Prevalence and Features of Laryngopharyngeal Reflux in Patients with Primary Burning Mouth Syndrome

Successful management of an idiopathic first bite syndrome: A case report and review

FBS is associated with surgical interventions or malignancies and could occur idiopathically. Also, this case highlights the successful management of FBS symptoms with pharmacological intervention with gabapentin and carbamazepine.

Digestive Biomarkers of Laryngopharyngeal Reflux: A Preliminary Prospective Controlled Study

OBJECTIVE

To investigate the digestive enzymes and biomarkers in the saliva of patients with laryngopharyngeal reflux (LPR) and asymptomatic individuals.

STUDY DESIGN

Prospective controlled study.

SETTING

Multicenter study.

METHODS

Patients with LPR at the hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and asymptomatic individuals were consecutively recruited from January 2020 to April 2023 from 2 University Hospitals. The saliva of patients (off PPIs) and asymptomatic individuals was collected to measure pH, elastase, bile salts, cholesterol, gastric, and pancreatic lipases. Anxiety, symptoms, and findings were studied through perceived stress scale (PSS), reflux symptom score (RSS), and reflux sign assessment (RSA).

RESULTS

Sixty-seven LPR patients and 57 asymptomatic individuals completed the evaluations. LPR patients reported higher PSS, RSS, and RSA than asymptomatic individuals. The mean saliva pH was more alkaline in LPR patients (7.23: 95% confidence interval [CI]: 7.08, 7.38) compared to controls (6.13; 95% CI: 5.95, 6.31; P = .001). The mean concentration of elastase was higher in patients (51.65 µg/mL; 95% CI: 44.47, 58.83 µg/mL) versus asymptomatic individuals (25.18 µg/mL; 95% CI: 21.64, 28.72 µg/mL; P = .001). The saliva cholesterol reported higher concentration in healthy individuals (3.43 mg/dL; 95% CI: 3.21, 3.65 mg/dL) compared to patients (1.16 mg/dL; 95% CI: 1.05, 1.27 mg/dL; P = .001). The saliva pH, and elastase concentration were significantly associated with the baseline RSS, while saliva cholesterol was negatively associated with the severity of RSS and RSA.

CONCLUSION

Cholesterol, bile salts, and elastase are biomarkers of LPR and should be considered to develop future non-invasive saliva device for the detection of LPR.

Assessing the role of dryness and burning sensation in diagnosing laryngopharyngeal reflux

Laryngopharyngeal reflux disease (LPRD) is a condition characterized by the regurgitation of stomach and duodenal contents into the laryngopharynx, with variable and non-specific symptoms. Therefore, developing an accurate symptom scale for different regions is essential. Notably, the symptoms of "dryness and burning sensation in the laryngopharynx or mouth" are prevalent among the Chinese population but are often omitted from conventional symptom assessment scales, such as the Reflux Symptom Index (RSI) and Reflux Symptom Score-12 (RSS-12) scales. To address this gap, our study incorporated the symptoms into the RSI and RSS-12 scales, developing the RSI-10/RSS-13 scales. Afterward, we assessed the role of the new scale's reliability (Cronbach's α and test-retest reliability), construct validity (confirmatory factor analysis and confirmatory factor analysis), and diagnostic efficiency. Our study encompassed 479 participants (average = 39.5 ± 13.4 years, 242 female) and 91 (average = 34.01 ± 13.50 years, 44 female) completed 24 h MII-pH monitoring. The Cronbach's α values of 0.80 and 0.82 for the RSI-10 and RSS-13 scales, respectively. RSI-10 and RSS-13 exhibited strong test-retest reliability (ICCs = 0.82-0.96) and diagnostic efficacy (AUC = 0.84-0.85). Furthermore, the factor analysis identified the RSS-13 and its three sub-scales (ear-nose-throat, digestive tract, respiratory tract) exhibited good to excellent structural validity (χ2/df = 1.95, P < 0.01; CFI = 0.95, RMSEA = 0.06, SRMR = 0.05). The AUC optimal thresholds for the RSI-10 and RSS-13 in the Chinese population were 13 and 36, respectively. Besides, the inclusion of the new item significantly improved the diagnostic efficiency of the RSI scale (P = 0.04), suggesting that RSI-10 holds promise as a more effective screening tool for LPRD, and global validation is needed to demonstrate the impact of this new symptom on the diagnosis of LPRD.

