Hypothesis:Increasingly, gastroesophageal reflux disease (GERD) is suggested to cause laryngeal signs and symptoms,1often referred to as laryngopharyngeal reflux(LPR). But can LPR still be said to exist in a patient who is unresponsive to aggressive therapy? What should we tell the group of patients whose symptoms or laryngeal signs do not improve under acid-suppressive therapy? Here are a few selected answers from my “learned” colleagues: (1) Patients' symptoms are most definitively still caused by LPR, and lack of response to acid suppression does not rule out reflux as the cause. (2) Intermittent acid reflux may still occur in this group causing patients' findings. (3) Acid is truly not the culprit, and pepsin is the main agent responsible. And (4) Surgical fundoplication should be attempted in the patients who do not respond to therapy. All of these suggestions assume that reflux is the symptoms' cause and never question whether the LPR diagnosis was incorrect in the first place. Should we continue to insist on reflux as the diagnosis just because we may not know what else might be the cause of patients' persistent symptom complex? I would argue that this is not good clinical care.
Michael F. Vaezi, MD, PhD, MSc (Epi)
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