Introduction

Gastroesophageal reflux disease (GERD) is defined as retrograde flow of gastric contents into the esophagus. The refluxed material, which contains acid, pepsin, biliary salts and pancreatic salts may irritate or damage the esophageal mucosa by direct action. The current pragmatic definition of GERD as reported by the last World Congress on Gastroenterology 9, is the following: "The diagnosis of gastroesophageal reflux disease should include all subjects who are exposed to the risk of physical complications of gastroesophageal reflux, or that clinically experience worsening of quality of life related to reflux, after the appropriate acknowledgement of the benign nature of the disorder." GERD has been the topic of studies for a long time now. Winkelstein in 1935, reported a case of peptic esophagitis as a new clinical entity, by correlating the symptoms with endoscopic findings. The same authors observed clinical improvement of patients treated with anti-reflux drugs. It is estimated that 10% of the American population have some daily symptoms of retrosternal heartburn or regurgitation, and 30 to 50% present less frequent symptoms6. Castell, in 19917, classified GERD symptoms in two large groups: esophageal and extraesophageal. Until recently, little was said about extraesophageal manifestations of gastroesophageal reflux disease, but currently they are easily recognized and more prevalent than initially thought. Many chronic otorhinolaryngological symptoms, such as chronic dysphonia, non-specific laryngitis, throat-clearing and globus pharyngeus are caused by gastroesophageal reflux. The most common laryngeal alterations found in patients with extraesophageal symptoms of gastroesophageal reflux are manifested on the posterior laryngeal region - among them, posterior laryngitis is the most common one. It is the thickness of the posterior laryngeal wall (interarytenoid region) and erythema of the posterior laryngeal wall15. The mucosa of that wall is recovered by ciliated pseudostratified epithelium, according to Hirano et al. 10, differently from the epithelium of the anterior laryngeal region, which is stratified squamous epithelium.

The present study described the pathology results of biopsy of posterior laryngeal walls of patients with gastroesophageal reflux disease.

Material and Method

From June and September 1998 we carried out biopsies of the posterior laryngeal wall of 7 patients who had gastroesophageal reflux disease. Owing to the difficulty in biopsy access without general anesthesia, it was performed right at the beginning of the surgical procedure for gastroesophageal reflux disease, or in other words, fundoplication was performed in all patients of this series.

All patients had gastroesophageal reflux disease and they had been submitted to upper digestive endoscopy that revealed distal erosive esophagitis. The device used for the procedures of upper digestive endoscopy was a gastroscope Olympus (Olympus Optical Co. - Japan) model V10.

Patients also underwent direct laryngoscopy to identify laryngeal alterations caused by gastroesophageal reflux. Direct laryngoscopy was conducted with rigid telescopic optic 70o SFT-1 model (Nagashima Co. - Japan).

Associated gastroesophageal reflux and laryngological lesions, according to Stemple, Glaze and Gerdeman, which were investigated by the present study during laryngoscopy were: posterior laryngitis, contact ulcer, glanuloma and leukoplasia.

The term "posterior laryngitis" was defined as follows: thickness of posterior laryngeal wall and/or arytenoid hyperemia.

The criteria for inclusion of the patients in the study were:

1. Patients with gastroesophageal reflux disease with simultaneous typical (esophageal) and atypical (extraesophageal) symptoms;
2. No previous history of allergic ENT diseases;
3. No smoking;
4. Patients with and without laryngeal lesions suggestive of gastroesophageal reflux.

The criteria for exclusion of the patients were:

1. Patients with gastroesophageal reflux disease only with esophageal symptoms;
2. Smokers.

After identification of type of symptom and performance of direct laryngoscopy, patients were classified into two groups:

I - Normal laryngoscopy
II - Laryngoscopy with abnormality.

Biopsy of posterior laryngeal wall was performed through suspension laryngoscopy, with rigid biopsy clamp. We removed three fragments in all patients and the material was referred to the Service of Pathology. In this study, the pathologist followed the criteria below to analyze the slides:

(a) to identify the epithelium of the posterior laryngeal wall as respiratory, which is the normal epithelium of the posterior laryngeal wall as defined by Hirano5
(b) to identify the presence of squamous metaplasia amidst the respiratory epithelium;
(c) to identify only the squamous epithelium on the posterior laryngeal wall, and
(d) to identify the same histologic characteristics related to gastroesophageal reflux in biopsy of esophageal mucosa.