Usefulness of pepsin saliva measurement for the detection of primary burning mouth syndrome related to reflux

OBJECTIVES

To study the diagnostic value of salivary pepsin tests for detecting laryngopharyngeal reflux (LPR) in patients with primary burning mouth syndrome (BMS).

METHODS

Patients with BMS and asymptomatic individuals were consecutively recruited from September 2018 to June 2023. Patients underwent hypopharyngeal-esophageal impedance pH-monitoring (HEMII-pH) and saliva collections to measure pepsin. Stomatology evaluation was carried out to exclude other causes of BMS. Oral, pharyngeal and laryngeal signs and symptoms were evaluated with Reflux Sign Assessment (RSA) and Reflux Symptom Score (RSS). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin test were calculated considering the highest values of pepsin tests at ≥ 16, ≥ 36, and ≥ 100 ng/mL cutoffs. Receiver operating characteristic curve (ROC) was evaluated.

RESULTS

Forty-nine patients with both BMS and LPR at the HEMII-pH and 21 asymptomatic individuals were recruited. Pepsin test was 83.7%, 79.6%, and 71.4% sensitive at cutoffs ≥ 16, ≥ 36, and ≥ 100 ng/mL, respectively. The ROC analysis reported that a threshold of ≥ 21.5 ng/mL was associated with sensitivity, specificity, PPV and NPV of 81.6%, 81.0%, 90.1% and 65.4%, respectively. The severity score of burning mouth symptom was significantly associated with the saliva pepsin concentration (rs = 0.263; p = 0.029) and the oral RSA (rs = 0.474; p = 0.007).

CONCLUSION

Pepsin test is a valuable diagnostic approach for detecting LPR in patients with BMS. Patients with high level of saliva pepsin reported more severe burning mouth symptoms. Future studies are needed to confirm the role of LPR in the primary BMS.

Milk-Derived Small Extracellular Vesicles Promote Osteogenic Differentiation and Inhibit Inflammation via microRNA-21

Chronic apical periodontitis (CAP) is a disease with characteristics of inflammation and bone loss. In this study, our objective was to examine the function of small extracellular vesicles (sEVs) obtained from milk in encouraging osteogenic differentiation and inhibiting inflammation by miR-21 in CAP. The expression of miR-21 was detected using qRT-PCR in human CAP samples. The impact of miR-21 on the process of osteogenic differentiation was investigated using CCK-8, qRT-PCR, immunofluorescence staining, and Western blot analysis. The evaluation of RAW 264.7 cell polarization and the assessment of inflammatory factor expression were conducted through qRT-PCR. The influence of sEVs on MC3T3-E1 cells and RAW 264.7 cells was examined, with a particular emphasis on the involvement of miR-21. In human CAP samples, a decrease in miR-21 expression was observed. MiR-21 increased the expression of osteogenesis-related genes and M2 polarization genes while decreasing the expression of M1 polarization genes and inflammatory cytokines. Treatment with milk-derived sEVs also promoted osteogenesis and M2 polarization while inhibiting M1 polarization and inflammation. Conversely, the addition of miR-21 inhibitors resulted in opposite effects. Our results indicated that sEVs derived from milk had a positive effect on bone formation and activation of anti-inflammatory (M2) macrophages and simultaneously reduced inflammation by regulating miR-21 in CAP.

Effectiveness and Tolerability of Ectoin® Mouth and Throat Spray Althaea Honey (ERS09) for Sore Throat due to Acute Pharyngitis and Dry Cough: A Multicentre, Actively Controlled, Open Label Study in Germany

