Can adenoids cause bad breath
Gastric acid reflux up to the throat
Heartburn and acid regurgitation are classic reflux symptoms and are usually clearly associated with gastro-esophageal reflux disease (GERD).
The cause of unspecific throat complaints such as hoarseness, throat clearing, lump / mucus feeling, swallowing disorders and dry, irritating cough is often less clear. Diagnosis is particularly difficult if there is no heartburn, which can occur in half of the cases with acid reflux in the throat.
The laryngopharyngeal reflux with hyperacidity and chronic inflammation of the throat and larynx is therefore often referred to as atypical reflux. In analogy to GERD, one also speaks of EERD (Extra Esophageal Reflux Disease).
Often there are chronic inflammatory changes in the affected mucous membrane. This can lead to persistent swellings of the vocal folds (Reinke's edema), which cause an additional deterioration of the voice, based on chronic laryngitis. Vocal fold polyps, granulomas and vocal cord nodules, especially in the back of the larynx, can be traced back to chronic damage caused by increased acidity.
Stomach acid, as well as acid gases from the stomach, can also pass into the trachea and bronchi and cause chronic (e.g. bronchitis), and in the case of long-term damage, irreversible changes (e.g. bronchiectasis).
In addition, increased acidity in the throat is responsible for other chronic diseases of the head and neck. Recurring childhood polyps (adenoids) can be traced back to EERD. This also applies to chronic sinus infections. Chronic middle ear complaints and impaired middle ear ventilation (middle ear catarrh) can be caused both indirectly, namely by an inflammatory swelling of the nasopharynx, and directly (the stomach enzyme pepsin has already been detected in the middle ear) by acid reflux.
The acid reflux can also affect the oral cavity and lead to bad breath, plaque on the tongue, burning sensation in the oral cavity, inflammation of the gums and tooth damage.
Important contributing factors for the occurrence of the symptoms mentioned are smoking, excessive strain on the voice, dehydration of the airways and insufficient fluid intake.
The diagnosis usually begins with a description of the symptoms by the person concerned. This can be simplified and systematized using standardized and validated questionnaires - an established inventory is e.g. the Reflux Symptom Index (RSI), which you can download from our website. In addition, information on eating habits and the medication taken are also helpful.
This is followed by the specialist ENT examination and, in particular, the endoscopy of the larynx. This is done either through the open mouth or, if desired, gently with a flexible, high-resolution video endoscope through the anesthetized nose, with the option of subsequently demonstrating the findings on the screen. This investigation is groundbreaking in many cases. However, the typical signs of inflammation in the larynx can also be absent.
In the presence of typical symptoms (ideally if there are also clear signs of inflammation in the larynx), medication can be given on a trial basis that reduce gastric acid production (proton pump inhibitors; PPIs). This is usually done twice a day for 2 months. If the treatment is successful, the diagnosis is considered confirmed.
The disadvantages of this approach are considered to be:
- Occurrence of side effects of possibly unnecessary therapy
- Increase in acid production in the stomach if the medication is taken when the acid level is not increased (rebound effect)
- In order to alleviate the existing symptoms, longer and / or higher dose medication intake may be necessary, so that no decisive statement can be made from the failure of the therapy to be successful
An objective method for mapping the degree of acidity is pH-metry. This is often done as a long-term measurement for the stomach and esophagus. To do this, a thin tube with measuring contacts is pushed over the nose and into the stomach. Correct positioning is ensured in an indirect way.
A measurement in the stomach and esophagus is, however, only partially suitable for diagnosing EERD, as the mucous membrane of the throat and larynx is less resistant to acid than in the deeper sections of the food pathway. Thus, a degree of acidity that does not damage the esophagus, for example, can lead to chronic throat and larynx inflammation. This would also be the reason for the lack of heartburn. In addition, the acid concentration between the esophagus and throat is normally not completely balanced, so that a conspicuous measurement in the esophagus does not allow a clear statement for the throat.
For the reasons mentioned, pH-metry is viewed in international literature as the gold standard for diagnosing EERD, provided that the measurement is made specifically in the affected areas, usually in the throat. As with the diagnosis of the larynx, the correct position is checked with an endoscope.
Gastroscopy, radiological procedures including the X-ray swallow examination, pressure measurements in the esophagus (esophageal manometry) and the detection of bile in the esophagus (bilirubin test) are further, mostly supplementary measures after confirmation or exclusion of an EERD.
The basis of reflux therapy is to avoid harmful eating habits. The following dietary measures are recommended to reduce excessive acid build-up in the stomach:
- no hot spices
- no food that is too hot or too greasy
- no acidic food and drinks
- no meals after 6 p.m.
- no sweets, especially chocolate
- no coffee, possibly black tea as well
- nothing grilled, fried or toasted
- Alcohol and nicotine abstinence
- lots of smaller meals
- Tilting the lying surface - the headboard of the bed should be raised about 10 cm
If the above measures do not improve, drug therapy is carried out with the aim of neutralizing stomach acid or reducing acid production. As already mentioned, the drugs can also be used in the context of the diagnosis. Since it can sometimes take up to 6 months for adequate therapy to be successful and, for example, with PPIs, the dose can be increased up to 4 times the initial dose, an objective diagnostic instrument is helpful for therapy control. Here, too, pH metry can be used.
If conservative therapy is unsuccessful, but also if there are corresponding findings from further diagnostics (e.g. diaphragmatic hernias, protrusions of the esophagus), surgical therapy should also be considered. The chances of success of an operation in people who do not respond to tablet therapy, for example, are judged controversially in the literature. The justification for such treatment should therefore be checked individually for each affected person.
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