Swelling of the true vocal cords can range from mild to severe; severe swelling appears as a polypoid part. Swelling of the vocal cords at this degree can result in severe voice hoarseness, stridor, or compromise of the respiratory tract. Edema develops in the superficial layer of the lamina propria of the true vocal cords also called the Reinke's space. Thus, it is often referred to as Reinke's edema. The presence of edema in the true vocal cords is a high indicator of laryngopharyngeal reflux, even in the absence of laryngeal erythema.
If the history and physical examination fail to reveal any serious pathologies, patients with suspected gastroesophageal reflux can start an empirical therapy, which mainly consists of lifestyle modifications and medication therapy (Tables 26 and 3). Evaluation is required if patients do not respond to empirical therapy or when they present with recurrent reflux. Surgical intervention may be required in these patients.
Further evaluation may include an esophagram, manometry, gastroscopy, 24-hour pH monitoring. The gold standard for diagnosing laryngopharyngeal reflux is 24-hour pH monitoring with a dual probe where the probes are placed in the larynx and esophagus. This procedure has increased our understanding of the pathophysiology of gastroesophageal reflux associated with otolaryngological complications.
Lifestyle changes that can improve reflux
Complications of gastroesophageal reflux are divided into four categories: laryngeal, pharyngeal, esophageal, and pulmonary.
Laryngeal
Laryngeal complications associated with GERD include: posterior laryngitis, laryngomalacia, functional voice disorders, posterior glottis stenosis, laryngospasms, nonspecific chronic laryngitis, Reinke's edema, contact ulcers, contact granulomas, leukoplakia, and carcinoma of the laryngeal cords, and subglottic stenosis.
Contact granulomas arise from the vocal processes (the cartilaginous posterior part) of the vocal cords and are considered an inflammatory response to damage to the perichondrium. Besides anti-reflux therapy in the treatment of vocal cord granulomas, botulinum toxin injections are used. The toxin paralyzes the vocal cords preventing the strong closure of the arytenoids during speaking or coughing, which leads to healing of the traumatized site.
Anti-reflux surgery may be considered in patients with chronic symptoms that do not respond to medication therapy. From a study, it is shown that 82% of patients had disappearance of laryngeal symptoms and normalization of laryngoscopic findings about six months from anti-reflux surgery. Patients in this study had gastroesophageal reflux confirmed by 24-hour pH metering and laryngeal pathology confirmed by laryngoscopy. They were referred for surgical therapy (Nissen fundoplication) after inadequate response to medication therapy.
Studies have shown that gastroesophageal reflux is implicated in 40-70% of patients with laryngeal symptoms and laryngoscopic evidence of laryngeal pathology. However, reflux is only implicated in 20-40% of patients with laryngeal symptoms and normal laryngoscopic examination.
Reflux is also implicated in the development of leukoplakia and squamous cell carcinoma of the vocal cords. Leukoplakia, defined as the development of a white plaque on a mucosal surface, does not carry a diagnostic implication in itself. However, in the presence of reflux, leukoplakia is considered a precancerous condition. In the above study, five patients were diagnosed with laryngeal carcinoma and underwent surgery and radiotherapy. Edema and leukoplakia persisted after treatment.
All patients later underwent anti-reflux surgery, and laryngeal abnormalities disappeared in three out of four patients (the fifth was lost during follow-up). Findings suggest that precancerous lesions may be associated with gastroesophageal reflux and may disappear with adequate therapy. Although some studies suggest that gastroesophageal reflux is a co-factor in the development of squamous cell carcinoma of the larynx, further research is needed to determine the significance of gastroesophageal reflux in the pathogenesis of this tumor.
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| FIGURE 5. Radiographic demonstration of Zenker's diverticulum. Note the barium filling the diverticular pouch. |
Pharyngeal
Pharyngeal complications of gastroesophageal reflux include cricopharyngeal dysfunction, chronic pharyngitis, and Zenker's pharyngeal diverticulum. This latter is a pseudodiverticulum originating from the Killian zone (Fig.5) located between the cricopharyngeal muscle and the inferior pharyngeal muscle. This area is prone to diverticulum formation due to muscle weakness.
Zenker's diverticulum results from increased intraluminal pressure caused by cricopharyngeal muscle spasm, which is associated with gastroesophageal reflux. Regurgitation of partially digested food should alert us to the presence of Zenker's diverticulum. A small diverticulum may be managed with observation. Surgery is reserved for patients with large, symptomatic diverticulum.
Esophageal
Esophageal complications of gastroesophageal reflux include esophagitis, webs and strictures, Barrett's esophagus, and carcinoma. Barrett's esophagus is defined as metaplasia from squamous epithelium to specialized columnar epithelium that occurs 2-3 cm above the gastroesophageal junction. Barrett's esophagus is an endoscopic diagnosis associated with an increased incidence of adenocarcinoma.
Pulmonary
Pulmonary complications of gastroesophageal reflux include aspiration, chronic cough, apnea, recurrent pneumonia, bronchitis and diphtheria, asthma, tracheal stenosis, stridor, and sudden infant death syndrome.VANITA AHUJA, M.D.,
is currently a resident in otolaryngology¬head and neck surgery at the National Naval Medical Center, Bethesda, Md. Dr. Ahuja completed a tour as a general medical officer at U.S. Naval Hospital, Yokosuka, Japan.
MYRON W. YENCHA, M.D.,
is head of the Department of Otolaryngology at the Naval Hospital, Pensacola, Fla. He completed a residency in otolaryngology¬head and neck surgery at Naval Medical Center, Portsmouth, Va.
LORENZ F. LASSEN, M.D.,
is director for surgical services at Naval Medical Center, Portsmouth, Va. Dr. Lassen completed a residency in otolaryngology¬head and neck surgery at Naval Medical Center, San Diego, and a fellowship in neurology/otology at the University of Pittsburgh.