A 70-year-old patient presents to his primary care physician with burning pain in his mouth and throat. Symptoms occur mainly in the morning, but can then last for several hours. In some cases, the symptoms worsen after food intake or during physical activity. The patient reports that he rarely suffers from reflux symptoms such as stomach burning and acid regurgitation.
Medical history and diagnosis: The patient was a non-smoker, rarely drank alcohol and was also in good general health. He was not taking any medications and showed no comorbidities in his medical history. Earlier, a therapy trial with a proton pump inhibitor (Pantozol®, 20mg once daily) was performed for two weeks, but this did not lead to any improvement of the symptoms and was therefore discontinued. Chewing gum after meals was more successful. Laboratory tests performed as part of the medical history and an endoscopy of the upper gastrointestinal tract were unremarkable overall. Examination by an ENT specialist revealed mild chronic sinusitis, but otherwise no other abnormalities.
After this consultation, the patient sought a second opinion from a gastroenterologist. The latter performed high-resolution manometry (HRM) and 24-hour pH-metry impedance measurement to determine the cause of the symptoms. Physiologic studies revealed a very weak upper esophageal sphincter and a small hiatal hernia in the supine position. Mobility of the tubular esophagus was normal. The 24-hour pH-metry impedance measurement showed acid exposure in the normal range with only a few reflux episodes per day, but prolonged acid exposure at night. An association between symptoms and proximal regurgitation of gastric contents was found. Based on these examinations, a diagnosis of reflux hypersensitivity with predominant laryngo-pharyngeal symptoms was made.
Therapy and course: The patient denied long-term therapy with a proton pump inhibitor (Nexium®, 40mg twice daily) and was instead treated with a high-dose H2 receptor antagonist (Ranitidine®, 300mg at night). Under this alternative reflux therapy, symptoms improved and the patient decided after a few weeks to switch to alginate therapy (Gaviscon®) at his own discretion.
Commentary by Prof. Mark Fox, MD: Laryngo-pharyngeal or supraesophageal reflux disease is a cause of chronic sore throat, burning discomfort in the mouth, and similar complaints. However, symptoms tend to be nonspecific and rarely improve with treatment with standard-dose proton pump inhibitors. Endoscopic examinations rarely reveal severe inflammation of the pharynx or esophagus in these patients. In addition, reflux disease can be detected by pH impedance measurement in only about 1 in 4 patients with these atypical symptoms [1].
In this case, it was the changes in high-resolution manometry that suggested gastroesophageal and gastro-pharyngeal reflux (i.e., weak sphincters [2]) and the borderline pathologic acid load at night observed in ambulatory pH-metry. In addition, there was a correlation between the occurrence of the reflux events and the patient’s symptoms. Based on the Lyon classification, which incorporates the findings of all relevant examinations, this combination of findings is diagnostic of reflux hypersensitivity [3].
In this case, high-dose acid suppression may be useful as a therapeutic approach because the laryngo-pharyngeal structures recover slowly after contact with acid. In this case, the patient preferred the H2 receptor antagonist Ranitidine®, which effectively suppresses basal nocturnal acid secretion. Regular administration of Gaviscon® was even more helpful. This preparation neutralizes the acid and forms a soothing layer on the oropharyngeal and esophageal membranes. It also creates an in raft on the stomach contents that suppresses acid and non-acid reflux. Mint aroma may also be therapeutic in reflux hypersensitivity with burning discomfort because peppermint oil is an agonist of Transient Receptor Potential Melastatin 8 (TRPM8), which is activated by menthol (the active ingredient in mint) and produces a cool sensation in the mouth [4].
Literature:
- Mainie I, Tutuian R, Shay S, et al: Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006;55: 1398-1402.
- Babaei A, Venu M, Naini SR, et al: Impaired upper esophageal sphincter reflexes in patients with supraesophageal reflux disease. Gastroenterology 2015;149: 1381-1391.
- Gyawali CP, Kahrilas PJ, Savarino E, et al: Modern diagnosis of GERD: the Lyon Consensus. Gut 2018;67: 1351-1362.
- Premkumar LS: Transient receptor potential channels as targets for phytochemicals. ACS Chem Neurosci 2014;5: 1117-1130.
