Impact of GE Reflux in Upper Airways Impact of GE Reflux in Upper Airways DiseaseDisease

Fernán Caballero FonsecaCentro Medico Docente La Trinidad

Caracas , VenezuelaDecember 2012

Reasons to Go to the Doctor Who has not have a patient with “frequent throat clearing

”?

Who has not have a patient with “Persistent sore throat”?

Who has not have a patient with “foreign body sensation ”?

Who has not have a patient with post nasal drip?

Who has not have a patient dysphonic?

Who has not have a patient with “nocturnal awakenings”?

GE RefluxEpidemiology

Gastroesophageal reflux disease (GERD) has become epidemic in the United States and in the developed world. Since 1970, the prevalence of reflux disease has increased 300 percent nationwide. Yearly, GERD accounts for approximately 5 million outpatient visits and close to 100,000 hospitalizations in America.

It is highly prevalent worldwide with a prevalence of 10%-20% in the western world. It is estimated that GERD affects 18.6 million people in the United States. The prevalence of weekly symptoms has increased to an annual rate of approximately 5% in North America. In the US adult population, 10%-20% of people have symptoms at least once weekly and 15%-40% of people have symptoms at least once monthly

World J Gastrointest Endosc. 2010 December 16; 2(12): 388–396. Published online 2010 December 16. doi: 10.4253/wjge.v2.i12.388 PMCID: PMC3010469

ERGEMechanisms

Transitory relaxation of LES

Increased Intra –abdominal pressure

Decreased oesophagus capacity

Delayed gastric empting

Esophagus

LES

Cruraldiaphragm

Pylorus

Stomach

Angle of His

Pharynx

UES

Reflux Barrier

4 components:

- Pressure (intrinsic and extrinsic factors)

- LES length

- Hiatal hernia

- Compliance or yield at the GEJ

GE RefluxMechanisms

Differential DiagnosisDifferential Diagnosis

Chonic rhinosinusitis

Funtional dysphonia

Chronic tonsilitis

Sleep apnea

Gastro oesophageal reflux disease GORD or GERD

Infants

Feeding refusal

Recurrent vomiting

Poor weight gain

Irritability

Sleep disturbance

Apparent life-threatening event

Older Child/Adolescent

Abdominal pain/heartburn

Recurrent vomiting

Dysphagia

Asthma

Recurrent pneumonia

Upper airway symptoms (chronic cough, hoarse voice)

Common Presenting Symtoms of GERD in Pediatric Patients

Rudolph CD, Mazur LF, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in

infants and children: recommendations of the North American Society for Pediatric Gastroenterology and

Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2:S1-31. Abstract

Associated Conditions

Chronic RhinosinusitisLaryngospasmGranulomaChronic laryngitisSubglotic stenosisLaryngeal cancerChronic otitis media

Swiss Med Wkly .2012;142w13544

How the Gastro Esophageal Reflux How the Gastro Esophageal Reflux Affects the Upper Airways?Affects the Upper Airways?

Rhino Sinusitis

Is There Evidence to Link Acid Reflux with Chronic Sinusitis or any Nasal Symptoms ?

A Review of the Evidence.

Poor evidence of cause-effect relationship

There are not good randomized controlled trials available.

The few adult studies are small case-control with moderate levels of potential bias.

There is not enough evidence to consider anti-reflux therapy in adults refractory CRS .

Flook EP, Kumar BN.Rhinology. 2011 Mar;49(1):11-6.

Symtoms Attributed to Laryngopharingeal Reflux

Hoarseseness Post nasal drip

Dysfagia Laryngospasm

Dysfonia

Sore or burning throat

Excessive throat clearing

Chronic cough

Globus

Gastroesophageal Reflux Disease and Chronic Sinusitis: In Search of an Esophageal-nasalReflex.

Gastroesophageal reflux and chronic rhinosinusitis .

Chloridic acid and saline solution.

Mucus production , nasal symptom scores and nasal peak flow.

Nasal - esophageal reflex.

Wong IW, Rees G, Greiff L, Myers JC, Jamieson GG, Wormald PJ.Am J Rhinol Allergy. 2010 Jul-Aug;24(4):255-9.

Proton Pump Inhibitor Therapy Improves Symptoms in Postnasal Drainage

75 patients randomized , double blind patients.

Lanzoprazole Vs placebo

Post nasal drip

50% improvement with Lanzoprasole Vs 5% Placebo

Durmus R, Naiboglu B, Tek A, Sezikli M, Cetinkaya ZA, Toros SZ, Eriman TM, Egeli E.Acta Otolaryngol. 2010 Sep;130(9):1053-7.

Laringopharyngeal Reflux

An Approach to the Management of An Approach to the Management of Paroxysmal Laryngospasm.Paroxysmal Laryngospasm.

