Association of Pepsin With Inflammatory Signaling and Effusion Viscosity in Pediatric Otitis Media

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.

Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review

Purpose: Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. Methods: A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. Findings: The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Conclusions: Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.

Pediatric Laryngopharyngeal Reflux in the Last Decade: What Is New and Where to Next?

BACKGROUND

Laryngopharyngeal reflux may affect people of any age; still, most of the accumulated knowledge concerns adults, and evidence regarding pediatric populations remains relatively restricted. This study aims to review the most recent and emerging aspects of pediatric laryngopharyngeal reflux from the last ten years. It also attempts to identify gaps in knowledge and highlight discrepancies that future research should urgently address.

METHODS

An electronic search of the MEDLINE database was conducted, limited to January 2012 through December 2021. Non-English language articles, case reports, and studies that concerned a purely or predominantly adult population were excluded. The information from the articles with the most relevant contribution was initially categorized by theme and subsequently synthesized into a narrative form.

RESULTS

86 articles were included, of which 27 were review articles, eight were surveys, and 51 were original articles. Our review systematically maps the research done in the last decade and provides an updated overview and the current state-of-the-art in this subject.

CONCLUSIONS

Despite discrepancies and heterogeneity in accumulating research, evidence gathered so far endorses a need for refining an escalating multiparameter diagnostic approach. A step-wise therapeutic plan appears to be the most reasonable management approach, starting with behavioral changes for mild to moderate, uncomplicated cases and escalating to personalized pharmacotherapy options for severe or nonresponsive cases. Surgical options could be considered in the most severe cases when potentially life-threatening symptoms persist despite maximal medical therapy. Over the past decade, the amount of available evidence has been gradually increasing; however, its strength remains low. Several aspects remain markedly under-addressed, and further adequately powered, multicenter, controlled studies with uniformity in diagnostic procedures and criteria are urgently needed.

Clinical Update Findings about pH-Impedance Monitoring Features in Laryngopharyngeal Reflux Patients

Purpose: The diagnosis of laryngopharyngeal reflux (LPR) is commonly based on non-specific symptoms and findings and a positive response to an empirical therapeutic trial. The therapeutic response is, however, unpredictable, and many patients need pH-impedance monitoring to confirm the diagnosis. Methods: A review of the recent literature was conducted in PubMED, Scopus, and Embase about the pH-study features of LPR patients. A summary of last evidence was proposed. Results: The awareness of otolaryngologists about indications and interpretation of pH-impedance monitoring is low. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is the most reliable examination determining the type and composition of hypopharyngeal reflux events (HRE) and the LPR features. The use of HEMII-pH is important to confirm the diagnosis in selected patients because non-specificity of symptoms and findings. There are no international consensus guidelines for the LPR diagnosis at the HEMII-pH. However, most studies supported the occurrence of >1 acid/weakly acid/nonacid HRE as diagnostic threshold. HREs are more frequently gaseous, weakly/nonacid compared with reflux events of gastroesophageal reflux. HREs occurred as daytime and upright, which does not support the value of double proton pump inhibitors or bedtime alginate. Oropharyngeal pH-monitoring is another approach reporting different sensitivity and specificity outcomes from HEMII-pH. The use of Ryan score for the LPR diagnosis at the oropharyngeal pH monitoring may be controversial regarding the low consideration of alkaline HREs. Conclusions: The awareness of otolaryngologists about HEMII-pH indication, features, and interpretation is an important issue regarding the high prevalence of LPR in outpatients consulting in otolaryngology. The HEMII-pH findings may indicate a more personalized treatment considering type and occurrence time of HREs.