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The Impact of Gastroesophageal Reflux in the ENT Pathology

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The Impact of Gastroesophageal Reflux in the ENT Pathology Romanian Journal of Rhinology, Vol. 6, No. 23, July - September 2016 DOI: 10.1515/rjr-2016-0016 LITERATURE REVIEW The impact of gastroesophageal reflux in the ENT pathology Violeta Melinte1,2,3, Codrut Sarafoleanu1,2,3 1“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2CESITO Centre, “Sfanta Maria” Hospital, Bucharest, Romania 3ENT&HNS Department, “Sfanta Maria” Hospital, Bucharest, Romania ABSTRACT Frequently encountered in medical practice, the gastroesophageal reflux (GER) is a chronic condition characterized by the passage of gastric acid or gastric contents into the esophagus. In otorhinolaryngology, the diagnosis of pharyngo-laryngeal or rhinosinusal inflammatory conditions secondary to GER is one of exclusion and it is based on a detailed anamnesis in which we are interested in symptoms, behavioural and medical risk factors, on the ENT clinical examination, the laryngo-fibroscop- ical assessment, the phoniatric examination, the barite pharyngo-esogastric exam, the upper gastrointestinal endoscopy and the esophageal manometry. The authors are making a systematization of the contribution of the gastroesophageal reflux has in the ENT pathology, em- phasising the sympytoms and the most frequent associated pathological entities. KEYWORDS: gastroesophageal reflux, extraesophageal reflux, chronic laryngitis, rhinosinusitis, post nasal drip INTRODUCTION crease in incidence in adults over 40 years can be no- ticed4. Frequently encountered in medical practice, the Between 6 and 10% of patients presenting in an gastroesophageal reflux is a chronic condition charac- ENT service are diagnosed with gastroesophageal re- terized by the passage of gastric acid or gastric con- flux. In 1995, Rival et al. found that 73% of patients * tents into the esophagus, without being accompanied with various complaints in the cervical region (n=216) by nausea or vomiting. In the literature, the term “lar- suffered from the gastroesophageal reflux disease yngo-pharyngeal reflux” is also used, and the Ameri- (GERD), symptomatology having improved in 84% of can Broncho-Esophagological Association introduced them by administration of antireflux treatment5. Five the term “extraesophageal reflux” for the extraesoph- years later, Kouffman et al. showed that of the 113 pa- ageal manifestations of regurgitation of gastric con- tients with laryngeal pathology and dysphonia in- tents1. cluded in the study, 50% had extraesophageal reflux, Contraindicaţii. Hipersensibilitate la substanțele active sau la oricare dintre excipienți(lactoza monohidrat). Atenţionări şi precauţii speciale pentru utilizare. Seretide Diskus nu se utilizează pentru tratamentul crizelor de astm bronşic, în acest caz fi ind necesară administrara unui bronhodilatator cu acțiune rapidă şi de scurtă the documentation being made by the esophageal pH durată. Pacienții trebuie sfătuiți să păstreze tot timpul asupra lor un inhalator necesar pentru tratamentul crizei. Tratamentul cu Seretide Diskus nu trebuie inițiat în timpul unei exacerbări sau dacă pacienții prezintă o agravare 6 semnifi cativă sau o deteriorare acută a astmului bronşic. În timpul tratamentului cu Seretide Diskus pot să apară reacții adverse grave legate de astmul bronşic şi exacerbarea acestuia. Pacienții trebuie sfătuiți să continue test . tratamentul, dar să ceară sfatul medicului dacă nu se mai realizează controlul astmului bronşic sau simptomele se agravează după inițierea tratamentului cu Seretide Diskus. Tratamentul cu Seretide Diskus nu trebuie întrerupt brusc la pacienții cu astm bronşic, datorită riscului de exacerbare a afecțiunii. Dozele trebuie scăzute treptat sub supravegherea medicului. La pacienții cu BPOC, oprirea tratamentului se poate asocia cu decompensări THE INCIDENCE OF THE GASTROESOPHA- simptomatice şi de aceea trebuie făcută sub supravegherea medicului. GEAL REFLUX DISEASE Similar altor corticosteroizi inhalatori, Seretide Diskus trebuie administrat cu precauție în cazul pacienților cu tuberculoză pulmonară activă sau pasivă, infecții fungice, virale sau altfel de infecții ale căilor respiratorii. Seretide Diskus trebuie utilizat cu precauție la pacienții cu tulburări cardiovasculare severe sau aritmii cardiace şi la pacienți cu diabet zaharat, tireotoxicoză, hipokaliemie netratată sau pacienți predispuşi a avea concentrații scăzute de CLINICAL FEATURES OF THE GASTRO- potasiu în sânge. A fost raportată o incidență crescută a infecțiilor de tract respirator inferior (în special pneumonii şi bronşite) în studiul TORC. Doza de corticosteroid inhalată trebuie redusă la cea mai mică doză cu care se menține un control efi cient asupra astmului. The gastroesophageal reflux is a pathology seen in