Research

Original Investigation

Hoarseness and Laryngopharyngeal Reflux

A Survey of Primary Care Physician Practice Patterns
Ryan Ruiz, BA; Seema Jeswani, MD; Kenneth Andrews, MD; Benjamin Rafii, MD; Benjamin C. Paul, MD;
Ryan C. Branski, PhD; Milan R. Amin, MD

Supplemental content at
IMPORTANCE Current approaches to the diagnosis and subsequent management of specific jamaotolaryngology.com
voice disorders vary widely among primary care physicians (PCPs). In addition, sparse
literature describes current primary care practice patterns concerning empirical treatment for
vocal disorders.

OBJECTIVE To examine how PCPs manage patients with dysphonia, especially with regard to
laryngopharyngeal reflux.

DESIGN, SETTING, AND PARTICIPANTS Prospective, questionnaire-based study by an academic

laryngology practice among academic PCPs from all major US geographic regions.

MAIN OUTCOMES AND MEASURES A 16-question web-based survey, distributed via e-mail,
concerning management and possible empirical treatment options for patients with
dysphonia.

RESULTS Of 2441 physicians who received the e-mail broadcast, 314 (12.9%) completed the
survey. Among those who completed the survey, 46.3% were family practitioners, 46.5%
were trained in internal medicine, and 7.2% identified as specialists. Among all respondents,
64.0% preferred to treat rather than immediately refer a patient with chronic hoarseness
(symptoms persisting for >6 weeks) of unclear origin. Reflux medication (85.8%) and
antihistamines (54.2%) were the most commonly selected choices for empirical treatment.
Most physician respondents (79.2%) reported that they would treat chronic hoarseness with
reflux medication in a patient without evidence of gastroesophageal reflux disease.

CONCLUSIONS AND RELEVANCE Most PCPs who responded to our survey report empirically Author Affiliations: Department of
treating patients with chronic hoarseness of unknown origin. Many physician respondents Otolaryngology–Head and Neck
Surgery, NYU Voice Center, New York
were willing to empirically prescribe reflux medication as primary therapy, even when University School of Medicine, New
symptoms of gastroesophageal reflux disease were not present. These data suggest that York, New York.
PCPs strongly consider reflux a common cause of dysphonia and may empirically treat Corresponding Author: Ryan C.
patients having dysphonia with reflux medication before referral. Branski, PhD, Department of
Otolaryngology–Head and Neck
Surgery, NYU Voice Center, New York
JAMA Otolaryngol Head Neck Surg. 2014;140(3):192-196. doi:10.1001/jamaoto.2013.6533 University School of Medicine, 345 E
Published online January 30, 2014. 37th St, Ste 306, New York, NY 10016
(ryan.branski@nyumc.org).

P
rimary care providers have a crucial role in the diagno-
sis and treatment of voice disorders. With a lifetime
prevalence of approximately 30%,1,2 voice disorders are
a considerable burden on the health care system. Primary care
providers are often responsible for the initial management of
these patients. Current approaches to the diagnosis and sub-
sequent management of specific voice disorders by primary
care physicians (PCPs) must be understood to create recom-
mendations and guidelines for optimal treatment.
Of the potential causative factors to be considered in a pa-
tient with dysphonia, laryngopharyngeal reflux (LPR) is par-
ticularly vexing because of its lack of association with typical
gastroesophageal reflux symptoms. No consensus exists among
physicians regarding the diagnosis and treatment of LPR.3 For
instance, in cases where LPR is suspected, empirical therapy
with proton pump inhibitors has been recommended to con-
firm the diagnosis; however, guidelines suggest that this class
of drug should not be prescribed to patients who lack recent
signs and symptoms of gastroesophageal reflux disease
(GERD).4,5 Empirical treatment could prevent unnecessary re-
ferrals; however, it could also delay treatment for more seri-
ous causes of dysphonia such as laryngeal cancer. The objec-
tive of this study was to examine how PCPs manage patients
with prolonged hoarseness of unclear origin. We hypothesize

