ously placed plastic stent should not be pulled through the skin. Munford R. Yates, III, M.D. Dino Ferrante, M.D. Klaus E. Mo ¨nkemu ¨ller, M.D. Division of Gastroenterology University of Alabama Birmingham, Alabama REFERENCE 1. Soehendra N, Binmoeller KF, Seifert H, et al. Therapeutic endoscopy. Color atlas of oerative techniques for the gastroin- testinal tract. Stuttgart: Georg Thieme, 1998:136 –56. Reprint requests and correspondence: Klaus E. Mo ¨nkemu ¨ller, M.D., Division of Gastroenterology, University of Alabama, 633 ZRB, UAB Station, Birmingham, AL 35294. Received Apr. 17, 2000; accepted Apr. 26, 2000. Is the Alkaline Reflux a Risk Factor for Laryngeal Lesions? TO THE EDITOR: In recent years, some studies (1, 2) have shown a relative high incidence of otolaryngological man- ifestations in patients with gastroesophageal reflux disease (GERD). Long history of reflux is the common unifying risk factor identified in patients with carcinoma of the laryngo- pharynx who never have smoked (3). The two major pro- posed mechanisms for GERD-associated laryngeal disor- ders are acid stimulation of vagal afferents in the distal and/or proximal esophagus, producing an increase in upper esophageal sphincter pressure and direct laryngeal contact with acid, pepsin, or non-acid injurious substances present in the gastroesophageal refluxate (4). The pH-metric assess- ment of acid reflux shows a pathological GERD in 27–78% of patients with laryngeal symptoms (5). Nevertheless, there are no literature data about a correlation between the oto- laryngologic manifestations and the biliary reflux in esoph- agus. We have observed three patients (A.E., male, 56 yr old; F.M., male, 75 yr old; and B.G., female, 59 yr old), referred to the Department of Otolaryngology because of, respec- tively, leucoplakia of right vocal cord, laryngeal squamo- cellular carcinoma, and dysphonia. All patients had under- gone surgical partial resection of the stomach. One patient (F.M.) had only a smoking habit as a risk factor for the laryngeal lesion. None of them reported typical reflux symp- toms. However, after informed consent, they underwent gastroscopy and esophageal 24-h pH-monitoring. Gastroscopy did not show lesions of esophageal mucosa typical of ill patients, but it documented an abundant biliar reflux in the residual gastric cavity. The pH-metric assess- ment was performed by positioning a pH electrode in the gastric cavity, another 5 cm above the lower esophageal sphincter, and the third 5 cm under the inferior edge of the upper esophageal sphincter. Analysis of data showed an abnormal alkaline reflux both in the residual gastric cavity and in the distal esophagus (percent total reflux time at pH  8: A.E., 35.1%; F.M., 55.3%; B.G., 27.4%). The pH registered at the proximal tract of the esophagus showed normal range values. Even if pH-metry is not the best method to assess alkaline reflux, we believe that, as well as acid reflux, the biliary reflux in the esophagus also could play a role in the patho- genesis of laryngeal manifestations. In our cases, in same way as acid reflux, alkaline reflux, could drive the vagal reflex, giving rise to laryngeal manifestations. Further stud- ies are needed to assess any laryngeal lesions in those patients who underwent surgical resection of the stomach. Until now, to our knowledge, there are no literature data regarding this. R. Cianci G. Fedeli G. Cammarota J. Galli S. Agostino S. Di Girolamo M. Maurizi G. Gasbarrini Departments of Internal Medicine and Gastroenterology Catholic University of Rome Rome, Italy Department of Otolaryngology Catholic University of Rome Rome, Italy REFERENCES 1. Smullen JN, Lejeune FE Jr. Otolaryngologic manifestations of gastroesophageal reflux disease. J LA State Med Soc 1999;151: 115–9. 2. Ormseth EJ, Wong RK. Reflux laryngitis: Pathophysiology, diagnosis and management. Am J Gastroenterol 1999;94: 2812–7. 3. Hanson DG, Jiang JJ. Diagnosis and management of chronic laryngitis associated with reflux. Am J Med 2000;108:112–9S. 4. Nostrant TT. Gastroesophageal reflux and laryngitis: A skeptic view. Am J Med 2000;108:149 –52S. 5. Johanson JF. Epidemiology of esophageal and supraesophageal reflux injuries. Am J Med 2000;108:99 –103S. Reprint requests and correspondence: G. Cammarota, Univer- sita ` Cattolica del Sacro Cuore, Policlinico “A. Gemelli,” Istituto di Medicina Interna e Geriatria, Largo A. Gemelli, 8, 00168 Rome, Italy. Received Apr. 13, 2000; accepted Apr. 26, 2000. 2398 Letters to the Editor AJG – Vol. 95, No. 9, 2000