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[DYSPHAGIA] laryngeal spasms.....

  • Subject: [DYSPHAGIA] laryngeal spasms.....
  • From: eripley@yahoo.com (Irene Campbell-Taylor)
  • Date: Sat, 22 May 1999 08:35:30 -0700 (PDT)

Many, some would say most, people with reflux do not have symptoms such
as heartburn etc. Laryngeal spasm such as you describe can be caused by
inhalation of aerosolized gastric juice refluxed into the mid or upper
esophagus altho' this usually happens during sleep it can occur
post-prandially. The only way to be sure about reflux is 24hr
ambulatory probe.

These studies, among many others, underline the importance of
considering the whole swallowing unit from lips to duodenum as one
functional module of the organism. The "sections" cannot be separated
from one another as they constantly influence each other in a feedback
and feed forward manner.
The article by Woo et al is particularly interesting re their finding
of thick mucus. I have long suspected that patients who complain of
thickened mucus after drinking milk are actually hypersensitive to it
and refluxing or simply manifesting the hyperreactivity in this
fashion. This has been reported in infants and children. While there
are many disease that present with swallowing dysfunction as a first
symptom, e.g. ALS and myasthenis gravis being two of the more common,
the first step in such a case would be to rule out GER by 24 hr

Toohill RJ; Kuhn JC. Role of refluxed acid in pathogenesis of laryngeal
disorders.Am J Med, 103:100S-106S  1997 
The neuroanatomic proximity of the larynx to the hypopharynx and
proximal esophagus make it particularly vulnerable to diseases that
occur in those 2 areas. This is particularly true of gastroesophageal
reflux disease (GERD). There is increasing awareness of this
relationship, and dysphonias from gastroesophageal reflux (GER) are far
more common than previously realized. These include symptoms and
findings of reflux laryngitis, vocal nodules, Reinke's edema, contact
ulcer and granuloma, laryngeal stenosis, and paroxysmal laryngospasm.
The treatment varies with the severity of each problem. Conservative
lifestyles and dietary control are helpful, but long-term medical
therapy with H2, H1, and prokinetic drugs are usually needed. Surgical
therapy may be indicated for such life-threatening problems as
laryngeal stenosis and paroxysmal laryngospasm. 

Hawkins BL. Laryngopharyngeal reflux: a modern day "great
masquerader".J Ky Med Assoc, 95:379-385  1997 
Laryngopharyngeal reflux is a new term given to gastroesophageal reflux
leading to atypical symptoms in the upper aerodigestive tract. The
manifestations of laryngopharyngeal reflux are varied and include
chronic hoarseness, globus pharyngeus, sore throat, chronic cough,
asthma, paroxysmal laryngospasm, and other less common symptoms. Making
the diagnosis requires accurate history taking and can be confirmed by
fiberoptic examination of the pharynx and larynx, as well as by
ambulatory esophageal and pharyngeal pH monitoring. Stepwise treatment
regimens are very effective in treating this condition, which
exacerbates or imitates many seemingly unrelated disorders.

Kozarek RA. Complications of reflux esophagitis and their medical
Gastroenterol Clin North Am, 19:713-731  1990

It is shortsighted to consider only the esophageal manifestations and
complications of esophageal reflux. That such reflux can directly
affect not only the lung but also the oropharynx and larynx, both by
direct acid contact and reflex neurologic mechanisms, has been
demonstrated repeatedly. The task of the future will be to place such
reflux into perspective as it remains only one of many genetic and
environmental factors associated with disparate and often confusing
disease processes.

Woo P; Noordzij P; Ross JA. Association of esophageal reflux and globus
Otolaryngol Head Neck Surg, 115:502-507  1996 
Thirty-one patients with globus sensation were examined by dual probe
pH manometry and videolaryngoscopy to investigate the role of
gastroesophageal reflux disease in association with globus. Abnormal
laryngeal findings, which included grossly abnormal and subtle changes,
were seen in 17 patients. These findings included pharyngeal erythema
(12 patients), interarytenoid pachydermia (11), laryngeal edema (11),
arytenoid erythema (9), and thick mucus (3). Twenty-one of the 31 pH
probe studies showed gastroesophageal reflux disease (14 grossly
abnormal, 6 borderline abnormal). There was no correlation between the
upright and supine position, nor was there correlation between positive
laryngeal findings and a positive pH probe study. We conclude that
globus sensation is often a nonspecific symptom of laryngopharyngeal
irritation in which gastroesophageal reflux disease plays a significant
role. Combining careful laryngoscopic examination with pH probe studies
can help to differentiate between patients with organic pathology
caused by gastroesophageal reflux disease and patients with other
nonspecific laryngopharyngeal disorders.

