Laryngeal gastroesophageal reflux disease (2023)

Patient has persistent hoarseness, has been to many places, has seen many ENT doctors, but still no relief. It was time to consult a gastroenterologist, it turned out that the patient had reflux esophagitis, and the doctor concluded that the patient's hoarseness was caused by reflux esophagitis. What are the characteristics of this disease? Why can reflux esophagitis cause persistent hoarseness? This article addresses this issue.

Extraesophageal manifestations associated with gastroesophageal reflux disease are common and present diagnostic and therapeutic challenges and can affect the lungs, upper airway, and mouth and are presented with asthma, laryngitis, chronic cough, dental wear, and noncardiac chest pain.

2. Laryngitis. management and throat. This is a common extraesophageal presentation associated with gastroesophageal reflux disease: up to 10-15% of all visits to ENT clinics are due to manifestations of laryngeal-oropharyngeal reflux.
Laryngeal symptoms of gastroesophageal reflux disease
Gastroesophageal reflux disease can cause many laryngeal symptoms, including hoarseness, pain or burning in the throat, pain when swallowing, a lump in the throat, coughing, repeated throat clearing, excess mucus, difficulty swallowing, and a tired voice. . These disorders are not specific to gastroesophageal reflux disease and laryngopharyngeal reflux disease and can also be caused by allergens, smoke, and various irritants. In a large case-control study, patients with esophagitis or esophageal stricture had a higher relative odds (OR) of having pharyngitis (OR: 1.60), anorexia (OR: 1.81), and chronic laryngitis (OR: 2.01) IM comparison to the control group. Many patients diagnosed with GERD do not have the classic symptoms of gastroesophageal reflux disease: heartburn is absent in more than half of patients with laryngopharyngeal reflux. In the PRO study of gastroesophageal reflux disease, the incidence of laryngeal dysfunction was 10.4% and was associated with older age, longer duration of GERD, and obesity. Interestingly, smokers are less likely to have laryngeal disease than non-smokers, possibly because the laryngeal mucosa is desensitized.

Why does gastroesophageal reflux disease cause this problem in the larynx?
The laryngeal manifestation of gastroesophageal reflux disease can be explained by direct damage from acid peptide exposure in the larynx via esophageal-oropharyngeal reflux (microaspiration theory) or by indirect acidification of the distal esophagus via the intermediate reflex (esophageal-bronchial reflex theory). . ). ). Both mechanisms cause chronic coughing and hawking, resulting in mucosal damage and typical signs and symptoms.
The laryngeal mucosa is more susceptible to damage than the esophageal mucosa: acid reflux, which contains acid and pepsin, and biliary reflux cause inflammatory lesions and precancerous lesions of the larynx. However, the inability to remove saliva causes more serious damage than the esophagus.
3. How is it diagnosed? Laryngoscopy revealed reflux-related disorders such as erythema, edema, lymphatic hyperplasia of the posterior wall of the larynx, ulceration, inferior glottis or posterior glottic stenosis, vocal cord polyps, granulomas, and leukocytes. Cancer. Although common in reflux laryngitis, most are nonspecific. Edema and congestion, commonly used to define reflux laryngitis, are non-specific and are highly operator-dependent parameters: in fact, signs of laryngeal irritation are present in more than 80% of healthy controls. Allergies, smoking, and voice abuse are common causes of larynx irritation and cause changes similar to those of acid reflux.
Role of esophageal pH monitoring
The use of ambulatory esophageal pH monitoring to diagnose laryngopharyngeal reflux is controversial. Monitoring pH of the proximal esophagus and pharynx has a sensitivity of 40% and 55%, respectively. Although pH monitoring detects reflux in only 40% of patients with symptoms of laryngeal dysfunction, impedance monitoring can detect the presence of mild acidic and alkaline, gaseous and acidic reflux. or fluid that can cause laryngeal dysfunction.
Saliva Pepsin Test
A promising non-invasive test for the diagnosis of reflux, although still controversial in its clinical use, is the detection of pepsin in saliva. Pepsin is a proteolytic enzyme secreted into the gastric lumen as pepsinogen and activated in an acidic medium: its determination at sites extragastric can demonstrate the presence of significant reflux. . Methods for measuring pepsin concentrations have not yet been standardized, with inconsistent accuracy. Using the western blot technique to collect sputum and salivary pepsin samples from GERD patients, Kim et al. reported sensitivity and specificity of 89% and 68%, respectively, based on pH monitoring results. . The monoclonal antibody test showed current, prospective, blinded positive and negative predictive values ​​of 87% and 78%, respectively.

