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Gastroesophageal Reflux and Pediatric Otolaryngologic Disease
The Role of Antireflux Surgery
Dana L. Suskind, MD;
Guy P. Zeringue III, MD;
Evelyn A. Kluka, MD;
John Udall, MD;
Donald C. Liu, MD, PhD
Arch Otolaryngol Head Neck Surg. 2001;127:511-514.
ABSTRACT
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Objective To determine the role of antireflux surgery in the treatment of gastroesophageal
reflux–induced otolaryngologic disease (GEROD).
Design A retrospective medical record analysis was performed. Patient demographics,
otolaryngologic disease secondary to gastroesophageal reflux (GER), method
of GER diagnosis, medical treatment used before antireflux surgery, and response
to surgical intervention were considered.
Setting Tertiary care children's hospital.
Patients Among patients undergoing antireflux surgery between January 1, 1996,
and December 31, 1999, children with GEROD were included in the study.
Interventions Children with GEROD who failed medical therapy underwent antireflux
surgery.
Main Outcome Measures The demographics of patients requiring antireflux surgery for treatment
of their otolaryngologic disease and their clinical response to surgery were
reviewed.
Results Fourteen (17%) of 82 children, ranging in age from 48 days to 3 years
(mean age, 9.7 months), who underwent antireflux surgery for GER at our institution
between 1996 and 1999 were diagnosed as having GEROD. Twelve (86%) of the
14 patients were found to have upper airway abnormalities, including subglottic
edema, fixed subglottic stenosis, reflex apnea, and recurrent croup. Two patients
(14%) had severe chronic sinusitis and otitis media. Nine (64%) of the 14
had normal neurologic function for their age vs 5 (36%) who had neurologic
impairment. After antireflux surgery, all 14 patients with GEROD had complete
resolution of clinical symptoms.
Conclusions Gastroesophageal reflux has an important role in the cause of numerous
otolaryngologic disorders. Although medical management should remain the mainstay
of GER therapy, antireflux surgery provided definitive and successful treatment
of potentially life-threatening manifestations of GEROD.
INTRODUCTION
OTOLARYNGOLOGIC manifestations of gastroesophageal reflux (GER) in children
are increasingly recognized and defined in the literature. The exposure of
the upper aerodigestive tract to gastric secretions results in numerous pathologic
conditions. Chronic rhinosinusitis, recurrent otitis media, chronic cough,
and airway abnormalities, such as subglottic stenosis, recurrent croup, laryngomalacia,
and reflex apnea, may be caused or exacerbated by GER.
Most GER of early childhood is functional, with only a small percentage
resulting in secondary pathologic conditions. Children with pathologic GER
and GER-induced otolaryngologic disease (GEROD) generally have an excellent
response to medical therapy. A few require surgical intervention in the form
of antireflux surgery. We describe a group of patients with GEROD requiring
surgical intervention.
PATIENTS AND METHODS
PATIENTS
A retrospective medical record review was performed. All patients undergoing
antireflux surgery for medically refractory GER between January 1, 1996, and
December 31, 1999, at the Children's Hospital of New Orleans, La, were included.
Manifestations of GER resulting in antireflux surgery were analyzed. Those
patients with an otolaryngologic disorder as a primary manifestation were
designated as having GEROD. Excluded were those whose otolaryngologic disease
was believed to be an incidental finding.
PREOPERATIVE EVALUATION
Prior workup and treatment of the patients' GER and the otolaryngologic
disorder were reviewed. All patients had GER diagnosed by barium sulfate swallow
test, pH probe, esophagoscopy with biopsy, or bronchoscopy with cytologic
evaluation for lipid-laden macrophages. Antireflux surgery was chosen after
failed medical therapy (ineffective course of an H2 receptor blocker,
proton pump inhibitor therapy, or a prokinetic agent) or if medical therapy
was bypassed because of life-threatening GER symptoms.
SURGICAL TECHNIQUE
Antireflux surgery in the form of Nissen fundoplication was performed
via standard laparotomy or, more recently, laparoscopy.
POSTOPERATIVE EVALUATION
The response to surgical intervention was evaluated through medical
record review and, in some instances, telephone interviews.
RESULTS
Fourteen (17%) of 82 children who underwent antireflux surgery for GER
had GEROD. There were 8 boys and 6 girls, with a mean age at surgery of 9.7
months (age range, 48 days to 3 years). Twelve (86%) of the 14 had upper airway
abnormalities, including 1 or more of the following: fixed subglottic stenosis,
subglottic edema, reflex apnea, and recurrent croup. Two (14%) had severe
chronic sinusitis and otitis media thought to be secondary to GER.
