الفهرس 
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Abstract
Oesophageal diseases
1.Gastro-esophageal reflux disease
Gastro-esophageal reflux disease (GERD) is defined by the Montreal consensus as a condition that develops when the reflux of gastric content causes trouble some symptoms or complications. (Vaezi MF. et al, 2016 )
The following symptom complexes are included:
Typical reflux syndrome defined by the presence of troublesome heartburn and/or regurgitation. Patients might also have other symptoms, such as epigastric pain or sleep disturbance. (Vaezi MF .et al ,2016)
The atypical presentations of GERD include chest pain, epigastric pain, and nausea. The extra-esophageal manifestations of GERD include dental erosions, hoarseness, globus sensation, sore throat, vocal cord irritation, vocal cord polyps and granulomas, posterior laryngitis. (Fass R , 2004)
Chronic cough, asthma, aspiration, pulmonary fibrosis, recurrent pneumonia, sleep abnormalities, and cardiac angina. Studies have shown that about half of the patients with nonerosive reflux disease or erosive esophagitis report extra-esophageal and atypical manifestations of GERD . (Fass R , 2004)
ENT symptoms frequently related to GORD include hoarseness, cough, globus, sore throat, excessive throat phlegm, postnasal drip, nasal congestion halitosis, and frequent throat clearing. Less common GORD related laryngopharyngeal disorders include paroxysmal laryngospasm, contact ulceration and granuloma, laryngeal and subglottic stenosis, and laryngeal and pharyngeal carcinoma . (Harding SM ,2003)
2.Eosinophilic Esophagitis
The relationship between GERD and Esinophilic Esophagitis , a chronic, immune-mediated disease characterized by symptoms of esophageal dysfunction and eosinophilic inflammation, is complex. Distinguishing EoE from GERD is challenging, as both conditions involve heartburn, chest pain, dysphagia, and esophageal eosinophilia, which may respond to PPIs. (Cheng E et al , 2014)
EoE is a clinico-pathological disease diagnosed by taking into account symptoms, endoscopy and histopathological findings
Eosinophilic esophagitis (EoE) is an increasingly recognized, chronic and anitgen/immune-driven inflammatory disease of the esophagus(Miehlke S ,2015).
EoE has now evolved to the second most common cause of chronic esophagitis after gastroesophageal reflux disease, and now represents the most frequent cause of dysphagia in young male patients. It is also recognized as the most common manifestation of all eosinophilic gastrointestinal disorders
3-Infectious esophagitis
Candida oesophagitis is, by far, the most common cause of esophageal symptoms in these patients, including children, accounting for 50- 100% of symptomatic patients (Chiou CC et al , 2000)
Candida oesophagitis is also common in patients without symptoms.. (Bonacini. M ,2001)
3-Cancer oesophagus
Cancer of the oesophagus is the fourteenth most common cancer in the UK but the sixth most common cause of cancer death.
Overall survival is poor, in England 1-year survival is 42.3% and at 5 years 14.3%. This is because the majority of patients present with incurable locally advanced or disseminated disease.
Throat symptoms
1-Dysphagia
Dysphagia is the subjective perception of impaired passage of swallowed material. It can be caused by a myriad of pathological processes that can be located anywhere from the oral cavity to the stomach. (Malagelada J , et al , 2014)
Importantly, dysphagia can be the presenting symptom of both pharyngolaryngeal and oesophagogastric cancers and as such, its presence can prompt referral to either head and neck or upper gastrointestinal suspected cancer pathways. (Murray IA et al , 2018)
2-Globus pharyngeus
A patient with globus pharyngeus (globus) feels an abnormally persistent and distressing sensation (globus sensation) in the throat ( Oishi N , et al ,2013)
Globus is a common condition affecting 6% of the population, (Cathcart R , 2007) and accounts for about 4% of new referrals to an otolaryngology clinic ( Oishi N , et al ,2013)
3-Cough
Chronic cough is a diagnostic and therapeutic challenge. Differences in the aetiology as well as patient background of chronic cough have been recognised among US, UK, and Japan (Niimi A , 2017). One of the marked differences has been the prevalence of gastro-oesophageal reflux disease (GORD). It has been one of the top three causes in Western countries; three series led by Richard Irwin of the USA showed an increasing prevalence from 10% (reported in 1981) to 21% (1990) and 36% (1998) (Irwin RS, 2006).