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 Hoarseness and Laryngopharyngeal Reflux Original Investigation Research

that the primary care community may emphasize empirical

Table. Demographic Information Regarding the Cohort
treatment for reflux over potential evaluative methods or treat- of Physician Respondents
ments in patients seen with dysphonia, even when other symp-
Variable Value
toms of reflux may be absent.
Practice location, %
Division 1 (New England): Maine, New Hampshire, 10.8
Vermont, Rhode Island, Connecticut
Division 2 (Mid-Atlantic): New York, Pennsylvania, 20.7
Methods New Jersey
Division 3 (East North Central): Wisconsin, Michigan, 18.2
Survey Design Illinois, Indiana, Ohio
The institutional review board at the New York University Division 4 (West North Central): Missouri, North 16.9
School of Medicine approved the present web-based, anony- Dakota, South Dakota, Nebraska, Kansas, Minnesota,
Iowa
mous, deidentified survey. A 16-question survey was de-
Division 5 (South Atlantic): Delaware, Maryland, 8.6
signed based on a literature review and clinical consensus (eFig- District of Columbia, Virginia, West Virginia, North
ure in the Supplement). Specific questions were designed to Carolina, South Carolina, Georgia, Florida
address current practices related to the clinical practice guide- Division 6 (East South Central): Kentucky, Tennessee, 5.7
Mississippi, Alabama
lines on hoarseness,6 as well as previous surveys addressing
Division 7 (West South Central): Oklahoma, Texas, 2.2
dysphonia.7 Section 1 (questions 1-5) addressed physician will- Arkansas, Louisiana
ingness to empirically treat dysphonia of longer than 6 weeks, Division 8 (Mountain): Idaho, Montana, Wyoming, 8.0
Nevada, Utah, Colorado
physician referral patterns, and empirical treatment choices.
Division 9 (Pacific): Alaska, Washington, Oregon, 8.9
Section 2 (questions 6-10) specifically addressed the role of re- California, Hawaii
flux in dysphonia, including the role for empirical treatment Practice setting, %
and subsequent evidence for dysphonia resolution after an- Academic 84.7
tireflux treatment. Section 3 (question 11) asked whether phy- Mixed 4.1
sicians had reviewed clinical practice guidelines in the litera- Private 11.1
ture pertaining to dysphonia. Section 4 (questions 12-16) Practice type, %
included demographic questions such as geographic area, type
Family medicine 46.3
of specialty, and years of clinical practice.
General practitioner 32.2
General practitioner/hospitalist 8.8
Survey Distribution
Hospitalist 5.5
The survey was distributed via e-mail to family medicine phy-
Specialist 7.2
sicians and general internists. These PCPs were chosen based
Time since completion of training, y 15.9
on their academic affiliation with institutions across the United
States. Academic departments that were contacted via e-mail
were chosen at random, although an effort was made to dis- sponded as general practitioner, general practitioner/
tribute e-mails geographically according to predetermined US hospitalist, or hospitalist), and 7.2% identified as specialists.
regions as outlined in the eFigure in the Supplement. Across all specialties, most physicians (84.7%) worked in an
academic setting. The mean time in practice since comple-
Data Accrual and Statistical Analysis tion of residency was 15.9 years. Physicians responded from
All data were collected via an online data management sys- all over the country in a uniform distribution across 9 regions
tem between February 5 and April 29, 2013. The survey link was in the United States (Table).
first distributed via e-mail to family practitioners and then to
general internists in the same fashion. One initial e-mail was Treatment vs Referral
sent to potential respondents, followed by a reminder e-mail Physician respondents were asked whether or not they would
approximately 3 weeks later. Each physician group was then treat or immediately refer a patient with chronic hoarseness
given an additional 3 weeks to complete the survey before the (symptoms persisting for >6 weeks) of unclear origin. In this
questionnaire was closed. Survey data were analyzed using the cohort, 64.0% of all respondents preferred to treat. Of those
1-sample z test to determine individual question significance physicians who decided to initially treat patients with chronic
and using Pearson product moment correlation χ2 test to evalu- hoarseness, 16.6% would treat for longer than 4 weeks before
ate for response trends between physician groups. referral, 51.2% would treat for 3 to 4 weeks before referral,
30.4% would treat for 1 to 2 weeks before referral, and 1.4%
would treat for less than 1 week before referral; 36.0% of phy-
sicians referred patients immediately. Almost all physician re-
Results
spondents (99.4%) would refer to an otolaryngologist at some
Respondent Profile point, independent of their decision to treat or refer.
Of 2441 physicians who received the e-mail broadcast, 339
(13.9%) started the survey, and 314 (12.9%) completed the sur- Medication Choice for Empirical Treatment
vey. Among those who completed the survey, 46.3% were fam- When asked what medications physicians prescribe rou-
ily practitioners, 46.5% were trained in internal medicine (re- tinely for patients with chronic hoarseness of unknown ori-

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 Research Original Investigation Hoarseness and Laryngopharyngeal Reflux

Figure 1. Medications Prescribed

100

90 Respondents
80 All
Internal medicine
70
Family medicine
Respondents, %

60

50

40

30

20

10

0
None Antibiotics Corticosteroids Reflux Medication Antihistamines Other Reported medications prescribed to
Prescribed Medication treat patients with persistent
hoarseness of unknown origin.

