Tos persistente y neuropatía laríngea / Persistent cough and laryngeal neuropathy

RESUMEN La tos persistente es un síntoma de consulta frecuente, de origen multifactorial, que involucra a diferentes especialidades como la neumología, la gastroenterología y la otorrinolaringología. Sus causas más frecuentes son la descarga nasal posterior, tos como variante del asma y reflujo gastroesofágico/faringolaríngeo. Una vez descartadas dichas causas, cobran importancia los trastornos sensoriales del nervio vago, una entidad relativamente nueva que también es conocida como neuropatía laríngea sensitiva. En la neuropatía laríngea, una injuria a nivel neuronal aferente del reflejo de la tos produce un estado de hipersensibilidad laríngea en la que estímulos normalmente ignorados (que no producen respuesta tusígena) comienzan a gatillar el reflejo. Las características clínicas de la tos y el descarte de las causas más frecuentes permite llegar a este diagnóstico. Su tratamiento tiene como objetivo la modulación de las vías neuronales alteradas basándose en 3 pilares: educación sobre la patología, recomendaciones conductuales (higiene vocal, estrategias de reducción de tos) y los fármacos entre los que se usan los inhibidores de bomba de protones, mucolíticos y neuromoduladores.

ABSTRACT Persistent cough is a common symptom for medical consultation, it is of multifactorial origin and involves different specialties such as pneumology gastroenterology and otorhinolaryngology. The most frequent causes are postnasal drip, cough variant asthma and gastroesophageal/pharyngolaryngeal reflux. Once these causes are discarded the vagus nerve sensory disorder becomes of importance, it is a relatively new entity also known as laryngeal sensitive neuropathy. In the laryngeal neuropathy, an injury in the afferent neuronal pathway of the cough reflex produces laryngeal hypersensitivity in which normally ignored stimulus (i.e. do not cause cough) start to trigger the reflex. The clinical features of the cough and the rule out of the most frequent causes allow the diagnosis. The objective of the treatment is to modulate the altered neuronal pathways based on 3 pillars: education regarding the pathology, behavioral recommendations (vocal hygiene, cough reduction strategies) and drugs among which proton pump inhibitors, mucolytics and neuromodulators are used.

Tos en otorrinolaringología: revisión actualizada del enfoque clínico / Cough in otolaryngology: an up to date of the diagnostic approach

La tos ocurre por la compleja acción del arco de la tos. En condiciones normales es esencial para proteger la vía aérea. Es un síntoma muy frecuente, con un gran número de etiologías posibles. El enfrentamiento diagnóstico de los pacientes con tos crónica, puede resultar un desafío diagnóstico. Deben considerarse las patologías más prevalentes, que incluyen el reflujo faringolaríngeo y la descarga posterior: ambas condiciones que son parte del área otorrinolaringológica. En el presente artículo de revisión se pretende entregar un enfoque actualizado de su enfrentamiento y manejo, con la finalidad de aportar información que resulte relevante para la práctica clínica diaria.

Cough occurs due to the complex action of the coughing arch. Under normal conditions it is essential to protect the airway. It is a very frequent symptom with a large of possible etiologies. The diagnosis process of patients with chronic cough can be a challenge. The most prevalent pathologies must be considered. Thus includes pharyngolaryngeal reflux and posterior discharge: both conditions that are part of the otorhinolaryngolocical area. In the present article review, we pretend to provide an updated approach and management to this condition, in order to asses relevant information to daily clinical practice.

Doença do refluxo gastroesofágico / Gastroesophageal reflux disease

A doença do refluxo gastroesofágico (DRGE) é considerada uma das afecções mais prevalentes em todo o mundo, podendo comprometer de forma significativa a qualidade de vida dos pacientes. Trata-se de uma afecção crônica que se desenvolve quando o refluxo do conteúdo gástrico causa sintomas incomodativos ou complicações, sendo sintomas incomodativos aqueles definidos pelos pacientes.

Gastric reflux disease (GERD) is considered one of the most prevailing sickness in all over the world that can affect meaningfully patient?s quality of life. It?s a case of chronic sickness which is developed when reflux of gastric contents causes disturbing, that are defined by patients, or complications.

