1. The Otolaryngologic Manifestation Of GERD Dr Khalil Sendi MD, FRCSC, FACS ENT SURGEON

2. The Antireflux BARRIER  Lower Esophageal Sphincter (LES).  Esophageal Acid Clearance.  Epithelial Resistance.  Upper Esophgeal Sphincter.

3. The lower Esophageal Sphincter Anatomic Factors: Anatomic Factors: Diaphragm “muscle sling”. Cardiac angle. Intra-abdominal Esophageal segment. Phrenoesophageal ligment (H.H). Neural Innervation: Neural Innervation: Causing relaxation of LES during swallowing. Hormonal factors: Hormonal factors: Gastrin increase LES pressure.

4. Esophageal Acid Clearance Peristalisis. Peristalisis. Saliva Bicarbonate. Saliva Bicarbonate.

5. Esophageal Epithelial Resistance Mucus viscoelastic + gel properties. Mucus viscoelastic + gel properties. A blood flow in sub-epithelial layer. A blood flow in sub-epithelial layer.

6. Upper Epithelial Sphincter Cricopharyngeal muscle ( tonic contraction) Cricopharyngeal muscle ( tonic contraction) Increase with decrease PH. Increase with decrease PH. Decrease with sleep. Decrease with sleep. Increase with inspiration. Increase with inspiration.

7. Pathogenesis of GERD Decreased Lower Esophageal Sphincter pressure. Decreased Lower Esophageal Sphincter pressure. Abnormal Esophageal motility Abnormal Esophageal motility Abnormal or reduced mucosal resistance. Abnormal or reduced mucosal resistance. Delayed gastric emptying. Delayed gastric emptying. Increases intra-abdominal pressure. Increases intra-abdominal pressure. Gastric hypersecretion (acid or pepsin). Gastric hypersecretion (acid or pepsin).

8. Decreased Lower Esophageal Sphincter pressure Hiatal hernia Hiatal hernia Diet: Diet:Fat.Mint.Cola.Cafine.Alcohol. Drugs: Drugs:Theophyline.Lidocaine.Diazepam.Progesterone. Ca-channel blocker.

9. Abnormal Esophageal motility Delayed esophageal emptying causing abnormal acid clearance duo to decrease peristaltic wave amplitude. Delayed esophageal emptying causing abnormal acid clearance duo to decrease peristaltic wave amplitude. Neuromuscular disease. Neuromuscular disease. Laryngectomy. Laryngectomy. Ethanol. Ethanol. GERD. GERD.

10. Decreased Mucosal Resistance Xerostomia: Xerostomia: Sicca syndrom Oral cavity radiation. Esophageal radiation. Autoimmune disease :  Cystic fibrosis.  Systemic sclerosis  Scleroderma. Tobacco Tobacco Ethanol Ethanol Drugs Drugs GERD GERD

11. Delayed Gastric Emptying Outlet obstruction Ulcer. Neoplasm.Neurogenic. Outlet obstruction Ulcer. Neoplasm.Neurogenic. Volume of feeding (childern). Volume of feeding (childern). Diat (Fat). Diat (Fat). Tobacco. Tobacco. Ethanol. Ethanol.

12. Increased Intraabdominal Pressure Tight clothing. Tight clothing. Diet: Over eating, carbonated beverage. Diet: Over eating, carbonated beverage. Obesity. Obesity. Pregnancy. Pregnancy. Occupation. Occupation. Exercise. Exercise.

13. GASTRIC HYPERSECRETION Stress: trauma,surgery, lifestyle. Stress: trauma,surgery, lifestyle. Tobacco. Tobacco. Ethanol. Ethanol. Drugs. Drugs. Diet. Diet.

14. Diagnostic tests of GERD Ambulatory 24h double probe PH monitoring. Ambulatory 24h double probe PH monitoring. Barium esophagography with videofluroscopy. Barium esophagography with videofluroscopy. Endoscopy. Endoscopy. Mucosal biopsy. Mucosal biopsy. Radionuclide scan. Radionuclide scan. Acid perfusion. Acid perfusion.

15. The otolaryngologic manifestation of GERD 10-50 % of ORL laryngeal complaint have GERD. 10-50 % of ORL laryngeal complaint have GERD. PH metry +ve in 78%. PH metry +ve in 78%. Esophagoscopy +ve in 27%. Esophagoscopy +ve in 27%.

16. Common Presenting Symptoms Hoarseness 71% Hoarseness 71% Chronic couph 51% Chronic couph 51% Globus pharyngeus 47% Globus pharyngeus 47% Heart burn / regurgitation 43% Heart burn / regurgitation 43% Chronic throat clearing 42% Chronic throat clearing 42% Dysphagia 35% Dysphagia 35%

17. 57% Denied heartburn. 57% Denied heartburn. 75% Denied GI symptoms. 75% Denied GI symptoms.

18. ENT Diseases associated with GERD Carcinoma of the larynx. Carcinoma of the larynx. (cigarette smoking, alcohol intake) (cigarette smoking, alcohol intake)  Decrease LES pressure.  Impair mucosal resistance.  Delay gastric emptying.  Stimulate gastric hypersecretion.

19. ENT Diseases associated with GERD Glottic and subglottic stenosis: Glottic and subglottic stenosis: mature or immature legions mature or immature legions

20. ENT Diseases associated with GERD Hoarseness. Hoarseness. Laryngitis. Laryngitis.

21. ENT Diseases associated with GERD Globus pharyngeus: Globus pharyngeus:  Inflammation and swelling of laryngopharyngeal tissue.  Referred discomfort from esophagitis.  Reflex hypertonicity of the UES.

22. ENT Diseases associated with GERD Cervical dysphagia Cervical dysphagia

23. ENT Diseases associated with GERD Chronic cough. Chronic cough. Referral otalgia. Referral otalgia. Recurrent sinusitis. Recurrent sinusitis. Recurrent nasal polypi. Recurrent nasal polypi.

24. ENT Diseases associated with GERD Management. Management.  History.  ENT examination.  Investigation.

25. ENT Diseases associated with GERD Treatment of laryngopharyngeal GERD Dietary modification Dietary modification Life style modification Life style modification Medication Medication  No eating 3h before sleep.  Low fat diet.  Avoidance of caffeine, mint, pop.  No alcohol.  Avoid overeating.  Antacid.  H2 blockers.

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