Can reflux reaching the larynx and pharynx irritate upper-airway mucosa and relate to chronic rhinosinusitis?

Reflux-related throat and voice complaints are common but diagnostically nonspecific. Available evidence supports biologic injury potential and an association with chronic rhinosinusitis (CRS), while emphasizing the need for objective reflux testing before attributing an individual’s upper-airway symptoms or mucosal findings to laryngopharyngeal reflux (LPR).

Mucosal effects and mechanisms

• Experimental and animal studies show that acid, weak acid, pepsin, and some bile acids can injure laryngeal epithelium, producing inflammation, erosion, barrier disruption, widened intercellular spaces, and reduced E-cadherin.
• Pepsin may promote oxidative stress and inflammatory signaling; inhibiting pepsin in reflux models reduced inflammation and preserved barrier integrity. Bile-acid effects can occur at acidic or basic pH, depending on the bile acid.
• In clinical practice, erythema, edema, posterior-commissure changes, mucus, and granuloma are not reflux-specific. Smoking, allergy, infection, voice use, and inhaled irritants can produce similar findings.

Relationship with chronic rhinosinusitis

• LPR is associated with CRS, not established as its cause. A 2025 meta-analysis found higher CRS prevalence among adults with LPR (OR 4.77, 95% CI 2.51–9.07).
• Consistent GERD-focused studies found GERD in 17.1% of CRS cases versus 9.1% of controls (adjusted OR 2.04), and an adjusted subsequent CRS hazard ratio of 2.36.
• Pepsin detection in sinonasal samples and reports of reflux events in 54% of recalcitrant CRS patients provide plausible exposure-related mechanisms, but do not establish that reflux is driving CRS in a given person.

Diagnostic implications

• Throat clearing, cough, dysphonia, globus, and mucus sensation cannot independently establish LPR. RSI is useful for tracking symptom severity, but showed sensitivity about 48% and modest discrimination (AUC 0.633) against physiologic testing.
• Ambulatory pH-impedance monitoring, typically off acid suppression when confirmation is needed, provides objective reflux evidence.

Bottom line

• Refluxate can injure upper-airway mucosa and is meaningfully associated with CRS, but symptoms, questionnaires, and laryngoscopic appearance alone should not be used to confirm LPR or justify reflux-directed treatment for CRS.