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Are persistent throat symptoms atypical features of gastric reflux and should they be treated with proton pump inhibitors?

BMJ 2014; 349 doi: (Published 09 October 2014) Cite this as: BMJ 2014;349:g5813
  1. Jason Powell, research fellow1,
  2. James O’Hara, consultant otolaryngologist, head and neck surgeon2,
  3. Janet A Wilson, professor of otolaryngology, head and neck surgery3
  1. 1Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
  2. 2Freeman Hospital, Newcastle upon Tyne, UK
  3. 3Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
  1. Correspondence to: J Powell jason.powell{at}
  • Accepted 18 August 2014

Persistent throat symptoms are common in adults. Globus pharyngeus (a feeling of a lump in the throat), dysphonia, throat clearing, cough, excessive phlegm, throat pain, and postnasal secretions are present in up to 25% of primary care attenders, and more than 60 000 people are referred to secondary otolaryngological care annually.1 Treating persistent throat symptoms with gastric acid suppression has been in vogue for more than a decade, on the basis that they represent “atypical” manifestations of gastro-oesophageal reflux disease (GORD).2 So called extraoesophageal reflux or laryngopharyngeal reflux is internationally acknowledged as a separate GORD subcategory from “typical” oesophageal reflux disease.3 However, the relation between gastric reflux and persistent throat symptoms, and the role of proton pump inhibitor (PPI) treatment remains controversial.4 5 More than half of UK otolaryngologists prescribe PPIs for persistent throat symptoms.6 The message has also filtered through to primary care that PPIs are a reasonable “empirical” treatment. PPI treatment is a substantial expense for healthcare systems and increasingly treatment of persistent throat symptoms is adding to this. The cost of PPI treatment to the National Health Service in England for all conditions, including persistent throat symptoms, was £425m (€540m; $694m) in 2006 and the global bill was £7bn.7

What is the evidence of uncertainty?

On 25 June 2014 we searched Medline and Embase databases and the Cochrane Library for studies dealing with persistent throat symptoms, gastric reflux, and treatment with PPIs. We used the search terms “throat symptoms” or “laryngopharyngeal reflux” or “extra-oesophageal reflux” or “extra-esophageal reflux” or “gastro-oesophageal reflux disease” or “gastro-esophageal reflux disease” or “proton pump inhibitors”.

Are persistent throat symptoms atypical features of gastric reflux?

The pathogenesis of persistent throat symptoms in gastric reflux is hypothesised to be through retrograde flow of gastric contents (particularly acid, bile, and pepsin) that affect the laryngopharynx by direct mucosal contact, or by a secondary mechanism.8 …

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