Keywords
esophagitis - gastroesophageal reflux - laryngitis
Palavras-chave
esofagite - refluxo gastroesofágico - laringite
Introduction
Erosive esophagitis - esophageal mucosal injury caused by both agents extrinsic as
intrinsic agents - change is routinely found in diagnostic centers in gastroenterology,
very often related to Gastroesophageal Reflux Disease (GERD). GERD it is, the high
prevalence of a public health problem, a chronic disease, recurrent and impairing
daily activities[1].
The association between GERD and laryngeal disorders has been discussed since 1960[2]. Recent studies suggest an association between laryngeal symptoms and pharyngeal
symptoms extra-esophageal reflux, as atypical presentation of Gastroesophageal Reflux
Disease[3].
The ENT symptoms can be classified into one entity called laryngopharyngeal reflux
(LPR), defined as being the result of retrograde gastric contents into the light larynx,
when, it comes in contact with the upper aerodigestive tract[4]. Most patients with LPR do not present classic symptoms of GERD such as heartburn
and regurgitation[5]. It is postulated that approximately 50-60% of chronic laryngitis are unwieldy compared
with GERD[2].
Are nonexistent in the literature that relates the degree of esophagitis with the
presence and degree of laryngeal lesions. This question appears to be important, since
it modifies the proposed treatment, and improved significantly and more quickly and
effectively the quality of life of patients correctly treated, according to the extent
of their disease.
The aim of this study is to determine the prevalence of laryngeal disorders in patients
with erosive esophagitis, evaluated in Digestive Endoscopy Service, Hospital de Clinicas,
Federal University of Parana - HC / UFPR. And our specific objective is to correlate
the presence of changes in laryngeal comparison with the degree of erosive esophagitis.
Method
Cross-sectional prevalence study conducted in the Departments of Digestive Endoscopy
and Per-Oral Endoscopy, Hospital de Clínicas / UFPR.
We evaluated all patients undergoing upper endoscopy at the Endoscopy Service of HC
/ UFPR, elective, during the period February 2009 to September 2009. Patients with
erosive esophagitis were classified according to the criteria of Los Angeles ([Graphic 1]) and responded to the questionnaire ([Graphic 2]). Then they underwent direct laryngoscopy by the same examiner, using a rigid laryngoscope,
and evaluated the presence of laryngeal disorders, as well as the nature of these
lesions (redness, nodules on vocal cords, edema, signs of posterior laryngitis) and
the degree of severity of these changes.
Graphic 1. Los Angeles classification for oesophagitis - A - class B - class b; C + D - class
c + d.
Graphic 2. Relation between changes in endoscopy, laryngoscopy and symptomatology in separate
groups according to classification of Los Angeles - A - endoscopy; B - laryngoscopy;
- C + D symptoms.
Data were organized into a database created in Epi-Info 6.0. Statistical analysis
was performed in the “SPSS for Windows.” The chi-square test was used to assess the
relationship between the study variables. The significance level adopted was less
than 5% (p <0.05).
The protocol followed the MS conditions laid down in Resolution 196/96 of the National
Health Council (CNS). After the patients were informed of the purpose of the study
all gave their written consent to participate. The study was approved by the Ethics
Committee on Human Research, HC / UFPR (0292.0.208.000-08).
Results
Thirty patients completed the study. Of these, 16 were male (53.3%) and 14 females
(46.6%). The mean age was 49.1 years, ranging between 27 and 81 years.
Patients with typical symptoms of gastroesophageal reflux disease accounted for 96.6%,
among these, 36.6% had atypical symptoms.
Patients were classified according to endoscopic findings according to the classification
of Los Angeles. Eighteen had changes consistent with class A (60%), class B with seven
(7%) and 5 with classes C + D (16.6%).
Of the 18 patients who had endoscopic changes compatible with Class A of Los Angeles
(60%) of 73%[13] had normal laryngoscopy and 27.7% (05) had changes consistent with posterior laryngitis.