Acute pharyngitis can cause sore throat. This multicentre, active-controlled, randomised, open-label, and parallel-group study, conducted according to the German Medical Devices Act, compared the effectiveness and tolerability of ERS09 mouth and throat spray with a well-established device for the treatment of sore throat caused by acute pharyngitis and dry cough. Patients were randomised 1:1 into ERS09/comparator groups (EMSER® Sore Throat Spray) for 7 ± 2 days. Patients and investigators reported effectiveness (change in total symptom score [TSS]) and safety endpoints (incidence of adverse events [AEs]; adverse device effects [ADEs]). A total of 186 patients were included (ERS09: n = 92; comparator: n = 94). The baseline-adjusted mean TSS over 7 days was -90.14 and -74.91 in the ERS09 and comparator groups, respectively (p < 0.05). The majority of patients reached a 50% reduction in symptoms by day 6 (ERS09 = 78.85; comparator = 75.8%). Most patients reported a soothing effect within five minutes (ERS09 = 82%; comparator = 71%). Improvements in individual symptoms were similar with no significant differences between groups; more patients in the ERS09 group reported an improvement in pharyngeal redness/swelling. Three AEs unrelated to medication, one ADE following ERS09, and no serious AE/ADE were reported. ERS09 was as well tolerated and effective as the established device, showing greater improvement in the management of some symptoms and greater patient preference.

The Effects of 6-Month Aqua Aerobics Training on Cardiometabolic Parameters in Perimenopausal Women-A Randomized Controlled Trial

BACKGROUND

Menopause is a time when women experience a number of physiological and anatomical changes resulting from a decline in ovarian function. It can be concluded that cardiovascular disease increases in perimenopausal and postmenopausal women, irrespective of age-related changes. Engaging in the amount of moderate physical activity recommended by the World Health Organization helps reduce the risk of death and adverse health events. The aim of the present study was to assess the effect of a 6-month aqua aerobics programme on cardiometabolic (anthropometric and biochemical) parameters in perimenopausal women.

METHODS

In this study, 30 women (control group-16, study group-14) participated in the 6-month aqua aerobics training programme. The mean age of women was 47.67 ± 6.79 year and BMI 26.33 ± 3.64 kg/m2. At the beginning and at the end of the study, anthropometric and blood samples analysis were performed. In the blood, lipid profile, morphotic elements were determined. Body composition, waist-hip ratio (WHR), visceral adiposity index (VAI), blood pressure (BP) were measured.

RESULTS

The aqua aerobics programme resulted in a significant decrease in the WHR (p < 0.05; ES: 2.143), diastolic blood pressure (DBP) (p < 0.05; ES: 1.005), and platelet-to-lymphocyte ratio (PRL) (p < 0.05; ES: 0.460) and an increase in haemoglobin (HGB) concentration (p < 0.05; ES: 0.643).

CONCLUSIONS

The type of physical activity described in the present study is a great way for perimenopausal women to take care of their overall well-being. The reduction in selected cardiometabolic parameters is important from the point of view of the protection of women's health.

Xerogenic medications may contribute to decreased unstimulated salivary flow in patients with oral burning and/or gastro-esophageal reflux disease

Background

Patients who complain of mucosal burning sensations (i.e., glossodynia and gastro-esophageal reflux disease, GERD) often take multiple medications. However, the relationship between xerogenic medication intake and salivary flow in these patients has not been thoroughly examined.

Methods

A retrospective study of 192 consecutive patients diagnosed with glossodynia (ICD-10-CM) at a regional center over a six-year period was performed. Data from electronic health records were extracted and relationships between medication intake, unstimulated whole salivary flow rate (UWSFR), xerostomia and GERD were determined by chi-square, t-test, and correlation analysis.

Results

Of 134 records that met inclusion criteria, 87.1% of patients reported daily intake of one or more xerogenic medications. Two or more xerogenic medications were taken significantly more often by patients with glossodynia reporting GERD than those with glossodynia without GERD (p = .02). UWSFR was negatively correlated with number of medications [r(103) = −.277, p = .005] and xerogenic medications [r(103) = −.195, p = .049]. The lowest UWSFR was observed with use of trazodone and cyclobenzaprine.

Conclusions

Daily xerogenic medication intake, hyposalivation, and xerostomia were commonly present and potentially interrelated in patients who suffer from glossodynia and/or GERD.

Practical implications

Clinicians should be aware of the consequences of prescribing multiple and certain xerogenic medications in reducing UWSFR, especially in patients physiologically at risk of hyposalivation such as those suffering from GERD and/or glossodynia.