Nine (64%) of the 14 had normal neurologic function for their age vs
5 (36%) who had neurologic impairment. In the neurologically impaired group,
5 had known causes: cerebral palsy (3 patients), Down syndrome (1 patient),
and chromosomal inversion and seizures (1 patient). There was a history of
premature birth in 7 of the 14 children. In the group with upper airway abnormalities,
6 children had a history of previous intubation and 3 did not. Three children
with upper airway abnormalities had incomplete medical records with regard
to previous interbation status. Surgical intervention included laparoscopic
Nissen fundoplication in 11 patients (79%) and open fundoplication in 3 (21%).
One child underwent a second open procedure after the initial fundoplication
failed 2 years postoperatively. The development of stridor and worsening reactive
airway disease heralded the recurrence of GER.
After surgery, the patients with chronic sinusitis and otitis media
had complete resolution of symptoms. Airway symptoms in all patients resolved,
including 3 patients who subsequently underwent successful laryngotracheal
reconstruction. One child with upper airway obstruction secondary to subglottic
edema and a subglottic cyst had complete resolution of stridor after antireflux
surgery alone. She eventually underwent uneventful marsupialization of the
subglottic cyst (Table 1).
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Patient Characteristics and Procedures*
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COMMENT
Gastroesophageal reflux is a common diagnosis in young children. It
is generally nonpathologic and is believed to occur in approximately 67% of
children aged 4 months, with resolution in most by 10 to 12 months.1 Although most children "outgrow" this functional reflux,
a small number have pathologic sequelae that may include failure to thrive,
hematochezia with anemia, esophagitis, or recurrent aspiration with pneumonia.2 It has been postulated that more than 40% of children
with GER have respiratory manifestations.3
The prevalence of lower airway symptoms in GER and the obvious anatomic continuity
make otolaryngologic pathologic conditions almost an anticipated finding.
This laryngopharyngeal reflux passes through the lower and upper esophageal
sphincter, spilling into the upper airway. Otolaryngologic manifestations
caused or exacerbated by GER may include chronic sinusitis, recurrent otitis
media, or airway abnormalities, such as subglottic stenosis, stridor, recurrent
croup, laryngomalacia, and reflex apnea.4, 5, 6
Conservative nonsurgical management is generally successful in the treatment
of GER and its sequelae. In most patients, thickening the dietary formula
and appropriate positioning of the child will be curative. Medical therapy
usually consists of gastric acid inhibition, using an antacid, H2
receptor blocker, a proton pump inhibitor, or a prokinetic agent. Halstead7 demonstrated a 35% reduction in need for airway surgery
for subglottic stenosis in patients receiving aggressive therapy for GER.
Although medical therapy is usually successful, there are certain instances
of failure. In a review of patients with GEROD referred for pH probe tests,
Bouchard et al8 found that nearly 20% of patients
had unresolved GEROD even after aggressive medical therapy.
Esophageal pH monitoring is considered the gold standard for the diagnosis
of GER. Upper gastrointestinal studies using ingested contrast material are
also commonly performed, which are specific but less sensitive. Other forms
of documentation may include formal esophagoscopy, bronchoalveolar lavage
showing lipid-laden macrophages, or a gastric emptying study.
There has been controversy in the literature with regard to actual standards
for pH studies, especially in infants. Walner et al9
found that an esophageal pH less than 4.0 for longer than 10% of the study
translated to high risk, and for 5% to 10%, marginal risk, for reflux-associated
airway symptoms in children with subglottic stenosis. Bouchard et al8 reported that, among patients referred for a pH probe
study for possible GEROD, 41% had positive findings. Patients with upper airway
abnormalities were more likely (>50%) to have positive test results than were
those with sinusitis or otitis media. Recently, there has been interest in
double-probe pH monitoring, which allows simultaneous monitoring of the esophageal
and pharyngeal pH, because some studies demonstrate significant underestimation
of laryngopharyngeal reflux with single-probe pH monitoring.10
Laryngopharyngeal reflux is the instigator of the inflammatory insult
leading to GEROD. This is seen in radiologic oral contrast studies demonstrating
GER to the oropharynx and nasopharynx. In rhinosinusitis, the gastric acid
begins the cycle of sinonasal edema and ostiomeatal complex obstruction. Bothwell
et al11 documented that the aggressive treatment
of GER in children with chronic sinusitis resulted in avoidance of sinus surgery
in most patients. In their study, 4 (13%) of 30 patients failed medical therapy
and ultimately required antireflux surgery.
