Written by George Barnes, MS, CCC-SLP, BCS-S
About the Author:
George Barnes, MS, CCC-SLP, BCS-S, is a Board-Certified Specialist in Swallowing and Swallowing Disorders with extensive clinical experience in reflux, dysphagia, and aerodigestive function. Known for his evidence-based, patient-centered approach, George advocates for comprehensive evaluation and targeted care plans that address the full scope of swallowing disorders, especially those that defy easy answers. He’s passionate about educating clinicians and empowering patients to understand the root causes of their symptoms better.
The Problem with Siloed Care for LPR and GERD
Have you ever felt like reflux management is like playing a game of hot potato? Where the primary passes the case to ENT, then ENT to GI, GI to SLP, and SLP back to ENT? Looks like heart burn isn’t the only thing that’s heating up. Over the past few decades, each and every healthcare discipline has become very good at studying and understanding what falls under their scope of practice. That sounds like a good thing, right? But here’s the thing, we’ve become great at seeing far through each of our scopes, but everything around it? Not so much.
These lonely scopes that we’ve built for ourselves have become known as healthcare silos and they are essentially isolated pockets of information, communication, and services that exist between different departments and providers. This fragmentation makes it difficult for anyone to get a full, holistic view of a patient's presentation.
This disjointed system can lead to a number of negative outcomes:
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Communication Breakdown: Information gets lost in translation.
Different disciplines often use their own jargon, and without effective communication, the patient's full story can become garbled or incomplete, much like a game of telephone where the final message is unrecognizable. -
Increased Risk of Error: When the full picture is not available, there is a higher risk of diagnostic errors and treatment delays. This is especially true for patients with complex, chronic conditions who see multiple specialists.
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Wasted Resources: The lack of coordinated care leads to duplicated efforts, such as repeated diagnostic tests, which are not only an inconvenience for the patient but also drive up healthcare costs.
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Poor Patient Experience: Patients can feel lost and overwhelmed as they navigate a system that lacks cohesion. This can be particularly frustrating for patients who are transferred between facilities or have their records scattered.
One clear example of this is in the management of laryngopharyngeal reflux (LPR), a complex condition that often requires the collaboration of multiple specialists. Unlike its cousin, GERD, which typically only impacts the esophagus and comes with clear, easy to recognize symptoms like heart burn, LPR is… sneakier. It's the silent assassin that sends gastric contents—not just acid, but pepsin and bile too—all the way up into the pharynx, larynx, and even the lungs. These sensitive tissues were not meant to deal with these caustic chemicals.
LPR is a complex, often under-diagnosed condition, and its symptoms can mimic a dozen other issues, from allergies to vocal dysfunction. Patients might complain of hoarseness, that persistent "lump in the throat" feeling (globus sensation), a nagging cough, and constant throat clearing. The real head-scratcher? Less than half of these patients will ever complain of heartburn. This "LPR without heartburn" phenomenon is a puzzle that no single specialist can solve alone. It takes a team. Reflux Revolutionaries: Unite!
The Reflux Team
So a history of medical specialists becoming more and more specialized means each discipline has dug super deep into each of our fields. And we continue to dig every day through the research we conduct, the training we undertake, and the clinical expertise we develop. But the further we dig the further we fall away from the sun we need to shed light on the problem. The solution? To start making tunnels towards each other's disciplines and coming back to the surface where we can begin to see the whole picture again.
There are three key players that need to unite to create this reflux team: The otolaryngologist (ENT), the gastroenterologist (GI), and the speech-language pathologist (SLP). Here’s a breakdown of how each member contributes to the game-winning strategy.
ENT: The First Line of Defense
An ENT is often the first clinician to see a patient with LPR symptoms, acting like the detective of the upper airway.
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Initial Clues: They use tools like the Reflux Symptom Index (RSI), a patient questionnaire, and the Reflux Finding Score (RFS), based on what they see with a scope. A score above a certain threshold (RSI > 12 or RFS > 7) can be a strong indicator of LPR.
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Visual Evidence: With a laryngoscope, the ENT can see the tell-tale signs of LPR, like redness, swelling, vocal fold edema, or posterior commissure hypertrophy. They may also monitor for serious complications such as laryngeal granulomas, glottic stenosis, and even laryngeal carcinoma, all of which are correlated with LPR.
