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Re: Can gastroesophageal reflux be predicted while advancing the endoscope through the laryngeal area?

Dear editor

We read with great interest the article by Mullhaupt et al regarding the examination of the laryngopharyngeal area during upper gastrointestinal endoscopy, after being trained for the examination of these anatomic structures.[1] Twenty-six laryngeal pathologies were discovered in 1311 cases. The most important of which was the demonstration of an early supraglottic cancer.

Upper gastrointestinal endoscopy has been performed on children for various indications. In pediatric gastroenterology practice, endoscopy is an important procedure beginning from the mouth. After inserting the endoscope through the oral cavity, the uvula, epiglottis, and crico-arytenoid cartilages with the vocal cords above are seen. While passing through the epiglottic area, the concomitant laryngitis, edema, hyperemia or ulceration of the arytenoids, laryngeal granulomas can be visualized. Examination of the laryngopharyngeal area is not a routine part of the endoscopic procedures done in children.

Although supraglottic cancer is extremely rare among children, a more common problem of laryngeal area during childhood is gastroesophageal reflux (GER), which affects almost 10% of children. Vomiting, recurrent upper or lower respiratory tract infections and weight loss are frequent clinical findings with GER. Extra-esophageal manifestations of GER have been identified and recognized more during the past decade. The phrase "extraesophageal reflux" refers to the effects of refluxed gastric material far from the esophagus. It has been shown that the contents of gastric juice, including hydrochloric acid and pepsin, are damaging not only to the esophagus but also to the pharyngeal and laryngeal tissues. The resistance of laryngeal mucosa to the refluxed gastric contents and the presence of adequate buffer effect of saliva are important factors, predicting the severity of laryngeal injury. Gaynor et al[3] reported the otolaryngological manifestations of gastroesophageal reflux, and stated that the presence of erythema, edema of the arytenoids and posterior part of the vocal cords or more chronic changes such as the presence of granulomas might suggest GER in etiology.

In our pediatric gastroenterology outpatient clinic, between 2003 and September 2004, 375 upper gastrointestinal endoscopies were performed in children aged 3 months to 17 years. The laryngopharyngeal area was investigated in 207 children during endoscopic procedure, of those, 40 children had edema of the vocal cords or arytenoids. Sixteen of these cases were due to caustic material ingestion; the remaining 24 had upper GI endoscopy for other indications. Among the 24 cases with laryngopharyngeal pathology, 11 had hyperemia and mucosal nodularity in the proximal, 14 had in the distal part of the esophagus. When the proximal and distal esophageal biopsies were compared in this group, 37% had proximal, 66% had distal histological esophagitis. Therefore, the presence of laryngeal edema made us suspect GER, and it is now our routine to take esophageal biopsies from upper and lower parts of the esophagus.

In the study of Mullhaupt et al, the importance of macroscopically noticable laryngeal lesions during endoscopy among adult patients is emphasized and most important of them is reported to be the discovery of an early supraglottic carcinoma. Upper GI endoscopy is also an important procedure for the diagnosis of GER and its supraesophageal manifestations, if it is performed by an endoscopist who has been trained on the normal anatomy and pathology of the laryngeal area. Thus, we agree to inspect the laryngopharyngeal area for not only the evaluation of malignancies (although seen extremely rare among children) but also for extraesophageal manifestations of GER.

References

1. Mullhaupt B, Jenny D, Albert S, Schmid S, Fried M. Controlled prospective evaluation of the diagnostic yiled of a laryngopharyngeal screening examination during upper gastrointestinal endoscopy. Gut 2004, 53:1232-1234.

2. Poelmans J, Feenstra L, Demedts I, Rutgeerts P. The yield of upper gastrointestinal endoscopy in patients with suspected reflu-related chronic ear, nose, and throat symptoms. Am J Gastroenterol 2004, 99:1419- 26.