Roy S. Goodman, M.D., F.A.C.S.

We've all heard of gastroesophageal reflux, especially now that medications to reduce stomach acid (H2 blockers) are available over the counter.  But more and more, it's becoming apparent that reflux can cause problems other than heartburn, problems that you would probably never think to associate with it.

Reflux means that acid and enzymes from the stomach are moving backwards-past the "valve" at the lower end of the esophagus and up into the esophagus.  (This "valve," the lower esophageal sphincter, is not one of the more efficient parts of the human body, and it usually gets worse with age.)  Where the acid and enzymes go from there determines the symptoms they will cause.

In my field-ear, nose, and throat-we're interested in cases of reflux where acid from the stomach reaches all the way up to the larynx (voice box) and beyond.  Remarkably, it usually gets there without causing the heartburn you'd expect.  In the first large study, 57 percent of patients with serious throat problems caused by reflux had no epigastric symptoms.  A more recent survey says that the figure is 85 percent!  How can stomach acid pass through the esophagus all the way up to the larynx and not cause symptoms in the esophagus?  Probably this happens because the lower esophagus can tolerate a fair number of exposures without any problem, while it takes only a few exposures-possibly as few as one per week-to cause a reaction in the throat.

When stomach acid does reach the larynx, it causes a variety of symptoms.  The most common is the sensation of a lump in the throat, often accompanied by a need to clear the throat frequently.  (What feels like a post-nasal drip may not be a post-nasal drip at all!)  Sometimes there is voice change, or a brief sensation that you can't take in air.  It's important to realize that all of these symptoms can have other causes as well, so even if you read this and realize that it describes you perfectly, you need someone (for example, me) to look at your larynx.

Reflux can cause more serious problems, too.  The granulomas (masses of inflammatory tissue) that we used to think were caused by intubation are probably the result of reflux.  Reflux contributes to the formation of polyps on the vocal cords.  It may even cause cancer of the larynx.

Reflux can even cause problems outside of the larynx.  It's probably a factor in many cases of asthma, and in children it probably contributes to sinus disease and middle ear disease.

So how do we diagnose reflux?  It's not easy!  You can have reflux for fifteen minutes out of a day and have symptoms all day.  Apparently you can have one episode of reflux and have symptoms for the next week.  Therefore the actual episodes can be very elusive, and an x-ray or even a sensitive monitoring device may not detect them.  Most otolaryngologists think that the best way to proceed in cases of suspected reflux is with a therapeutic trial: treat the patient as though he has reflux, and if the symptoms get better then your diagnosis is confirmed.  This approach isn't easy either, because the symptoms usually take at least a month to respond.

When possible, we treat reflux with medication and with lifestyle change.  Ideally you should be able to control your reflux by avoiding tobacco, alcohol, chocolates, caffeine, mints, and carbonated beverages, by not eating for a few hours before bedtime, and by elevating the head of your bed.  (You'll notice that all of the consumables to avoid, except for pop, are things that you would traditionally indulge in after a big meal.  I think that they became traditional because people would stuff themselves, then have coffee, a liqueur, a chocolate, a mint or a smoke, and it would make them feel better by allowing some reflux and thereby taking the pressure off the stomach.  It's not good for you, but it would make you feel better at the time!)  If that doesn't do it, there are medications to reduce stomach acid production.  If medication doesn't do the job, surgery may be necessary--and for some patient! s, the surgery is actually less of an undertaking than a lifetime of medication.  Fortunately, new endoscopic techniques have made the surgery much less of an undertaking than it used to be.

Dr. Goodman is an ear, nose, and throat specialist practicing in White Lake.

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