Extraesophageal reflux: Clinical manifestations and tools for diagnosis and treatment

Extraesophageal reflux is a complex clinical entity, classically presenting with laryngopharyngeal symptoms including chronic cough and vocal changes, but it is also implicated in conditions such as subglottic stenosis and lung injury. Diagnosis is challenging, in large part due to the oftentimes vague presenting symptoms with multiple possible etiologies, as well as limited consistency of currently available diagnostic tests. Furthermore, effective medical treatment is limited, and acid suppression therapy such as proton pump inhibitors has shown low to mixed efficacy in relieving signs and symptoms of reflux outside the esophagus. In this review, we will address laryngopharyngeal reflux and its diagnosis based on symptoms and exam findings, and diagnostic tools such as impedance monitoring and salivary pepsin testing. A summary of the use and limitations of acid-suppressing therapies for extraesophageal reflux and the rationale for targeting pepsin as a nonacid component of reflux will be presented. Finally, the current literature on the potential role of reflux in subglottic stenosis and lessons learned regarding reflux in the lung transplant surgery field in higher risk patient populations will be discussed.