump inhibitor (PPI) trials to establish a diagnosis of laryngeal symptoms due to LPR are evolving, and objective diagnostic testing may be warranted in patients who fail to respond to PPI. Dual pH-MII, HRM, and salivary pepsin testing are currently under active study for improved diagnosis of reflux contributions to laryngeal symptoms. The clinical application of these diagnostic testing modalities has been validated in the literature, though more normative data in healthy controls and improved symptom association prediction algorithms are warranted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Campagnolo AM, Priston J, Thoen RH, et al. Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol. 2014;18(2):184–91.

    PubMed Central  PubMed  Google Scholar 

  2. Cohen SM, Kim J, Roy N, et al. Direct health care costs of laryngeal diseases and disorders. Laryngoscope. 2012;122:1582–8.

    Article  PubMed  Google Scholar 

  3. El-Serag HB. Time trends of gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol. 2007;5(1):17–26.

    Article  PubMed  Google Scholar 

  4. Altman KW, Stephens RM, Lyttle CS, et al. Changing impact of gastroesophageal reflux in medical and otolaryngology practice. Laryngoscope. 2005;115:1145–53.

    Article  PubMed  Google Scholar 

  5. Book DT, Rhee JS, Toohill RJ, et al. Perspectives in laryngopharyngeal reflux: an international survey. Laryngoscope. 2002;112:1399–406.

    Article  PubMed  Google Scholar 

  6. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. 2005;294(12):1534–40.

    Article  CAS  PubMed  Google Scholar 

  7. Hoppo T, Komatsu Y, Jobe BA. Antireflux surgery in patients with chronic cough and abnormal proximal exposure measured by hypopharyngeal multichannel intraluminal impedance. JAMA Surg. 2013;148(7):608–16.

    Article  PubMed  Google Scholar 

  8. Koufman JA. Laryngopharyngeal reflux and voice disorders. Diagnosis and treatment of voice disorders. 4th ed. San Diego: Plural Publishing; 2014.

    Google Scholar 

  9. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002;16(2):274–7.

    Article  PubMed  Google Scholar 

  10. Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope. 2001;111(8):1313–7.

    Article  CAS  PubMed  Google Scholar 

  11. Chang BA, MacNeil SD, Morrison MD, et al. The reliability of the reflux finding score among general otolaryngologists. J Voice. 2015;29(5):572–7.

    Article  PubMed  Google Scholar 

  12. Singendonk M, Pullens B, van Heteren J, et al. OP-5 interobserver validity of the reflux finding score for infants (RFS-I) in flexible versus rigid laryngoscopy. J Pediatr Gastroenterol Nutr. 2015;61(4):510–1.

    Article  PubMed  Google Scholar 

  13. Kahrilas PJ, Shaheen NJ, Vaezi MF. American gastroenterological association institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1392–413.

    Article  PubMed  Google Scholar 

  14. Heidelbaugh JJ, Metz DC, Yang YX. Proton pump inhibitors: are they overutilised in clinical practice and do they pose significant risk? Int J Clin Pract. 2012;66(6):582–91.

    Article  CAS  PubMed  Google Scholar 

  15. Vaezi MF, Richter JE, Stasney R, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope. 2006;116:254–60.

    Article  CAS  PubMed  Google Scholar 

  16. Fass R, Noelck N, Willis MR, et al. The effect of esomeprazole 20 mg twice daily and perception parameters of the voice in laryngopharyngeal reflux. Neurogastroenterol Motil. 2010;22:134–45.

    Article  CAS  PubMed  Google Scholar 

  17. Reichel O, Dressel H, Wiederanders K, et al. Double-blind, placebo-controlled trial with esomeprazole for symptoms and signs associated with laryngopharyngeal reflux. Otolaryngol HNS. 2008;139:414–20.

    Google Scholar 

  18. Lam PKY, Ng ML, Cheung TK, et al. Rabeprazole is effective in treating laryngopharyngeal reflux in a randomized placebo-controlled trial. Clin Gastroenterol Hepatol. 2010;8(9):770–6.

    Article  CAS  PubMed  Google Scholar 

  19. Qadeer MA, Phillips CO, Lopez AR, et al. Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: A meta-analysis of randomized controlled trials. Am J Gastroenterol. 2006;101(11):2646–54.

    Article  CAS  PubMed  Google Scholar 

  20. Williams RBH, Szczesniak MM, Maclean JC, et al. Predictors of outcome in an open label, therapeutic trial of high-dose omeprazole in laryngitis. Am J Gastroenterol. 2004;99:777–85.

    Article  CAS  PubMed  Google Scholar 

  21. Friedman M, Maley A, Kelley K, et al. Impact of pH monitoring on laryngopharyngeal reflux treatment: improved compliance and symptom resolution. Otolaryngol HNS. 2011;144(4):558–62.