The Gastroenterologist (GI): The Gut-Level Expert
While the ENT looks at the damage, the GI's job is to go to the source: the stomach and esophagus.
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Gold Standard Diagnosis: The GI's best tool is 24-hour pH monitoring, often with a dual probe to check both the esophagus and the throat, which is considered the gold standard for diagnosis. They might also use multichannel intraluminal impedance (MII) to catch non-acidic reflux events, which are just as damaging, since pepsin can cause issues even at relatively higher pH levels.
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Medical Strategy: GIs are the experts in pharmacological management. They are the ones who manage the dosing for medications like proton pump inhibitors (PPIs) and other agents. They know that LPR often requires a higher dose (twice-daily PPI) for a longer period (several months) because the larynx is so sensitive and slow to heal. If they’re smart, they’ll consider incorporating an alginate therapy like RefluxRaft to supplement traditional medications or even as a safe and effective alternative in mild to moderate cases.
The Speech-Language Pathologist (SLP): The Coach and Educator
This is where the SLP comes in. The SLP’s role is to coach the patient through the behavioral changes that are foundational to long-term success.
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Behavioral Toolkit: SLPs help patients with lifestyle and dietary changes that can make a huge difference. This includes simple but effective advice on avoiding food triggers, eating earlier in the evening, skipping tight clothes, and elevating the bedhead.
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Managing Symptoms: SLPs work directly on the symptoms that impact daily life, like hoarseness, chronic cough, and throat clearing. They teach patients vocal hygiene techniques and help them break maladaptive habits that can cause more laryngeal trauma.
The Power of a Unified Front
When these three specialists work together, the patient isn't just a collection of symptoms. They are seen as a whole person. This team approach allows for a more accurate and holistic diagnosis, combining clinical findings with objective data. This data is useless by itself, but can change lives if communicated effectively across disciplines and to the patient in a way that speaks to their specific complaints and concerns. The result is a comprehensive treatment plan that integrates medication, lifestyle changes, and behavioral therapies to address all aspects of the disease. This not only leads to better symptom resolution and fewer complications but also helps us avoid misdiagnosis and over-treatment.
We’ve already dug ourselves into a hole that’s hard to get out of. So let’s begin to make tunnels to connect back and help the patient get rid of their disjointed plan of care riddled with conflicting information and mixed messages. Instead, let’s connect the dots for the patient, see the full picture, and give them a plan that addresses their most ambitious goals for health and quality of life.
References:
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Heda, R., Toro, F., & Tombazzi, C. R. (2025). Physiology, Pepsin. StatPearls Publishing.
Johnston, N., Dettmar, P. W., Bishwokarma, B., Lively, M. O., & Koufman, J. A. (2007). Activity/stability of human pepsin: Implications for reflux-attributed laryngeal disease. The Laryngoscope, 117(6), 1036–1039. https://doi.org/10.1097/mlg.0b013e31804154c3
Kowalik, K., & Krzeski, A. (2017). The role of pepsin in the laryngopharyngeal reflux. Otolaryngologia Polska, 71(6), 7–14. https://doi.org/10.5604/01.3001.0010.5367
Lechien, J. R., Saussez, S., Muls, V., Barillari, M. R., Chiesa-Estomba, C. M., Hans, S., & Karkos, P. D. (2020). Laryngopharyngeal reflux: A state-of-the-art algorithm management for primary care physicians. Journal of Clinical Medicine, 9(11), 3618. https://doi.org/10.3390/jcm9113618
Loughlin, C. J., & Koufman, J. A. (1996). Paroxysmal laryngospasm secondary to gastroesophageal reflux. The Laryngoscope, 106(12 Pt 1), 1502–1505. https://doi.org/10.1097/00005537-199612000-00016
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Tack, J. (2005). Review article: Role of pepsin and bile in gastro-oesophageal reflux disease. Alimentary Pharmacology & Therapeutics, 22(Suppl. 1), 48–54. https://doi.org/10.1111/j.1365-2036.2005.02609.x
Vakil, N., van Zanten, S. V., Kahrilas, P., Dent, J., & Jones, R. (2006). The Montreal definition and classification of gastroesophageal reflux disease: A global evidence-based consensus. The American Journal of Gastroenterology, 101(8), 1900–1920. https://doi.org/10.1111/j.1572-0241.2006.00630.x