Figure 2. Causation and Treatment of Reflux

A B
70 70

60 60

50 50
Respondents, %

Respondents, %

40 40

30 30

20 20

10 10 Respondent views regarding the

0 0 frequency that reflux is involved in
Never Sometimes Most of Always Unknown None Some Half Most All Unknown hoarseness (A) and how often
the Time patients experience complete
Reflux Is Causative for Hoarseness Hoarseness Resolves With Antireflux Treatment resolution of hoarseness with reflux
management (B).

gin, reflux medication (85.8%) and antihistamines (54.2%) were lution of hoarseness with prescription of reflux medication,
most commonly selected. Across all respondents, 41.0% re- 57.6% reported that at least 3 weeks of therapy was necessary
ported prescribing both reflux medication and antihista- to achieve these results.
mines routinely. The most common other response was nasal
corticosteroids. Approximately 15% of responding physi- Treatment Without Evidence of GERD
cians reported that they do not routinely prescribe medica- When physicians were asked whether or not they would treat
tions for patients with chronic hoarseness. Responses among chronic hoarseness with reflux medication in a patient with-
physicians followed the same trend when selecting a prefer- out symptoms consistent with GERD, 79.2% reported the af-
ential therapy (Figure 1). No statistically significant differ- firmative (data not shown). This decision to treat reflux was
ence was observed in the prescription of reflux medication be- statistically significant across all physician specialties (P < .001).
tween physician groups (P = .48).
Physician Experience With Treating Dysphonia
Reflux and Its Contribution to Hoarseness Of the respondents, 74.2% treated fewer than 2 patients with
Across all respondents, 61.3% reported that reflux was “some- hoarseness per month, 9.9% treated 3 to 5, 0.6% treated 6 to
times” involved in the manifestation of hoarseness, and 27.0% 10, and 1.3% treated more than 10; 14.0% of respondents treated
believed that reflux was involved “most of the time” no patients with hoarseness per month. In addition, 72.3% had
(Figure 2A). In total, 55.7% thought that “some” of their pa- not reviewed any clinical practice guidelines regarding the
tients improved with antireflux treatment, while 11.0% of phy- evaluation and management of patients with hoarseness.
sicians perceived that most of their patients improved. When
queried whether reflux medication led to complete resolu-
tion of symptoms, 56.6% believed that “some” of their pa-
tients completely resolved, while only 9.4% of physicians
Discussion
thought that “most” of their patients completely resolved Empirical treatment of long-standing hoarseness by PCPs be-
(Figure 2B). Of those respondents who reported complete reso- fore visualization of the larynx is a potentially concerning is-

