The Otolaryngologic The Otolaryngologic Manifestation Of GERDManifestation Of GERD

Dr Khalil SendiDr Khalil Sendi

MD, FRCSC , FACSMD, FRCSC , FACS

ENT SURGEONENT SURGEON

The Antireflux BARRIERThe Antireflux BARRIER

Lower Esophageal Sphincter (LES).Lower Esophageal Sphincter (LES). Esophageal Acid Clearance.Esophageal Acid Clearance. Epithelial Resistance.Epithelial Resistance. Upper Esophgeal Sphincter.Upper Esophgeal Sphincter.

The lower Esophageal SphincterThe lower Esophageal Sphincter

Anatomic Factors:Anatomic Factors:Diaphragm “muscle sling”.Diaphragm “muscle sling”.Cardiac angle.Cardiac angle.Intra-abdominal Esophageal segment.Intra-abdominal Esophageal segment.Phrenoesophageal ligment (H.H).Phrenoesophageal ligment (H.H).

• Neural Innervation:Neural Innervation:Causing relaxation of LES during swallowing.Causing relaxation of LES during swallowing.

• Hormonal factors:Hormonal factors:Gastrin increase LES pressure.Gastrin increase LES pressure.

Esophageal Acid ClearanceEsophageal Acid Clearance

PeristalisisPeristalisis.. Saliva Bicarbonate.Saliva Bicarbonate.

Esophageal Epithelial ResistanceEsophageal Epithelial Resistance

Mucus viscoelastic + gel properties.Mucus viscoelastic + gel properties. A blood flow in sub-epithelial layer.A blood flow in sub-epithelial layer.

Upper Epithelial SphincterUpper Epithelial Sphincter

Cricopharyngeal muscle (Cricopharyngeal muscle (tonic contraction)tonic contraction) Increase with decrease PH.Increase with decrease PH. Decrease with sleep.Decrease with sleep. Increase with inspiration.Increase with inspiration.

Pathogenesis of GERDPathogenesis of GERD

Decreased Lower Esophageal Sphincter pressure.Decreased Lower Esophageal Sphincter pressure. Abnormal Esophageal motilityAbnormal Esophageal motility Abnormal or reduced mucosal resistance.Abnormal or reduced mucosal resistance. Delayed gastric emptying.Delayed gastric emptying. Increases intra-abdominal pressure.Increases intra-abdominal pressure. Gastric hypersecretion (acid or pepsin).Gastric hypersecretion (acid or pepsin).

Decreased Lower Esophageal Decreased Lower Esophageal Sphincter pressureSphincter pressure

Hiatal herniaHiatal hernia

Diet:Diet:Fat.Fat.Mint.Mint.Cola.Cola.Cafine.Cafine.Alcohol.Alcohol.

• Drugs:Drugs:Theophyline.Theophyline.Lidocaine.Lidocaine.Diazepam.Diazepam.Progesterone.Progesterone.Ca-channel blocker.Ca-channel blocker.

Abnormal Esophageal motilityAbnormal Esophageal motility

• Delayed esophageal emptying causing abnormal acid Delayed esophageal emptying causing abnormal acid clearance duo to decrease peristaltic wave amplitude.clearance duo to decrease peristaltic wave amplitude.

• Neuromuscular disease.Neuromuscular disease.• Laryngectomy.Laryngectomy.• Ethanol.Ethanol.• GERD. GERD.

Decreased Mucosal Decreased Mucosal ResistanceResistance

Xerostomia:Xerostomia:Sicca syndromSicca syndrom

Oral cavity radiation.Oral cavity radiation.

Esophageal radiation.Esophageal radiation.

Autoimmune diseaseAutoimmune disease:: Cystic fibrosis.Cystic fibrosis. Systemic sclerosisSystemic sclerosis Scleroderma.Scleroderma.

TobaccoTobacco EthanolEthanol DrugsDrugs GERDGERD

Delayed Gastric EmptyingDelayed Gastric Emptying

Outlet obstruction Outlet obstruction Ulcer. Neoplasm.Neurogenic.Ulcer. Neoplasm.Neurogenic.

Volume of feeding Volume of feeding (childern).(childern).

