COMMENTARY

What Is the Prevalence of GERD Signs in the Laryngopharyngeal Area During Routine Upper Gastrointestinal Endoscopy?

David A. Johnson, MD, FACG, FACP

Disclosures

July 12, 2007

Limited Diagnostic Value of Laryngopharyngeal Lesions in Patients With Gastroesophageal Reflux During Routine Upper Gastrointestinal Endoscopy

Vavricka SR, Storck CA, Wildi SM, et al
Am J Gastroenterol. 2007;102:716-722

Summary

There is an ever-expanding literature base reporting on the association between gastroesophageal reflux disease (GERD) and laryngeal complications. This has led many physicians, in particular otolaryngologists, to make the diagnosis of laryngopharyngeal reflux in an array of patients with laryngeal complaints. The basis for this diagnosis is typically laryngeal symptoms and some perceived abnormality on direct laryngeal examination. On the basis of this suspected diagnosis, these patients are typically started on a course of acid suppressive therapy, most commonly with a proton pump inhibitor (PPI). Despite the excellent efficacy (80% to 90%) demonstrated in clinical trials of PPIs for esophageal manifestations of GERD (symptoms and esophagitis healing), clinical trials with PPIs in patients with suspected laryngopharyngeal reflux have shown that up to 50% of patients do not respond. One reason to explain this difference in efficacy is that the patients who do not respond to therapy do not have abnormal esophageal acid reflux on pH testing.[1] Thus, the diagnosis suspected on laryngeal exam did not correlate with the suspected inciting causality of GERD. So the question remains as to the diagnostic specificity of laryngeal findings in GERD-related laryngopharyngeal reflux.

Vavricka and colleagues evaluated 1311 upper endoscopy studies that involved a structured examination of the laryngopharyngeal area. All examinations were videotaped and then reviewed by 3 gastroenterologists and 1 otolaryngologist, all blinded to the esophageal endoscopic findings. A group of 132 patients with typical esophageal findings of GERD (as assessed by Savary-Miller grades) was then compared with a matched control group of patients without GERD symptoms and with a normal esophagoscopy.

Assessment of the laryngeal examination was divided into 10 specific anatomic areas that were thought to represent typical regions where laryngopharyngeal reflux could be manifested. The specific structures were posterior pharyngeal wall, interarytenoid bar, posterior commissure, posterior cricoid wall, arytenoid complex, true and false vocal folds, anterior commissure, epiglottis, and the aryepiglottic folds. Erythema, edema, erosions, cobblestoning, surface irregularity, and mass lesions (polyps) were specifically noted.

There was no difference in the prevalence of abnormal findings in 9 of the 10 distinct larynx/pharynx sites evaluated. The only statistically significant difference noted was for posterior pharyngeal cobblestoning (66% vs 50%; P = .004). The measure of agreement (kappa score) was poor (kappa 0.31-0.08) for arytenoid complex, anterior commissure, epiglottis, and aryepiglottic fold assessments and fair to good (kappa 0.42-0.73) for the other parameters assessed.

Viewpoint

It is clear, particularly to gastroenterologists, that otolaryngologists have embraced the diagnosis of laryngopharyngeal reflux with zeal. Despite the enthusiasm to establish this diagnosis, the response of patients to therapy for this suspect diagnosis has been suboptimal. This current study demonstrates nicely that the laryngoscopic findings clearly are not the "gold standard" in the diagnosis of GERD-related laryngopharyngeal reflux. Accordingly, patients in whom the diagnosis is suspected, on the basis of laryngoscopic findings, but who fail to respond to directed acid suppressive therapy, likely do not have GERD. Additional studies with impedance pH monitoring may help more definitively exclude the suspected GERD diagnosis. Clinicians evaluating these patients need to better understand the limits of the laryngeal examination as it relates to GERD and laryngopharyngeal reflux. Other factors associated with laryngeal irritation need to be considered, including voice abuse, smoking, repetitive throat clearing, asthma (and related coughing), and postnasal drip. Clearly, all that is "red in the larynx" does not equal GERD.

Abstract

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