Gastroesophageal reflux disease: its importance in ear, nose, and throat practice

Is There a Potential Link between Gastroesophageal Reflux Disease and Recurrent Respiratory Tract Infections in Children?

BACKGROUND

The implications of gastroesophageal reflux disease in respiratory tract infections have been investigated over time. The aim of our study was to evaluate the relationship between these two pathologic entities and the outcome after proper antireflux treatment.

METHODS

A group of 53 children with recurrent respiratory tract infections admitted in the gastroenterology clinic of a children's hospital in North-East Romania was investigated for gastroesophageal reflux disease through 24 h pH-metry. Those with a Boix-Ochoa score higher than 11.99 received proton pump inhibitor treatment and were reevaluated after 2 months.

RESULTS

A total of 41 children were found with a positive Boix-Ochoa score. After 2 months of antireflux therapy, eight patients still had a positive Boix-Ochoa score.

CONCLUSIONS

Recurrent respiratory tract infections with symptoms resistant to treatment should be considered a reason to investigate for gastroesophageal reflux, because the symptoms may be due to micro- or macro-aspiration of the gastric refluxate or to an esophageal-bronchial reflex mediated through the vagal nerve.

The Association Between ENT Diseases and Obesity in Pediatric Population: A Systemic Review of Current Knowledge

Obesity in pediatric population is an important global problem. The prevalence of obesity in children is dramatically rising. According to World Health Organization, about 41 million children under the age of 5 years are obese or overweight worldwide. Overweight and obesity are well-known risk factors for a number of health disorders. Diseases commonly observed in this group of patients are metabolic disorders, type 2 diabetes mellitus, cardiovascular diseases, fatty liver disease, musculoskeletal problems, and many others. The main aim of this study was to present the current knowledge of the association between childhood obesity and common otorhinolaryngological disorders. It is suggested that obese children are more prone to suffer from otorhinolaryngological illnesses than the lean ones. Obesity may predispose to otorhinolaryngological diseases in various ways. It strongly interferes with the immune system (increases serum levels of interleukin 6, tumor necrosis factor, C-reactive protein, and leptin and reduces adiponectin concentration) affecting organs of the upper respiratory tract. Additionally, obesity induces mechanical disorders in the upper airways. According to our review, obesity predisposes to otitis media with effusion, acute otitis media, recurrent otitis media, obstructive sleep apnea, sensorineural hearing loss, adenotonsillar hypertrophy, and post-/perioperative complications after adenotonsillectomy. Obesity in children significantly correlates with both obstructive sleep apnea (OSA) and asthma and constitutes a significant component of "OSA, obesity, asthma" triad.

Characteristics of laryngopharyngeal reflux in patients with chronic otitis media

OBJECTIVE

To summarize the characteristics of laryngopharyngeal reflux (LPR) in patients with chronic otitis media.

METHODS

This was a prospective study in which 31 patients with chronic otitis media were enrolled. General patient information, reflux symptom index (RSI), reflux finding scores (RFSs), and Ryan scores were summarized.

RESULTS

Most (29/31, 93.5%) patients had a negative RSI (RSI ≤ 13). The most common symptoms of these patients were throat clearing (22/31, 71.0%), symptoms of the stomach and esophagus (19/31, 61.3%), and excess throat mucus or postnasal drip (14/31, 45.2%). In contrast to the RSI, most patients (22/31, 71.0%) had a positive RFS (RFS > 7). Among all of the signs found under the transnasal fiber-optic laryngoscope, erythema was the most frequent symptom (31/31, 100.0%), followed by vocal cord edema (27/31, 87.1%), and posterior commissure hypertrophy (27/31, 87.1%). Most cases (24/31, 77.4%) had a positive Ryan score, and most positive scores were upright scores.

CONCLUSIONS

Most patients with chronic otitis media had LPR simultaneously. The LPR in these patients manifested mainly by a positive RFS under a laryngoscope and not by symptoms of the larynx and pharynx. This suggests that LPR may be an important factor in the pathogenesis of COM and anti-reflux treatment may play a significant role in the management of chronic otitis media.

Treatment Paradigm for Nasal Airway Obstruction

Nasal airway obstruction (NAO) is a common otolaryngic complaint with many potential causes, frequently structural or inflammatory in nature. Patients typically have multiple coexisting factors leading to symptoms. Good patient outcomes require careful preoperative evaluation, including nasal endoscopy, to accurately identify sources of obstruction and tailor intervention appropriately. Common structural causes of NAO include inferior turbinate hypertrophy, nasal septal deviation, and narrowing or collapse of the internal or external nasal valves. The internal nasal valve has the narrowest cross-sectional area within the nasal airway and is thus most sensitive to changes in dimension due to anatomic variation or surgical intervention.

