Gastroesophageal reflux: A critical factor in pediatric subglottic stenosis

Idiopathic progressive subglottic stenosis: findings and treatment in 52 patients

Rarely, patients develop severe idiopathic subglottic stenosis. In 34 years, we have observed this disorder in 52 patients. All but 1 of the patients were female--a finding that suggests a hormonal cause. Without treatment, the airway progressively narrows--in some cases, until the patient requires tracheotomy. Laser submucosal resection and rotation mucosal flaps open and stabilize the airway and provide effective palliation. However, unlike traumatic subglottic stenosis, which has been cured with this technique, the idiopathic form causes submucosal fibrosis that regenerates spontaneously. Thus, treatment helps, but does not cure, the patient. The characteristic pathological finding is of submucosal dense fibrotic tissue with evidence of chronic inflammation. The clinical findings and treatment are here discussed.

PH monitoring in the distal and proximal esophagus in symptomatic infants

BACKGROUND

Standard distal esophageal pH monitoring data are sometimes within normal ranges in children with clinically suspected gastroesophageal reflux disease. Therefore, the authors hypothesized that the amount of acid reflux reaching the proximal esophagus may be greater in some subgroups of patients than in healthy controls or in other subgroups of patients.

METHODS

The parameters of 24-hour pH monitoring in the proximal part of the esophagus were analyzed in 120 symptomatic infants in who the reflux parameters in the lower esophagus were clearly within normal ranges (reflux index < 5.0%). The infants were classified into four patient groups: excessive regurgitation (n = 41): inconsolable crying (n = 31), apparent life-threatening event (ALTE) (n = 18), and chronic respiratory disorders (n = 30). The control group consisted also of 120 infants. The following parameters were calculated: reflux index, the number of reflux episodes, the number of reflux episodes lasting longer than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT, duration of reflux episodes divided by number of reflux episodes).

RESULTS

The patients with chronic respiratory disorders were significantly older than the patients in the other groups and the controls. In the distal esophagus, there was no statistically significant difference between the reflux parameters. As could be expected, every parameter was statistically (paired t test, Wilcoxon signed-rank test) significantly smaller in the proximal than in the distal esophagus, except for the ACT in infants who presented with inconsolable crying. In the proximal esophagus, there was no statistically significant difference between the different patient subgroups or controls, except for the number of reflux episodes in the group with chronic respiratory disorders and the group with inconsolable crying, applying one-way analysis of variance. As determined by applying the Mann-Whitney test, the number of reflux episodes in the upper esophagus was significantly higher in the group with chronic respiratory disorders than in the other patient groups and controls. Therefore, the authors' data do not support the hypothesis that reflux reaching the proximal esophagus is a frequent cause of ALTE. However, the data may suggest that the number of reflux episodes reaching the proximal esophagus in children with chronic respiratory disorders and with distal pH monitoring data within normal ranges may be increased. Whether this finding reflects reality or a statistical coincidence, or is influenced by the older age of this patient group, needs further evaluation.

CONCLUSIONS

In theory, dual simultaneous esophageal pH monitoring in the distal and proximal esophagus may increase the diagnostic accuracy of pH monitoring in infants. Our results do not support a substantial advantage of a systematic application of this new technique, especially not in infants presenting with ALTE, excessive regurgitation, or inconsolable crying. In the subgroup of patients with chronic respiratory disorders, more data are needed before conclusions can be determined and recommendations can be made.

Improved airway healing using transforming growth factor beta-3 In a rabbit model

Laryngeal wound healing is essential following laryngotracheal surgery. Patients with poor wound healing develop poor epithelial closure and increased granulation tissue which cause a stenosis of the repaired airway. Transforming growth factor-beta3 has been shown to enhance wound healing in cutaneous wounds, but has never been used in the airway. This study utilized a rabbit laryngeal wound-healing model that has been shown to be reproducible with limited morbidity. Thirty-four rabbits underwent a cricoid-split operation with collagen sponge insertion. All animals were classified randomly into three groups: local administration of placebo (Group G1, n = 13), 0.18 microg transforming growth factor-beta3 (Group G2, n = 11) and of 1.0 microg transforming growth factor-beta3 (Group G3, n = 10). All animals survived the postoperative period without respiratory distress. The airway was harvested six days after surgery and assessed by light microscopy. Histologic evidence for healing was subjectively graded by two blinded, independent investigators, and the results were statistically analyzed for significance. A significant improvement in the epithelial closure (p < 0.01) and subepithelial connective tissue closure (p < 0.005) was found in the 1.0 microg transforming growth factor-beta3 group (G3) compared with the placebo group (G1). Analysis of the 0.18 microg transforming growth factor-beta3 group (G2) did not reveal any significant differences compared with the placebo group (G1). These results suggest an application for transforming growth factor-beta3 in accelerating wound healing in the larynx.

