Controversies and Concepts Surrounding Rhinogenic Laryngitis

TORONTO-The rapid rise in visits to otolaryngology practices due to acid reflux is something most otolaryngologists-head and neck surgeons can appreciate. Reflux is increasing the patient numbers, period.

According to figures in the National Ambulatory Care Survey (NACS), outpatient visits to all specialties rose dramatically for the past several years with regard to gastroesophageal reflux disease (GERD), plateauing at 13 million visits for all physician groups, said Kenneth W. Altman, MD, PhD, of Mount Sinai Hospital in New York.

If you look at the over-45-year-old age group, [reflux] accounts for almost 10 percent of all outpatient medical visits, he said. That is a pretty significant number in terms of all outpatient care.

During the recent American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) annual meeting here, a group moderated by Dr. Altman provided a state-of-the-art review of the significant overlap between the clinical manifestations of laryngeal and rhinologic disease.

Dr. Altman said that a closer look at the NACS data showed a spike in asymptomatic laryngopharyngeal reflux (LPR) patients, specifically those having a significant number of refluxing episodes without any symptoms.

Take a look in the larynx of any patient that comes to see you with cerumen impaction with no reflux history or reflux symptoms and you’ll find that the sensitive findings of LPR are not specific to reflux, he said. In other words, you’ll find abnormal findings in people that are entirely asymptomatic.

Then we can add to that the significant amount of asymptomatic sinonasal disease…of which the drainage is often so intermittent we may not even see it on our exams. And we all know about the complexities of the reactive airway syndrome, bridging allergic rhinitis, sinusitis, reactive airway disease, and bronchitis.

Dr. Altman then posed questions concerning the impact of rhinological disease on the larynx, determining what is responsible for the symptom of postnasal drip, the impact of extraesophageal reflux on rhinitis and sinusitis, the role of the autonomic nervous system in specific clinical cases, and the ideal management approach to patients with these disorders.

Careful Diagnosis Necessary

Michael S. Benninger, MD, of the Henry Ford Health System in Detroit, was the first to discuss his research, detailing his findings regarding the frequency of laryngeal disease-not simply reflux-being mistaken for a nasal or sinus disorder.

Often, laryngopharyngeal reflux is mistaken for sinus disease because of the sensation and mucus…and you have to convince patients that that is the case, Dr. Benninger said. Although the larynx may be the source of the major symptoms, there is greater proof that reflux can exacerbate chronic conditions such as chronic rhinositis, allergic rhinitis, and in children otitis media. Currently now in my recalcitrant chronic rhinosinusitis patients I put them empirically on reflux treatment and I have had anecdotal cases where people have improved, despite being on nasal steroids and leukotriene modifiers and allergy medications.