Adenoid hypertrophy and chronic rhinosinusitis: Helicobacter pylori on antral lavages, adenoid tissue and salival inmunoglobuline A on paediatric patients

OBJECTIVE

To determine Helicobacter pylori presence on antral lavages, adenoids and salival inmunoglobuline A on paediatric patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and adenoid hypertrophy.

METHODS

Adenoid tissue, liquid obtained from antral lavages and saliva from 28 children diagnosed with CRSsNP, from the paediatric otorhinolaryngology practice of "Dr. Domingo Luciani" Hospital was taken and processed by means of polymerase chain reaction (PCR) using cagA, vacA and babA primers, also anatomopathological examination using Giemsa stain of the adenoids, determination of salivary specific secretory inmunoglobuline A (sIgA), socio-economic condition using the Graffar scale and associated gastrointestinal symptoms were assessed.

RESULTS

No evidence of Helicobacter pylori neither in antral lavages liquid nor adenoid tissue was found using PCR and Giemsa stain. sIgA was present in 28.6% of the subjects. The most frequently found symptoms were, diarrhea in 17.9%, distension and abdominal pain in 10.7%, 64.3% of the patients were in working (28.6%) and low middle (35.7%) classes.

CONCLUSIONS

Helicobacter pylori is not present neither in maxillary sinuses nor adenoid tissue of the evaluated patients, sIgA it is a non-invasive method for assessment of immunologic challenge with the bacteria, not the presence of acute or chronic infection.

Correlation Between Tympanosclerosis and Helicobacter pylori

Background:

Tympanosclerosis is a condition caused by calcification of tissues in the middle ear mucosa that sometimes results hearing loss. Helicobacter pylori is one of the pathological and etiologic factors in the development of tympanosclerosis.

Objectives:

The purpose of this study was to show the role of H. pylori in the different aspects of chronic suppurative otitis media using the polymerase chain reaction (PCR) technique.

Patients and Methods:

This case-control and cross-sectional study was performed on all patients with chronic otitis media, candidates for surgical operations, in 2013. They were allocated into the case group with tympanosclerosis and the control group without tympanosclerosis. During the surgical operation, biopsy was done from middle ear and the samples were studied to see if they contained H. pylori using the PCR method.

Results:

From a total of 19 patients with tympanosclerosis , 16 cases (84.2%) were H. pylori positive, while in the control group 15 (45.4%) cases out of the 37 cases were H. pylori positive, which showed a significant difference (P = 0.002). Age and gender of the patients, ear dryness and perforation size were not correlated with the presence or absence of H. pylori.

Conclusions:

There is a significant correlation between tympanosclerosis and H. pylori (P = 0.002). This correlation can single out H. pylori as a pathological factor in the development of tympanosclerosis; however, further studies are needed to prove this correlation.

Gastroesophageal reflux disease in children with chronic otitis media with effusion

OBJECTIVE

We aimed to evaluate a possible relation between gastroesophageal reflux disease and middle ear effusion in children.

METHODS

Children who came to ear, nose, and throat (ENT) department with the symptoms of hearing loss or aural fullness and diagnosed as OME by examination and tympanometry were included into the study. Children were reviewed gastroesophageal reflux disease symptoms including the following: (a) airway symptoms: stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, hoarseness, and throat clearing; (b) feeding symptoms: frequent emesis, dysphagia, choking: gagging, sore throat, halitosis, food refusal, regurgitation, pyrosis, irritability, failure to thrive, and anemia. Diagnosis is made with at least one positive test of radionuclide gastroesophageal scintigraphy or 24 h pH probe in the patients with reflux. ENT findings were also examined between gastroesophageal reflux disease positive and gastroesophageal reflux disease negative groups.

RESULTS

Approximately 39 (54.9%) of 71 children had at least 1 positive test for gastroesophageal reflux disease. Between the gastroesophageal reflux disease-positive and gastroesophageal reflux disease-negative groups, symptoms of reflux were not significantly different. Two pooled variables were created: airway complex (stridor, frequent cough, throat clearing), and feeding complex (irritability, pyrosis, failure to thrive). Percentage of positive symptom complexes were no statistically different between gastroesophageal reflux disease-positive and gastroesophageal reflux disease-negative groups (>0.05). Ear, nose, and throat disorders (including rhinitis/sinusitis, adenoid hypertrophy, tonsillitis/pharyngitis, and laryngitis) were more frequent in gastroesophageal reflux disease-positive group. Tonsillitis/pharyngitis was significantly different between the gastroesophageal reflux disease positive and gastroesophageal reflux disease-negative groups.

CONCLUSIONS

Upper respiratory tract infections were seen more frequently in gastroesophageal reflux disease positive group. Children who present with gastroesophageal reflux disease symptoms are more likely to have a positive gastroesophageal reflux disease test. However, no concordance may be found between the complaints and gastroesophageal reflux disease findings. For this reason, a decision about gastroesophageal reflux disease should not only be made by looking to complaints; diagnostic tests must also be performed.

Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis

OBJECTIVES

Studies have shown that gastroesophageal reflux disease occurs more frequently than expected in children with chronic rhinosinusitis. The objective of this study is to further understand the relationship of pediatric chronic rhinosinusitis and gastroesophageal reflux disease in children with symptoms of rhinorrhea, nasal congestion, and chronic cough.

METHODS

A retrospective chart review of 63 children, ages 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough. The patients underwent maxillary cultures, adenoidectomy, and distal third esophageal biopsies. Children with esophageal biopsies showing esophagitis were classified as positive for gastroesophageal reflux disease, and maxillary antral swabs growing a high density of bacteria were classified as positive for chronic rhinosinusitis.

RESULTS

Six months to 5 years old children (n=43), 6 (14%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 11 (26%) had positive esophageal biopsies alone, 23 (53%) had positive maxillary antral cultures alone, and 3 (7%) had neither. Six to 10 years old children (n=20), 9 (45%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 1 (5%) patient had positive esophageal biopsies alone, 3 (15%) patients had positive maxillary antral cultures alone, and 7 (35%) patients had neither. Twenty-seven (42%) of the patients from the whole study had gastroesophageal reflux positive biopsies. The younger children were statistically likely to have chronic rhinosinusitis and gastroesophageal reflux disease independently of each other (p=0.0002). A direct group comparison found the younger group to have independent chronic rhinosinusitis and gastroesophageal reflux disease and the older group to have simultaneous chronic rhinosinusitis and gastroesophageal reflux disease (p=0.0006).

CONCLUSION

In children with the presenting symptoms of rhinorrhea, nasal congestion, and chronic cough, younger children tend to have either chronic rhinosinusitis or gastroesophageal reflux disease, whereas older children tend to have a more complicated etiology of chronic rhinosinusitis and gastroesophageal reflux disease or other. In all of these patients gastroesophageal reflux disease plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.

Management of a rare case of arytenoid mucosa oedema inducing stridor and cough

OBJECTIVE

Current guidelines recommend a multidisciplinary systematic integrated approach to patient with chronic cough in which nowadays otolaryngologists play an increasingly valuable role as new procedures are used for evaluation and treatment. Surgery has been never taken into consideration to treat refractory chronic cough.

METHOD

We present a rare case of arytenoid mucosa oedema inducing stridor and cough, lasting 8 months, that critically affected the quality of life of a 15-year-old adolescent arrived to our emergency department with prominent arytenoid oedema causing paroxysmal cough and laryngeal stridor and that was successfully treated by laryngeal debridement.

RESULTS

In this case report we observed that prominent swelling of arytenoid mucosa might sustain a vicious cycle of cough persistence and that laryngeal surgical debridement might interrupt it resolving the particular clinical condition.

CONCLUSION

The description of this case could be of some help for clinicians to draw new insight about diagnosis and therapy of rare selected cases of chronic refractory cough.

Gastroesophageal reflux and rhinosinusitis

Gastro-esophageal reflux disease (GERD) and chronic rhino-sinusitis (CRS) are prevalent disorders. Coexistence by chance is to be expected in a number of patients. Coexistence due to shared pathogenic mechanisms is controversial. In this paper, we have described the characteristics of GERD and CRS epidemiologically, diagnostically, and pathophysiologically, and reviewed the existing data about a potential role of gastro-esophageal reflux (GER) in the pathogenesis of CRS. A causal link between GERD and CRS has so far not been sufficiently documented. However, some studies do indicate a correlation. Hence, anti-reflux measures should be considered as an option in CRS, particularly in patients where conventional medical and surgical treatment is insufficient.

Gastroesophageal reflux and chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are two common conditions which have been reported to occur together more frequently than expected. It has, therefore, been proposed that GERD may have an aetiologic role in CRS. This study reviews the results of research into the possible reflux and reflex mechanisms that may link CRS and GERD.

RECENT FINDINGS

Robust assessment of gastric reflux into the nasopharynx using circumferential pH probes which are less subject to artefact have demonstrated that direct reflux into the nasopharynx is a rare event. Pepsinogen has only been found in the nasal cavity in one study which had unexpected results, raising doubts about the validity of the methodology. A reflex increase in nasal congestion and mucus secretion has been demonstrated experimentally, but in a small number of patients, which precluded statistical significance. The relationship between reflux and mucus secretion is supported, though, by randomized controlled trials showing decreased postnasal drip with proton-pump inhibitor therapy.

SUMMARY

Recent evidence suggests that GERD does not play a causative role in CRS. However, there is evidence of an oesophageal-nasal reflex, particularly in regard to mucus secretion and symptoms of postnasal drip. The presence of GERD would, therefore, be expected to worsen nasal symptom scores.

