Refluxo laringofaríngeo em adultos: avaliação, diagnóstico e tratamento

Abstract

Introduction: Laryngopharyngeal reflux (LPR) is defined by the reflux of gastric contents into the laryngopharynx. Although there is an underlying link between gastroesophageal reflux disease (GERD) and LPR, since reflux must traverse the esophagus to reach the laryngopharynx, it is the tissue damage and triggering of specific clinical symptoms that differentiate them. The most common symptoms include hoarseness, recurrent or persistent clearing of the throat, excess mucus in the throat, dysphagia, postprandial or recumbent cough, and persistent globus or foreign body sensation. Objectives: discuss the assessment and management of laryngopharyngeal reflux in adults. Methodology: Integrative literature review based on scientific databases from Scielo, PubMed and VHL, from January to April 2024, with the descriptors "Laryngopharyngeal reflux", "Adults" and "Assessment". Articles from 2019-2024 (total 88) were included, excluding other criteria and choosing 5 full articles. Results and Discussion: There are two competing approaches to the diagnosis of LPR. The first uses empirical treatment and depends on the patient's response to therapy; The second approach involves specific LPR testing before initiating therapy. There is no consensus on the best approach for all patients. The empirical treatment approach tends to be more appropriate for patients with non-severe symptoms and in young, otherwise healthy patients. In patients with more severe symptoms and those with more complex medical histories, we typically prefer testing before initiating therapy as it can offer information that can help individualize treatment. We generally offer both options to patients and engage in shared clinical decision making to determine the preferred approach. Most patients opt for the empirical approach as testing for LPR can be uncomfortable and can often be associated with increased direct costs. For greater specificity and to rule out other pathology, particularly in patients in whom the diagnosis is uncertain based on clinical assessment, laryngoscopy is usually performed. For all patients with non-severe LPR symptoms or mild LPR on trial, we suggest initial dietary and lifestyle modifications rather than drug therapy. For patients with LPR symptoms that are not controlled with a diet and lifestyle modification trial, and for patients with more severe symptoms or with evidence of severe LPR on trial, we suggest adding a proton pump inhibitor (PPI) instead of other medicines. There is no consensus on optimal PPI dosing, but we prefer initiation of therapy with once-daily dosing with the option of increasing to twice-daily dosing depending on patient response. Patients are seen for follow-up at three months to assess their response to treatment. For patients who are symptom-free, we discontinue the PPI and advise indefinite continuation of lifestyle and dietary modifications; For patients who remain mildly symptomatic on once-daily PPI therapy, we perform laryngoscopy (if it has not already been done), continue current PPI therapy for an additional two to three months, and then retry discontinuation of the PPI. For patients who remain moderately to severely symptomatic on once-daily PPI therapy, we perform laryngoscopy (if it has not already been done), increase PPI to twice daily, and often add a histamine 2 (H2) blocker to be taken at bedtime. Patients who continue to have severe and refractory LPR symptoms on PPI therapy and those who are unable to wean from PPI therapy are referred for consideration of interventional management. Conclusion: Although many of these symptoms are nonspecific, they should trigger concern about laryngopharyngeal reflux, particularly if these symptoms are experienced together and/or if the patient has associated symptoms of GERD (heartburn, dyspepsia) or an occasional sour taste in the mouth.