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Extraesophageal reflux disease

last modified on: Tue, 12/05/2023 - 08:38

return to: Proton Pump Inhibitor Side Effects PPI Considerations

see also: Swallowing Disorders Management ProtocolsManagement of Swallowing Disorders; Speech PathologistsReflux Symptom Index (RSI)


  1. Definitions
    1. GER: Gastroesophageal reflux
    2. GERD: Gastroesophageal reflux disease: defined as "chronic gastrointestinal disorder characterized by the regurgitation of gastric contents into the esophagus" (Antunes et al. 2023). Antunes et al. (2023) cites a prevalence of 20% in the United States. Symptoms include heartburn and regurgitation. Can lead to reflux esophagitis, reflux stricture, Barrett’s esophagus or adenocarcinoma.
    3. EER: Extraesophageal reflux: Reflux up into hypopharynx, nasopharynx, oropharynx, larynx or trachea.  
    4. EERD: Extraesophageal reflux disease: Non gastrointestinal manifestations of reflux. As per Chen et al (2023), "Several extraesophageal symptoms have been associated with GERD, although the strength of evidence to support a causal relation varies. Possible extraesophageal manifestations of GERD include cough, laryngeal hoarseness, dysphonia, pulmonary fibrosis, asthma, dental erosions/caries, sinus disease, ear disease, post-nasal drip, and throat clearing​" (Chen et al. 2023).
      1. Asthma: There is a clear association between EERD and asthma. However, current literature as to weather EERD has a causative role in asthma is controversial.
      2. Chronic cough: EERD has been reported to be the cause of 10-40% of cases of chronic cough.
      3. Laryngitis: EERD has been reported to be a common cause of laryngitis.
  2. History:
    1. Symptoms: 
      1. Hoarseness
      2. Cough
      3. Chronic throat clearing
      4. Chronic sore throat
      5. Change in voice
      6. Dysphagia
      7. Globus sensation
      8. Postnasal drip
      9. Strange taste in mouth
      10. Note: only 40% have heartburn
    2. Reflux Symptom Index (RSI)
      1. A nine-item outcome tool to diagnose laryngopharyngeal reflux. 
      2. An RSI > 13 is abnormal
      3. Reflux Symptom Index (RSI)


  1. Flexible fiberoptic laryngoscopy: Classically see edema and erythema involving the posterior third of the larynx. 
  2. Empiric therapy: Most reliable diagnostic test to confirm EERD is documented resolution of symptoms with antireflux treatment.
  3. pH testing: Recommended as next step for those who fail empiric therapy for EERD.  Most reliable test in diagnosis of GERD with sensitivity and specificity of 92%. Must stop acid-suppressing medications at least 3 days in advance.  
  4. Intraluminal impedance testing: Assesses nonacid reflux. 
  5. Endoscopy and barium esophagram. The incidence of esophagitis is lower than in patients with GERD and thus the yield of these examinations in confirming the diagnosis is low. Endoscopy has value in detection of complications of GERD.


  1. Lifestyle modifications
    1. Esophageal Reflux Precautions
  2. Medical treatment
    1. Standard dose of PPI BID or double dose of PPI at bedtime for 2-3 months. 
    2. If treatment is effective, can titrate dose down, or try H2 receptor blocker. 
      1. Can also consider transition to alginate therapy after 6 months of PPI
    3. If treatment is unsuccessful consider pH probe.
  3. Antireflux surgery. Fundoplication. For those intolerant to reflux medications or resistant to PPI.


Belafsky PC, Postma GN, Koufman JA.  Validity and reliabiltiy of the reflux symptom index (RSI).  Journal of Voice 2002, 16(2):274-277

Napierkowski J, Wong RK. Extraesophageal manifestations of GERD. Am J Med Sci. 2003 Nov;326(5):285-99.

Khan AM, Hashmi SR, Elahi F, Tariq M, Ingrams DR.  Laryngopharyngeal reflux: A literature review. Surgeon. 2006 Aug;4(4):221-5.

Frye JW, Vaezi MF.  Extraesophageal GERD. Gastroenterol Clin North Am. 2008 Dec;37(4):845-58, ix.

Chen JW, Vela MF, Peterson KA, Carlson DA. AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review. Clin Gastroenterol Hepatol. 2023 Jun;21(6):1414-1421.e3. doi: 10.1016/j.cgh.2023.01.040. Epub 2023 Apr 14. PMID: 37061897.

Antunes C, Aleem A, Curtis SA. Gastroesophageal Reflux Disease. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: