Diagnosis and management of supraesophageal complications of reflux disease
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Corresponding author Timothy T. Nostrant, MD A. Alfred Taubman Health Care Center, 1500 East Medical Center Drive, Room 3912, Ann Arbor, MI 48109-0362, USA. E-mail: [email protected] Current GERD Reports 2007, 1:117–124 Current Medicine Group LLC ISSN 1934-967X Copyright © 2007 by Current Medicine Group LLC
Supraesophageal reflux disease may manifest in numerous ways, including reflux laryngitis, long-term cough, long-term sinusitis, and dental enamel loss. The mechanisms of pharyngeal and laryngeal reflux are not clearly defined, and standard reflux testing does not consistently demonstrate supraesophageal reflux. The diagnosis is usually based on clinical suspicion when other causes of symptoms are not found and on the patient’s response to empiric acid suppression. With the development of dual- and triple-probe pH monitoring, through which proximal esophageal pH can be assessed along with distal esophageal pH, the physician may be able to correlate reflux with patient symptoms. Therapy consists primarily of behavioral modifications and aggressive acid suppression, though some alternative therapies do exist.
Introduction Supraesophageal reflux symptoms occur in up to one third of patients with classic gastroesophageal reflux disease (GERD) and in a similar percentage of patients without classic symptoms. Supraesophageal manifestations of GERD include laryngitis, asthma, long-term cough, long-term sinusitis, and dental enamel loss (Table 1). The physician must maintain a high degree of suspicion when the cause of these problems is unclear or when standard therapy fails, and the diagnosis of supraesophageal reflux problems is often complicated by the lack of definitive testing. This review focuses on the diagnosis and management of laryngeal and pharyngeal complications of GERD. This review briefly addresses long-term cough, because its mechanism may involve extrathoracic events, but it is presented in more depth in the literature.
Reflux Laryngitis A variety of symptoms may suggest reflux laryngitis, including hoarseness, throat clearing, globus sensation, halitosis, or prolonged vocal cord warm-up [1•]. In patients with posterior laryngitis, symptoms of throat pain, hoarseness, and throat clearing occur in 50%, 45%, and 23% of patients, respectively, whereas cough occurs in 18% and weak voice in 9% [2]. Many of these patients consult otolaryngologists initially because prominent laryngeal complaints are present alone or supersede the milder classic symptoms [3]. Barium esophagram, upper endoscopy, and standard esophageal manometry are diagnostic in less than 25% of such patients. Standard reflux testing demonstrates abnormal acid reflux in two thirds of patients, whereas 24-hour pH monitoring is positive for distal reflux in 80% and for proximal reflux in 30%. Poor acid clearance and esophageal dysmotility have been seen by some investigators [3] but not by all [4,5]. Bernstein testing is negative in most patients and is usually only positive if the patient describes heartburn [3,4]. The mechanism of symptoms in
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