Only 22%[4] of the patients had atypical symptoms - of these, 50% with changes laryngoscopy.
Among the 07 patients classified as class B from Los Angeles (23.3%), 42.8%[3] showed posterior laryngitis. Three complained of atypical symptoms (42.8%), of which
two showed abnormal laryngoscopy.
Class C and D were diagnosed in 5 patients (16.6%) all showed abnormal laryngoscopy:
3 posterior laryngitis, a crack and a triangular posterior varicosity. All patients
were symptomatic.
The presence of laryngeal changes were more prevalent in more severe esophagitis (grades
C and D Los Angeles) when compared to milder forms (classes A and B), a statistically
significant difference (p <0.05).
Discussion
According to the American Bronchoesophagological Association, the most common symptoms of LPR are hoarseness (97%), globus pharyngeus (95%) and hoarseness (95%)[9].
Koufman
[10] was the first to distinguish GERD LPR, in his study with 899 patients found that
hoarseness was found in 87% of patients with LPR and only 3% of patients with GERD,
heartburn was already present in 83% of patients with GERD, whereas only 20% occurred
in patients with LPR.
There are three ways to confirm LPR: (1) improvement of symptoms after medical treatment
with lifestyle changes and medication, (2) endoscopic observation of the mucosa affected
(3) demonstration of reflux events in studies of pH monitoring and study impedance
multichannel[4].
Vaez
[11] states that the EDA has a positivity of only 50% of endoscopic esophageal injury
in patients with typical symptoms of GERD in patients with LPR has that number reaches
only 20%. Due to low sensitivity of EGD and pH monitoring, and low specificity of
laryngoscopy, empiric treatment with PPI has been considered the first step in the
diagnosis of extra-esophageal manifestations of GERD[2]. Those patients in which there is no response other diagnosis should be investigated.
Endoscopic findings generally show nonspecific signs, however, suggestive of LPR:
hyperemia, edema and narrowing mainly concentrated in the posterior larynx (posterior
laryngitis).The endoscopic examination (either rigid or flexible laryngoscope) should
be performed in all patients suspected of LPR[12]. In a study published by Ylitalo
[12], 74% of laryngeal contact granulomas were related to LPR. The pseudosulco was found
2.5 times more often in patients with LPR[13]. However, only 70% of pseudosulcos are related to LPR.
Laryngeal inflamed tissues are more easily damaged during intubation, the greatest
risk of granulomas and contact ulcers, and often are involved in symptomatic subglottic
stenosis and lower airway disease[4].
Benini et al
[14], studying the effect of mucosal damage as much as esophageal larynx as a cause of
decreased cough threshold, the study included only patients with esophagitis, a total
of 21 patients, found an incidence of posterior laryngitis in 13 patients (61.9%).
In a study by Toros et al[5], only 11% of patients with LPR symptoms showed changes consistent with GERD and
endoscopy.
As occurs with GERD, the response to the treatment of laryngopharyngeal reflux (LPR)
with proton pump inhibitors (PPIs) has been described as highly variable[15]. Unlike GERD, treatment for LPR, in many cases, is more aggressive and prolonged
in order to achieve full resolution[10].
The treatment of patients with LPR is based on the use of proton pump inhibitors in
double dose, divided in two doses, 30-60 minutes before meals[4]. If after three months of treatment with appropriate changes in lifestyle and appropriate
doses of PPIs there is no response, no need for additional tests to confirm diagnosis.
When the doctor fails to recognize LPR, patients may have prolonged symptoms and delayed
healing of injuries, as well as being subjected to unnecessary costs, often high by
inadequate diagnosis[16].
Conclusion
Laryngeal disorders are frequent findings in patients with esophagitis, more frequent
the greater the degree of esophageal injury. The doctor should therefore use both
tests in their diagnostic armamentarium for patients with complaints of typical and
atypical GERD.
