ENT-GERD.docVIP

Otolaryngologic Manifestations of Gastroesophageal Reflux Thomas A. Salzer, M.D. Gastroesophageal reflux is the retrograde flow of gastric contents back into the esophagus. It is one of the most common problems encountered by physicians in all specialties, affecting nearly 30% of Americans. In the pathologic state esophageal, pulmonary or laryngeal complications may arise. All branches of our specialty encounter manifestations of gastroesophageal reflux disease (GERD). Patients traditionally present with a multitude of vague complaints for which no clear etiology can be identified. Inappropriate or incomplete treatment may be instituted or the patients complaints might be dismissed as supratentorial. In this presentation, the otolaryngologic signs and manifestations of GERD will be reviewed. The pathophysiology and diagnosis of GERD will then be discussed followed by an outline of the currently accepted treatment protocol. A review of the otolaryngologic literature reflects the relatively recent and diverse association between GERD and various laryngopharyngeal conditions. The following conditions have been reported, some of which will be discussed later in more detail: laryngeal carcinoma, subglottic stenosis, chronic laryngitis, contact ulcer, laryngeal granuloma, cricoarytenoid fixation, intubation granuloma, laryngomalacia, pachydermia, laryngospasm, chronic cough, chronic pharyngitis, dysphagia, globus pharyngeus and Zenkers diverticulum. Causality is difficult to establish in medicine, however several clinical and laboratory studies have been performed which link GERD to laryngeal injury. Pepsin is the primary injurious component of the refluxate. Pepsin injury is characterized by mucosal ulceration, erosion and extensive submucosal hemorrhage. Exposure to acid, bile, and trypsin results in minimal submucosal edema. Though most active in an acidic environment, pepsin maintains 70% of its maximal activity at Ph 4.5. Kaufman recently demonstrated intermittent