Association of medications with burning mouth syndrome in Taiwanese aged patients

Background/purpose

Burning mouth syndrome (BMS) occurs more frequently in middle-aged or elderly patients, especially the older female patients. It may relate to multiple medications in the older people. This study aimed to evaluate the association of polypharmacy with BMS.

Materials and methods

Eighty BMS patients aged from 45 to 80 years were recruited into this study, and their medical data, especially the medication records, were collected and analyzed to assess the association of polypharmacy with BMS.

Results

Of the 80 BMS patients, 14 did not take any medication, 38 took 1-4 medicines, 17 took 5-8 medicines, and 11 took ≥9 medicines. The mean number of medicines taken by each BMS patient is 4.49. For the 80 BMS patients, the mean number of medicines taken by each BMS patient was significantly higher in the older age group (7.00 ± 7.76; age ≥65 years; n = 31) than in the relatively younger age group (2.90 ± 2.95; age 45-64 years; n = 49) (P = 0.001). The similar result was also observed in the female BMS patients. We also found that psychotropics, gastroprotectors and gastrointestinal tract (GI)-associated drugs, and antihypertensives were the three most commonly used drugs in our 80 BMS patients. Among them, the relatively high frequencies of using anxiolytics and antidepressants in the psychotropics, and beta-blockers in the antihypertensives were observed.

Conclusion

Our findings suggest that multiple medications (polypharmacy) may play an important role in the development of BMS, especially for the older female BMS patients.

Optimal Timing of the Salivary Pepsin Test for the Diagnosis of Laryngopharyngeal Reflux

OBJECTIVE

To investigate the optimal time point for diagnosing laryngopharyngeal reflux (LPR) through combining 24-h hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-h HEMII-pH) monitoring and the multi-time point salivary pepsin test (MTPSPT).

STUDY DESIGN

Prospective uncontrolled trial.

METHOD

Patients with and without LPR symptoms were included as the test group and the control group, respectively. The patients in the test group underwent 24-h HEMII-pH and MTPSPT. The results of 24-h HEMII-pH were used as a diagnostic criterion for LPR, and the diagnostic value of salivary pepsin tests performed at different time points was compared by receiver operating characteristic (ROC) analysis.

RESULTS

A total of 153 patients were included. Based on 24-h HEMII-pH, the positive rate of LPR in the test group of patients was 84.00%. In the control group, only one person (3.57%) had a positive salivary pepsin test result. The area under the curve (AUC) of the MTPSPT was 0.827. In addition, we separately calculated the AUC of the combined salivary pepsin test at different time points, and found good diagnostic value (AUC = 0.799) when the test was combined with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests. However, when the number of tests were further increased, the diagnostic value did not improve significantly.

CONCLUSION

Salivary pepsin testing combined with waking, 1 h and 2 h after breakfast and lunch, and 1 h after dinner has almost the same diagnostic value as MTPSPT, and testing at these time points can be an effective method for diagnosing LPR.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Prevalence of reflux-related symptoms in South-Hungarian blood donor volunteers

Background/Aim

Population-based studies on the prevalence of GERD-related symptoms are still missing in Eastern Europe, therefore, we aimed to obtain such data in South-East Hungarian subjects.

Methods

A total of 2,002 apparently healthy blood donor volunteers were consecutively enrolled and completed detailed questionnaires related to general factors, demographic data, socioeconomical factors, and the presence and frequency of typical and atypical GERD-related symptoms.

Results

Among 2,002 study participants, 56.5% were completely asymptomatic. The prevalence of typical GERD symptoms appearing at least monthly or weekly was 16.5% and 6.8%, respectively. Two-thirds (209/330) of the patients experienced at least monthly occurring typical GERD symptoms and also had associated atypical symptoms and this was even more pronounced when comparing subgroups with higher symptom frequencies. Significant correlations were found between monthly GERD-related complaints and height, body mass index (BMI), coffee consumption, and smoking. Positive family history was another significant factor in all the symptom-frequency categories. GERD-related symptom frequency showed a linear association with sex (R² = 0.75, P = 0.0049). Typical and atypical GERD symptoms were significantly more common in those with chronic diseases than those without. Heartburn was observed in 12.5% and 4.4% (P<0.05) and acid regurgitation was seen in 6.9% and 1.8% (P<0.05), respectively.

