Presentation on theme: "Impact of GE Reflux in Upper Airways Disease Fernán Caballero Fonseca Centro Medico Docente La Trinidad Caracas, Venezuela December 2012."— Presentation transcript:
Impact of GE Reflux in Upper Airways Disease Fernán Caballero Fonseca Centro Medico Docente La Trinidad Caracas, Venezuela December 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 Reflux Epidemiology 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 December 16; 2(12): 388–396. Published online 2010 December 16. doi: /wjge.v2.i PMCID: PMC
ERGE Mechanisms Transitory relaxation of LES Increased Intra – abdominal pressure Decreased oesophagus capacity Delayed gastric empting Esophagus LES Crural diaphragm 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 Reflux Mechanisms
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 Rhinosinusitis Laryngospasm Granuloma Chronic laryngitis Subglotic stenosis Laryngeal cancer Chronic otitis media Swiss Med Wkly.2012;142w13544
How the Gastro Esophageal Reflux Affects the Upper Airways?
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 EPFlook EP, Kumar BN.. RhinolRhinology 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-nasal Reflex. Gastroesophageal reflux and chronic rhinosinusitis. Chloridic acid and saline solution. Mucus production, nasal symptom scores and nasal peak flow. Nasal - esophageal reflex. Wong IWWong IW, Rees G, Greiff L, Myers JC, Jamieson GG, Wormald PJ. Greifrs JC, J, Wormal Am J Rhinol Allergy Jul-Aug;24(4): Rhinol Alll-Aug;24(4
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 Sep;130(9):
An Approach to the Management of 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 Jan;122(1):57-60.
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
Otologic Findings in Children with 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 Nov;71(11): Serra A, Cocuzza S, Poli G, La Mantia I, Messina A, Pavone P.
Laryngitis - Disphonia
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 Mosca Acta Otorhinolaryngol Ital 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 Mosca Acta Otorhinolaryngol Ital October; 26(5): 264–270 Grade A :Erythema/Oedema back and/or lateral regions; Grade B :Erythema/Oedema back and/or lateral and front regions; Grade C:Erosion/Granulation back and/or lateral regions; Grade D:Erosion/Granulation back and/or lateral and front regions.
Clinical and Phmetric Evaluation of Gastro-esophageal Reflux Impact on Upper 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 ; Vol 90 ( n°03 ) :
Role of Rhinitis in Laryngitis: Another 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 Aug;120(8):
Diagnosis Pharyngeal –laryngeal symptoms. Post nasal drip. Indirect laryngoscope and posterior rhinoscopy. Video endoscopy.
Final 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.