EXTRA ESOPHAGEAL REFLUX AND SYMPTOMS OF THE EAR, NOSE, THROAT (cont'd)

Effects of EER on the pharynx, sinuses, and ears

Not only can EER irritate the larynx, it can also irritate the pharynx (throat). Reflux can flow up into the oro- and naso-pharynx and may even reach the nasal and sinus cavities (Figure 5). EER has accordingly been implicated in a number of symptoms and disorders of the pharynx, nose, sinuses, and ears. Pharyngeal signs and symptoms associated with or caused by EER include: sensations of choking or a lump in the throat with or without constant throat clearing, adenoid enlargement, rhinosinusitis, eustachian tube dysfunction and middle ear infections.

Globus pharyngeus (lump in the throat)
Inflammation of the pharynx can result in globus pharyngeus, which is the medical term for having a sensation of a lump in the throat (9). The sensation is most notable between swallows. EER is the most common underlying factor, although other anatomical, physiological, and psychological factors should be considered.

Enlarged tonsils
Enlarged adenoids, which can block the nasal airway, may also be attributable to EER in very young children. In a study of children less than 2 years old who underwent surgery for removal of enlarged adenoids, 42% also had a GERD diagnosis. By contrast, GERD was diagnosed in only 7% of a control group of children getting surgery for insertion of ear tubes but whose adenoids were normal. The association between reflux and adenoid enlargement was even stronger in children age 1 or less. In this age group, 88% of those requiring adenoidectomy had a GERD diagnosis, whereas only 14% of the control group getting ear tubes had a GERD diagnosis (21).

Rhinosinusitis (nose and sinus infection)
Reflux may be a factor in inflammation of the nose and sinuses. Called rhinosinusitis, this inflammation is caused by obstruction of the final common pathway of the maxillary, ethmoid, and frontal sinus tracts (Figure 6). Although infection is often present, it is not typically the primary underlying factor for rhinosinusitis. Rather, infection occurs secondarily because the impaired drainage due to swelling, or edema, of sinus and nasal tissues creates an ideal environment for the growth of bacteria. Anything irritating the sinus and nasal tissues can result in swelling of tissues: Allergies, cigarette smoke, recurrent viral infections, and EER. Edema from EER is a common cause of sinus obstruction (22). People with chronic sinus problems often have corrective surgery. However, Bothwell et al. (23) found that 89% of children who underwent reflux therapy in addition to maximal medical management of allergy and other irritants could avoid sinus surgery.

Otitis media (middle ear infection)
Like the sinuses, the ear has natural openings that must remain functional to prevent problems. As in rhinosinusitis, the development of middle ear infections (otitis media) is a secondary complication that results from impaired function of the eustachian tube. Studies using animal models have shown that exposure of the middle ear and the eustachian tube to acid and pepsin results in failure of the eustachian tube to perform its dual function of sweeping out secretions and modulating pressure within the ear (24, 25). In a study examining patients who had chronic ear problems, treatment with the anti-reflux medication omeprazole resulted in complete resolution of symptoms (26).