This document summarizes reflux and eosinophilic esophagitis. It defines gastroesophageal reflux (GOR) and gastroesophageal reflux disease (GORD) when symptoms are present. Laryngopharyngeal reflux (LPR) and extraesophageal reflux disease (EORD) are also discussed. The physiology and mechanisms of injury from acid exposure are explained. Common symptoms and investigations are outlined, including pH monitoring, impedance testing, and endoscopic findings. Associated conditions like laryngomalacia, subglottic stenosis, and apparent life-threatening events are covered. Management includes lifestyle changes and pharmacological or surgical interventions.

1. SCOTT BROWN LEARNING
2020
CHAPTER – 44)REFLUX AND EOSINOPHILIC OESOPHAGITIS
VOLUME-2
PAGE NO- 501 TO 512
PRESENTER- DR.M.PRABHAKARAN M.S. ENT
MODERATOR- DR.ARUL SUNDARESH KUMAR M.S ENT

2. GOR/GORD ????
• Gastro-oesophageal reflux (GOR) occurs when stomach contents travel
in a retrograde direction above the level of the lower oesophageal
sphincter which contain hydrochloric acid and pepsin and may include
bile and pancreatic enzymes.
• If the patient develops symptoms, signs or histological changes, the
term gastrooesophageal reflux disease (GORD) is used.

3. LPR/EORD ????
• Laryngopharyngeal reflux (LPR)/(EOR) not only involves the
laryngopharynx but also areas such as the lingual tonsil, pharyngeal
tonsils, sinuses, Eustachian tubes and trachea
• The term extraoesophageal reflux disease (EORD) may be used when
this reflux causes symptoms and pathology.

4. PHYSIOLOGY AND MECHANISM OF INJURY
• The pharynx and particularly the glottis and subglottis are sensitive to the injurious
effects of reflux.
• Intermittent exposure of pepsin , gastric acid ,bile acids which works in low pH
environment.
• the presence of mucosal trauma exaggerates the condition
Cellular damage

5. • Low pH causes a reduction in ciliary motility which may increase the exposure time
and potentiate the inflammatory effects of reflux.
• This may promote cough or throat clearing which may increase the inflammation.
• Acidification of the lower oesophagus and micro aspiration may lead to
bronchospasm, apnoea and pulmonary disease due to vagally mediated chemoreflexic
effects on cord mobility .
• Stimulation of the lower oesophagus produces laryngeal adduction and laryngospasm

6. SYMPTOMS
• Emesis, regurgitation, burping, feed refusal and back arching irritability, and
regurgitation after feeds with episodes of arching, crying and torticollis
• Older children may complain of heartburn, abdominal pain, hoarseness, throat clearing
or chronic cough
• Signs of increased work of breathing – tracheal tug, subcostal or intercostal recession
• Apnoeic and cyanotic spells are always significant on sleep
• Nocturnal Chronic cough
• An abnormal voice or cry may be a manifestation of reflux laryngitis

7. H/O & SIGNS TO BE NOTED ??
• Severity of emesis , Irritability and increased noisy breathing after Feeds , duration of feeds
• History of recurrent pneumonias or croups with multiple hospitalizations
• Signs of neurological impairment could potentiate the effects of reflux.
pharyngeal hypotonia and uncoordinated swallowing will lead to pooling of secretions in the
hypopharynx
This will increase the exposure time of the larynx to refluxate and increase the risk of aspiration.

8. SYMPTOMS

9. INVESTIGATIONS
Contrast swallow
• A contrast swallow has the advantage of demonstrating anatomical abnormalities
such as a tracheo-oesophageal fistula, a hiatus hernia and achalasia.
• It may detect aspiration especially when used as part of a videofluoroscopic
examination of swallow.
• not a good investigation to detect reflux events.
• not routinely done in reflux unless an underlying anatomic abnormality is
suspected.

