Pediatric Extraesophageal Reflux Disease: A Diagnostic Dilemma

We must not overlook the diagnostic value of endoscopy in evaluating pediatric patients with suspected reflux disease.4 While systematically evaluating the larynx and trachea for pathology, we must realize that most laryngeal and tracheal signs attributed to reflux disease in the literature are actually nonspecific findings indicative of inflammation from a variety of potential causes. Findings such as pseudosulcus vocalis, edema of the vocal folds or posterior glottis, and follicular bronchitis of the trachea are nonspecific signs that certainly can be seen with reflux disease, but can also be seen with a variety of other conditions, including infectious, allergic, or inflammatory causes. I recall authoring a manuscript about follicular bronchitis observed in several children from a variety of causes and stating that cobblestoning of the trachea was a nonspecific finding arising from hyperplasia of lymphoid follicles. I was surprised to later see the manuscript quoted as equating follicular bronchitis to reflux disease! Until outcome studies show us that laryngeal and tracheal findings resolve with antireflux therapy, these findings must be viewed as suspicious for reflux disease, but not diagnostic.

The value of laryngoscopy and bronchoscopy is further enhanced when combined with esophagoscopy and biopsy. Preoperatively obtaining consent from patients for esophagoscopy can prove particularly fruitful intraoperatively in the event that laryngoscopy and bronchoscopy findings are normal. Evaluating the esophagus for erythema, ulceration, linear furrows, trachealization, and white patches should be combined with biopsying the distal, mid, and proximal esophagus to detect eosinophilic esophagitis (EE) as well as reflux esophagitis. Although both flexible and rigid esophagoscopy are adequate for obtaining biopsies, flexible esophagoscopy offers improved insufflation, advanced fiberoptics to assess the submucosal esophageal vascularity, and the ability to proceed with simultaneous gastroscopy and duodenoscopy. I often coordinate endoscopy with our pediatric gastroenterologists who not only offer flexible esophagoscopy, but also provide great insight in managing our complicated mutual patients.

Eosinophilic esophagitis is a relatively recently described phenomenon that usually presents with dysphagia and/or food impaction but can also have associated airway symptoms. Radioallergosorbent testing (RAST) for common food allergens is not always positive in patients with EE, which renders detection difficult. Recognizing this dilemma, the American Gastroenterology Association recently published diagnostic criteria for EE based on both histologic and clinical findings. Patients with EE respond best to swallowed inhalational steroids, but some patients also respond to antireflux medication, further confusing the diagnosis between the two disease processes. Scattered eosinophils within the mucosa of the esophagus is diagnostic of reflux esophagitis, but aggregates of eosinophils, or more than 15 per high-power field, are diagnostic of EE. It is likely that many patients with EE were diagnosed historically with reflux disease before the quantification of eosinophils was determined to be a differentiating factor. Consideration for EE lends further support to the value of esophagoscopy with biopsy.