Acquired total (grade 4) subglottic stenosis in children

Pediatric acquired total subglottic stenosis (SGS) is a challenging problem. The management of these patients has evolved at our institution over the past 25 years. We conducted a retrospective study to evaluate the surgical management and outcomes of children with grade 4 SGS. Fifty-six patients have presented with acquired grade 4 SGS since 1981. The causes included previous surgery (34), prolonged intubation (15), bums (1), and unknown causes (6). Of the 56 patients, 44 (79%) were decannulated; 120 total procedures were performed, and 39 patients (70%) required more than 1 procedure for decannulation. The decannulation rate has risen from 67% in the 1980s to 86% in the 1990s. Patients who underwent cricotracheal resection (CTR) had a higher decannulation rate than patients who underwent laryngotracheal reconstruction (LTR) with anterior and posterior costal cartilage grafting (CCG) (92% versus 81%), and were less likely to need additional open procedures to achieve decannulation (18% versus 46%). The decannulation rate for children with grade 4 SGS has improved because of advances in surgical technique. Currently, the principal operations used at our institution are 1) CTR and 2) LTR with anterior and posterior CCG. There was a trend toward a higher decannulation rate in patients who underwent CTR, and they were less likely to require further reconstructive surgery before decannulation.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease

OBJECTIVE

To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

STUDY DESIGN

Retrospective chart review

METHODS

Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy).

RESULTS

A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality.

CONCLUSION

Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.

Mapping of a gene for severe pediatric gastroesophageal reflux to chromosome 13q14

CONTEXT

Gastroesophageal reflux (GER) has not previously been widely regarded as a hereditary disease. A few reports have suggested, however, that a genetic component may contribute to the incidence of GER, especially in its severe or chronic forms.

OBJECTIVE

To identify a genetic locus that cosegregates with a severe pediatric GER phenotype in families with multiple affected members.

DESIGN

A genome-wide scan of families affected by severe pediatric GER using polymorphic microsatellite markers spaced at an average of 8 centimorgans (cM), followed by haplotyping and by pairwise and multipoint linkage analyses.

SETTING

General US community, with research performed in a university tertiary care hospital.

SUBJECTS

Affected and unaffected family members from 5 families having multiple individuals affected by severe pediatric GER, identified through a patient support group.

MAIN OUTCOME MEASURES

Determination of inheritance patterns and linkage of a genetic locus with the severe pediatric GER phenotype by logarithm-of-odds (lod) score analysis, considering a lod score of 3 or greater as evidence of linkage.

RESULTS

In these families, severe pediatric GER followed an autosomal dominant hereditary pattern with high penetrance. A gene for severe pediatric GER was mapped to a 13-cM region on chromosome 13q between microsatellite markers D13S171 and D13S263. A maximum multifamily 2-point lod score of 5.58 and a maximum multifamily multipoint lod score of 7.15 were obtained for marker D13S1253 at map position 35 cM when presumptively affected persons were modeled as unknown (a maximum multipoint score of 4.88 was obtained when presumptively affected persons were modeled as unaffected).

CONCLUSION

These data suggest that a gene for severe pediatric GER maps to chromosome 13q14. JAMA. 2000;284:325-334

Medical management of gastroesophageal reflux

Gastroesophageal reflux (GER) is a common problem which can manifest as vomiting, failure to thrive, recurrent pneumonias, asthma, sinusitus, or subglottic stenosis. The medical management plan should be individualized. A "happy spitter" who has no complications of GER may respond well to conservative management, including positioning and thickening of feedings. A child with complications may require treatment with H-2 antagonists or proton pump inhibitors in conjunction with prokinetic agents. Children with gastrointestinal symptoms suggestive of GER who do not respond to antireflux management may need to be treated for eosinophilic esophagitis. Recent studies that assess the effect of medications on recognized complications of GER are reviewed.