INTRODUCTION

Gastroesophageal reflux disease (GERD) is defined as upward movements of gastric content to the esophagus without vomiting. Laryngopharyngeal reflux (LPR) is defined as upward movements of gastric content into the laryngopharyngeal area. Gastroesophageal reflux disease (GERD) occurs when the gastric content irritates the surface mucosa of the upper airways and digestive tract1. GER are clinical different variations from GERD2,3,4.

Most common symptoms of GERD are heartburn and acid regurgitation, followed by epigastralgia, post-prandial satiety, retrosternal pain, nausea and dysphagia. Other uncommon related symptom is malaise caused by increase of salivary flow associated with the onset of heartburn5.
Patients with GERD are normally seen by Otorhinolaryngologists, since they do not have any typical complaints of reflux such as heartburn. They complain of other related symptoms of reflux of the gastric content inside upper airway and digestive tract6 and reflux above the upper esophageal sphincter2. Most common clinical symptoms of otorhinolaryngological problems related to reflux include hoarseness, chronic coughing, throat clearing, globus sensation, granulomas of vocal folds, laryngeal carcinoma, halitosis, otalgia, odynophagia and stridor 2,3,6. Pharyngeal globus occur in 0.7 to 4.1% of the patients examined by otorhinolaryngologists 5. Many patients with LPR do not have heartburn or dyspepsia2,7 J. A. Koufman reported that two thirds of ENT patients with vocal and laryngeal disorders have GRDE as a primary cause or as an etiological significant co-factor still reporting that GERD seems to be the most common cause of voice disorders7. Nonetheless, there are no studies related to the severity of the laryngeal findings.

Currently, the prevalence of ear, nose and throat disorders related to GERD is unknown. It estimated that 4 to 10% of the ENT patients would have GERD-related symptoms or findings 5.

Coffin reported the first association between laryngeal and gastroesophageal disease in 1903, speculating that "eructation of stomach gases" and hyperacidity were responsible for the symptoms in many of his patients such as "post-nasal secretion". In his opinion, this problem was overlooked because many of these patients did not have gastrointestinal symptoms5. Cherry and Margulus, reported three cases of patients with contact ulcer in larynx and esophageal reflux evidenced in studies carried out with barium in 1968. Subsequent studies estimated that GERD was the primary etiology in 10% of patients with chronic cough, in 5 to 10% of the patients with hoarseness, and in 25 to 50% of patients with globus and small but clearly defined laryngeal cancer6.

There are at least two likely mechanisms to explain the association between reflux and laryngeal disease. A mechanism that postulates a distal esophageal reflex mediated by the vagus nerve, sensitive to gastric acid that causes laryngeal complaints and epithelial lesions. The second one describes direct injury of the larynx, which is supported by animal studies showing that acid fluids are capable of inducing damage in laryngeal structures2,5,8.

Physiological reflux occurs in the esophagus. Major defense mechanisms against corrosive action of gastric acid are: clearance of esophageal acid, mucosa resistance and salivary secretion. It may be that such defense does not exist in pharyngolaryngeal transition and a small amount of acid reflux may have devastating effects4,8 due to acid sensitivity.

OBJECTIVE

The objective of this study was to evaluate major complaints of patients with Gastroesophageal reflux disease (GERD) treated in the outpatient unit of Laryngology and Voice Care Center, Santa Casa de Misericórdia of Sao Paulo, and relate them to videolaryngoscopy findings.

MATERIAL AND METHOD

A retrospective study was carried out in patients with signals of laryngopharyngeal reflux in videolaryngoscopy and through their clinical records they were assessed in the Laryngology and Voice Service from March 1998 to May 2000.

Patients were divided into three different groups: Mild LPR -videolaryngoscopy revealed mild edema and/or hyperemia of arytenoid and retrocricoid regions; Moderate LPR - in which moderate edema of arytenoid and retrocricoid areas was present in addition to intrarytenoid edema; and severe LPR - in which in addition to the findings above mentioned, there was also retrocricoid granulation, intrarytenoid pachidermia and more severe edema.

Patients were assessed according to age, gender and ear, nose, throat and gastric complaints.
Additionally, patients were evaluated according to the frequency of the most common complaints in total sampling, according to the frequency of complaints in different groups and according to the major complaint in each group, in other words the complaint that brought the patient to the outpatient unit, and according to digestive complaints in each group.

RESULTS

One hundred and fifty-seven patients were studied in total, with 110 female and 47 male patients.
Age range included adult patients from 21 to 85 years old. Patients were divided according to their age range as follows: 54 patients aged 21 to 40 years; 73 patients aged 41 to 60 years; and 30 patients aged 61 to 85 years.
Videolaryngoscopy findings were as follows:

 34 patients with mild LPR;
 60 patients with moderate LPR;
 63 patients with severe LPR;

The complaints were as follows:
 Dysphonia: 109 out of 157 patients (69.42%);
 Throat Clearing: 83 out of 157 patients (52.86%);
 Pharyngeal Globus: 103 out of 157 patients (65.60%);
 Heartburn: 52 out of 157 patients (33.12%);
 Cough: 29 out of 157 patients (18.97%);
 Odynophagia: 18 out of 157 patients (11.46%);
 Dysphagia: 17 out of 157 patients (10.82%);
 Chocking: 04 out of 157 patients (2.54%).










