EXTRA ESOPHAGEAL REFLUX AND SYMPTOMS OF THE EAR, NOSE, THROAT

Introduction

Intermittent reflux of stomach contents into the esophagus is a normal physiological process. It occurs because of transient relaxation of the sphincter located where the esophagus connects to the stomach. Gastroesophageal reflux is considered to be abnormal or pathologic if it produces symptoms, and is then referred to as gastroesophageal reflux disease (GERD).

GERD is a well-documented and common occurrence among adults, but during the last twenty years, it has been increasingly recognized as a clinical entity among children and infants. GERD most commonly results in vomiting, abdominal or chest pain, heartburn, arousal from sleep, and regurgitation (spitting up).

If gastric reflux reaches the level of the pharynx (throat) by moving past both the lower and upper esophageal sphincters (Figure 1), it is termed extra-esophageal reflux (EER). Evidence is accumulating that EER can be a factor in disorders of the upper and lower airway in both adults and children (reviewed in 1, 2).

Infants may be especially predisposed to reflux-related problems because they have relatively more reflux events than adults. In a survey of 948 infants, it was found that nearly 50% of babies less than 3 months old had reflux events that resulted in regurgitation or spitting up at least once a day (3). The number increased to a maximum of 67% of 4-month-olds. By 1 year of age, percent of infants with daily regurgitation events was less than 5%.

Although symptoms of GERD are fairly easy to diagnose, extra-esophageal reflux is a more difficult diagnosis. “Silent reflux” or atypical reflux in which the patient has no gastrointestinal symptoms is very common in children with upper and lower airway complaints. Determining the involvement of EER requires verifying its presence by some diagnostic methodology.

A methodology commonly used to determine whether a person has gastroesophageal reflux is to measure acidity by means of a pH-detecting “probe” placed at the lower esophageal sphincter (LES, Figure 1). However, traditional pH probes placed to detect acid reflux at the LES can easily overlook EER in the child. A significant percentage of children who have EER show normal pH data from probes placed at the LES (4, 5). Therefore, a better approach to EER diagnosis is to monitor pH in the pharynx or upper esophagus. Although pharyngeal probes provide excellent measures of EER, they are uncomfortable for some children because the procedure involves insertion of rubber tubing through the nose. Parents also shy away, especially once they learn the tubing must stay in the nose for 24 hours.

An innovative alternative for diagnosing EER is the Bravo pH capsule. This capsule is wireless, and is placed in the upper esophagus just behind the upper esophageal sphincter (6). The Bravo system has been a very good way to measure upper esophageal reflux without any tubing.

In this chapter we focus on how EER results in damage to cells and tissues of the larynx and upper respiratory tract. We also discuss a number of ear, nose, throat, and laryngeal disorders commonly encountered in pediatric patients and examine evidence for the role of EER in causing or exacerbating these conditions.