Pediatric Extraesophageal Reflux Disease: A Diagnostic Dilemma

Avoiding overzealous diagnosis while still maintaining EERD in the differential diagnosis is critical to managing our patients. Of a survey of the 265 ASPO members regarding reflux disease conducted by John Little, MD, from East Tennessee Children’s Hospital, in which 25% responded, more than 90% felt that reflux is a significant diagnosis in their pediatric otolaryngology practices. I was pleased to discover from this enlightening survey that most pediatric otolaryngologists do not believe reflux is a significant cause of vocal cord nodules, sinusitis, or otitis media. However, I was surprised to learn that two-thirds of responders prescribe antireflux medication for infants with laryngomalacia. I have not found treatment to be particularly effective in enough infants with laryngomalacia to warrant treating all, and find that very few with overt regurgitation even respond to treatment. I was also surprised to find that few pediatric otolaryngologists believe that reflux plays a role in causing apnea, an association that I believe is a relatively significant one.

It is easy to understand how reflux is an overdiagnosed phenomenon. The literature is replete with case reports of reflux-related disease in pediatric patients, and the tendency to consider this diagnosis in patients with difficult-to-manage conditions is a natural one. We pride ourselves in helping patients, and there is nothing quite so rewarding as observing a patient improve on antireflux medication after he or she has seen numerous physicians and been treated unsuccessfully with inhalers, steroids, and antibiotics. These rewarding examples make us hopeful that reflux is the culprit in many of our patients with difficult pathology. Sometimes it is the culprit and sometimes it is not.

Controlled studies correlating symptoms, diagnostic results, and outcome of antireflux therapy are lacking in the pediatric otolaryngology literature. Although completing such studies is an arduous task, it remains an essential one. Multidisciplinary clinics among gastroenterologists, pulmonologists, and otolaryngologists are a credit to institutions establishing them. These clinics sacrifice productivity of their physicians for improved patient care and convenience. Such centers will continue to drive our understanding of reflux disease in the future.

References

1. Bauman NM, Sandler AD, Maher JH, Schmidt C, Smith RJH. Reflex laryngospasm induced by stimulation of distal esophageal afferents. Laryngoscope 1994;104:209-14.
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2. Bauman NM, Bishop WP, Sandler AD, Smith RJ. Value of pH probe testing in pediatric patients with extraesophageal manifestations of gastroesophageal reflux disease: a retrospective review. Ann Otol Rhinol Laryngol Suppl 2000;184:18-24.
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3. Wenzl TG, Silny J, Schenke S, Peschgens T, Heimann G, Skopnik H. Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique. J Pediatr Gastroenterol Nutr 1999;28:423-8.
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4. Orenstein S, DiLorenzo C, Hassall E, Bauman NM. Controversies and cases: issues in diagnosis and management of pediatric GERD. American Academy of CME, Suppl Contemp Pediatr 24(2):1-6.
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