Diat (Fat).Diat (Fat).Tobacco.Tobacco.Ethanol.Ethanol.

Increased Intraabdominal PressureIncreased Intraabdominal Pressure

Tight clothing.Tight clothing.Diet: Diet: Over eating, carbonated beverage.Over eating, carbonated beverage.

Obesity.Obesity.Pregnancy.Pregnancy.Occupation.Occupation.Exercise.Exercise.

GASTRIC HYPERSECRETIONGASTRIC HYPERSECRETION

Stress:Stress: trauma ,surgery, lifestyle.trauma ,surgery, lifestyle.

Tobacco.Tobacco. Ethanol.Ethanol. Drugs.Drugs. Diet.Diet.

Diagnostic tests of GERDDiagnostic tests of GERD

Ambulatory 24h double probe PH monitoring.Ambulatory 24h double probe PH monitoring. Barium esophagography with videofluroscopy.Barium esophagography with videofluroscopy. Endoscopy.Endoscopy. Mucosal biopsy.Mucosal biopsy. Radionuclide scan.Radionuclide scan. Acid perfusion.Acid perfusion.

The otolaryngologic manifestation The otolaryngologic manifestation of GERDof GERD

10-50 %10-50 % of ORL laryngeal complaint have GERD. of ORL laryngeal complaint have GERD. PH metry +ve in 78%.PH metry +ve in 78%. Esophagoscopy +ve in 27%.Esophagoscopy +ve in 27%.

Common Presenting SymptomsCommon Presenting Symptoms

Hoarseness 71%Hoarseness 71%Chronic couph 51%Chronic couph 51%Globus pharyngeus 47%Globus pharyngeus 47%Heart burn / regurgitation 43%Heart burn / regurgitation 43%Chronic throat clearing 42%Chronic throat clearing 42%Dysphagia 35%Dysphagia 35%

57% Denied heartburn.57% Denied heartburn.75% Denied GI symptoms.75% Denied GI symptoms.

ENT Diseases associated with GERDENT Diseases associated with GERD

Carcinoma of the larynx.Carcinoma of the larynx. (cigarette smoking, alcohol intake)(cigarette smoking, alcohol intake)

Decrease LES pressure.Decrease LES pressure. Impair mucosal resistance.Impair mucosal resistance. Delay gastric emptying.Delay gastric emptying. Stimulate gastric hypersecretion.Stimulate gastric hypersecretion.

ENT Diseases associated with GERD ENT Diseases associated with GERD

Glottic and subglottic stenosis:Glottic and subglottic stenosis:

mature or immature legions mature or immature legions

ENT Diseases associated with GERDENT Diseases associated with GERD

Hoarseness.Hoarseness.Laryngitis.Laryngitis.

ENT Diseases associated with GERDENT Diseases associated with GERD

Globus pharyngeus:Globus pharyngeus: Inflammation and swelling of Inflammation and swelling of

laryngopharyngeal tissue.laryngopharyngeal tissue. Referred discomfort from esophagitis.Referred discomfort from esophagitis. Reflex hypertonicity of the UES.Reflex hypertonicity of the UES.

ENT Diseases associated with GERDENT Diseases associated with GERD

Cervical dysphagiaCervical dysphagia

ENT Diseases associated with GERDENT Diseases associated with GERD

Chronic cough.Chronic cough.Referral otalgia.Referral otalgia.Recurrent sinusitis.Recurrent sinusitis.Recurrent nasal polypi.Recurrent nasal polypi.

ENT Diseases associated with GERDENT Diseases associated with GERD

Management.Management. HistoryHistory.. ENT examination.ENT examination. Investigation.Investigation.

ENT Diseases associated with GERDENT Diseases associated with GERDTreatment of laryngopharyngeal GERDTreatment of laryngopharyngeal GERD

Dietary modificationDietary modification

Life style modificationLife style modification MedicationMedication

No eating 3h before sleep.No eating 3h before sleep. Low fat diet.Low fat diet. Avoidance of caffeine, mint, Avoidance of caffeine, mint,

pop.pop. No alcohol.No alcohol. Avoid overeating.Avoid overeating.

Antacid.Antacid. H2 blockers.H2 blockers.

Thank YouThank You