Laryngopharyngeal reflux (LPR) is retrograde movement of gastric contents into the larynx and pharynx leading to a variety of upper aerodigestive tract symptoms. It is estimated that 4-10% of patients presenting to otolaryngologists have LPR.¹² Furthermore, 50-60% of chronic laryngitis cases and difficult-to-treat sore throats may be related to LPR.³

Many of the symptoms related to LPR are nonspecific, such as voice change, chronic throat clearing, chronic cough, globus pharyngeus, and dysphagia. Most patients complaining of these symptoms do not show specific abnormalities on a laryngeal examination.⁴ The most commonly reported physical findings of LPR on fiberoptic endoscopy are edema and erythema of the larynx.⁵⁶ At least two studies have found laryngeal abnormalities in a healthy asymptomatic population.⁷ The lack of definite abnormal findings accounting for these symptoms and variability of the condition suggest the possibility of an association with psychological factors.⁸⁹¹⁰¹¹ These psychological factors may have an important role in the predisposition, initiation, progression, and aggravation of LPR symptoms.⁹¹⁰¹¹

The present study investigated the associations between depression, somatization, and anxiety and the presence of LPR in a routine clinical practice to better understand the relationships between depression, somatization, anxiety, and LPR.

LPR-related symptoms are commonly presented to otolaryngologists. Some authors have reported that 10% of patients presenting have LPR.¹⁸ Kamani et al.¹⁹ estimated that the prevalence of LPR symptoms in the UK population was 34.4%. Globus sensation, throat clearing, cough, and other nonspecific symptoms are different presentations that may be related to LPR. The most commonly reported physical findings of LPR on fiberoptic endoscopy are edema and erythema of the larynx.⁶²⁰ At least two studies have found that laryngeal abnormalities are detectable in the healthy asymptomatic population.²¹²² The inconsistent findings related to presentation of LPR and uncertainty of the etiological background of these presentations suggests a possible association between these presentations and psychological problems.²³

Many studies have evaluated the psychological influence in patients with non-specific upper aerodigestive tract symptoms, particularly globus. Globus has been thought to be a definite hysterical symptom, as it is strongly associated with depressive illness responds well to antidepressant therapy.¹⁰ Park et al.²⁴ reported that patients with globus tended to have somatization regardless of LPR but patients without reflux reveal significantly higher scores on all other symptom dimensions of the Symptom Checklist-90-Revised. Globus symptoms in men indicate a much more profound psychological problem than those in women with the same complaint.¹¹ Barofsky et al.²⁵ also observed a group of patients who complain of swallowing difficulties but who have normal pharyngeal function following radiological and psychological evaluations but have clinically significant psychological characteristics. However, studies investigating the relationship between LPR and psychological factors are rare. A recent cohort study found that one-third of patients with LPR suffer from anxiety and significantly reduced social activities compared with those in controls.²⁶ However, in other studies, patients with LPR did not demonstrate any psychological distress.²⁷²⁸ Mesallam et al.²⁸ reported that the psychological background of patients with LPR does not affect the patients' self-perception of their reflux-related problem. Chronic laryngeal signs and symptoms associated with gastroesophageal reflux (GERD) are often referred to as LPR or reflux laryngitis. LPR is an extraesophageal variant of GERD, because the main symptomatic region involves the laryngopharynx. The relationship between psychological distress and GERD is complex and poorly defined. GERD may contribute to psychological distress, and in fact, psychological distress may contribute more significantly to poor quality of life than do symptoms. In a meta-analysis by El-Serag, persistent GERD symptoms despite medical treatment were associated with decreased psychological and physical well-being.²⁹ van der Velden et al.³⁰ found that subjects with residual GERD symptoms had an odds ratio of 2.8 and 3.2 for anxiety and depression, respectively.

We provide evidence suggesting that a significant portion of patients with LPR may struggle with symptoms of depression during the clinical course of their disorder. In the present study, the mild to severe depression rate was 46.2% (90 of 231). In addition, 41 (51.9%) of our 79 patients with LPR had depression, whereas only 49 (32.2%) of the 152 patients without LPR had depression. This finding suggests that patients with LPR may suffer from a broad range of clinical manifestations of depression. These are the first data supporting a substantial influence of depression on LPR. These results may help clinicians understand the role of depression as a potential moderator in the clinical manifestation of LPR.

The limitations of this study include the following. First, the study cohort was small, leading to large standard deviations. Second, we did not consider other psychiatric comorbidities. Third, no formal diagnosis of depression was made by structured interview. Future studies employing prospective, randomized methods to examine the psychological problems in patients with LPR are warranted.

In conclusion, the present study preliminarily demonstrates that clinicians may need to carefully evaluate depression to properly management patients with LPR. Subsequent adequately-powered studies with a better design will be crucial to validate and support our preliminary findings.