Prevalence of Esophagitis in Patients With pH-Documented Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR), the backflow of stomach contents into the laryngopharynx, differs from classic gastroesophageal reflux disease (GERD) in many ways. Patients with LPR routinely report symptoms of dysphonia, globus pharyngeus, cough, chronic throat clearing, dysphagia, and excessive throat mucus, but usually do not complain of heartburn.  However,  heartburn is a common symptom of  GERD. Preliminary reports suggest that patients with LPR typically do not have esophagitis. This may be because the patterns and mechanisms of LPR and GERD are different.  Double-probe pH monitoring and manometric data of patients with LPR show that patients with LPR are predominantly upright (daytime) “refluxers” with normal esophageal motility and acid clearance.  Conversely, patients with GERD are typically supine (nocturnal) refluxers with esophageal dysmotility and  prolonged periods of esophageal exposure to gastric contents.  We hypothesize that the above differences account for differences in the symptoms and manifestations of LPR and GERD and, specifically, that patients with LPR usually do not have esophagitis, considered the sine qua non of GERD.

Diagnostic assessment of patients with laryngopharyngeal symptoms using pH monitoring of the esophagus was first reported in the 1980s, but Wiener et al. were the first to use simultaneous esophageal and pharyngeal pH monitoring in this group. This technique accurately determines acid reflux events above the upper esophageal sphincter, at the laryngeal inlet, and within the esophagus. When guided by manometry, double-probe pH monitoring remains the gold standard for the diagnosis of LPR.

Screening of the esophagus in patients with GERD for associated disease (e.g., esophagitis, Barrett’s metaplasia, stricture, neoplasm) has long been the standard of medical  practice. Before the availability of transnasal esophagoscopy (TNE), most otolaryngologists relied on barium esophagography to screen the esophagus for related disease because it was a relatively noninvasive method.  However, barium studies have a relatively low sensitivity for esophagitis and Barrett’s metaplasia; reflux is radiographically apparent in only 33% of patients with pH-documented GERD and in only 25% of patients with endoscopically proven esophagitis.

Esophagoscopy is a far more sensitive and specific test for esophagitis and associated pathological conditions, particularly when coupled with biopsy of the esophageal mucosa. Transnasal esophagoscopy is a relatively new technology that has the additional advantages of allowing esophagoscopy to be performed in the office with the patient seated and not sedated, requiring only topical anesthesia.  Currently at our center, we routinely employ TNE as a screening and as a diagnostic tool. We have virtually abandoned barium esophagography as a part of our reflux testing battery. The purpose of the present investigation was to determine the prevalence of endoscopically and histologically demonstrated esophagitis in otolaryngologic patients with pH-documented LPR.

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James A. Koufman, MD; Peter C. Belafsky, MD, PhD; Kevin K. Bach, MD; Elena Daniel, MD; Gregory N. Postma, MD

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