In children, symptoms such as chronic cough, wheezing, stridor, voice changes, persistent asthma and dental erosion are often presumed to be due to gastro-oesophageal reflux and empirical treatment with PPIs is offered. Usual investigations, such as a barium meal, gastroscopy and a 24-hour pH monitoring confirm gastro-oesophageal reflux but whether this is causing extra-oesophageal symptoms or producing changes in the larynx and pharynx is not something to be taken for granted. In this study, the authors investigated children with laryngeal symptoms and detected presence of pepsin in tracheal aspirate, done at the time of laryngobronchoscopy.
They found a significant correlation of the presence of pepsin in the trachea with positive laryngopharyngeal findings such as interarytenoid oedema, obliteration of vocal folds, posterior commissure hypertrophy and ‘cobblestone’ mucosa.
These laryngo-bronchoscopic changes were not associated with positive standard tests for gastro-oesophageal reflux. Detection of pepsin in the trachea was associated with croup and cystic fibrosis. The message given here is that presence of pepsin in the trachea and not gastro-oesophageal reflux causes the macroscopic changes noted on laryngobronchospy. If pepsin is absent, these changes may well be due to other conditions that may require alternative investigations such as allergen testing.