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 Hoarseness and Laryngopharyngeal Reflux
sue for otolaryngologists. In previous investigations, presump-
tive diagnoses made by general practitioners based on patient
history were incongruent with final diagnoses made by oto-
laryngologists on laryngoscopic examination.8 In the case of
laryngeal carcinoma, evidence has shown that physician de-
lay in diagnosis is a prognostic indicator associated with
increased morbidity and more advanced disease. 9 , 1 0
Therefore, incorrect empirical treatment by PCPs could delay
necessary interventions for more serious laryngeal patho-
logic conditions.
In the present study, 64.0% of physicians chose to empiri-
cally treat a patient with hoarseness of unknown origin last-
ing longer than 6 weeks, with a treatment regimen lasting up
to 4 weeks. Although no evidence in the literature supports a
precise duration to referral, most recommendations suggest
referral after 2 weeks of persistent symptoms.11,12 In contrast
to our results, Turley and Cohen 7 reported that approxi-
mately two-thirds of PCPs elect to refer patients with dyspho-
nia lasting more than 2 weeks. Given the differences in ques-
tion design between the study by Turley and Cohen and the
present data, it is difficult to determine exactly how long PCPs
would wait before referral. However, it is reasonable to as-
sume from the data presented herein that many PCPs are will-
ing to attempt empirical treatment before a specialist has had
the opportunity to visualize the larynx, despite the persis-
tence of symptoms exceeding 6 weeks. Furthermore, 72.3% of
physicians who responded reported never having read guide-
lines concerning the management of hoarseness. Although it
would be difficult to draw any broad conclusions about na-
tional PCP practices from this survey, it is of concern that a sub-
stantial number of academic PCPs would choose to monitor
and treat patients with dysphonia for extended periods with-
out visualization of the larynx and without any guideline-
based treatment regimen.
In our physician cohort, it is clear that most consider LPR
a common cause of dysphonia of unclear origin and treat pa-
tients accordingly. Many of the symptoms associated with LPR
such as dysphonia, throat clearing, and globus pharyngeus are
nonspecific. In addition, LPR is difficult to diagnose even with
visualization of the larynx. Recent evidence from our group
has highlighted that patients with hoarseness who have been
diagnosed as having LPR by PCPs and even general otolaryn-
gologists and are subsequently referred to a specialty laryn-
gology clinic often have significant missed pathologic
conditions.13 Concern is growing that physicians may be over-
emphasizing the role of LPR as causative of dysphonia.
Possibly the most notable finding in this study was that
79.2% of respondents would empirically treat patients hav-
ing dysphonia without evidence of concurrent GERD, a prac-
tice that is not supported by clinical practice guidelines. Fur-
thermore, 85.8% of respondents prescribed reflux medication,
yet only 9.4% found that this therapy provided complete reso-
lution of symptoms. No conclusive evidence exists that pro-
ton pump inhibitor therapy is effective for LPR. Reviews of the
literature have pointed to a substantial placebo effect in treat-
ment trials for patients with LPR.3,4 A 2006 Cochrane review
identified 6 randomized controlled trials that evaluated pro-
ton pump inhibitor therapy for LPR; all 6 studies reported a
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Original Investigation Research
significant placebo response, and none met full criteria to de-
termine treatment effectiveness.14 After the Cochrane re-
view, the most recent randomized trial (by Vaezi et al15) also
showed no statistical difference between the use of esome-
prazole and placebo in patients with chronic posterior laryn-
gitis. Because little evidence supports the treatment of LPR
without the symptoms of GERD or without a laryngoscopic
evaluation, these data suggest some level of disconnect in treat-
ment strategies between the otolaryngology and primary care
communities. However, published primary care literature ad-
vocates for a protocol-based approach to dysphonia manage-
ment and calls for antireflux treatment only in the presence
of GERD.5 Therefore, it is clear that PCPs and otolaryngolo-
gists should be more vocal about a systematic approach to an-
tireflux treatment in the setting of dysphonia within the pri-
mary care population. Previous efforts have informed the
primary care community about the proper management of vo-
cal disorders12,16; however, it is clear that future communica-
tion between specialties, on a regional or national level, is still
necessary.
Our data show infrequent use of antibiotic therapy. The
2009 clinical practice guideline6 included a strong recommen-
dation against antibiotic use for patients with dysphonia and
a Cochrane review showed minimal benefit for antibiotic
therapy in patients with chronic laryngitis.17 In addition, an
ever-present concern among physicians is the increasing rate
of antibiotic-resistant bacteria; it is reassuring that most PCPs
do not consider antibiotics an appropriate empirical treat-
ment option for patients with dysphonia.
The present study is not without limitations. As with all
questionnaire-based studies, respondents may have misin-
terpreted questions. Physicians were asked to make concrete
choices about patient treatment options with limited infor-
mation about patient history. As such, it is possible that the
respondents were forced into certain response choices be-
cause of the context of the question. This point is of particu-
lar concern when trying to apply any broad conclusions about
PCP practice from this study sample alone. In addition, this
study could be subject to selection bias; some physicians may
have been more likely to participate because of their familiar-
ity with voice issues. However, the demographic distribution
of the respondents at least indicates that respondents have di-
verse training backgrounds and patient demographics.
Conclusions
Primary care physicians who responded to our survey pre-
ferred to treat patients with chronic hoarseness (>6 weeks) of
unknown origin rather than refer immediately. These physi-
cian respondents treated hoarseness most commonly with re-
flux medication. In addition, they reported that they would
treat hoarseness of unknown origin with antireflux treat-
ment when symptoms of GERD were not present. These data
indicate that PCPs strongly consider reflux a common cause
of dysphonia, and many physicians may also believe that
empirical treatment with reflux medication is indicated be-
fore referral.
JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3 195
 Research Original Investigation
ARTICLE INFORMATION
Submitted for Publication: September 3, 2013;
final revision received November 4, 2013; accepted
December 3, 2013.
Published Online: January 30, 2014.
doi:10.1001/jamaoto.2013.6533.
Author Contributions: Mr Ruiz and Dr Branski had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of data analysis.
Study concept and design: All authors.
Acquisition of data: Ruiz, Jeswani, Andrews.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Ruiz, Branski.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Ruiz, Branski.
Administrative, technical, or material support: Ruiz,
Jeswani, Andrews, Rafii, Paul.
Conflict of Interest Disclosures: None reported.
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