Pediatric middle ear infections and gastroesophageal reflux

Clinical evaluation of pepsin for laryngopharyngeal reflux in children with otitis media with effusion

OBJECTIVE

We sought to evaluate the clinical role of pepsin for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME).

METHODS

Pepsin/pepsinogen and fibrinogen were analyzed in fifty effusion and blood samples of children with OME using enzyme linked immunosorbent assay (ELISA). Ambulatory 24-h dual-probe pH monitoring was additionally performed in 31 children divided into two groups according to response of medical treatment.

RESULTS

The effusion levels of pepsin/pepsinogen ranged from 8.5 to 1512 μg/dl and were up to 4-540 times higher than the concentrations found in plasma samples. The effusion levels of fibrinogen ranged from 0.05 to 4.1g/dl. Some effusion samples showed fibrinogen concentrations did not exceed 10 times higher than the concentrations found in plasma samples and others showed lower concentrations. The pH of effusion samples was 7.13 to 8.72. Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant acid reflux documented by either the esophageal probe or the pharyngeal probe and all of them had LPR. There is a significant positive correlation between the level of pepsin assayed in the effusions and the number of pharyngeal reflux episodes measured by pH monitoring.

CONCLUSIONS

Analysis of pepsin/pepsinogen in effusion samples of children with OME, using ELISA, can be considered as a reliable biochemical marker for assessment of laryngopharyngeal reflux.

Detecting nasopharyngeal reflux: a novel pH probe technique

OBJECTIVES

We sought to ascertain the normal pH values in the aerosolized environment of the nasopharynx in healthy subjects and utilize a novel pH probe that allows measuring acidity in a nonliquid environment.

METHODS

Between November 2009 and February 2011, healthy volunteers without a history of reflux or eustachian tube dysfunction were enrolled in the prospective study. A total of 20 subjects had a Dx-pH Measurement System Probe (Respiratory Technology Corp) placed near the torus tubarius. The pH probe records the pH throughout the 24-hour study. A pH below 5.5 while the subject was upright or below 5.0 while the subject was supine was used as a criterion to determine a reflux event. Recording was stopped during meals.

RESULTS

For normal individuals with no history of reflux or eustachian tube dysfunction, the pH values obtained from the nasopharynx ranged from 6.10 to 7.92. The average pH was 7.03 (SD, 0.67). Eight subjects (40%) had at least 1 reflux event during the 24-hour pH study.

CONCLUSIONS

By utilizing a novel self-condensing pH probe, we were able to perform a 24-hour pH study in the nasopharynx of 20 healthy individuals. In our study, the average pH for individuals without symptomatic reflux or eustachian tube dysfunction was 7.03. Interestingly, 8 control subjects had at least 1 episode of pH below 5.5 while awake or below 5.0 while asleep, which was considered to be a reflux event in our study.

Investigation of gastric pepsinogen in middle ear fluid of children with glue ear

CONCLUSION

The presence of pepsinogen in middle ear effusion (MEE) supports the relationship between gastroesophageal reflux (GER) and otitis media with effusion (OME). Measurement of pepsin/pepsinogen can be considered as a simple and reliable method for assesment of reflux in children. However, further research is needed to establish a definite association between GER and OME before beginning antireflux treatment in the management of MEE.

OBJECTIVE

The aim of this study was to investigate the relationship between GER and chronic OME, and to confirm the presence of gastric enzyme in the MEE of children with OME.

METHODS

This was a prospective study. MEE and blood samples were obtained from 42 children undergoing tympanostomy tube placement. Total pepsinogen concentrations of effusions and serum samples were measured with a commercial ELISA using a human pepsinogen I specific antibody. Albumin levels of effusions and serum samples were also measured with ELISA for comparison with pepsinogen levels.

RESULTS

Measurable pepsinogen was present in all MEEs from patients, with levels higher than the serum values. The difference between the levels of pepsinogen measured in MEE and serum was statistically significant (p < 0.01), but albumin levels were higher in serum than in MEE and the difference was statistically significant (p < 0.01).

