The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD): A Clinical Investigation of 225 Patients Using Ambulatory 24‐Hour pH Monitoring and an Experimental Investigation of the Role of Acid and Pepsin in the Development of Laryngeal Injury

Abstract

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order to test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double‐probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty‐five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24‐hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double‐probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty‐eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentag with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow‐up was available on 68% of the patients and the mean follow‐up period was 11.6 ± 12.7 months. After 6 months of treatment, symptoms had resolved in 85% and medical therapy had failed in 15%. Subsequently, an additional 20% experienced medical treatment failure. Fifteen percent of patients underwent Nissen fundoplication, and all subsequently had resolution of symptoms. To further investigate the role of gastroesophageal reflux in the development of laryngeal damage, experiments mimicking the effects of intermittent reflux (of acid and pepsin) on the canine larynx were performed. The results of these experiments revealed:1. Intermittent reflux (three episodes per week) can result in severe laryngeal damage if there is prior mucosal injury;2. pepsin, and not hydrochloric acid, is the principal injurious agent of the refluxate; and,3. severe laryngeal damage can occur even when the pH of the refluxate is 4.0. The manuscript describes the limitations and advantages of standard diagnostic procedures and of 24‐hour pH monitoring. The differences between gastroenterology and otolaryngology patients with GERD are emphasized and specific new diagnostic and therapeutic recommendations are made.