ENT Acid Related Disorders

1. Laryngopharyngeal Reflux
(LPR)
Frederick Mars Untalan MD

2.  LPR is the abnormal reflux of gastric contents
into the esophagus
 The acidic properties of the chyme causes
damage to the esophageal mucosa

3. Pediatric Reflux
 Functional
Gastroesophageal
Reflux
 GERD
 Secondary
Gastroesophageal
Reflux

4. Typical presentation of LPR
 Crying/Irritability
 Poor feeding
 Regurgitation
 Epigastric pain
 FTT/weight loss
 Sore throat
 Waterbrash
 Hematemesis
 Anemia

5. Atypical presentation of LPR
 Apnea/Bradycardia  Sandifer’s syndrome
 ALTEs  Hoarseness/
 Wheezing/Asthma Laryngitis
 Stridor  Otalgia
 Recurrent pneumonia  Sinusitis
 Chronic cough

6. LPR Untreated
 Resolves by 2 years
of age in 60% of
GERD
 Persists until age 4
in 30%
 ½ stricture, ½
malnutrition

7. LPR in Otolaryngology
 Chronic Sinusitis – avoid FESS
 Chronic Cough
 Globus Pharyngeus- osteophytes, FB,
cricopharyngeus, tonsils, goiter, web, cervical lad,
mass
 Dysphagia

8. Diagnosing LPR
Tetra-probe

9. Gastroesophageal Reflux
Disease

10. Reflux Contents
 Stomach produces caustic substances that aid in
digestion
 Parietal cells-HCl
 Chief Cells-
Pepsinogen
 Mucous Neck Cells-
Lipase

11. Reflux Contents cont.
 In addition to the stomach, other organs involved
in digestion also secrete damaging substances.
 Pancreas- Trypsinogen, amylase, lipase
 Liver - Bile salts

12. Esophageal damage
 Largely depends on contents of reflux
Gastric acid only: mild damage
Combination of gastric acid,
pancreatic enzymes, bile salts,
pepsin: severe mucosal damage

13. Medical Treatment of GERD
 Acid Suppressants
 Antacids – Al toxicity & osteomalacia
 H-2 Blockers – Usually sufficient
Proton Pump Inhibitors –
Omeprazole; Rapebprazole

14. Surgical Treatment of GERD

16. Under Pressure
 Each sphincter is maintained at a high resting
pressure.
 This prevents movement of ingesta and chyme
into the esophageal body when fasting.

17. Control of reflux
 Main control is the mechanical and intrinsic tone
of the LES
 Other mechanisms:
-Interdigitating rugal folds
-Right diaphragmatic crus
-Oblique entrance into stomach
-Gastric distention
-Abdominal portion of esophagus

18. LES
 The gastroesophageal
junction
 Ring of increased
thickness
 A high pressure zone, not a
true sphincter.
 Resting tone from
myogenic and neurogenic
forces
 THE MAJOR DEFENSE
AGAINST REFLUX

19. Causes of LPR
 Decreased resting tone of the LES
 Transient LES relaxations
 Delayed gastric emptying
 Impaired esophageal
clearance
 Reduced salivation
 Anesthesia

20. Prevalence and impact

21. The LPR / ENTARDS iceberg
Persistent symptoms &complications
Frequent symptoms
(seen by MD)
Occasional symptoms
(not seen by MD)

22. LPR ETIOLOGY
 Common Cavity Phenomenon
 LES Pressure
 Motility vs Clearance
 Saliva acid neutralization

23. LPR MANIFESTATIONS
 Heartburn/Regurgitation
 Dysphagia/Odynophagia
 Barrett’s Esophagus….. Cancer
 Pulmonary complications
 Throat complications

26. LPR TREATMENT
 Acid suppression
 H2 / PPI / Antacids
 Improve Motility
 Metoclopramide/Cisapride
 Antireflux surgery

27. Reflux Strictures
 2-10% of LPR
 Decreasing incidence due to PPI
 Chronic inflammation and fibrosis
 Most are less than 1cm in length
 Common in scleroderma

30. Surgery for reflux strictures
 Indications:
 Frequent dilatations while on maximal PPI
 Oesophageal perforation complicating dilatation
 Non-dilatable stricture, eg longitudinal strictures
 More than one previous failed anti-reflux surgery
 Severely disordered oesophageal body motility

32. Malignant Oesophageal Obstruction
 Early curable oesophageal cancers uncommonly cause
oesophageal obstruction
 Radical resection is required
 Most oesophagectomies will prove to be palliative because occult
metastatic disease
 Represents locally advanced oesophageal cancer requiring
palliative treatment
 Palliated patients usually survive 4-6 months

38. Laser treatment
 Nd:YAG is most widely used
 Alleviates obstruction ( 90%)
 Controls haemorrhage
 Complications ( 1-5% )
 No procedural mortality
 Hurley JF et al Aust N Z J Surg 1997

40. Complications
Early Late
 Pain  multiple treatments
 perforation  benign strictures
 pneumoperitoneum (20%)
 pneumomediastinum  swallowing problems
 gastric distension  motility disturbance
 bleeding ( 1%)

41. Combination of laser treatment
 External or internal XT
 Internal after-loading iridium-192 improves first
dysphagia-free interval in SCC group
 Sander R et al Gastrointest Endosc 1991

42. Chemically induced tumour necrosis
 Ethanol or polidocanol
 Tumour oedema/ swelling may temporary worsen
dysphagia
 Inexpensive and readily available
 As effective as laser but more pain
 Carazzone A et al Eur J Surgery 1999

43. Radiotherapy
 External beam XT
 Poor palliation of dysphagia ( 40%)
 Serious complications
 Pulmonary fibrosis, fistula, strictures
 Brachytherapy
 Selectron remote control after-loading machine
 Relief of dysphagia : 70 % SCC, 60 % adenoCa

44. Investigations
 Gastrografin and/or barium oesophagram
 22% positive barium on negative gastrogafin
 Buecker A et al.Radiology 1997
 11%25% false negative results
 Jones WG et al. Ann Thorac Surg 1992

46. Primary repair
 Usually recommended in early injuries
 Recent series extended to late injuries with acceptable
results ( 1/9 mortality)
 Lawrence DR et al. Ann Thorac Surg 1999
 Leak rate: 23% in early injury, 50 % late injury
 Reinforced primary repair: leak rate 7%
 Wright CD et al. Ann Thorac Surg 1995

48. Iatrogenic perforation
 Intraluminal injury
 endoscopy, bougienage, pneumatic dilatation,
variceal sclerotherapy or ligation, endoprosthesis
insertion
 Operative injury
 antirflux surgery, cardiomyotomy, anterior cervical
spine surgey, thoracic aneurysm repair, tube
thoracostomy

49. etiology
 Iatrogenic injury accounts 70% of perforations
 In normal oesophagus ( injury in cervical part)
 Piriform fossa is most common location
 Kyphosis, hyper-extension of the neck, cervical
osteophytes, oesophageal diverticulum
 Obstructed oesophagus  injury in thoracic
part
 75-90% endoscopic injuries are in lower
oesophagus

50. Traumatic perforation
 Penetrating injury:
 stab injuries, gunshot wounds
 blunt injury
 MVA, cervical spine injury

51. Penetrating injury
 Approximately 19% of all oesophageal injury
 Stabbing usually involves cervical oesophagus
 Gunshot wounds thoracic oesophagus
 Often associated injuries

52. Oesophageal perforation from blunt
trauma
 Exceedingly rare
 Blast injury, MCA, fracture dislocation of Cx spine
 Diagnosis usually delayed due to associated injuries