Recurrent acute otitis media and gastroesophageal reflux disease in children. is there an association?

OBJECTIVE

To investigate whether there is a relationship between gastroesophageal reflux disease (GERD) and recurrent acute otitis media (RAOM) in infants and children. Possible risk factors are also explored.

MATERIAL AND METHODS

221 consecutive children who had symptoms and signs associated with GERD and had undergone a prolonged ambulatory 24-h esophageal pH-monitoring. Thirty-four children were excluded from the study due to age, neurological deficits, congenital abnormalities, immunodeficiency syndromes or other chronic systemic disorders. The remaining 187 children (96 boys and 91 girls), aged between 40 days and 33 months (mean age of 18.3 months) were assigned into three groups according to their Reflux Index (RI%). Group A: 49 children (26.2%) without GERD (control group); Group B: 78 children (41.7%) with low to moderate RI; and Group C: 60 children (32.1%) with severe GERD. Parental interviews and personal medical files of the National Health System were used for data collection. However, episodes of acute otitis media were taken into account only if they were diagnosed by a physician. The follow-up period ranged from 6 to 8 years in order to cover the peaks of otitis media incidence in childhood.

RESULTS

The results revealed that 6 children from Group A (12.24%), 11 from Group B (14.1%) and 19 from Group C (31.67%) presented episodes of RAOM. The difference was statistically significant (p=0.01). Furthermore, in children who received anti-reflux treatment, the incidence of RAOM substantially decreased and eventually became approximate to that of the control Group A (12.32%). Logistic regression revealed that the strongest risk factor for recurrent otitis media was severe GERD (odds ratio, 4), then attendance at day-care centres (odds ratio, 3), followed by allergies (odds ratio, 2.7).

CONCLUSIONS

Severe GERD could be implicated in the multifactorial etiology of RAOM in infants and children.

Pepsin assay: a marker for reflux in pediatric glue ear

OBJECTIVE

To evaluate if analysis of pepsin/pepsinogen in middle ear effusions can be considered a diagnostic marker for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME).

MATERIAL AND METHODS

Ambulatory 24-hour dual-probe pH monitoring was carried out on 31 children with OME. Middle ear effusions were collected from 17 children during myringotomy. Total pepsin/pepsinogen concentrations in effusions were measured by ELISA using antipepsin antibody.

RESULTS

Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant LPR. The concentrations of pepsin/pepsinogen in middle ear effusions, ranged from 0.085 to 5.02 microg/ml, were found to be up to 4.5 to 231.44 times higher than the serum levels. There was a significant positive correlation between the level of pepsin/pepsinogen assayed in the effusions of the 17 children and the number of pharyngeal reflux episodes measured by pH monitoring.

CONCLUSIONS

Control of LPR may be an essential component in the successful management of OME in pediatric patients. Pepsin/pepsinogen analysis in effusions of children, using ELISA, can be considered a reliable marker for assessment of reflux in children with OME.

Update on eustachian tube dysfunction and the patulous eustachian tube

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent knowledge on eustachian tube dysfunction and the patulous eustachian tube.

RECENT FINDINGS

A clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators identified within the eustachian tube and middle ear cells were causally linked with otitis media with effusion. Increasing evidence was found that allergic disease and reflux may be two of the most important contributors of tubal inflammation causing otitis media with effusion. The adenoid size and proximity to the torus tubaris may also be important in considering which patients with persistent otitis media with effusion may benefit from adenoidectomy. Computed tomography scan has documented loss of soft tissue within the cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic approach to seal the tubal lumen has been found to be effective in relieving patulous symptoms.

SUMMARY

These studies suggest that allergic rhinitis and gastroesophageal reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy should also be considered in patients who have adenoids that obstruct the torus tubaris. Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further research is needed to identify a clinically useful test for eustachian tube dysfunction.