Hanson and others. reported a high response rate for medical and non-medical laryngopharyngeal reflux: half of the patients responded to behavior changes, while 54% of them were unsuccessful. in this method it reacts with H2 blockers. PPI therapy is the standard of care for patients with chronic pharyngeal symptoms when GERD is suspected as the underlying cause, although single-dose PPI therapy has not been shown to be effective. Superiority over placebo in the treatment of laryngopharyngeal reflux. An experimental study recommended double-dose PPI as first-line therapy in patients with suspected laryngopharyngeal reflux for positive suppression of oropharyngeal acid reflux. A 2016 meta-analysis of 13 RCTs in patients with laryngopharyngeal reflux showed an improvement in reflux symptoms (as measured by the reflux symptom index [RSI]) with twice-daily treatment. days for 3 to 6 months, although no differences in response rates and effects on laryngeal mucosa were observed between PPIs and placebo. On the other hand, a recent meta-analysis of controlled trials including patients with laryngopharyngeal reflux showed no benefit from PPI therapy. This negative finding can be partly explained by the difficulty in identifying patients with laryngopharyngeal reflux in the absence of specific diagnostic tools. The diagnosis of laryngitis associated with gastroesophageal reflux disease is suspected by the presence of symptoms such as hawking, cough, and lymphadenopathy, and signs such as laryngeal edema and erythema, although these symptoms are not specific to reflux. Patients who do not respond to PPI therapy may have a disease unrelated to reflux or a functional component. The lack of effectiveness of PPIs in clinical studies can also be explained by the high response rate to placebo of around 40%.
Recommended first line of treatment
Empirical PPI therapy over a period of one to two months is a reasonable first approach in patients without alarm symptoms and with a high suspicion of associated laryngeal disease. about reflux. If symptoms improve, therapy can be continued for up to 6 months to allow the laryngeal tissue to heal. Thereafter, the dose should be reduced to minimal acid suppression, resulting in a sustained response. In patients who do not respond to PPIs, impedance or pH monitoring can be used to rule out reflux as a cause of laryngeal discomfort.
The combination of PPIs and prokinetics is recommended.
Ren et al. rated the combination of PPIs and prokinetics as effective in improving quality of life, although it had no significant effect on symptoms or responses. Endoscopic implications of extraesophagitis associated with gastroesophageal reflux disease.
role of dietary changes
Among the non-drug treatments for laryngopharyngeal reflux, dietary changes have been shown to be effective: patients eating a low-fat, high-protein, alkaline diet have a higher rate of symptom resolution. However, a recent systematic review concluded that there is insufficient evidence to recommend dietary changes for laryngopharyngeal reflux.
Diploma
The diagnosis of extraesophageal manifestations associated with gastroesophageal reflux disease is not straightforward and is often ruled out. Esophagogastroduodenoscopy plays a secondary role, more useful in case of alarming symptoms. 24-hour esophageal pH monitoring is relevant for diagnosing extraesophageal manifestations. This test allows for the diagnosis of acid reflux events in the esophagus, and by monitoring pH impedance, reflux of acidic and non-acidic materials into the esophagus can also be identified. The PPI test is often used as the first diagnostic step. In atypical cases, diagnostic tools such as laryngoscopy and bronchoscopy can be useful to detect abnormalities associated with reflux lesions.

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