The otolaryngologic literature more commonly addresses upper airway
disease related to GER rather than rhinologic or otologic disease. This is
also reflected in our series. The mechanism involved is believed to be direct
trauma of the gastric juices on the airway, leading to inflammation and eventual
chondritis and subglottic stenosis. This is exacerbated in the intubated patient,
in whom the endotracheal tube may cause the initial subglottic injury.12 This may explain the high number of patients in our
series with a history of intubation, premature birth, or both. These children
may have had their initial insult while intubated, which progressed as their
upper airways continued to be bathed in gastric acid. Nielson et al13 described 7 infants with stridor and GER and reported
that 3 ultimately required a fundoplication. Two of the 3 patients had premature
births with a history of intubation, and the other child had been intubated
for 1 month.
Another manifestation of GER is the apparent life-threatening event
in which an infant is found lifeless, bradycardic, or cyanotic.14
This is thought to be a functional obstruction in the upper airway rather
than a structural obstruction. A recent review of 30 children with apparent
life-threatening events indicated that 53% had GER.14
The mechanism is postulated to be 2-fold: (1) the laryngeal chemoreflex induced
by aspiration of gastric acid15 and (2) sensory
stimulation of the distal esophagus without laryngeal aspiration.16 One of our patients had the formal diagnosis of an
apparent life-threatening event and demonstrated massive GER on upper gastrointestinal
studies using ingested contrast material. Several of the other patients, although
without the formal diagnosis of an apparent life-threatening event, had similar
symptoms.
Why certain subsets of patients with GEROD fail medical therapy and
require surgical intervention is unknown. The presence of significant airway
abnormalities in most of our patients may have lowered the threshold for proceeding
with surgical intervention when medical therapy failed. The presence of upper
airway obstruction may require a trade-off of one surgery (tracheotomy) for
another (antireflux surgery). Several of our patients with severe subglottic
stenosis (with tracheotomies) required antireflux surgery before laryngotracheal
reconstruction. A few years after successful reconstruction, 1 child manifested
failure of the fundoplication, with new onset of stridor.
Although most of our patients had normal neurologic function, many had
a history of premature birth, intubation, or both. As postulated previously,
these patients may have had an early upper airway insult that continued to
progress in the presence of sustained GER. In addition, 10 children were younger
than 1 year. Theoretically, GER is most prevalent in this age group, the lower
esophageal sphincter is least functional, and the airway is narrowest.
The dogma that GER is a medical disease often results in hesitation
on the part of the gastroenterologist and otolaryngologist to proceed with
antireflux surgery. The clinical resolution of our patients after antireflux
surgery is evidence that surgery is a safe and effective treatment for complicated
cases of GER. When there is a potentially life-threatening pathologic condition,
mechanical and physiological elimination of GER via fundoplication can be
critical. The great strides in minimally invasive laparoscopic techniques
have transformed a formally morbid procedure into one with small punctate
incisions with far less morbidity.
A significantly higher percentage of children (64% vs 36%) undergoing
antireflux surgery for GEROD had normal neurologic function. This is in contrast
to many reports in the surgical literature, in which most children receiving
antireflux surgery had neurologic impairment.17
The reason for this discrepancy and the actual incidence of GEROD in children
with normal neurologic function deserve further investigation.
CONCLUSIONS
Gastroesophageal reflux has an often overlooked, but important, role
in the cause of numerous otolaryngologic disorders. Although medical management
is, and should remain, the mainstay of GER therapy, antireflux surgery provided
definitive and successful treatment of potentially life-threatening manifestations
of GEROD.
AUTHOR INFORMATION
Accepted for publication September 22, 2000.
Presented as a poster at the Combined Otolaryngology Spring Meeting,
Orlando, Fla, May 16-17, 2000.
From the Departments of Otolaryngology (Drs Suskind, Zeringue, and
Kluka), Pediatric Gastroenterology (Dr Udall), and Pediatric Surgery (Dr Liu),
Louisiana State University Medical Center at New Orleans.
Corresponding author and reprints: Dana L. Suskind, MD, Department
of Otolaryngology, Louisiana State University Medical Center at New Orleans,
200 Henry Clay Ave, New Orleans, LA 70118 (e-mail: susliu{at}lsuhsc.edu).
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