ESOPHAGEAL REFLUX Reacţii adverse. Foarte frecvente: Cefalee, rinofaringite. Frecvente: Candidoză orală şi faringiană, pneumonie, bronşite,hipokaliemie, iritație faringiană, răguşeală/disfonie, sinuzită, contuzii, crampe musculare, fracture traumatice, artralgii, mialgii. Pentru informații complete privind reacțiile adverse, atenționările şi precauțiile speciale privind utilizarea Seretide Diskus vă rugăm consultați Rezumatul Caracteristicilor Produsului. all age groups, its incidence in adults constantly in- creasing, while in children it is recorded in 75%2,3. A The gastroesophageal reflux (GER) and the extrae- Decembrie 2015, Cod zinc: RO/SFC/0018/15(1) Decembrie predilection of the gastroesophageal reflux disease ac- sophageal reflux (EER) are two different entities, dif- cording to gender has not been described, but an in- ferentiating, first of all, by symptoms they cause. Corresponding author: Violeta Melinte, MD, CESITO Centre, ENT&HNS Department, “Sfanta Maria” Hospital, 37-39 Ion Mihalache Blvd., District 1, Bucharest, Romania *Aerolizer nu este înregistrat in România e-mail: [email protected] salmeterol/propionat de fluticazonă Seretide_Advert_GSKDC-PT-ROU-2016-3038_D1.indd AA 1/11/2016 9:10:32 PM 142 Romanian Journal of Rhinology, Vol. 6, No. 23, July - September 2016 In the case of GERD, the main complaints of pa- pear. Chronic rhinosinusitis, chronic hypertrophic tients are heartburn, retrosternal pain and regurgita- rhinitis, postnasal drip, serous otitis media, sleep tion. The extraesophageal reflux disease has less spe- apnea, chronic cough or oropharyngeal mycosis can cific symptoms, being represented primarily by hem- also be due to EER10-12 (Table 1). Chronic recurrent ming, pharyngeal foreign body sensation, cough, pharyngitis occurs as a consequence of the gastric re- hoarseness or pharyngeal dryness (retrosternal heart- flux in approximately 60% of the cases10. burn rarely appears). The signs of EER may or may Symptoms of the extraesophageal reflux can be di- not be accompanied by the typical symptoms of a re- vided into two categories: laryngeal and extralaryn- flux disease. It should be mentioned that the same geal. The most common symptoms associated with the amount of material discharged, which can be easily laryngo-pharyngeal reflux are those signalling the in- neutralized by the esophageal defence mechanisms, volvement of the larynx and are represented by can cause hypo-pharyngo-laryngeal lesions7, which is chronic cough, dysphonia (episodic or chronic), why in EER esophageal lesions may be missing. The odynophagia, vocal fatigue, laryngospasm13. Regard- two diseases evolve differently in the long run too, ing the extralaryngeal manifestations, feeling of “lump GERD having a high risk of complicating with an es- in the throat” (globus), dysphagia, chronic hemming, ophageal adenocarcinoma, while EER presents a high sore throat, mucus hypersecretion, postnasal drip, risk of developing laryngeal or lung carcinoma, sinus- halitosis, nocturnal cough, pharynx burning sensa- itis and otitis8,9. tion, otalgia may be representative10-12. In otorhinolaryngology, the diagnosis of pharyngo- Paraclinical explorations are especially used when laryngeal or rhinosinusal inflammatory conditions sec- we have an uncertain diagnosis, when symptoms are ondary to EER is one of exclusion and it is based on a atypical, recurrent or associated with complications, if detailed anamnesis in which we are interested in symp- there is no adequate response to treatment or before toms, behavioural and medical risk factors, on the the antireflux surgery. Carr et al.14 studied the changes ENT clinical examination, the laryngo-fibroscopical specific to EER in a group of 77 patients, using direct assessment (Figure 1), the phoniatric examination, laryngoscopy and bronchoscopy, and found that there the barite pharyngo-esogastric exam, the upper gastro- were pharyngolaryngeal alterations consisting in lin- intestinal endoscopy and the esophageal manometry. The examination for diagnostic certainty, both for GER and EER, is represented by monitoring of the Table 1 ENT manifestations of EER esophageal pH test. EER is characterized by extraesophageal manifesta- Chronic Recurrent Pharyngitis tions of the gastric reflux. There are numerous dis- Sore throat eases in the otorhinolaryngology which can be deter- mined by this disorder, the most common being Chronic laryngitis chronic reflux laryngitis10. Moreover, at the level of the Vocal cord granulomas, nodules, ulcer larynx, vocal nodules, granulomas and contact ulcer, Laryngospasm vocal cord polyp, sulcus glottidis, pharyngo-laryngeal Pharynx and larynx cancer, laryngospasm, subglottic stenosis may also ap- Subglottic stenosis Cancer Sulcus glottides Dysphonia Globus Chronic rhinosinusitis Nasal Chronic hypertrophic rhinitis and sinusal Postnasal drip
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