The assessment of children with suspected laryngopharyngeal reflux: An Otorhinolaringological perspective

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.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM)

PURPOSE

Paradoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required.

METHODS

Data were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration.

RESULTS

Patients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (β = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (β = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r² = 0.42).

CONCLUSIONS

On average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized.

Usefulness of matrix metalloproteinase-7 in saliva as a diagnostic biomarker for laryngopharyngeal reflux disease

Several diagnostic methods are currently being used to diagnose LPRD (laryngopharyngeal reflux disease), but have the disadvantage of being invasive, subjective, or expensive. Our purpose in this study was to investigate the correlation between pepsin and MMP-7 (Matrix Metalloproteinase-7) in pharyngeal secretions of subjects according to RSI (Reflux Symptom Index) score to find out the diagnostic value of MMP-7. We recruited 173 subjects aged between 19 and 85 years who completed the RSI scale. All samples were taken after waking up, and the amount of the pepsin and MMP-7 in saliva were measured by means of an enzyme activity assay. There was a significant increase of pepsin and MMP-7 activity in the study group with an RSI score of 13 or higher. The sensitivity and specificity of MMP-7 for predicting the possibility of an RSI of 13 or more was higher than that of pepsin. When MMP-7 and pepsin were combined, this sensitivity and specificity increased. An enzyme assay of MMP-7 in saliva may be a noninvasive and easy technique for diagnosing LPRD.

[Value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux in children]

OBJECTIVE

To study the value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux (LPR) in children.

METHODS

A total of 274 children with chronic cough who were treated from January 2016 to December 2019 were enrolled. The DX-pH detection system was used to conduct 24-hour airway pH monitoring. The association between chronic cough and LPR was analyzed.

RESULTS

Among the 274 children, there were 168 boys and 106 girls, with a median age of 62.8 months and a median airway pH value of 7.3. Of all the 274 children, 99 (36.1%) had LPR, and the incidence rate of LPR was 36.9% (62/168) in boys and 34.9% (37/106) in girls (P=0.737). The comparison of the incidence rate of LPR among children aged < 1 year, 1-6 years, and > 6 years showed that the younger children had a significantly higher incidence rate of LPR than the older ones (P=0.003). There was no significant difference in the incidence of LPR between the two groups with chronic cough of unknown etiology and definite etiology. The incidence of chronic cough was positively correlated with that of LPR (r_s=0.861, P < 0.01). Among the 99 children with positive RYAN index, 65 (66%) suffered from simple LPR.

CONCLUSIONS

LPR is highly associated with the development of chronic cough, and airway pH monitoring may be a safe and effective method for the diagnosis of LPR.

Frequency of gastroesophageal reflux disease in children with adenoid hypertrophy

OBJECTIVES

Recent studies have suggested that the reflux of gastric contents can cause adenoid hypertrophy (AH). The frequency of gastro-oesophageal reflux disease (GERD) in this AH population is unknown, but according to studies using pH-metry it may be as high as 65%. The aim of this study was to estimate the frequency of GERD among children with AH.

METHODS

This was a cross-sectional, multicentre, prospective study of children with AH selected for adenoidectomy. The diagnosis of AH was made by a single laryngologist using a flexible fiberscope. All children had 24-hr multichannel intraluminal pH-impedance (MII/pH) assessment. A GERD diagnosis was made using BioVIEW software analysis after manual review by a single investigator.

RESULTS

38 consecutive patients (21 males, mean age 6.58 years) were enrolled in the study. GERD was diagnosed in 5 (13.2%) patients. A total of 1462 gastro-oesophageal reflux events (GERs) were detected by MII/pH and the majority (60.9%) were acidic. The only significant differences between the GERD-positive and GERD-negative groups were the total number of GERs, and the number of acid GERs.

CONCLUSION

It is first study using MII/pH to assess the frequency of GERD in children with AH. The data suggest that GERD in children with AH seems to be not as common as it was previously raised. Further studies are needed to confirm these results.

The Role of Nutritional and Dietary Habits in Etiology in Pediatric Vocal Fold Nodule

OBJECTIVES

In pediatric pediatric vocal fold nodule (VFN) patients, different causes have been suggested in the development of the vocal cord nodule, including laryngopharyngeal reflux (LPR). It is known that the content of consumed foods, obesity, and other dietary behaviors are among the risk factors for the development of reflux. The aim of this study was to evaluate dietary and food consumption habits in pediatric VFN patients.

METHODS

This prospective-controlled study included 50 children with VFNs (age range 5-14 years) and 50 age-matched children without any voice disorders as a control group. BMI values of each participant were evaluated according to age-percentile range. The voice usage habits and personality structure of all the children were questioned. All patients underwent laryngeal examination and voice analysis. The Turkish Pediatric Voice Handicap Index (t-PVHI) and Child Voice Handicap Index-10 (t-CVHI) were completed by patients or their parents. The examination findings of all patients were evaluated with the reflux finding score (RFS), and their complaints were questioned with the reflux symptom index (RSI). In addition, eating and drinking at night, fast eating and excessive food consumption habits and the frequency of consumption of packaged foods defined as junk food, carbonated beverage were questioned. The data obtained were compared statistically between the two groups.

RESULTS

There was no significant difference between the study and control groups in terms of age, gender distribution, median BMI value, voice usage habits, and personality structure. In the study group, t-PVHI, t-CVHI, jitter, schimmer values, the mean RFS, and RSI scores were significantly higher than those of the control group. The number of children with high consumption of junk food and carbonated drinks was higher in the study group. There was no significant difference between the two groups in terms of dietary habits.

CONCLUSION

Food consumption habits may play a role in childhood voice problems in this population.