Manifestações extraesofágicas da DRGE / Extraesophageal manifestations of GERD

A doença do refluxo gastroesofágico é decorrente do fluxo retrógrado de secreção cloridropéptica para o esôfago e órgãos adjacentes, causando um espectro variável de lesões e sintomas. Sua incidência vem aumentando nos últimos anos e sua prevalência estimada na população brasileira é de cerca de 12%. A DRGE tem como manifestações típicas a pirose e a regurgitação, podendo se apresentar com queixas extraesofágicas tais como asma, tosse crônica, dor torácica não cardíaca e sintomas otorrinolaringológicos.

Gastro-oesophageal reflux disease is caused by the retrograde flow of gastric acid-peptic secretion into the esophagus and adjacent organs, causing a variable spectrum of lesions and symptoms. Its incidence has been increasing in recent years and its estimated prevalence in the Brazilian population is about 12%. Typical manifestations of GERD are heartburn and regurgitation, but the disease may present with extraesophageal complaints such as asthma, chronic cough, non-cardiac chest pain and ENT symptoms.

Doença do refluxo gastroesofágico / Gastroesophageal reflux disease

A doença do refluxo gastroesofágico (DRGE) é uma afecção crônica frequente na prática médica, interferindo negativamente na qualidade de vida dos pacientes. Apresenta um amplo espectro de sintomas, classificados como típicos e atípicos, sendo a pirose a principal manifestação. O tratamento inclui medidas comportamentais farmacológicas e eventualmente cirúrgicas

Gastroesophageal reflux disease (GERD) is a common chronic condition that affects negatively the patient's quality of life. Patients with GERD can exhibit a wide variety of symptoms, both typical and atypical. Heartburn is the main clinical presentation. Treatment consists of supportive and pharmacological measures; surgery may eventually be required

Laringitis por reflujo: mito o realidad? / Reflux laryngitis: mith or reality?

La enfermedad por reflujo gastroesofágico (ERGE) es un trastorno gastrointestinal frecuente que representa una de las causas de consulta más común en medicina general y gastroenterología. Recientemente, se ha descrito que la ERGE puede asociarse a manifestaciones otorrinolaringológicas como laringitis, tos crónica, odinofagia, escurrimiento nasal posterior y asma. En su fisiopatología se involucran mecanismos directos e indirectos, considerándose al ácido como el agente más nocivo, aunque otras sustancias pueden lesionar las estructuras laríngeas como pepsina, moco y contenidos duodenales. El diagnóstico de ERGE laríngeo se basa en la realización cuestionarios específicos, laringoscopia y la pHmetría ambulatoria de 2 canales. Independientemente del método diagnóstico empleado, cuando se asume que la ERGE es causa de síntomas laríngeos, en la actualidad el uso de medicamentos que suprimen el acido (especialmente IBPs) constituye la piedra angular del tratamiento, aunque los resultados clínicos sobre su efectividad son muy controversiales. En la presente revisión se analizan los aspectos más controversiales respecto a la fisiopatología, diagnóstico y tratamiento de las manifestaciones laríngeas de la ERGE...

Gastro-esophageal reflux disease (GERD) is a frequent gastrointestinal disorder that has became one of the most common conditions presenting in general and gastroenterology practice. Recently, it has been described that GERD may have otolaryngological manifestations such as laryngitis, chronic cough, odynophagia, posterior nasal drip and asthma. Several patophysiological mechanisms have been described, but abnormal acid exposure is the most important. However, there is evidence that other substances can damage laryngeal structures, such as pepsin, mucus and duodenal content). Laryngeal GERD is diagnosed by using specific questionnaires, or by the presence of laryngeal signs in the laryngoscopy or by the detection of abnormal acid exposure using a dual ambulatory pH monitoring. Suppressive acid secretion drugs (specifi cally PPI´s) represent the gold standard therapy when laryngeal symptoms are related to GERD. However, the evidence regarding the effectiveness of PPI´s in laryngeal GERD are controversial. In this review, we analyze the most relevant issues regarding the pathophysiology, diagnosis and treatment of laryngeal GERD...