15 patients ; 9 females and 6 men

Average age 56 +/- 6 years.

80% associated to to GERD.

Treated with PPI

6 total improvement, 4 partial improvement and 5 did not respond.

Obholzer RJ, Nouraei SA, Ahmed J, Kadhim MR, Sandhu GS.J Laryngol Otol. 2008 Jan;122(1):57-60.

Vocal Cord Dysfuction

Etiology?Etiology?

Symptoms

• Cough

• Dispnea

• Dysphonia

• Estridor

• Weezing

• Dysfagia

• Anxaiety

Vocal Cord Dysfuntion

GERD and VCD

Powell et al. (2000)

22 patients (age <18) with VCD

21/ 22 patients with severe aritenoid oedema and congestion during endoscopy .

Loughlin et al. (1996)

12 adult patients with VCD

11/ 12 patients with laringytis during endoscopy

10/12 with abnormal PH-24hs

All patients responded to anti reflux therapy with total improvement of the VCD syptoms.

GERD and VCD

Cukier-Blaj et al.:Laryngoscope 118: February 2008

Otitis Media

Otologic Findings in Children with Otologic Findings in Children with Gastroesophageal Reflux.Gastroesophageal Reflux.

73 children ( average 13 months.).

Fail AE , timpanogram curves B, and one or two sighs of GERD .

40 treated children , 29 not treated 4 no follow up .

52,5% resolution Vs 45% in the control group ,and by 40% improvement Vs 30% on the control group.

Int J Pediatr Otorhinolaryngol. 2007 Nov;71(11):1693-7. Serra A, Cocuzza S, Poli G, La Mantia I, Messina A, Pavone P.

Laryngitis - DisphoniaLaryngitis - Disphonia

Multicentric study: statistical correlation Multicentric study: statistical correlation between clinical data and instrumental between clinical data and instrumental findings in laryngo-pharyngeal reflux: findings in laryngo-pharyngeal reflux:

proposal for a new ENT classification of proposal for a new ENT classification of refluxreflux

CA Leone and F MoscaActa Otorhinolaryngol Ital. 2006 October; 26(5): 264–270

Front regions •2/3 front aryepiglottic plicas;•2/3 front vocal cords , epiglottis.

Back regions( and / or lateral)

•1/3 back aryepiglottic plicas •1/3 1/3 back aryepiglottic vocal cords•Arytenoids•Interarytenoid mucosa• Pyriform sinus

Multicentric study: statistical correlation between clinical data and instrumental findings in laryngo-pharyngeal reflux:

proposal for a new ENT classification of reflux

CA Leone and F MoscaActa Otorhinolaryngol Ital. 2006 October; 26(5): 264–270

Grade A :Erythema/Oedema back and/or lateral

regions;Grade B :Erythema/Oedemaback and/or lateral and front

regions;Grade C:Erosion/Granulationback and/or lateral regions;

Grade D:Erosion/Granulationback and/or lateral and front

regions.

Clinical and Phmetric Evaluation ofClinical and Phmetric Evaluation ofGastro-esophageal Reflux Impact on Gastro-esophageal Reflux Impact on

Upper Airways in AdultUpper Airways in Adult

95 patients evaluation clinical parameters Vs phmetric findings.

Positive correlation in 81,2% of the patients.

Ulcers 80%, leucoplasias 71,4% y granulomas 100% of phmetrics positives.

Sethom Anissa, Khemaies Akkari, Khaled Riahi, Imed Miled, Sonia Benzarti, Mohamed Kamel ChebbiLa tunisie Medicale - 2012 ; Vol 90 ( n°03 ) : 243 - 247

Role of Rhinitis in Laryngitis: Another Role of Rhinitis in Laryngitis: Another Dimension of the Unified Airway.Dimension of the Unified Airway.

134 AR patients, 54 Non allergic rhinitis , and 62 controls.

Prevalence de dysphonia: 32.8% AR, 26.9% NAR y 8.1% controls (P<0,001)

Odds ratio, 4.22; 95% confidence interval compared with Asthma, GE reflux and inhaled corticoid usage .

Turley R, Cohen SM, Becker A, Ebert CS Jr.Ann Otol Rhinol Laryngol. 2011 Aug;120(8):505-10.

DiagnosisDiagnosis

Pharyngeal –laryngeal symptoms.

Post nasal drip.

Indirect laryngoscope and posterior rhinoscopy.

Video endoscopy .

Final thoughtsFinal thoughts

The GE reflux is a very common disease and its prevalence seems to be growing.

It has direct relationship with many entities in the ENT area .

By large is a clinical diagnosis but many patients may lack GI symptoms , para clinical evaluation may help in some patients.

Many patients, but not all, will improve with anti reflux therapy.

The PPI trial may be useful toll as diagnosis and treatment in many patients with GERD.