Most Gastroenterologists Don’t Understand Airway Reflux

Have you ever wondered why there are so many different (medical) terms for acid reflux?  There are so many terms because different  medical specialist groups use different terms that they invented to describe their viewpoints.  The table below shows the most common ones.

Most Common Medical Terms for Acid Reflux
Gastroesophageal reflux disease (GERD)
Laryngopharyngeal reflux (LPR)
Gastro-oesophageal reflux disease
Extraesophageal reflux disease
Supraesophageal reflux disease
Esophago-pharyngeal reflux
Gastropharyngeal reflux
Atypical reflux disease
Esophageal erosions
Barrett’s esophagus
Reflux esophagitis
Reflux laryngitis
Silent reflux
Esophageal reflux
Airway reflux

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 are 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.

GIs are unfamiliar with the signs and symptoms of airway reflux, but they insist on using diagnostic tests designed for esophageal reflux to evaluate airway reflux, because that’s what they know and understand.

Many gastroenterologists make their livings performing sedated endoscopies, mainly  esophagoscopy (aka EGD, esophagogastroduodenoscopy) and colonoscopy. This involves intravenous sedation, recovery, and it is sometimes associated with serious (even life-threatening) complications.

Sedated EGD is overkill for screening the esophagus for pathology such as Barrett’s in patients with acid reflux. We recommend transnasal esophagoscopy instead. Transnasal esophagoscopy (TNE) can be done in the doctor’s office without sedation, with comfort, and without complications.  Is TNE new? Not really. At the Voice Institute of New York, we have been performing TNE routinely for more than a decade. Gastroenterologists, however, have been reluctant, or at least slow, to embrace this technology. Why?

Last year, there were 10,000,000 sedated endoscopies done in the United States by approximately 10,000 gastroenterologists (GIs). If every GI did endoscopy (which they don’t), then each would have performed 1,000 last year,  that is, 20 per week or 4 per day.

The “facility fees” alone for sedated endoscopy were $10,000,000,000, that’s right, $10 billion!  The average facility fee for endoscopy last year was $1,000. And that’s just the fee that the endoscopy facility received; this does not include the doctors’ professional fees. Do the math; if the GI doctor owned her/his endoscopy facility, and many are owned by groups of GIs, the take “facility fee” take-home would be $1,000,000, that is $1,000 per X 1,000 procedures). GI doctors appear to have a significant conflict of interest in favor of sedated EGD procedures.

When GIs perform sedated EGDs, usually they do not examine the throat. Indeed, the endoscope is usually passed blindly, that is, without viewing the path into the esophagus. This is one of the reasons that GIs do not recognize airway reflux. By the way, it is time to stop using all those different terms for acid reflux. It now makes sense just to use two: ESOPHAGEAL REFLUX and AIRWAY REFLUX.

Patients with Airway Reflux DO NOT Usually Have Esophageal Reflux

We have published articles examining how ineffective GI diagnostics were in patients with airway reflux. We found that 80% of patients with airway reflux did not have esophageal findings of reflux. This is because the airway is 500 times more susceptible to damage from reflux than the esophagus. The latter organ is robust by comparison so that the acid/etc. can pass through the esophagus quickly and then do damage to structures in the airway. In addition, we found that the positive predictive value of esophageal (only) reflux (pH) monitoring in patients with airway reflux was 49%.  Would you get a test that got it right less than half of the time?  And impedance testing isn’t much better.

GIs also do not understand the importance and impact of diet in people with airway reflux. A month ago, I had a patient come see me from Oregon. She had airway reflux, and I started her on the Reflux Induction Diet and antireflux medication. A few days ago she returned dramatically improved. “Your reflux diet makes all the difference in the world,” she reported; then she added, “I went back to my GI and told him what happened, and you know what he said?  ‘I have reflux too, but I don’t want to change my diet; I love burgers and fries and all … so I take pills and they help’.”  After that interaction the patient confided that she wouldn’t be seeing that GI doctor ever again.

Almost One in Five Americans Have Airway Reflux

In the Time Square Study, we found that 22% of Americans had esophageal reflux and 18% had airway reflux. Not surprisingly, many of the people with airway reflux had “silent reflux,” meaning that they suffered acid reflux without heartburn or indigestion. These numbers are a wake-up call. It is time to recognize that airway reflux is common, important, and still under-diagnosed and under-treated. What are the symptoms?

Symptoms of Airway Reflux
Chronic cough
Choking episodes
Difficulty swallowing
Lump-in-the-throat sensation
Food and/or pills getting stuck
Too much throat mucus
Chronic throat clearing
Shortness of breath
Post-nasal drip
Sore throat

“Asthma” is a very interesting presenting symptom in my clinic. True asthma is characterized by wheezing, trouble getting air out. About 8% of people with airway reflux have reactive airway disease, including laryngospasm, paradoxical vocal fold movement, and pseudo-asthma. With reflux, patients have difficulty getting air in (not out), and they almost always know the difference.

“When you have an ‘asthma’ attack, do you have more trouble getting the air in or out,” I ask, and 90% my patients respond “IN” without hesitation. Most people with adult-onset asthma actually have reflux-related reactive airways disease, and  when the reflux is effectively treated, the “asthma” usually disappears. The same is true of chronic cough symptoms; most are due to reflux.

At present, ENT (ear, nose, and throat) doctors are the ones to see for people with airway reflux, not gastroenterologists. Here is a slight but important paradox: Endoscopy (esophagoscopy, TNE) is not how you diagnose airway reflux. That takes a throat examinations and sometimes special (pH) testing. If one has reflux, however, a screening endoscopy should be performed to rule-out significant esophageal disease. We now know that people with airway and esophageal reflux have a similar incidence of esophageal cancer and pre-cancer. Silent reflux causes just as much cancer and the non-silent type.

Meanwhile, what is missing? What is needed?  In a way, the biggest problem with airway reflux is that most physicians, even those who recognize its symptoms, don’t have a way to confirm the diagnosis. At the Voice Institute of New York, we do special airway reflux testing, and we are now working on two new diagnostics for airway reflux; see The first is a spit-in-a-cup screening test (similar to a pregnancy test) that detects pepsin, the principle enzyme of the stomach. Pepsin is only made in the stomach so that if a person has detectable pepsin in their spit, they have acid reflux (either airway or esophageal reflux). In preliminary testing, the spit test for pepsin is approximately 90% accurate.  This is terrific for a screening test. We hope that we can have the test, known as Koufman Reflux Test Strips (YouTube video) on the market by the summer of 2012. It will help physicians and their patients by making the right diagnosis.

Also under development by Koufman Diagnostics, is a definitive,  turn-key, airway reflux pH testing system that may be employed by any physician regardless of medical specialty (e.g., pulmonology, gastroenterology, otolaryngology, family practice) to make a definitive diagnosis of airway (and/or esophageal) reflux. The system uses ambulatory pH-monitoring technology with foolproof probe-placement and a software that makes interpretation foolproof.  This test is also coming this year.

If you think you have airway reflux, see an ENT doctor, or come see me here at The Voice Institute of New York.  Also, the book,  Dropping Acid: The Reflux Diet Cookbook & Cure, may help.

1 comment to Most Gastroenterologists Don’t Understand Airway Reflux

  • Kristie

    This information is so true. My son has airway issues, had a supraglotoplasty. Then had to have a Nissen for airway reflux. Our pulmonologist and otolaryngologist knew more than the GI.
    Thanks for this article.