    Google Scholar 

  22. Glicksman JT, Mick PT, Fung K, et al. Prokinetic agents and laryngopharyngeal reflux disease: a systematic review. Laryngoscope. 2014;124(10):2375–9.

    Article  PubMed  Google Scholar 

  23. Chander B, Hanley-Williams N, Deng Y, et al. 24 versus 48-hour Bravo pH monitoring. J Clin Gastroenterol. 2012;46:197–200.

    Article  PubMed  Google Scholar 

  24. Francis DO, Summer E, Goutte M, et al. Feasibility of dual wireless esophageal pH monitoring: randomized blinded sham-controlled trial. Otolaryngol HNS. 2012;147(1):91–7.

    Google Scholar 

  25. Thompson JK, Koehler RE, Richter JE. Detection of gastroesophageal reflux: value of barium studies compared with 24-hr pH monitoring. Am J Roentgenol. 1994;162:621–6.

    Article  CAS  Google Scholar 

  26. Koufman JA, Belafsky PC, Bach KK, et al. Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Laryngoscope. 2002;112(9):1606–9.

    Article  CAS  PubMed  Google Scholar 

  27. Sereg-Bahar M, Jerin A, Jansa R, et al. Pepsin and bile acids in saliva in patients with laryngopharyngeal reflux—a prospective comparative study. Clin Otolaryngol. 2015;40(3):234–9.

    Article  CAS  PubMed  Google Scholar 

  28. •• Hayat JO, Yazaki E, Moore AT, et al. Objective detection of esophagopharyngeal reflux in patients with hoarseness and endoscopic signs of laryngeal inflammation. J Clin Gastroenterol. 2014;48(4):318–27. Patients with hoarseness and objective evidence esophagopharyngeal reflux were more likely to benefit from intense PPI therapy. Further, detection of pepsin in the saliva demonstrated good correlation with observed reflux events on dual pH-MII testing and may be a useful screening tool in these patients.

  29. Hayat JO, Gabieta-Somnez S, Yazaki E, et al. Pepsin in saliva for the diagnosis of gastro-oesophageal reflux disease. Gut. 2015;64(3):373–80.

    Article  CAS  PubMed  Google Scholar 

  30. • Hoppo T, Sanz AF, Nason KS, et al. How much pharyngeal exposure is “normal?” Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg. 2012;16:16–25. Published normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH. LPR events should be considered abnormal in symptomatic patients.

  31. Johnson LF, DeMeester TR. Development of the 24-hour intraesophageal pH monitoring composite scoring system. J Clin Gastroenterol. 1986;8(Suppl 1):52–8.

    Article  PubMed  Google Scholar 

  32. Shay SS, Bomeli S, Richter J. Multichannel intraluminal impedance accurately detects fasting, recumbent reflux events and their clearing. Am J Physiol Gastrointest Liver Physiol. 2002;283:376–83.

    Article  Google Scholar 

  33. Xiao YL, Lin JK, Cheung TK, et al. Normal values of 24-hour combined esophageal multichannel intraluminal impedance and pH monitoring in the Chinese population. Digestion. 2009;79:109–14.

    Article  PubMed  Google Scholar 

  34. Feng G, Wang J, Zhang L, et al. A study to draw a normative database of laryngopharynx pH profile in Chinese. J Neurogastroenterol Motil. 2014;20(3):347–51.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Knight RE, Wells JR, Parrish RS. Esophageal dysmotility as an important co-factor in extraesophageal manifestations of gastroesophageal reflux. Laryngoscope. 2000;110:1462–6.

    Article  CAS  PubMed  Google Scholar 

  36. • Tsutsui H, Manabe N, Uno M, et al. Esophageal motor dysfunction plays a key role in GERD with globus sensation—analysis of factors promoting resistance to PPI therapy. Scand J Gastroenterol. 2012;47:893–99. Multichannel intraluminal impedance and esophageal manometry were used to investigate esophageal motility in a study population of symptomatic, PPI-resistant patients. Nearly one-half of patients with PPI-resistant LPR had abnormal esophageal motility.

  37. •• Carroll TL, Fedore LW, Aldahlawi MM. pH impedance and high-resolution manometry in laryngopharyngeal reflux disease high-dose proton pump inhibitor failures. Laryngoscope. 2012;122:2473–81. Multichannel intraluminal pH impedance and high-resolution manometry were useful in the diagnosis and management of recalcitrant LPR.

  38. Kawamura O, Aslam M, Rittmann T, et al. Physical and pH properties of gastroesophageal refluxate: a 24-hour simultaneous ambulatory impedance and pH monitoring study. Am J Gastroenterol. 2004;99:1000–10.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to J. M. Bock.

Additional information

This article is part of the Topical Collection on Laryngopharyngeal Reflux.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Little, R.E., Bock, J.M. Beyond Laryngoscopy: Current Objective Diagnostic Testing and Interpretation for LPR. Curr Otorhinolaryngol Rep 4, 43–48 (2016).

Download citation

  • Published:

  • Issue Date:

  • DOI: