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.
Explore this issue:January 2007
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.
Dr. Benninger said that physicians might need to treat reflux along with chronic rhinosinusitis or allergic rhinitis, making sure not to overlook unique groups of patients whose laryngeal disease is related to an underlying, diffuse hyperactive airway disease. While differentiating these patients may be difficult, Dr. Benninger suggested focusing on the nose first.
If they don’t have the nasal symptoms, then focus on the larynx, he said. Focus your evaluation on the more likely site. If they do not respond to empiric trial therapy, then consider another diagnosis and in some patients consider hyperactive airway disease and reflux exacerbation of chronic rhinogenic condition.
Albert L. Merati, MD, of the Medical College of Wisconsin in Milwaukee, focused on the possibility of LPR causing rhinologic symptoms. His study focused on patients complaining of postnasal drip with no historical or endoscopic evidence of any sinonasal inflammatory infectious disease. Each had a clean nose, but with postnasal drip as their main symptom, he said.
The question we wanted to get answered was whether or not patients with postnasal drip as their dominant symptom have increased prevalence of LPR, Dr. Merati said. We also felt that signs for LPR would improve in postnasal drip patients following PPI treatment.
Dr. Merati said that the data indicated that acid exposure time for the clean nose group was significantly higher than that for controls. And while probe findings did not typically predict the response to therapy, the postnasal drip symptoms improved in terms of severity, frequency, hoarseness, throat clearing, and cough. The study also indicated possible mechanisms by which acid reflux may induce postnasal drip sensation are direct mucosal contact or a neurogenic mechanism.
We know that there is interrelatedness between the foregut derivatives, such as you might get glottic closure form the lower esophagus without the acid ever getting to the pharynx or larynx, he said. We need to detach ourselves from the thinking that the reflux…has to get to the pharynx to cause pharyngeal symptoms.
It does not have to. While that is certainly embraceable and understandable and is probably the dominant cause of most of what we see, it is not the only way it can happen.
Dr. Merati’s College of Wisconsin colleague, Todd A. Loehrl, MD, who cautioned the audience that his data required a very simplified version of the autonomic nervous system in order to be presented in such a short window, followed Dr. Merati.
The principal symptoms of vasomotor rhinitis have thus been due to an autonomic input to the nose, he said. It has also been suggested that the autonomic nervous system reacts with the inflammatory response…basically an increase in sympathetic activity overall has an anti-inflammatory or immunosuppressive effect.
It is a response of the nasal mucosa…to environmental or emotional stimuli and many people feel this may occur in conjunction with allergic rhinitis; however, its ideology remains undetermined.
Dr. Loehrl said his team found that patients diagnosed with vasomotor rhinitis have evidence of autonomic nervous system dysfunction characterized by a relative hypoactivity of the sympathetic component. Patients with both disorders tend to have the same hypoactive sympathetic dysfunction, but to a greater degree.
Based on what we know…this might be playing a role in the patients’ upper airway inflammatory response, he said.
Examine All Angles
Calling herself a cleanup woman and philosopher, Gayle E. Woodson, MD, of the University of Illinois-Springfield, closed out the session talking about the importance of looking at the patient form all angles when diagnosing and treating diseases in this realm.
More than one thing that can cause laryngitis, she said. The upper airway and digestive tract are inter-related.
Let’s think for a moment, what is the single most common cause of acute laryngitis? It is upper respiratory infection and that is the most common cause of what will lead to-self-perpetuating chronic laryngitis.
Dr. Woodson said other inciting events-acute allergy, vocal trauma, severe reflux episodes, chronic nasal congestion-can all play a part in bringing laryngitis to the fore.
You can get the acute event out of the way and still have this [ongoing] cycle, she said. You have to break into that cycle somewhere.
Acid reflux can be a very important part of that. You can have a negative pH probe, but that doesn’t mean you’re not refluxing every three to four days and didn’t happen to reflux on the day the study was done.
Medications-from an otolaryngologist or other doctor-can also be contributing factors, Dr. Woodson said.
There is not one magic bullet to treat this, she said. You have to think about all of the contributing factors.
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©2007 The Triological Society