Histologic alterations resultant from gastroesophageal reflux that are normally found in the esophagus and were adopted in the present study were:

(a) presence of intraepithelial inflammatory cells on the lamina propria;
(b) thickness of the basal cell layer (on the respiratory pseudostratified epithelium, this criterion was not applied);
(c) elongation of corium papillae;
(d) vascular proliferation on papillary corium.

Patients that presented only one of the four histology alterations reported above were considered as having gastroesophageal reflux alterations manifested in the larynx.



Discussion

A number of chronic otorhinolaryngological and pulmonary symptoms such as hoarseness, chronic throat clearing, globus pharyngeus, dysphagia, chronic cough, stridor and asthma are related to GERD. Bain et al.1 suggested that the direct irritation of the mucosa and aberrant and retrograde reflex mechanisms, via vagus nerve, were two of the mechanisms implied in the onset of pharyngeal and laryngeal symptoms. Batch2 in 1988, studied patients who presented only globus pharyngeus and submitted them to a detailed clinical and psychological questionnaire, in addition to gastroesophageal reflux investigation (manometry and 24-hour pH monitoring). The author found high incidence of gastroesophageal reflux and also reported improvement of symptoms in 70.5% of the patients treated with anti-reflux medication for 6 weeks. The same author did not find differences in the psychological profile of the patients when compared to other otorhinolaryngological problems.

Koufman16 studied the presence of gastroesophageal reflux in patients who had otorhinolaryngological manifestations of GERD with double canal 24-hour pH monitoring, and divided them into groups of different symptoms. The author reported the following results of presence of gastroesophageal reflux: laryngeal carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus pharyngeus (58%), dysphagia (45%), chronic cough (52%) and miscellaneous (13%).

Macedo18 studied 74 patients with extraesophageal symptoms of GERD with and without laryngeal lesions suggestive of acid reflux and found 79.41% of gastroesophageal reflux in the group with laryngeal lesions and 55% of gastroesophageal reflux in the group without laryngeal lesion, with statistically significant difference in the presence of gastroesophageal reflux in the group with laryngeal lesion. Investigation of gastroesophageal reflux was based on upper digestive endoscopy.

In addition, many chronic and neoplastic processes of aerodigestive tract, such as cricopharyngeal hypertrophy, esophageal membrane, laryngeal cancer and subglottic stenosis have been related to GERD1, 16, 17.

Despite the fact that the response of the esophageal epithelium to acid reflux has already been well documented12, 23, histopathologic response of the upper respiratory epithelium to acid has only been shown in experimental animal models17, 18, 25. Few articles in the literature addressed the histology of laryngeal posterior wall, especially in patients with gastroesophageal reflux disease13. Hirano, in 1986, studied 20 (10 male and 10 female) larynxes collected from autopsy10. The study demonstrated that the mucosa of the laryngeal posterior wall presented ciliated pseudostratified epithelium, contrasting with the lining epithelium of the anterior glottis, which was stratified squamous.

The results of the present study showed that 42.85% of the patients presented squamous epithelium as the recovering layer of the laryngeal posterior wall; 42.85% presented areas of squamous metaplasia amidst the respiratory pseudostratified epithelium, and only 28.57% had respiratory epithelium. All patients had gastroesophageal reflux disease with both typical and atypical symptoms. Therefore, the results suggested that gastroesophageal reflux may modify the recovering epithelium of the laryngeal posterior wall because of the chronic stimulus of the acid, transforming the ciliated pseudostratified epithelium into squamous epithelium. Damage mechanisms are facilitated by low position of the larynx, associated to relaxed glottic posture (abduction) which favors the direct action of the refluxed content, differently from what happens in swallowing, when the larynx is at a higher position, with the epiglottis lowered and the laryngeal vestibule and the vocal folds plane are completely closed.