DISCUSSION

The most common complaints of the 157 patients examined were: hoarseness (69.42%), pharyngeal globus (65.60%), throat clearing (52.86%), heartburn (33.12%), cough (18,97%), odynophagia (11.46%), dysphagia (10.82%) and chocking (2.54%), as shown in Graph 1. These findings are not in accordance with those from Fraser et al., that found during the study of 87 patients that the most common complaints were cough (38%) and hoarseness (36%)9, but they are in accordance with the study from Eckley et al., in which the investigation of 20 patients with chronic pharyngolaryngitis due to LPR found out that 95% of those patients had pharyngeal globus, 85% had throat clearing, 70% had dysphonia, and 60% had cough. The data collected by Wong Roy et al., which reported hoarseness in 92% of the patients with reflux laryngitis4,5,10 are also in accordance.

The most common complaint was dysphonia (Graph 1). It could be explained because we are dealing with patients that had a complaint that caused professional and social hindrances; in addition, the fact that such patients are part of the voice outpatient care unit creates a bias towards detecting individuals with dysphonia. The analysis of Table 1 and Graphs 2 and 3 showed that dysphonia is the most common symptom in the three groups. This could be explained by the edema and inflammatory lesions found in vocal folds of the patients determined by LPR that change the dynamic of vocal production. Additionally, all patients were members of the outpatient care unit, which means that our sample was not randomized. Although Koufman stated that GERD is associated with approximately 55% of patients investigated with complaints of hoarseness this prevalence was not observed in other studies5.
The second most common complaint of our patients was globus sensation (Graph 1). This was the third most common complaint in groups with moderate reflux (Table 1 and Graph 3). A substantial number of patients with such complaints have GERD, but it is still unclear if symptoms represent discomfort due to esophagitis, esophageal dysmotility, and hypertonicity of cricopharyngeal muscle or if it results from acid inoculation into laryngopharyngeal structures3. Other studies have reported that the most common symptom in patients with laryngopharyngeal reflux is globus and that approximately 23 to 60% of the patients with globus have GERD as etiological factor.1,3

The third most common complaint was throat clearing. We also found out that throat clearing was the second most common complaint in the group of patients with mild, moderate and severe reflux (Table 1 and Graph 3).

Heartburn was the fourth most frequent complaint, with similar distribution among the three groups (Table 1 and Graphs 3 and 4).

Odynophagia was not a very common complaint (11.46%) and had similar distribution among the three groups (Table 1 and Graph 3).

Seventeen out of 157 patients had dysphagia complaint and this was not very frequent (10.82%); it was more frequent in the groups with moderate and severe reflux (Table 1 and Graph 3).
Dysphagia and odynophagia of GERD could be caused by three likely mechanisms:

a. Direct irritation of laryngopharyngeal structures;
b. Discomfort of neck region secondary to esophageal dysfunction;
c. Dysfunction of the upper esophageal sphincter.

Henderson et al. reported dysphagia in 51.7% of 1,000 patients with GERD. Toohill reported 12% dysphagia as primary symptom in 207 patients with GERD6, which was similar to our findings of 10.82%.
Cough was not a common complaint, since only 18.97% (29 out of 157 patients) had mentioned it. The distribution of these patients along the different groups revealed that this symptom had similar incidence in the three groups.

Choking was not a common complaint: only 4 out of 157 patients, with three of such patients having moderate reflux and 1 having severe reflux. This low incidence of choking could be explained by the profile of our outpatient unit that provides care to low-income population - access to medical health care is limited and no one would wait a long time because of such complaint.

