Current Opinion in Otolaryngology & Head & Neck Surgery:
LARYNGOLOGY AND BRONCHOESOPHAGOLOGY: Edited by Jacqui E. Allen
Allen, Jacqui E.a,b
aDepartment of Otolaryngology, North Shore Hospital, Takapuna, Auckland
bDepartment of Surgery, University of Auckland, Grafton, Auckland, New Zealand
Correspondence to Dr Jacqui E. Allen, MBChB, FRACS, Department of Surgery, University of Auckland, Grafton, Auckland, New Zealand. Tel: +64 9 620 7156; fax: +64 9 631 1966; e-mail: email@example.com
This issue covers two topics that often make otolaryngologists wince – chronic cough and oesophageal motility disorders. However, both illnesses are becoming more commonplace in our practices and will continue to increase in prominence and prevalence as diagnostic tools improve and research focusses light on the pathogenesis of these disorders. In addition, these two areas demonstrate a common factor which is perhaps even more important: that of ‘overlap’ of medical disciplines and the need for multidisciplinary collaboration. Neither chronic cough nor oesophageal motility is thought of as a typical otorhinolaryngology (ORL) problem – in fact, respiratory physicians and gastroenterologists would be considered experts in managing each field, respectively. However, it is clear that otolaryngologists are seeing these illnesses and have a place in diagnosis, workup and management of these conditions, and that collaboration with our colleagues will lead to improved and more timely diagnosis, better treatment algorithms and happier patients. In this issue, reviews are provided by specialists in other fields to enable otolaryngologists to acquire knowledge and extend our event horizon. Technology drives this expansion to some degree with the availability of narrow calibre endoscopes allowing unsedated in-office flexible oesophagoscopy to be performed readily for a fraction of the cost of typical sedated oesophagogastroduodenoscopy. High-resolution manometry provides fascinating and visually appealing images of the pharynx and oesophagus. Although it has been developed by the gastroenterology world, otolaryngologists are at the forefront of defining pharyngeal parameters and novel applications for this tool.
It has never made sense to me that we should be interested in swallow until it reaches the upper oesophageal sphincter, but disinterested thereafter. Following the bolus to its first resting place in the stomach makes sense, particularly given the frequency with which distal oesophageal disorders are manifested by pharyngeal symptoms . More and more research has demonstrated the association of laryngopharyngeal symptoms with oesophagitis, Barrett's oesophagus, dysmotility and structural oesophageal disease, but the inability to determine from symptoms the degree of tissue damage. When Reavis et al. reported that the symptom most closely correlated with oesophageal adenocarcinoma was persistent cough, not heartburn or regurgitation, and that laryngeal symptoms were more prevalent in this group than typical reflux symptoms, the gauntlet was thrown down. Otolaryngologists can justify, and in fact expect, that they should be part of the management paradigm and part of the discussion for cough and motility disorders. We need to take up the gauntlet and develop our skills in these areas not only for our own edification, but also for the benefit of the patient.
Cough is the most common presentation to primary care in the USA . Because chronic cough is seen by a multitude of disciplines, this issue presents a viewpoint on the cause and management of cough from ORL, respiratory medicine and gastroenterology researchers. These alternate approaches remind us of the multiplicity of factors involved in cough generation and the number of conditions that may produce this symptom. It is interesting that despite a huge expenditure ($3.6 billion annually in the USA) on over-the-counter cough preparations and the global applicability of any effective remedy, there are not more effective antitussive agents available. This research gap needs to be filled. In addition, we still lack mechanistic information regarding human cough triggering. The value of animal modelling in cough cannot be overestimated as it has provided huge insights, but there are some serious caveats and limitations of these models, not least the inability to exercise voluntary suppression of cough in an animal model. Carefully designed studies are required to make the most of animal model research. Considering chronic cough as part of a sensory central modulation disorder akin to chronic pain explains many of the features of this condition. The time course of the disease matches, and the variety of triggers that are able to generate cough support the central convergence. In addition, this concept facilitates research directed at alternate targets and therapies aimed at neuropathic symptoms. As further research unravels chronic cough, our treatment paradigm may shift again.
The oesophagus demonstrates a complex neuromuscular arrangement with elements of skeletal muscle and smooth muscle, intrinsic and extrinsic neural effectors and autonomic neural drive. It requires precise coordination with the pharynx, airway and gut. Incoordination or dysfunction of the normal directionality, propulsion and reactivity of the oesophagus leads to incomplete bolus clearance and symptom generation. An appreciation of motility disorders enables us to fully interpret the pharyngolaryngeal symptoms and identify those patients in whom oesophageal disease is contributing. This issue contains three wonderful summary articles about the most common oesophageal motility disorders and the current state of understanding and management. Achalasia and its subtypes are discussed with an excellent management algorithm. This disorder, unlike other motility disorders, does have an effective surgical management available, although the procedure is not performed by otolaryngologists. The relationship between dysmotility and reflux is clarified. Dysmotility may be a cause or an effect of reflux. Considering motility changes as a source of symptoms helps guide investigation and medical therapy. Spastic disease of the oesophagus is not common, but requires a completely different treatment paradigm. High-resolution manometry has redefined spastic disorders with variants and subtypes identified as well as enabling diagnostic criteria refinement. Differentiation between age-related oesophageal changes and ineffective oesophageal motility is functionally and clinically important.
As always in Current Opinion in Otolaryngology & Head and Neck Surgery, the aim is to encapsulate the critical aspects of the clinical topic and make it applicable to the common practice. I believe this issue provides a ‘state-of-the-art’ update on cough and oesophageal dysmotility with relevant detail that can be incorporated immediately into our differential diagnoses and treatment strategies. I hope it stimulates your interest in these areas and leads to improvement in your management of patients presenting with these complex conditions.
Conflicts of interest
No conflicts of interest to declare.
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