Out of the total number of patients in the present study, 71.4% presented histologic alterations resultant from gastroesophageal reflux that are found in the esophagus. Histologic diagnosis of reflux esophagitis had been established in previous studies3, 5, 11, 14. Morphometric indicators of cellular growth, such as basal cell thickness and papillary increase are sensitive and specific indicators of reflux esophagitis11, 14. Winter24 and Shub21 showed that specificity of inflammatory cells (neutrophils and eosinophils) as histologic markers of reflux esophagitis in children was higher than 90%. However, other studies with inflammatory cells as histologic markers of reflux esophagitis have been considered inconclusive3, 5, 20. Black4 reported that it is quite obvious, based on his studies and others in the literature, that intraepithelial inflammatory cells and morphometric measures of thickness of basal cell layer and size of papillae are markers of reflux esophagitis. However, the importance lies on defining sensitivity of the histologic tracers for diagnosis of reflux esophagitis. Vandenplas22 reported that there seems to be a consensus among North-American and European doctors about GERD in children: the approach of esophageal biopsy has no positive impact since the presence or absence of histologic esophagitis does not influence management and treatment of these patients. Esophageal biopsy is only helpful to contribute and/or exclude gastroesophageal reflux as an etiology of the symptoms.

Kambic13 published a study in which he performed biopsies of the laryngeal posterior wall in 44 patients with chronic acid laryngitis. The results showed that all patients presented typical histologic alterations of the peptic process, such as pseudostratified epithelium with basal hyperplasia and stroma infiltrate with tendency to migrate between the epithelial cells.

Histopathologic results of the present study showed that all patients presented at least one of the four histologic alterations suggestive of peptic damage caused by gastroesophageal reflux. Future studies should be performed with larger number of subjects and with control group to check the occurrence of histologic alterations in the control group - and also to study the sensitivity of histologic parameters related to gastroesophageal reflux.

The results of the study suggested that gastroesophageal reflux may be related to changes in the epithelium of the laryngeal posterior wall, as well as to inflammatory histologic alterations in the same region. Biopsy of laryngeal posterior wall may turn out to be an investigation method of GERD for patients with extraesophageal symptoms. Further studies with control group are required to confirm the data.

References

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13. KAMBIC, V; RADSEL, Z. Acid Posterior Laryngitis. J. Laryngol Otol. 98:1237-40, 1984.
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18. MACEDO-FILHO, E.D. - Estudo da presença de refluxo gastroesofageano em pacientes com lesões na região posterior da laringe, comparação com grupo controle. Curitiba, 1996. Dissertação (Mestrado em Cirurgia) - Setor das Ciências da Saúde, Universidade Federal do Paraná.
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20. SEEFELD, U.; KREJS, G.J.; SIEBENMANN, R.E. et al. Esophageal Histology in Gastroesophageal Reflux: Morphometric Findings in Suction Biopsies. Am J Dis Dig. 22:956-64, 1977.
21. SHUB, M.D.; ULSHEN, M.H.; HARGROVE, C.B. Esophagitis: a Frequent Consequence of Gastroesophageal Reflux in Infancy. J Pediatric 107:881-4, 1985.
22. VANDENPLAS, Y. Reflux Esophagitis: Biopsy or Not? J Pediatric Gastrol Nut 22:326-7, 1996.
23. WEINSTEN, W.M.; BOGOCH, E.R.; BOWES, K.L. The Normal Human Esophageal Mucosa: A Histologic Reappraisal. Gastroenterology. 68:40-4, 1975.
25. WYNNE, L.F.; RAMPHAL, R.; HOOD, C.I. Tracheal Mucosal damage after aspiration. A Scanning Electron Microscope Study. Ann Rev Respirat Dis 124:728-32, 1981.
24. WINTER, H.S.; MADARA, J.L.; STAFFORD, R.J. et al. Intraepithelial Eosinophils: a New Diagnostic Criterion for Reflux Esophagitis. Gastroenterology 83:818-23, 1982.

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1 Physician, Service of Endoscopy and Human Voice, Hospital Nossa Senhora das Graças
2 Head of the Service of Digestive Tract Surgery, Hospital Nossa Senhora das Graças
3 Resident in Digestive Tract Surgery Hospital Nossa Senhora das Graças
4 Pathologist, Service of Pathology, Hospital Nossa Senhora das Graças
5 Medical undergraduate, Hospital Nossa Senhora das Graças

Study conducted at the Service of Endoscopy, Hospital Nossa Senhora das Graças - Curitiba/PR
Address correspondence to: Dr. Guilherme F. Gomes - Rua Carlos de Carvalho, 1041, apto. 302
(0xx41): 80340-180 - Curitiba/PR.

Tel (55 41): 335-8127 E-mail: guibi@netpar.com.br

Article submitted on April 03, 2001. Article accepted on April 27, 2001.