Extraesophageal manifestations (laryngitis, exercise-induced reflux disease)

Malcolm Robinson MD: There are a rather large number of upper respiratory complications of reflux disease, and they're increasingly being recognized to be important. The ear, nose and throat doctors increasingly are recognizing laryngitis due to reflux, and this has become a very important therapeutic area where laryngitis can be quite responsive to antisecretory therapy, but there are even correlations between reflux disease and recurrent sinusitis, and even some data in children that chronic otitis may be due to reflux disease, in which case the treatment for chronic otitis media in children may actually be antisecretory therapy instead of recurrent courses of antibiotics, insertion of tubes and all of the other things that we're doing currently.

Alan Cutler MD: Persistent laryngitis may very well be caused by acid reflux disease. The acid splashes up into the esophagus and into the posterior pharynx and onto the vocal chords. One can use a proton pump inhibitor to treat these patients.

Unfortunately, if you stop the proton pump inhibitor, within six to eight weeks, the majority of the patients have relapsed with their laryngitis. Some people believe that almost all ENT symptoms are reflux related. I'm unsure about this yet, but I'll be curious to see what happens in the future.

Malcolm Robinson MD: Work from our own laboratory has indicated that patients who have exercise will often reflux, and this can be significantly symptomatic, either in terms of typical reflux symptoms or atypical symptoms, including asthma in particular, or chronic cough, and so we believe that it is very important to consider the possible role of exercise-induced reflux and exercise-induced respiratory symptoms and that appropriate treatment for this would involve either continuous or at least intermittent therapy to prevent such exercise-induced reflux.

Alan Cutler MD: Any maneuver that increases intra-abdominal pressure can make reflux disease worse. Exercise, vigorous exercise, abdominal crunches can definitely induce acid to splash up into the esophagus and induce the symptoms of heartburn. That's why we tell people they shouldn't eat three hours before exercising.

When extraesophageal symptoms are controlled with the use of proton pump inhibitors, chances are the patients are going to have to remain on those proton pump inhibitors. Studies to date in which they've tried to step down or discontinue the proton pump inhibitors have not been effective. So patients who have extraesophageal symptoms that are controlled on PPIs need to remain on those proton pump inhibitors.