More information about text formats
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. 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 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.
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,
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-
3. Gaynor E. Otolaryngologic manifestations of gastroesophael reflux. Am J
Gastroenterol 1991, 86:801-808.