10. PH MONITORING
• Ambulatory 24-hour pH monitoring has been the mainstay of
diagnosing GORD in children
• This is usually done passing the probe nasally, attempting to site the
electrode 5 cm above the gastro-oesophageal junction
• The probe remains in place for24 hours pH monitoring provides
excellent information regarding lower oesophageal acid exposure but
does not provide evidence of non-acid reflux or about extraoesophageal
reflux.
• Dual probe pH monitoring attempts to provide more information about
pH at the upper oesophagus and pharynx
• Achieving a consistent position for the upper electrode has been

11. • Multichannel oesophageal intraluminal impedance testing :
A combined impedance and pH probe can detect and distinguish acid and
nonacid reflux as well as aerosolized, liquid or mixed reflux
• Gastric emptying scintigraphy: helpful for delayed gastric emptying.
• Biopsy:
Oesophageal biopsy is the mainstay of making a histopathological diagnosis
of oesophagitis and eosinophilic oesophagitis. It may also be helpful in inflammatory
bowel disease, coeliac disease and Barrett’s oesophagus.

12. ENDOSCOPIC FINDINGS
• Posterior larynx is in close proximity to the oesophageal inlet, the most vulnerable
extra-oesophageal site to reflux exposure
• This relates to postglottic oedema and arytenoid oedema with loss of the normal
arytenoid contour. It is suggested that severe arytenoid oedema, postglottic oedema
and enlargement of the lingual tonsil may be pathognomonic for GORD
• The laryngeal ‘pseudosulcus’ refers to the appearance of a fold parallel to the free
edge of the vocal cord. This may involve just the posterior cord or extend the length of
the cord.
• It is thought to be a manifestation of infraglottic oedema .This finding appears to
have a high sensitivity for reflux although its specificity is lower.
• Other findings that have been described include generalized erythema, ventricle
effacement and cord nodules

13. acute reflux episode bathing
the posterior glottis.
generalized erythema and ventricular
effacement – a so-called ‘active larynx
severe posterior inflammation.

14. valleculae demonstrating
lingual tonsil enlargement
Tracheal view
showing ‘cobblestoning
posterior pharyngeal
wall ‘cobblestoning’.

15. Vocal cords demonstrating
vocal cord ‘pseudosulcus
Larynx showing arytenoid
inflammation and redundancy

16. ASSOCIATED CONDITIONS -
LARYNGOMALACIA
• Infants with laryngomalacia who have coughing, choking, regurgitation and feeding
difficulties may be considered candidates for empiric acid reflux suppression
especially in the presence of emesis.
• A certain number of infants will clinically improve and acid suppression should be
weaned based on symptom resolution.
• Antireflux therapy in all patients in the immediate post-operative period
• If not improved aryepiglottoplasty and supraglottoplasty surgery was done

17. SUBGLOTTIC STENOSIS
• The exposed mucosal surfaces and prolonged endotracheal intubation could serve as
an environment in which reflux exposure could affect wound healing. This could
lead to failure.
• Reflux therapy has been seen to improve outcomes of endoscopic treatments for
SGS and possibly reduce the number of children requiring surgery.

18. APPARENT LIFE-THREATENING EVENTS
• A mechanism for reflux mediation through direct contact,vagally mediated via the
oesophagus, or indeed via aspiration-associated reflux events have been suggested.
• There is also evidence that short non-pathological central apnoea is associated with
reflux and it may be that this is a protective phenomenon

19. NASOPHARYNX AND OROPHARYNX
• RHINOSINUSITIS
In adults with refractory sinus diseases, increased nasopharyngeal altered pH and
increased rates of gastrooesophageal reflux have also been demonstrated.
• Early results demonstrating pepsin in nasal lavage seem encouraging and may
represent a possible means of detecting reflux involvement in sinus disease.

20. OTITIS MEDIA :
• pepsin/pepsinogen was detected in middle-ear effusions at much higher
concentrations than were present in serum.
• The source of this could only be gastric and raised the possibility that reflux might
play a role in otitis media with effusion
• ADENOTONSILLAR HYPERTROPHY :
• Children with a history of GOR appear also to have a higher rate of post-operative
complications after adenotonsillectomy

21. MANAGEMENT
• Simple lifestyle changes
• Neonates are fed upright with feeds ‘little and often’.
• Feed thickening may help with emesis.
• For adolescent smoking cessation, alcohol avoidance and weight loss if obese are
recommended.
• Cessation of habitual throat clearing and vocal hygiene advice may be of benefit
• Pharmacological agents include barrier agents, prokinetic therapy, histamine-2 receptor
antagonists and proton pump inhibitors (PPIs).
• Surgical intervention is fundoplication, with laparoscopic techniques

22. THANK YOU