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Chronic Cough and Vocal Cord Dysfunction: The Role of GER

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Part of the Respiratory Medicine book series (RM, volume 2)

Abstract

Gastro-esophageal reflux disease (GERD) is typically associated with heartburn and regurgitation. Chronic cough is one of three established extra-esophageal manifestations, along with asthma and laryngitis. More recently, a high prevalence of GER has been found in patients with vocal cord dysfunction (VCD), leading to the hypothesis that this is another extra-esophageal manifestation of GER. GER may induce extra-esophageal symptoms through different mechanisms (i.e directly through microaspiration), or indirectly via either a vagally-mediated esophago-bronchial reflex, sensitization of the cough reflex or laryngeal hyper-responsiveness. Although widely used, empiric treatment with proton-pump inhibitors (PPIs) has not been shown to be beneficial in adults with chronic cough, and PPI therapy is not efficacious in infants and children. Anti-reflux treatment has been shown to be beneficial in several case reports of patients with VCD; however, there is currently insufficient evidence to advocate the empirical use of PPIs.

The gold standard for detecting a temporal relationship between reflux events and cough has been 24 hours pH monitoring with subjective cough assessment. The introduction of pH/impedance technology has allowed more accurate detection of the physical and chemical properties of GER and has highlighted the importance of non-acid reflux. Simultaneous manometric and acoustic cough detection has allowed a more sensitive, objective assessment of cough epochs related to reflux. This may allow for better phenotyping and selection of patients for treatment. Antireflux surgery has also been performed successfully in uncontrolled studies. However, prospective, controlled studies are necessary to confirm the role of anti-reflux surgery (ARS) in the management of GER-related cough. Concurrent laryngeal abnormalities suggestive of esophago-pharyngeal reflux are common in patients with VCD. Further studies involving pH/impedance monitoring need to be carried out in patients with VCD in order to confirm more than just a chance association of cough with reflux events. Both chronic cough and VCD can have multiple coexisting causes and require a multidisciplinary approach to the management of patients.

Keywords

Gastro-esophageal reflux Reflux induced cough Esophago-bronchial reflex Vocal cord dysfunction Impedance-pH monitoring Proton pump inhibitors Anti-reflux surgery Paradoxical vocal fold motion 

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© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Department of GastroenterologySt. George’s University of LondonLondonUK
  2. 2.The Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryLondonUK

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