Filiaci F; Zambetti G; Luce M; Lo Vecchio A; Docimo M; Romeo R .
Research of non-specific hyperreactivity of upper airways in subjects
with gastro-esophageal reflux (G.E.R.): preliminary reports.Allergol
Immunopathol (Madr), 25:266-271  1997
An association between asthma and gastro-esophageal reflux (GER) is
well recognized but the underlying mechanism is still unclear. The
authors suggest that could exist an association between GER and upper
airways hyperreactivity and this association could represents the
mechanism underlying the lower esophageal sphincter releasing, that
determine the reflux. In fact they suppose that, the noxious injury of
acid reflux follows a course that could be:
pharynx-->larynx-->bronchi-->1/3 inferior of the esophagus-->reflux.
>From these presuppositions the authors carried out a study on the
possible relationship between GER and non-specific hyperreactivity of
upper airways on 14 subjects, divided in 2 groups: 10 subjects with
functional GER, 4 subjects suffering from GER caused by hiatus hernia
as control group. From a through analysis of objective examination and
from the results of the NSNPT with histamine resulted that all subjects
with functional GER were rhinopathics. In all tests both in vivo
(Skin-test) and in vitro(RAST) for the most common allergens
(pollens-inhalant-mycophites-alimentary) the results were negative. The
authors also found an involvement of paranasal sinuses that raised: 91%
in the patients with recurrents phlogosis due to non specific nasal
hyperreactivity; 40.9% in the allergic subjects ; 100% in the
ASA-intolerance subjects. The NSNSPT with histamine showed in the group
with functional GER a hyperreactivity with sneezes in 6/10 subjects,
and 1/4 subjects of the group with GER with hiatus hernia. The RRM
variations showed an unilateral nasal hyperreactivity in 6/10,
bilateral in 3/10 subjects of the group with functional GER. In the
group with GER with hiatus hernia only 1/4 subject showed reliable
unilateral RRM variation. From the analysis of data resulted that
subjects with functional GER showed a completely involvement of the
upper airways and not only of the pharynx and larynx, caused by non
specific hyperreactivity at the NSNPT with histamine, associated with a
chronic pathology.

Koufman JA. The otolaryngologic manifestations of gastroesophageal
reflux disease (GERD): a clinical investigation of 225 patients using
ambulatory 24-hour pH monitoring and an experimental investigation of
the role of acid and pepsin in the development of laryngeal
injury.Laryngoscope, 101:1-78  1991 Apr
Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed
to be an important etiologic factor in the development of many
inflammatory and neoplastic disorders of the upper aerodigestive tract.
In order to test this hypothesis, a human study and an animal study
were performed. The human study consisted primarily of applying a new
diagnostic technique (double-probe pH monitoring) to a population of
otolaryngology patients with GERD to determine the incidence of overt
and occult GERD. The animal study consisted of experiments to evaluate
the potential damaging effects of intermittent GER on the larynx. Two
hundred twenty-five consecutive patients with otolaryngologic disorders
having suspected GERD evaluated from 1985 through 1988 are reported.
Ambulatory 24-hour intraesophageal pH monitoring was performed in 197;
of those, 81% underwent double-probe pH monitoring, with the second pH
probe being placed in the hypopharynx at the laryngeal inlet. Seventy
percent of the patients also underwent barium esophagography with
videofluoroscopy. The patient population was divided into seven
diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and
tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus
pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a
group with miscellaneous disorders (n = 18). The most common symptoms
were hoarseness (71%), cough (51%), globus (47%), and throat clearing
(42%). Only 43% of the patients had gastrointestinal symptoms
(heartburn or acid regurgitation). Thus, by traditional symptomatology,
GER was occult or silent in the majority of the study population.
Twenty-eight patients (12%) refused or could not tolerate pH
monitoring. Of the patients undergoing diagnostic pH monitoring, 62%
had abnormal esophageal pH studies, and 30% demonstrated reflux into
the pharynx. The results of diagnostic pH monitoring for each of the
subgroups were as follows (percentage with abnormal studies): carcinoma
(71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia
(45%), chronic cough (52%), and miscellaneous (13%). The highest yield
of abnormal pharyngeal reflux was in the carcinoma group and the
stenosis group (58% and 56%, respectively). By comparison, the
diagnostic barium esophagogram with videofluoroscopy was frequently
negative. The results were as follows: esophagitis (18%), reflux (9%),
esophageal dysmotility (12%), and stricture (3%). All of the study
patients were treated with antireflux therapy. 

--- Ron & Carolyn McClanahan <rmcclana@kvmo.net> wrote:
> THis is actually what I meant to write instead of
> esophageal. . . . good
> ans but the guy definitely denies reflux symptoms
> etc. . . .exactly what is
> paradoxical vocal fold dysfunction and what are some
> of the throat
> breathing exercises?? Another question. . . we know
> that EARLY signs of
> neurological disorders can be detected by swallowing
> difficulties. . .Are
> there some specific things we could be looking at
> besides the peristaltic
> deterioration assoc with ALS etc....I had a
> suggestion to refer this
> laryngeal spasm pt for neuro consult. . . what is
> the indication here. . .
> Carolyn McClanahan
> rmclana@kvmo.net
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