Diagnosis of Extraesophageal Reflux

Understanding of gastroesophageal reflux disease (GERD) has grown to include a wide spectrum of disorders related to the retrograde passage of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with varied list of symptoms including chronic cough, laryngitis, asthma, as well as complications such as recurrent pneumonia and infant apnea. The role of a gastroenterologist in patients referred for evaluation of suspected EER is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. There is no single gold standard diagnostic test that can establish reflux as the etiology for the suspected extraesophageal symptoms. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if esophageal pH or pH-impedance monitoring can identify patients with abnormal reflux, they do not consistently predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been likely overestimated in patients with suspected EER. Understanding the individual strengths as well as limitations of available diagnostic modalities and how they potentially may be complementary is critical to the care of this challenging group of patients.