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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
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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”?
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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
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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
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Reflux Barrier
4 components:
- Pressure (intrinsic and extrinsic factors)
- LES length
- Hiatal hernia
- Compliance or yield at the GEJ
GE RefluxMechanisms
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Differential DiagnosisDifferential Diagnosis
Chonic rhinosinusitis
Funtional dysphonia
Chronic tonsilitis
Sleep apnea
Gastro oesophageal reflux disease GORD or GERD
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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
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Associated Conditions
Chronic RhinosinusitisLaryngospasmGranulomaChronic laryngitisSubglotic stenosisLaryngeal cancerChronic otitis media
Swiss Med Wkly .2012;142w13544
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How the Gastro Esophageal Reflux How the Gastro Esophageal Reflux Affects the Upper Airways?Affects the Upper Airways?
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Rhino Sinusitis
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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.
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Symtoms Attributed to Laryngopharingeal Reflux
Hoarseseness Post nasal drip
Dysfagia Laryngospasm
Dysfonia
Sore or burning throat
Excessive throat clearing
Chronic cough
Globus
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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.
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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.
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Laringopharyngeal Reflux
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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.
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Vocal Cord Dysfuction
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Etiology?Etiology?
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Symptoms
• Cough
• Dispnea
• Dysphonia
• Estridor
• Weezing
• Dysfagia
• Anxaiety
Vocal Cord Dysfuntion
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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.
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GERD and VCD
Cukier-Blaj et al.:Laryngoscope 118: February 2008
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Otitis Media
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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.
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Laryngitis - DisphoniaLaryngitis - Disphonia
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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
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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.
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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
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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.
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DiagnosisDiagnosis
Pharyngeal –laryngeal symptoms.
Post nasal drip.
Indirect laryngoscope and posterior rhinoscopy.
Video endoscopy .
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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.