Conclusion

The prevalence of GERD-related symptoms in South Hungary was significantly lower than that in Western countries and was closer to Eastern values. The presence of mild, non-exclusionary chronic diseases significantly increased the prevalence of GERD-related symptoms, as well as positive family history of GERD, height, BMI, coffee consumption, and smoking.

An epidemiological survey of gastroesophageal reflux disease at the digestive endoscopy center in Guangzhou

OBJECTIVE

This study aims to investigate the detection rates, common symptoms and risk factors of gastroesophageal reflux disease (GERD), and laryngopharyngeal reflux disease (LPRD) at the digestive endoscopy center.

METHODS

A multicenter cross-sectional survey conducted at three hospitals and a total of 565 eligible participants were enrolled. All the patients completed routine ENT examination, gastroscopy, gastroesophageal reflux questionnaire (GerdQ), reflux symptom index (RSI) and a self-designed 25-item symptoms table survey.

RESULTS

Among the 565 eligible participants, the detection rates of GERD and LPRD were 18.41% (104/565) and 9.91% (56/565), respectively. The detection rate of GERD combined with LPRD was 3.19% (18/565). Among GERD and LPRD patients, males (vs. females), middle-aged and elderly patients (vs. young people), BMI ≥ 24.0 kg/m² (vs. BMI < 24.0 kg/m²), with current smoking history (vs. no smoking), and current drinking history (vs. no drinking), lying down immediately after meal (vs. no lying down immediately after meal) were significantly higher (all p < 0.05). The most common extraesophageal symptoms in patients with GERD were dry mouth (66.35%), globus sensation (56.73%), dry throat and pharyngeal itching (55.77%). The most common extraesophageal symptoms in patients with LPRD were globus sensation (91.07%), dry throat and pharyngeal itching (83.93%), and dry mouth (82.14%).

CONCLUSION

GERD and LPRD had a high detection rate at the digestive endoscopy center in Guangzhou, China. Older age, BMI ≥ 24.0 kg/m², smoking and drinking history were risk factors for both GERD and LPRD. Neither GerdQ nor RSI scores included common extraesophageal symptoms.

Atypical Clinical Presentation of Laryngopharyngeal Reflux: A 5-Year Case Series

Background: Laryngopharyngeal reflux (LPR) is a common disease in otolaryngology characterized by an inflammatory reaction of the mucosa of the upper aerodigestive tract caused by digestive refluxate enzymes. LPR has been identified as the etiological or favoring factor of laryngeal, oral, sinonasal, or otological diseases. In this case series, we reported the atypical clinical presentation of LPR in patients presenting in our clinic with reflux. Methods: A retrospective medical chart review of 351 patients with LPR treated in the European Reflux Clinic in Brussels, Poitiers and Paris was performed. In order to be included, patients had to report an atypical clinical presentation of LPR, consisting of symptoms or findings that are not described in the reflux symptom score and reflux sign assessment. The LPR diagnosis was confirmed with a 24 h hypopharyngeal-esophageal impedance pH study, and patients were treated with a combination of diet, proton pump inhibitors, and alginates. The atypical symptoms or findings had to be resolved from pre- to posttreatment. Results: From 2017 to 2021, 21 patients with atypical LPR were treated in our center. The clinical presentation consisted of recurrent aphthosis or burning mouth (N = 9), recurrent burps and abdominal disorders (N = 2), posterior nasal obstruction (N = 2), recurrent acute suppurative otitis media (N = 2), severe vocal fold dysplasia (N = 2), and recurrent acute rhinopharyngitis (N = 1), tearing (N = 1), aspirations (N = 1), or tracheobronchitis (N = 1). Abnormal upper aerodigestive tract reflux events were identified in all of these patients. Atypical clinical findings resolved and did not recur after an adequate antireflux treatment. Conclusion: LPR may present with various clinical presentations, including mouth, eye, tracheobronchial, nasal, or laryngeal findings, which may all regress with adequate treatment. Future studies are needed to better specify the relationship between LPR and these atypical findings through analyses identifying gastroduodenal enzymes in the inflamed tissue.