4-Hoarseness of Voice
Laryngopharyngeal reflux disease (LPRD) is an inflammatory condition defined as the backflow of gastric contents into the laryngopharynx, where it comes in contact with the tissues of the upper aerodigestive tract. (Lechien JR, et al ,2017)
Endoscopy is a powerful diagnostic tool and is the only modern day imaging technique that can look directly inside an organ. It is therefore practised in the investigation, diagnosis and treatment of many gastrointestinal diseases. The main focus of this article is an introduction into the use of modern flexible fibre optic endoscopes within the gastrointestinal (GI) tract. There are many different types of endoscopic procedure and specialist instruments; however, the basic equipment and principles are similar for all types of procedure and scope. (Keen T , Brooks C, 2017 )
Endoscopic finding Of ENT patient , upper endoscopy revealed upper esophagitis in 20 (40%) patients, middle esophagitis in 2(8%) patients and lower esophagitis 2 (8%) patients.
There is mass in esophagus in 10 (20%) patients. GERD grade A was seen in 16 (32%), grade B in 4 (8%) patients and grade C in 4(8%) patients while Barrett”s esophagus seen in 4(8%) patients. There is gastritis in 20 (40%) patients and Duodenitis in 2 (4% ) patients.
The most important throat symptoms recorded by the patients were dysphagia (92% ), Gobus pharyngeus ( 48% ), chocking (44% ), frequent throat clearing (72%), dry cough (16 %), spitting of blood ( 8%), sore throat (20%), and hoarseness of voice(12%).Beside their predominant symptoms most of patients had additional two or more ENT symptoms
CT scanning was done for all studied patients. 16% had normal CT finding, 80% had circumferential mural thickening which involve the pharyngo- esophageal junction in 16(32%) patients, Upper esophagus in 18 (36%) patients, Lower esophagus in 10 (20%) patients and Greater curvature of stomach in 6 (12%) patients .Another important CT finding is enlarged cervical Lymph nodes seen in 2(4%) patients
Biopsy was taken from Upper, middle and lower esophagus for histopathological examination. Normal microscopic examination of esophageal mucosa seen in 8 (16%) patients, reflux esophagitis was detected in 10(20% ) patients, esoinophilic esophagitis in 4 (8%) (n=4) patients, mild chronic non specific esophagitis in 16(32%) ,hyperplastic squamous epithelium in 8(16%) and dysplasia of squamous epithelium in 4 (8%)
Patients with suspected gastroesophageal disease related throat signs and symptoms are often initially treated by ENT physicians, and the non responders are often referred to gastroenterologists who contend that many such patients do not have reflux. Thus, identifying and treating laryngitis associated reflux has proven to be challenging to both ENT physicians and gastroenterologists (Ahmed TF . et al ,2010)
In our study population consisted of 50 patients (men 22, 28 women; mean age: 54.8 years old, range 22–80 years old).
In the present study we investigated the presence of abnormality during the upper GI endoscopy in consecutive patients with upper refractory throat symptoms
The most important throat symptoms recorded by the patients in our study were dysphagia (92% ), Gobus pharyngeus ( 48% ), chocking (44% ), frequent throat clearing (72%), dry cough (16 %), spitting of blood ( 8%), sore throat (20%), and hoarseness of voice(12%)
In study done by Poelmans .et al ,2004 reported that main throat complaints include productive cough in 16.5% , hoarseness of voice in 13.3 %, globuspharyngeus in 7.1% of their patients and ,miscellaneous complaints like halitosis, laryngospasm, nasal congestion were found in 14%
Regarding endoscopic findings, esophagitis found in 24 patients. With high prevalence of upper esophagitis (40%), only 8% had middle and lower esophagitis). A similar study by Ossako.et al ,1987 reported that prevalence of esophagitis was 10% of ENT patients with unexplained throat symptoms
Similarly Batch .et al,1988 reported endoscopic esophagitis in 63% in patients with globus and McNally PR.et al,1989 reported esophagitis in 63% in patients with hoarscence of voice.
The high prevalence of upper esophagitis (40%) reported in our study may be explained by El Serage .et al,1997 who suggested patients with esophagitis had supra esophageal reflux.
Our study reported that significant association between dysphagia and dry cough with upper esophagitis. This is similar to results by Poelmans J. et al, 2004 which showed that esophagitis was prevalent in patients with cough and significantly higher than in patients with throat symptoms (P=0.01) and patients with globus
So we concluded that :
Patients with refractory throat symptoms, there is high prevalence of upper esophagitis and gastroesophageal reflux.
Use upper GI endoscopy as an initial investigation in patients with refractory throat symptoms with normal laryngoscope and CT finding should be advocated especially when the cost of endoscopy is low and high risk of complication as Baretts esophagous or complicated GERD.