This article reviews the evaluation and management of patients with suspected extraesophageal manifestations of gastroesophageal reflux disease, such as asthma, chronic cough, and laryngitis, which are commonly encountered in gastroenterology practices. Otolaryngologists and gastroenterologists commonly disagree upon the underlying cause for complaints in patients with one of the suspected extraesophageal reflux syndromes. The accuracy of diagnostic tests (laryngoscopy, endoscopy, and pH- or pH-impedance monitoring) for patients with suspected extraesophageal manifestations of gastroesophageal reflux disease is suboptimal. An empiric trial of proton pump inhibitors in patients without alarm features can help some patients, but the response to therapy is variable.
Key points
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Suspected extraesophageal manifestations of gastroesophageal reflux disease, such as asthma, chronic cough, and laryngitis, are commonly encountered in gastroenterology practices.
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Otolaryngologists and gastroenterologists commonly disagree with the underlying cause for the complaints in patients with one of the suspected extraesophageal reflux syndromes.
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The accuracy of diagnostic tests (laryngoscopy, endoscopy, and pH- or pH-impedance monitoring) for patients with suspected extraesophageal manifestations of gastroesophageal reflux disease is suboptimal.
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An empiric trial of proton pump inhibitors in patients without alarm features can help some patients, but the response to therapy can be quite variable.
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Esophageal reflux testing with pH- or pH-impedance monitoring should be reserved for patients with an inadequate response to empiric therapy.
Gastroesophageal reflux disease (GERD) affects approximately 40% of the US population. Typical GERD symptoms include heartburn and acid regurgitation. However, extraesophageal manifestations of GERD, such as cough, hoarseness, and asthma, also occur. Over the last 2 decades, these entities, often called extraesophageal reflux (EER), have gained a lot of attention clinically and in the medical literature. The expense of managing patients with suspected EER has been estimated to cost over 5 times that of patients with typical GERD symptoms.
In 2006 the Global Consensus Group published the “Montreal Definition and Classification of GERD,” which was created via a modified Delphi process of worldwide experts. Within this report, the manifestations of GERD were divided into 2 major groups of syndromes, esophageal syndromes and extraesophageal syndromes . The esophageal syndromes were classified as symptomatic syndromes (typical reflux syndrome and reflux-chest pain syndrome) or syndromes with esophageal injury (reflux esophagitis, reflux stricture, Barrett esophagus, and esophageal adenocarcinoma). The extraesophageal syndromes were divided into those with established associations (reflux-cough, reflux-laryngitis [ Box 1 ], reflux-asthma, and reflux-dental erosion syndromes) and those with proposed associations (pharyngitis, sinusitis, idiopathic pulmonary fibrosis, and recurrent otitis media) ( Fig. 1 ).
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