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Respiratory disorders
Pharyngitis, laryngitis in the adult and gastroesophageal reflux
C. Beauvillain de Montreuil (Nantes)
Manifestations of gastroesophageal reflux (GER) are numerous and may prove misleading. They sometimes occur in patients with known reflux and can then be easily related to a cause (although it is important not to overlook an associated pathology). In other cases, they reveal a reflux which can only be identified and confirmed by suitable complementary examinations.
Clinical symptoms
Laryngeal signs: dysphonia is the main symptom (71% of patients in the larynx group in a study of 225 patients by Koufman [1]).
Nocturnal dry cough, which was found in 53% of patients in Koufman's series and in nearly 50% of cases in many other studies, is as much a tracheopulmonary as a laryngeal sign.
Pharyngeal signs can consist in pharyngeal paresthesia, difficulty in swallowing saliva, pharyngeal burning sensations occurring during eating and less frequently true dysphagia.
Rarer and more misleading signs, including otalgia, torticollis and retrosternal pain may be suggestive of coronary pain or even dental erosion.
Clinical examination
This examination [2-5] includes classical ENT studies as well as nasal fiberoscopy:
- the most suggestive feature (and the most common one) is an inflammation of the arytenoid region and of the posterior third of the vocal cords;
- less frequently, the examination reveals a granulome in the region of the vocal apophyses;
- infrequent cases of subglottic stenosis have been described, but these are suggestive of an associated pathology;
- rare cases of cancer of the larynx (vocal cords) have been related to reflux in non-smokers.
Morrison [6] reported 6 cases of cancer of the glottis in non-smokers with GER. Ward and Hanson [7] found that 19 non-smokers and non-drinkers out of 138 patients with cancer of the larynx had moderate or severe GER.
Koufman [1] suggested that pepsin in contact with the larynx during reflux might suppress protection of the mucosa and enhance the effect of tobacco or alcohol, thereby constituting a cofactor of laryngeal cancer.
The clinical signs suggestive of GER, (pyrosis, heartburn and especially postprandial regurgitations or those triggered by the decubitus or leaning forward), were detected in less than half of the cases studied by Koufman [1] and Weiner et al. [8].
Complementary examinations
- Barium transit has poor sensitivity.
- Esogastric fiberoscopy searches for signs of inflammation of the lower esophagus and allows for biopsies.
- The main examination is pH monitoring performed with a single electrode or, preferably with two [1], one being placed in the lower esophagus and the other 5 cm above the cardia.
Weiner et al. [8] and Koufman [1] have emphasized the usefulness of 24-hour ambulatory pH monitoring in patients with hoarseness subsequent to reflux (33/78 patients had increased reflux in standing position).
Treatment also constitutes a therapeutic test. Medical anti-reflux treatment will be carried out for 6 months. In case of failure confirmed by pH monitoring (around 15%), Nissen's operation may be recommended.
References