Gavage-related reflux in rats: identification, pathogenesis, and toxicological implications (review)

After oral gavage dosing of rats, reflux may occur, resulting in serious respiratory effects and mortality. Published information on gavage-related reflux is limited, as it has not yet been a focus of research. Nevertheless, it represents a recurrent challenge in daily toxicology practice of oral gavage dosing. The absence of clear guidance and criteria for the identification and management of reflux-induced effects can limit the ability to properly interpret toxicity study results. The review presented herein includes an overview of experimental data from gavage studies in rats, in which reflux was observed, and provides a comprehensive analysis of the literature on reflux in general and the different potential pathways contributing to gavage-related reflux in rats. The article aims to increase the awareness and understanding of the pathogenesis of gavage-related reflux and provides guidance on identification of potential risk factors, as well as interpretation of histological changes and their toxicological relevance. Furthermore, differentiation of reflux-induced effects from direct compound-related toxicity and from gavage errors is addressed in particular, and the importance of nasal histology is discussed.

Unexpected nasal changes in rats related to reflux after gavage dosing

In a three-week oral gavage toxicity study in rats, a high incidence of respiratory symptoms and high mortality was noted in compound-dosed rats only. Because of audible respiration, an effect in the upper respiratory tract was suspected and the nasal cavity was included for examination. Histology revealed extensive necrosis and purulent inflammation within the nasal passages, indicative of direct irritation. Since posterior nasal regions were most affected, with food material present within the inflammatory exudates, reflux and retrograde aspiration of irritant material (possibly stomach contents with test formulation) into the nasal cavity were suspected. Lowering the dose volume and fasting the rats prior to gavage dosing substantially reduced the respiratory effects and mortality. The current article focuses on the histological changes in the nasal cavity indicative of gavage-related reflux and provides guidance on differentiation between technical gavage error and gavage-related reflux.

Traditional management of ear, nose and throat (ENT) diseases in Central Kenya

Diseases of ear, nose and throat (ENT) often have serious consequences including hearing impairment, and emotional strain that lower the quality of life of patients. In Kenya, upper respiratory infections are among the most common infections encountered in outpatient facilities. Some of these infections are becoming difficult to control because some of the causing microorganisms have acquired antibiotic resistance and hence the need to develop new drugs with higher efficacy. Ethnobotanical studies have now been found to be instrumental in improving chances of discovering plants with antimicrobial activity in new drug development. In Kenya the majority of local people are turning to herbal remedies for primary health care needs. In most cases the sources of these remedies are undocumented and the knowledge about them passed orally form generation to generation, hence under threat of disappearing with current rates of modernisation. This study explored the traditional remedies used in managing various ENT diseases in seven districts of the Central Province of Kenya. The most common ENT conditions managed using traditional therapies include: common cold, cough, tonsillitis, otitis-media, chest pains and asthma. The results indicate that 67 species belonging to 36 plant families were utilized in this region. These plants were of varying habits; herbs (37.3%), shrubs (34.4%), trees (25.4%) as well as some grasses and sedges (3%). The traditional preparations were found to be made mainly from leaves (49%), roots (20.5%) and barks (12.5%). For each of the ENT conditions multiple species are utilized mainly as individual preparations but occasionally as polyherbal concoctions. In the case of common cold for example, 30 different species are used. Plants reported in this survey are important candidates for antimicrobial tests against ENT disease causing micro-organisms, especially those with antibiotic resistance.

Extraesophageal reflux in children

PURPOSE OF REVIEW

To summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children.

RECENT FINDINGS

Extraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions.

SUMMARY

Pediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.

Ultrasonographic study of postcibal gastro-esophageal reflux and gastric emptying in infants with recurrent respiratory disease

AIM

To check the utility of postcibal ultrasonography for the evaluation of reflux in relation to gastric emptying in infants with recurrent respiratory symptoms and to link imaging with clinical data.

METHODS

Esophageal reflux (hyperechoic retrograde filling) and gastric emptying (antral areas) were quantified before and after ingestion of a standard formula in 35 untreated infants (13 with chronic cough, 22 with recurrent bronchitis) and in 31 controls.

RESULTS

The prevalence of abnormal (> or =8 episodes) postcibal refluxes was 74% in patients and 3% in controls. Number, duration of the longest episode and extent of refluxes were significantly higher in patients compared to controls. Number of refluxes was higher in patients with symptomatic refluxes than in those without. Infants with recurrent bronchitis had more refluxes than those with chronic cough and controls. Extent and timing of gastric emptying were similar in patients and controls.

CONCLUSION

Esophageal ultrasonography is a useful and physiological test in infants with recurrent respiratory diseases, which have a high prevalence of abnormal postcibal esophageal reflux and a gastric emptying similar to that of normal controls. Esophageal reflux is more severe in subjects with recurrent bronchitis than in those with chronic cough.