Background: Gastroesophageal reflux disease (GERD) is a disorder resulting from the reversed flow of gastroduodenal contents into the esophagus, and producing different symptoms, while laryngopharyngeal reflux (LPR) is a disorder resulting from the reversed flow of gastric contents into the hypopharynx. The aim of this work is to evaluate LPR in cases of GERD. Methods: The present study was performed on fifty GERD patients diagnosed by gastroscope. LPR was assessed by reflux symptoms score (RSI) and reflux finding score (RFS). Accordingly, patients are classified into: Group I = 25 patients with manifest LPR, and Group II = 25 control patients without LPR symptoms. Results: GERD accounts for 17.4% of attendants of gastroscope unit, where manifest LPR accounts for 29.1% of GERD cases recording mean RSI and RFS 16.48 and 8.44 respectively. Silent LPR accounts for 8% recording mean RFS 7. Conclusion: There is a significant direct proportional relationship between severity of GERD and the RSI and RFS (p = 0.015 and 0.005 respectively).
Gastroesophageal reflux disease (GERD) is diagnosed clinically or histologically due to abnormal exposure of the oesophagus to gastric contents [
This study was conducted on adult patients with GERD diagnosed at Gastrointestinal Endoscopy Unit, Faculty of Medicine, Cairo University. Exclusion criteria: a) Patients giving history of peptic ulcer disease or anti ulcer medications or previous anti ulcer surgery, b) Patients having local laryngopharyngeal affection and those having causes inducing GERD like allergy, alcohol, tobacco, drugs.
The selected patients were divided into 2 groups: Group I: patients complaining of any of the LPR symptoms, and Group II: control cases who were not complaining of any of the LPR symptoms.
All patients were subjected to: a) History taking, including evaluation of GERD symptoms as heart burn, regurgitation, halitosis, dysphagia and dyspepsia, and LPR symptoms, defined as RSI, including hoarseness, throat clearing, postnasal drip, dysphagia, irritant cough, dyspnea, and globus, as designed by Belafsky et al. (2002) [
The study was approved by the institutional ethical committee, and all patients provided an informed consent.
This study was a cross sectional study, conducted on attendants of Gastrointestinal Endoscopy Unit, Faculty of
Medicine, Cairo University from May 2012 to June 2013.
GERD was diagnosed in 17.4% of attendants (86/494 patients). GERD patients were then divided into 2 groups: Group I: constituted of 25 patients (29.1%) having LPR. All reported by symptoms and were confirmed by laryngoscope, therefore termed as “Manifest LPR”, and Group II: GERD patients without LPR symptoms which constituted of 61 patients (70.9%), however, 25 patients where further examined by laryngoscope to serve as control group. Most of the control group (23/25 patients; 92%) were laryngoscopically free while 2 only (8%) had LPR. Accordingly, group II is subdivided into IIA who are “LPR-free”, and IIB who are defined as “Silent LPR” respectively.
Demographic features of the studied groups are shown in Table3 None of the demographic features showed a statistical difference between the 2 groups. Obesity was higher in Group I than in Group II but without recording a statistical difference, however, it is worth noting that obesity was reported by most of the studied patients (39/50 patients; 78%).
Gastrointestinal symptoms of the studied groups are shown in Table4 Heart burn and regurgitation were the commonest symptoms (80% each) however, halitosis, dysphagia and nausea, which were less common, were significantly higher in Group I than in Group II (p = 0.01, 0.01 and 0.037 respectively).
LPR symptoms in manifest LPR (Group I) are illustrated in
Oesophagogastroduodenoscopic examination of the studied groups is shown in Table5 Laryngoscopic examination (RFS) of the studied groups is shown in Table6 Laryngoscopy detected positive signs of LPR in 2 patients in Group II (Group IIB). Both recorded erythema, vocal fold edema and diffuse laryngeal edema, while ventricular obliteration, posterior commissure hypertrophy and thick endolaryngeal mucus were detected in one of them. They recorded mean RFS = 7. Therefore termed as silent LPR.
Correlation between GERD grade and LPR symptom index and LPR finding score are illustrated in Figures 2(a) and (b) respectively. Predictability of RSI according to RFS is illustrated in
GERD is a common disease that may present with disabling symptoms [
In this study, GERD accounts for 17.4% among attendants of gastroscope unit. This figure is intermediate. It was higher than that recorded in Asia (˂5%) [
In this study, neither sex nor age predilection was recorded in GERD. This is similar to Dent [
LPR: Laryngopharyngeal reflux, GERD: Gastroesophageal reflux disease, BMI: Body mass index.