Fifty-two out of 157 patients with reflux (33.12%) complained of heartburn. Among those 52 patients, 29.41% were from the group of mild reflex, 33.33% were from the group of moderate reflux and 34.92% were from the group of severe reflux. Those data showed similar frequency of heartburn complaint among the three groups. Heartburn is a typical symptom of GERD and it is common in patients with gastroesophageal symptoms, but it is uncommon in those patients that have head and neck manifestations (laryngoesophageal reflux)1,3. Among those patients with heartburn, in addition to gastroesophageal reflux, they also had laryngoesophageal reflux since many of them had also other symptoms such as throat clearing, globus sensation, dysphonia, etc. with videolaryngoscopy findings compatible with LPRD. Many authors have reported low prevalence of heartburn (6-43%) in LPRD patients 5,7. Koufman7 reported in his clinical trials that in a study designed by Ossakow et al., in 63 ENT patients and 36 GI patients, hoarseness was found in 100% of the former and 0% of the latter group of patients, whereas heartburn was reported in 89% of GI patients and in only 6% of the ENT patients. He also reported that other authors referred low incidence of heartburn as a symptom of ENT patients: 43% in the study of Koufman and 20% in the study of Toohill et al. He reported that such patients do not present heartburn because they do not have esophagitis, which is present in GER patients7. Nonetheless, these findings contrasted with those from Eckley et al., who upon investigating 20 adult patients with suggestive symptoms of chronic laryngitis caused by LPR found that 75% of such patients had pyrosis 3. Costa et al. investigated a group of 27 patients with pharyngolaryngeal symptoms and found that 77% of the patients had digestive symptoms and the rate increased to 100% if the symptoms were severe; in addition, 60% had abnormalities in upper aerodigestive endoscopy. The author still reported that among those 27 investigated patients, 44% had marked reflux in direct laryngoscopy and 83.3% out of those patients showed abnormalities in upper digestive endoscopy (mild gastritis or esophagitis), and 83.3% of the clinical pathology analysis of the larynx of those patients showed unspecific chronic inflammatory process, clearly showing reliability and conformity between videolaryngoscopy, upper digestive endoscopy and clinical pathology analysis10.

CONCLUSIONS

 Dysphonia was the most common complaint in 157 patients and was also the major complaint among the different groups of patients with LPRD - mild, moderate or severe and it was more frequent in the groups of patients with LPRD.
 Pharyngeal globus is also a common complaint of LPRD patients and is mainly associated with moderate and severe reflux.
 Throat clearing is a frequent complaint of patients with mild, moderate or severe LPRD.
 Heartburn was not a common complaint in those patients investigated and it seemed to have similar occurrence in patients of the three LPRD groups.
 Odynophagia as well as dysphagia, choking and cough were not common symptoms of these patients.

REFERENCES

1. Ahuja V, Yencha, MW, Lassen LF. Head and neck manifestations of Gastroesophageal Reflux Disease. American Family Physician 1999; 60: 873-80.
2. Koufman JA, Sataloff RT, Toohil R. Laryngopharyngeal Reflux (LPR): Consensus Conference Report. Center for Voice Disorders Homepage. Disponível em: www.bgsm.edu/voice/; abril de 2001.
3. Eckley CA, Marinho VP, Scala WR, Costa HO. PH-metria esofágica de 24 Horas de Duplo Canal no Diagnóstico da Laringite por Refluxo. Revista Brasileira de Otorrinolaringologia 2000; 66(2):110-4.
4. Eckley CA, Lima G, Duprat AC, Costa HO. Repercussões Otorrinolaringolgógicas da Doença do Refluxo Gastroesofágico na Infância. Revista Brasileira de Otorrinolaringologia 2001; 67(1):68-72.
5. Wong Roy KH, Hanson DG, Waring PJ, Shaw G. ENT Manifestations of Gastroesophageal Reflux. The American Journal of Gastroenterology 2000; 95(8) (suppl 2):15-22.
6. Klinkenberg Knol EC. The Otolaryngologic Manifestations of Gastroesophaeal Reflux Disease. Scand J Gastroenterol 1998; 33(suppl)225:24-8.
7. Koufman JA. Reflux and Voice disorders. Center for Voice Disorders Homepage.Disponível em: www.bgsm.edu/voice/, abril de 2001.
8. Smit CF, Van Leeuwen AMJ, Mathus-Vliegen LMH, Devriese PP, Semin A, Tan J, Schouwenburg PF. Gastropharyngeal and gastroesophageal Reflux in Globus and Hoarseness. Arch otolaryngol Head Neck Surg 2000; 126: 827-30.
9. Fraser AG, Morton RP, Gillibrand J. Presumed laryngo-pharyngeal reflux: investigate or treat? The Journal of laryngology and otology 2000; 144:441-7.
10. Costa HO, Eckley CA, Fernandes AMF, Destailleur D, Villela PH. Refluxo gastroesofágico: comparação entre os achados laríngeos e digestivos. F méd (BR) 1997; 114(supl 3):97-101.

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1 Resident Physician, Department of Otorhinolaryngology, Santa Casa de Misericórdia de Sao Paulo.
2 Professor, Department of Otorhinolaryngology, Santa Casa de Misericórdia de Sao Paulo.
3 Assistant Professor, Department of Otorhinolaryngology, Santa Casa de Misericórdia de Sao Paulo.
4 Joint Professor, Department of Otorhinolaryngology, Santa Casa de Misericórdia de Sao Paulo.
Affiliation: Santa Casa de Misericórdia de Sao Paulo - SP.
Address correspondence to: Daniela Oliverio Burati - Rua Dona Antônia de Queiroz, 435, apto 84 Consolação 01307-010 Sao Paulo
Tel/fax (55 11) 3120-3258 /(55 11) 9623-7287 - E-mail: dburati@ig.com.br
Study presented at II Congresso Triológico de Otorrinolaringologia, held in Goiânia from August 22 - 26, 2001.
Article submitted on July 02, 2001. Article accepted on July 10, 2003.