Ear Nose and Throat Disease

GERD may be associated with a number of ENT syndromes, including recurrent hoarseness, throat clearing, sore throat, and globus, and signs, such as laryngitis, vocal cord granulomas, ulcers, leukoplakia, sinusitis, and even laryngeal cancer. These patients are usually diagnosed by our ENT colleagues based upon symptoms and signs of inflammation involving the posterior third of the vocal cords and interarytenoid areas, which are both in close proximity to the upper esophageal sphincter. However, the specificity of these findings has recently been questioned; our study in 100 healthy volunteers without ENT complaints found signs associated with "reflux laryngitis" in 86% of these subjects (Hicks et al, 2002). In these individuals, other causes could usually be found, including smoking, alcohol, excessive voice use, allergies, or asthma.

Case studies without controls suggest that 60 to 90% of patients with suspected acid-related ENT symptoms improve with acid suppression (Wong et al, 2000). Here again, PPIs are more effective than H2 receptor antagonists, and extended treatment for 3 months or more may be required. In our experience with over 60 patients, there was no difference, based on signs and symptoms, between twice daily dosing with omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium), with 40% of patients responding in 2 months and an additional 20% responding in 4 months. The addition of an H2 receptor antagonist at night was no more effective than twice daily PPI alone. In this area, placebo-controlled studies are particularly lacking. One small study found no efficacy for twice daily lansoprazole for 3 months. Another study randomized 20 patients with signs and symptoms of chronic laryngitis to lansoprazole (Prevacid) 20 mg or placebo twice daily for 3 months. In the PPI group, six patients (50%) achieved a complete symptom response compared with only one patient (10%) in the placebo group, but laryngeal signs generally did not fully resolve. Predictors of response have not been identified in this or other studies, although patients with milder laryngeal signs show better improvement of symptoms.

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