Visuoperceptual Analysis of the Videofluoroscopic Study of Swallowing: An International Delphi Study

INTRODUCTION

The Videofluoroscopic Swallow Study (VFSS) is a commonly used dysphagia assessment that is routinely analysed visuoperceptually. However, no consensus exists regarding which visuoperceptual measures should be used to analyse VFSSs. Current visuoperceptual measures for VFSSs are limited by poor quality and incomplete or indeterminate psychometric properties.

OBJECTIVE

This study aimed to establish the content validity for a new visuoperceptual VFSS measure for oropharyngeal dysphagia in adults, by identifying relevant domains of the construct and generating items and corresponding response scales.

METHODS

Consensus among experts in dysphagia and VFSS from over 20 countries was achieved across three rounds of anonymous online surveys, using the Delphi technique. Participants judged relevance and comprehensiveness of definitions of visuoperceptual domains of VFSS and the relevance of various domains to the overall construct. After reaching consensus on definitions of relevant domains, consensus on items were established using the same process.

RESULTS

Participants achieved consensus on definitions of 32 domains recommended for analysis, and at least one item per domain (range 1-4). Domains selected by participants included both those which occur in existing measures and domains which have not been included in any measures to date. This study will form the basis for content validity of a new measure for VFSS.

CONCLUSIONS

This first phase of developing a visuoperceptual measure of VFSS resulted in the identification of 32 domains and 60 items for oropharyngeal dysphagia. Developers can now advance to the next phase of measure construction; prototype development and psychometric testing.

Reflux and dental disorders in the pediatric population: A systematic review

OBJECTIVES

To investigate the role of laryngopharyngeal reflux (LPR) or gastroesophageal reflux disease (GERD) in the development of dental disorders in pediatric population.

METHODS

PubMed, Scopus Cochrane database were assessed for subject headings using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) recommendations. Relevant studies published between January 1990 and January 2020 describing the association between reflux and dental disorders in children were retrieved. Three authors reviewed the LPR diagnosis method; inclusion criteria and outcomes. The bias analysis was performed through the tools of the Oxford Centre for Evidence-Based Medicine evidence levels.

RESULTS

The electronic search identified 126 publications, of which 11 clinical studies and 2 basic science researches met our inclusion criteria. There is an important heterogeneity between studies about diagnostic method and clinical outcome evaluation. All studies based the reflux diagnosis on GERD criteria. No author considered hypopharyngeal nonacid reflux episodes through hypopharyngeal-esophageal intraluminal multichannel impedance pH monitoring (HEMII-pH). The results of studies support a higher prevalence of dental erosion in children with GERD compared with healthy individuals. Controversial findings were found about the potential association between reflux and caries, and the modification of both saliva composition and production in reflux children.

CONCLUSION

The association between reflux and dental disorder is still uncertain. Future studies considering pharyngeal acid and nonacid reflux episodes through HEMII-pH are needed to confirm this hypothesis. The pepsin detection in saliva would be an additional way for detecting LPR in children with dental disorders.

[Comparative study of three methods in the diagnosis of laryngopharyngeal reflux in children]

Objective:To compare the consistency of RSI and RFS, pepsin detection and 24 h Dx-pH monitoring in the diagnosis of laryngopharyngeal reflux （LPR） in children. Method:A retrospective analysis was made of 76 children with suspicious LPR. A total of 65 children with suspicious LPR were finally diagnosed. RSI and RFS scales, pepsin detection and Dx-pH monitoring were performed simultaneously. The diagnostic consistency of the three methods was tested, and the sensitivity and specificity were calculated. Result:The sensitivity of pepsin detection, 24 h Dx-pH monitoring, RSI and RFS in the diagnosis of LPR in 76 suspected LPR patients were 95.31%, 66.15% and 84.62%, and the specificity were 100%, 81.82% and 72.73%. The pepsin detection was well consistent with the scale（Kappa>0.75）, pepsin detection and 24 h Dx-pH monitoring were in medium consistency（Kappa=0.467）, and 24 h Dx-pH monitoring and scale were in medium consistency（Kappa=0.446）. Conclusion:Pepsin detection can be used as a reliable index for the diagnosis of LPR in children. It is objective, economical, non-invasive, comfortable and easy to spread.

Investigation of pepsin in tears of children with laryngopharyngeal reflux disease

OBJECTIVES

Numerous investigations postulated that laryngopharyngeal reflux (LPR) is implicated in the pathogenesis of various upper airway inflammatory diseases as sinusitis or dacryostenosis. The presence of pepsin in tears might be confirmed the presuntive hypothesis of the arrival in the nasolacrimal ducts and precorneal tears film through the laryngopharyngeal reflux of either gastric acid or stomach secretions (pepsin) with inflammatory potentialities. The aim of this preliminary study was to identify the presence or absence of pepsin in the tears collected from children with a high suspicion of LPR who underwent 24-h pH (MII-pH) monitoring to confirm the disease.

METHODS

This study enrolled 20 patients suffering from symptoms of laryngopharyngeal reflux that underwent 24-h multichannel intraluminal impedance (MII)-pH monitoring to confirm the disease. The findings of the study group were compared with those of a control group of patients with negative pH monitoring. The quantitative analysis of human pepsin concentration in the tear samples was performed by ELISA method in both groups.

RESULTS

Four children (20%) of the study group showed pepsin in the tears. All of the subjects belonging to the control group were negative for its presence. No difference differences in the total number of reflux episodes and the number of weakly basic reflux in the pepsin positive patients vs. pepsin negative children were present.

CONCLUSIONS

20% of the children with diagnosed LPR showed pepsin in the tears. Our specific investigation might provide information regarding sinusitis or dacryostenosis.