Gastroesophageal reflux disease is the most common disease of the esophagus and involves the return of stomach secretions into the esophagus. This return occurs as a result of the loss of tone of the lower gastroesophageal sphincter, located precisely at the junction of the esophagus with the stomach. This sphincter acts as a functional valve that opens whenever we eat or drink. In the case of the loss of tone of this "valve", it will remain open for a long time and gastric fluids will return back into the esophagus. Such a situation occurs in the case of a hiatal hernia, which is the elevation of gastric mucosa into the esophagus.
A consequence of prolonged and untreated gastroesophageal reflux disease is damage to the mucosa of the esophagus in the form of erosions or ulcers and more rarely with the appearance of cardioesophageal cancer. The most typical presentation of this disease is chest burning and acid reflux into the esophagus.
However, gastroesophageal reflux disease can also present with atypical symptoms. About 20-60% of patients with reflux have throat complaints without having any obvious "chest burning". The most common atypical symptom given by gastroesophageal reflux is the sensation of something stuck in the throat, which we call "pharyngeal globus", a sign that can confuse the doctor and may change the direction of problem tracking, thus forgetting the cause: the stomach. Therefore, a high index of suspicion is necessary.
Laryngoscopy can confirm the diagnosis of laryngopharyngeal reflux and gastroscopy can confirm gastroesophageal reflux and further assess the mucosa of the esophagus for damage or not. During this examination, we have seen redness of the posterior larynx and thickening of the vocal cords. Treatment should be started with gastric acid inhibitors as well as lifestyle changes. If gastroesophageal reflux remains untreated, in addition to damage to the esophageal mucosa, it can lead to chronic laryngitis, voice changes, chronic cough, voice scratching, vocal cord granuloma, and other problems.
Gastroesophageal reflux is defined as the movement of gastric contents into the esophagus without vomiting. Laryngopharyngeal reflux is the movement of gastric contents into the laryngopharyngeal area. Reflux disease will manifest when gastric contents irritate the mucosal surface of the upper aerodigestive tract.
The primary barrier of gastroesophageal reflux is the lower esophageal sphincter, which is located at the level of the diaphragmatic hiatus and acts as the main security of reflux (Fig. 1a, 1b, 1c). Other structures involved in preventing reflux include the intra-abdominal segment of the esophagus, the gastroesophageal angle, diaphragmatic crura, and the phrenoesophageal ligament.
Gastric motility also plays a role by delaying stomach emptying, predisposing to reflux. The upper esophageal sphincter mainly consists of the cricopharyngeal muscle and the circular muscle fibers of the esophagus immediately distal to it. The upper esophageal sphincter is called the pharyngoesophageal junction and serves as the primary barrier in preventing pharyngolaryngeal reflux.
Differences between gastrointestinal symptoms and throat-related symptoms as a result of reflux.
The pathophysiology of reflux with gastrointestinal symptoms differs from that in patients with throat-related symptoms. Patients with gastrointestinal symptoms have esophageal dysmotility and dysfunction of the lower esophageal sphincter, whereas patients with throat manifestations have dysfunction of the upper esophageal sphincter but good esophageal motility.
Patients with gastrointestinal symptoms feel reflux when lying on their back, while patients with throat manifestations have laryngopharyngeal reflux all the time, even when they are standing up. According to one study, 18% of patients with ENT symptoms have esophagitis
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| FIGURE 1A. The upper aerodigestive tract (cricopharyngeal muscle, the arch of the aorta, diaphragmatic hiatus), the upper esophageal sphincter (cricopharyngeus), the lower esophageal sphincter, and the connection of the esophagus with surrounding structures. |
Burning, the most classic symptom of reflux, is common in patients with gastrointestinal symptoms but is unusual in patients with throat manifestations of reflux. One study reports only a 20-43% incidence of chest burning in patients with otorhinolaryngological symptoms.
Throat symptoms in patients with gastroesophageal reflux.