This is one of a series of occasional articles that highlight areas of practice where management lacks convincing supporting evidence. The series adviser is David Tovey, editor in chief, the Cochrane Library. This paper is based on a research priority identified and commissioned by the National Institute for Health Research’s Health Technology Assessment programme on an important clinical uncertainty. To suggest a topic for this series, please email us at uncertainties@ thebmj. com

Persistent throat symptoms are common in adults. Globus pharyngeus (a feeling of a lump in the throat), dysphonia, throat clearing, cough, excessive phlegm, throat pain, and postnasal secretions are present in up to 25% of primary care attenders, and more than 60 000 people are referred to secondary otolaryngological care annually. 1 Treating persistent throat symptoms with gastric acid suppression has been in vogue for more than a decade, on the basis that they represent “atypical” manifestations of gastro-oesophageal reflux disease (GORD). 2 So called extraoesophageal reflux or laryngopharyngeal reflux is internationally acknowledged as a separate GORD subcategory from “typical” oesophageal reflux disease. 3 However, the relation between gastric reflux and persistent throat symptoms, and the role of proton pump inhibitor (PPI) treatment remains controversial. 4 5 More than half of UK otolaryngologists prescribe PPIs for persistent throat symptoms. 6 The message has also filtered through to primary care that PPIs are a reasonable “empirical” treatment. PPI treatment is a substantial expense for healthcare systems and increasingly treatment of persistent throat symptoms is adding to this. The cost of PPI treatment to the National Health Service in England for all conditions, including persistent throat symptoms, was£ 425m (€ 540m; $694 m) in 2006 and the global bill was£ 7bn. 7