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Can gastro-oesophageal reflux be predicted while advancing the endoscope through the laryngeal area?
  1. M Ugras,
  2. D Ertem,
  3. S Cam,
  4. E Tutar,
  5. E Pehlivanoglu
  1. Marmara University School of Medicine, Istanbul, Turkey
  1. Correspondence to:
    Dr D Ertem
    Marmara University School of Medicine, Tophanelioglu cd 13-15, Altunizade Istanbul 81190, Turkey; dertem{at}hotmail.com

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We read with great interest the article by Mullhaupt et al regarding examination of the laryngopharyngeal area during upper gastrointestinal endoscopy, after being trained for examination of these anatomical structures (

). Twenty six laryngeal pathologies were discovered in 1311 cases, the most important of which was demonstration of an early supraglottic cancer.

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

Although supraglottic cancer is extremely rare among children, a more common problem of the laryngeal area during childhood is gastro-oesophageal reflux (GOR), which affects almost 10% of children. Vomiting, recurrent upper or lower respiratory tract infections, and weight loss are frequent clinical findings with GOR. Extraoesophageal manifestations of GOR have been identified and recognised more during the past decade.1 The phrase “extraoesophageal reflux” refers to the effects of refluxed gastric material far from the oesophagus. It has been shown that the contents of the gastric juice, including hydrochloric acid and pepsin, are damaging not only to the oesophagus but also to pharyngeal and laryngeal tissues. Resistance of the laryngeal mucosa to refluxed gastric contents and the presence of the adequate buffering effect of saliva are important factors predicting the severity of laryngeal injury. Gaynor and colleagues2 reported the otolaryngological manifestations of gastro-oesophageal reflux, and stated that the presence of erythema, oedema of the arytenoids and posterior part of the vocal cords, or more chronic changes such as the presence of granulomas might suggest GOR in aetiology.

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

In the study of Mullhaupt et al, the importance of macroscopically noticeable laryngeal lesions during endoscopy among adult patients was emphasised and the most important was reported to be discovery of an early supraglottic carcinoma. Upper gastrointestinal endoscopy is also an important procedure for the diagnosis of GOR and its supraoesophageal manifestations, if it is performed by an endoscopist who has been trained in the normal anatomy and pathology of the laryngeal area. Thus we agree with inspection of the laryngopharyngeal area, not only for evaluation of malignancies (although seen extremely rare among children) but also for extraoesophageal manifestations of GOR.

References

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Footnotes

  • Conflict of interest: None declared.

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