Extraesophageal manifestations of reflux disease: myths and reality

Because of the anatomic proximity of the esophagus and the upper respiratory tract, it is not surprising that, in some patients with GERD, symptoms attributable to the respiratory and upper aerodigestive tract may occur. The prevalence of respiratory or other extraesophageal manifestations of GERD remains unknown, however, primarily because in any given patient it is often difficult to determine whether GERD is causing the extraesophageal condition or whether the two conditions are coexisting independently. Acid can reflux into the hypopharynx or trachea in some patients with GERD, thereby causing a variety of respiratory tract symptoms. Additionally, vagovagal reflexes triggered by acid that comes in contact with the esophageal or tracheal mucosa may contribute to the pathogenesis of GERD-related respiratory symptoms, particularly wheezing and coughing. The clinician should be particularly suspicious of underlying GERD in patients with unexplained dental caries, posterior laryngitis, chronic unexplained cough, and intrinsic asthma that does not respond to (or worsens with) bronchodilator therapy. Intensive medical antireflux therapy should be instituted in patients with a suspected extraesophageal manifestation of GERD. Failure to respond to this should not lead automatically to antireflux surgery; the clinician should use 24-hour pH monitoring to document the relationship between GERD and extraesophageal complications and to demonstrate that intensive medical therapy has indeed failed to eliminate acid reflux.