Oesophagopharyngeal reflux.

G ASTROESOPHAGEAL reflux disease (GORD) is the most common oesophageal disease. Besides the typical presentation of heartburn and acid regurgitation, GORD can cause atypical symptoms. An estimated 20–60% of patients with GORD have head and neck symptoms without heartburn 1 and at least 10% of patients who attend a general ear, nose and throat clinic will have symptoms or signs related to reflux. 2 Gastroesophageal reflux is the upward movement of gastric contents into the oesophagus. Oesophagopharyngeal reflux, more recently known in the United States as laryn-gopharyngeal reflux, is the movement of gastric contents beyond the oesophagus up to the pharyngeal and laryngeal area. Oesophagopharyngeal reflux is different from gastroe-sophageal reflux both in symptom presentation as well as findings. Some degree of reflux in the distal oesophagus is considered normal. A number of defence mechanisms, the so-called anti-reflux barrier, prevent the oesophagus from being injured by the corrosive action of gastric acid. This barrier consists of: 1. The lower oesophageal sphincter tone. 2. The crura of the diaphragm. 3. The oesophageal peristaltic acid clearance. 4. The mucosal resistance. 5. The salivary secretion. 6. The upper oesophageal sphincter tone. The mechanism of oesophagopharyngeal reflux is different to that of gastroesophageal reflux. It is believed that the primary cause for the development of oesophagopharyngeal reflux might be upper oesophageal sphincter dysfunction. 3 In contrast to the oesophagus, the pharynx, larynx and tra-cheobronchial tree are not adapted to handle reflux and, therefore, any presence of acid reflux in the laryngopharyn-geal area is abnormal and potentially harmful. 4 Patients with oesophagopharyngeal reflux usually deny heartburn, which is the commonest presentation of gastroesophageal reflux. Koufman showed that only 20–43% of patients with head and neck symptoms complained of heartburn. 3 Another study revealed that only 18% of patients with head and neck manifestations of gastroesophageal reflux had oesophagitis. 5 Patients with gastroesophageal reflux have oesophageal dysmotility, whereas those with oesophagopharyngeal reflux have good oesophageal motility. 5 Finally gastroesophageal reflux patients are mainly supine (nocturnal) refluxers, while oesophagopharyngeal reflux patients are predominantly upright (daytime) refluxers. 6 The patient's description of symptoms is important. Damage by the acid refluxate beyond the oesophagus can cause a variety of symptoms, the so-called atypical manifestations of reflux, which can be divided into pulmonary symptoms like pneumonia, chronic cough, asthma, chest pain and otorhinolaryngological manifestations, such as globus pharyngeus, dysphonias, sore throat, posterior laryngitis, subglottic stenosis and otitis media with effusion …