New Nosology of Acid Reflux: “Esophageal Reflux” and “Airways Reflux”

re·flux n [ L re– back + fluxus– flow ] 1: a flowing back  2: a process of refluxing

This is the voice box of a patient with severe airways reflux. Indeed, it is so swollen that the airway (breathing passages) are narrowed.

This may come as a surprise, but reflux is more complicated and controversial than almost any other common disease.1-3 Reflux is like the elephant in the famous tale of the three blind men and the elephant:

The first blind man, feeling the leg of the elephant, exclaims, “I can see it clearly; the elephant is like a tree.” The second blind man holds the trunk and says, “No, the elephant is like a very large snake.” The third blind man grasps an ear. “Aha, you are both wrong,” he says. “The elephant is rather like a giant leaf.” Each of the blind men embraces a part of the truth, but none understands its entirety.

In the case of reflux, the three blind men might be represented by three medical specialties, each one focusing on a different part of the aerodigestive tract: (1) The otolaryngologist (ENT physician) specializes in the ears, nose, and throat; (2) the gastroenterologist (GI physician) specializes in the esophagus (the swallowing tube that connects the throat with the stomach); and (3) the pulmonologist (PUL physician) specializes in the lungs. Many other medical specialties encounter patients with reflux as well, including internists, family practitioners, pediatricians, and critical care specialists.

Part of the problem is that each medical specialty has its own language and set of diseases related to reflux. While “acid reflux” is the most common lay term for the disease, GERD, gastroesophageal reflux disease, and LPR, laryngopharyngeal reflux, are the terms widely used by GIs and ENTs, respectively. See the table below for a list of common terms for reflux.

That there are so many different terms for reflux suggests fragmentation within the medical community with regard to the mechanisms and manifestations of disease. To make matters worse, most medical specialists remain unaware of the literature and research from other specialties. At least the three blind men in the fable shared their findings with each other—because medical specialists don’t.

Table: Most Common Medical Terms for Reflux
Gastroesophageal reflux disease (GERD)
Gastro-oesophageal reflux disease (GORD) [U.K.]
Reflux esophagitis, esophageal erosions
Extraesophageal reflux disease
Supraesophageal reflux disease
Gastropharyngeal reflux
Atypical reflux disease
Heartburn / Erosive esophagitis
Barrett’s esophagus
Esophagopharyngeal reflux
Laryngopharyngeal reflux (LPR)
Silent reflux
Esophageal reflux
Airways reflux
Throat reflux

In 1987, I coined the term LPR, specifically to differentiate my patients with throat reflux from those with esophageal reflux, that is, GERD. A year or so later, Dr. Walter Bo and I came up with the term “silent reflux,” is a very useful and descriptive term. Dr. Bo was the chair of the anatomy department at Wake Forest University. In 1988, Walter was my patient and he had LPR. After I explained how one could have reflux without also having heartburn, Walter rolled his eyes and said, “I see … I have the silent kind of reflux.” “Yes, Walter,” I said. “That’s it; you have SILENT REFLUX.”

Meanwhile, since writing Dropping Acid: The Reflux Diet Cookbook & Cure—the sales of which have been trending upwards ever since its publication—it has become clear that people (i.e., non-physicians) find the terms laryngopharyngeal reflux and gastroesophageal reflux disease (even just LPR and GERD) cumbersome and overly medical. The terms have obvious meaning to doctors: LPR means the backflow of gastric contents into the laryngopharynx (the throat and the voice box), and GERD means the backflow of gastric contents into the esophagus (the swallowing tube that connects the throat and stomach).

I propose to change the terminology forever.  The most encompassing and descriptive terms are AIRWAYS REFLUX and ESOPHAGEAL REFLUX.

I am an airway reflux expert. I recently estimated that in my medical practice I have seen, and cared for, over 100,000 patients with airway reflux. These include thousands of patients misdiagnosed as having asthma, sinusitis, allergy, and laryngitis.

Common Symptoms of Airways Reflux
Nasal congestion, sneezing, and/or runny nose
Ear fullness, popping, or intermittent echoing
Unexplained progressive dental and gum disease
Difficulty swallowing or painful swallowing
Chronic throat clearing and post-nasal drip
Awaking from sleep coughing or wheezing
A lump-in-the-throat sensation
Hoarseness or voice breaks
Shortness of breath
Trouble sleeping
Chronic cough

One parting thought: In my practice, of 100 patients who present with a diagnosis of “asthma,” only 15% actually have it. If you want to know the difference between real asthma and reactive airways disease secondary to reflux, here’s the pearl: If you have more trouble getting air “in” rather than “out” during an “asthma attack,” it’s not asthma! (By the way, the word NOSOLOGY refers to the classification or nomenclature of diseases.)


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