LPR: Laryngopharyngeal reflux, GERD: Gastrooesophageal reflux disease.
LPR: Laryngopharyngeal reflux, GERD: Gastroesophageal reflux disease.
El-Serag found GERD increased with age (highest in the 60 - 69 years range, with a slight decrease afterwards), meanwhile, women had a slightly higher risk at age >50 years [
LPR: Laryngopharyngeal reflux, GERD: Gastrooesophageal reflux disease, RFS: Reflux Finding Signs.
aged >70 years, and conversely, found heartburn ranging from 82% in patients aged <21 years to 34% of those aged >70 years [
In the current study, 39 patients (78.0%) were obese (mean BMI = 31.8). Obesity was confirmed to be a strong predictor (95%) [
Heartburn was reported by 3/4 of the studied patients (38/50 patients; 76%), comparably present in Groups I and II (20 patients; 80% and 18 patients; 72% respectively), meanwhile grade A was more in Group II than in Group I (19 patients; 76% versus 15 patients; 60% respectively), while grades B, C & D (moderate & severe) are more in the Group I than in Group II. This confirmed the fact that heartburn was the only symptom related to GERD and LPR severity [
Haematemesis was reported by 4 patients (8%), comparably present in Groups I and IIA. It is worth noting that they were following up their underlying oesophageal varices, complication of cirrhosis. This agrees with El-Serag who related history of haematemesis to positive GERD endoscopic examination [
Regarding LPR, manifest LPR was present in 25 patients (29%) which is lower than that reported in an international survey (60%) [
LPR was not significantly related to either sex or age. On the contrary, Patigaroo et al. in their LPR study, found gender and age predilection (male:female = 2:3, and patients mostly-40%-belonged to age range 31 - 40 yrs) [
In this study, postnasal drip and throat clearing were the most prevalent symptoms (96% each). Throat clearing is the most related symptom to LPR [
These figures are less than that recorded by Kouffman; throat clearing (98%), persistent cough (97%), globus (95%), and hoarseness (95%) [
Meanwhile, hoarseness was intermediate to previous studies e.g. >50 [
Accordingly, the mean (RSI) score in manifest LPR was 16.48, while Patigaroo et al. reported higher score i.e. 24.75 [
All of the studied GERD patients in this study had oesophagitis at variable degrees, as all of them were enrolled already diagnosed endoscopically, not on clinical suspect. Many other studies reported normal oesophogoscopy (62.7%, 59.6%, 60% - 70%, and 50% [
Hiatus hernia was present in 11 patients (22%), comparably detected in both groups (6 and 5 patients in Groups I and II respectively). It was documented for its high specificity (95%) in predicting GERD [
Barrett’s esophagus was detected in 2 patients of GERD (4%), both belonged to Group I. It was lower than that recorded previously e.g. 7.4% [
None of the patients showed esophageal carcinoma. This agrees with the fact its risk is low despite being strongly associated with GERD [
The commonest laryngoscopic signs were vocal fold oedema, diffuse laryngeal oedema, erythema and posterior commisure hypertrophy (50%, 46%, 44%, 40% respectively). All were significantly higher in Group I than in Group II (92%, 84%, 80% and76% versus 8%, 8%, 8% and 4% respectively). This is lower than that recorded in an international survey i.e. arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%) [
Thick endolaryngeal mucus was detected in 14 patients (28%); mostly (13/14 patients; 92.8%) in Group I (52%), the left patient was nonsymptomatized. This is higher than that recorded by Ylitalo and Ramel; 50% - 60% in LPR [
Laryngeal granuloma was detected in 8 patients (16%), all belonged to Group I (32%). This figure is intermediate to other studies e.g. Maronian et al. found GERD in all patients with organic subglottic stenosis and 71% with idiopathic subglottic stenosis. They concluded GERD a synergistic factor that stimulates laryngeal granulomatous reaction that may result in stenosis [
Pseudosulcus was detected in 6 patients (12%), all belonged to Group I. It is confirmed as a strong predictor (90%) for LPR [
Accordingly, mean RFS of Group I was 8.44, which is lower than that recorded by Patigaroo; 12 [
In this study, both RSI and RFS were significantly correlated with GERD grade (p = 0.015 and 0.005 respectively), and RSI was a significant predictor for RFS (p = 0.00), despite the stated fact that the endoscopic laryngeal signs do not correlate with LPR symptom severity, and treatment is recommended to continue for ≥6 months or until complete resolution of signs [
RSI is a significant predictor for RFS, and both, RSI and RFS, are significantly proportionate to GERD, yet Silent LPR did exist among control patients.