Letters to the Editor

The True Incidence of GERD-Induced Globus


Am Fam Physician. 2000 Mar 15;61(6):1643-1646.

to the editor: The abstract in the recent article1 on head and neck manifestations of gastroesophageal reflux disease (GERD) contained statistics that did not appear in the body of the article. The authors stated in the abstract that “An estimated 20 to 60 percent of patients with GERD have [ENT] symptoms without a heartburn.”1 The closest data in the body of the article stated that “in 23 to 60 percent of patients presenting with globus sensation, GERD is the etiologic factor.”1 The latter statement gives the incidence of GERD within a specific presenting complaint, whereas the abstract makes a much broader statement regarding the likely presenting symptom among all patients with GERD.

As noted in another article,2 inconsistency of data in abstracts is fairly common. However, the accuracy of the abstract is important because this is the section most likely to be read. In this article,1 the incidence of the presenting complaint in a common disorder is especially important because it is intended to influence how family physicians interpret patient symptoms and formulate differential diagnoses.

Additionally, the authors' assertion (quoted above) that many patients who present with globus sensation have GERD appears flawed. The references that support this assertion come from three subspecialty journal articles, which likely represent a select patient population different from that seen in primary care offices.

The factors discussed above make it difficult to tell if head and neck manifestations of GERD are likely to be an important issue for primary care patients and their physicians.


1. Ahuja V, Yencha MW, Lassen LF. Head and neck manifestations of gastroesophageal reflux disease. Am Fam Physician. 1999;60:873–80.

2. Pitkin RM, Branagan MA, Burmeister LF. Accuracy of data in abstracts of published research articles. JAMA. 1999;281:1110–1.

in reply : We thank Dr. Cardinal for his comments. The intent of our article1 was to inform primary care physicians of the atypical (head and neck) presentations of gastroesophageal reflux disease (GERD) and to alert readers that GERD does occur in the absence of the classic “heartburn” symptom. Recognition of patients with this atypical presentation at the primary care level and initiation of treatment is important.

With regard to the abstract percentages, Dr. Cardinal should refer to page 874 of our article.1 Additionally, because most of the references were from subspecialty journals, the percentages may be slightly biased. For example, in an otolaryngologic practice, the percentage of patients with head and neck symptoms without heartburn approaches 60 percent, while in a primary care setting that number is closer to 20 percent.25 The reason is that patients with heartburn will be diagnosed and treated at the primary care level, avoiding the need for referral. In my practice, the majority of patients referred from primary care physicians and diagnosed with laryngopharyngeal reflux do not report having heartburn; the most common presenting complaint is globus sensation.

Dr. Cardinal's comment on the globus sensation data being flawed is inaccurate. Although the data were obtained from sub-specialty journals, the patients in the studies were referred from primary care physicians. Therefore, the data were derived from patients with the complaint of globus sensation who were initially evaluated at the primary care level and then referred for further evaluation. Thus, the patient populations are similar and primary care physicians can expect to evaluate this type of patient complaint.

GERD is a common disorder, and the primary care physician needs to recognize patients with atypical (head and neck) presentations in the absence of heartburn and initiate proper therapy. Early detection and treatment at the primary care level can prevent complications, reduce symptoms, improve quality of life and prevent the need for subspecialty referral.


show all references

1. Vanita A, Yencha MW, Lassen LF. Head and neck manifestations of gastroesophageal reflux disease. Am Fam Physician. 1999;60:873–80....

2. Koufman JA. Gastroesophageal reflux and voice disorders. In: Rubin JS, ed. Diagnosis and treatment of voice disorders. New York: Igaku-Shoin, 1995: 161–75.

3. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991;101(4 pt 2 suppl 53):1–78.

4. Toohill RJ, Mushtag E, Grossman TW, et al. Pharyngeal, laryngeal, and tracheobronchial manifestations of gastroesophageal reflux. Proceedings of the XXIV World Congress of Otolaryngology-Head and Neck Surgery. Berkeley: Kugler and Ghendini Publishing, 1985.

5. Ossakow SJ, Elta G, Colturi T, Bogdasarian R, Nostrant TT. Esophageal reflux and dysmotility as the basis for persistent cervical symptoms. Ann Otol Rhinol Laryngol. 1987;96:387–92.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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