Gastroesophageal Reflux and Upper Airway Disease: A Commentary

Estimating the incidence rate ratio of common cold among patients with non-apnea sleep disorders: a retrospective cohort study

The purpose was to explore the potential effects of nonapnea sleep disorders (NSDs) and hypnotic use on the incidence of common cold. This study adapted population-based retrospective cohort study designed. We used the data from the Taiwan National Health Insurance Research Database between 1998 and 2011. In total, 59,476 patients with NSDs were included in the study cohort, and the reference cohort comprised 59,476 propensity score-matched patients. We conducted a Poisson regression analysis to assess the incidence of common cold. The overall incidence of common cold was significantly higher than that in the reference cohort. Compared with the patients of the reference cohort without hypnotic use, those of the NSDs cohort with benzodiazepines and zolpidem use had higher incidence of common cold. In conclusion, study cohort had a higher incidence of developing common cold, and particularly pronounced in NSDs with hypnotic use.

Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background

Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.

Matrix association region/scaffold attachment region: the crucial player in defining the positions of chromosome breaks mediated by bile acid-induced apoptosis in nasopharyngeal epithelial cells

Background

It has been found that chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC). CRS can be caused by gastro-oesophageal reflux (GOR) that may reach nasopharynx. The major component of refluxate, bile acid (BA) has been found to be carcinogenic and genotoxic. BA-induced apoptosis has been associated with various cancers. We have previously demonstrated that BA induced apoptosis and gene cleavages in nasopharyngeal epithelial cells. Chromosomal cleavage occurs at the early stage of both apoptosis and chromosome rearrangement. It was suggested that chromosome breaks tend to cluster in the region containing matrix association region/scaffold attachment region (MAR/SAR). This study hypothesised that BA may cause chromosome breaks at MAR/SAR leading to chromosome aberrations in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is a deletion hotspot in NPC.

Methods

Potential MAR/SAR sites were predicted in the AF9 gene by using MAR/SAR prediction tools. Normal nasopharyngeal epithelial cells (NP69) and NPC cells (TWO4) were treated with BA at neutral and acidic pH. Inverse-PCR (IPCR) was used to identify chromosome breaks in SAR region (contains MAR/SAR) and non-SAR region (does not contain MAR/SAR). To map the chromosomal breakpoints within the AF9 SAR and non-SAR regions, DNA sequencing was performed.

Results

In the AF9 SAR region, the gene cleavage frequencies of BA-treated NP69 and TWO4 cells were significantly higher than those of untreated control. As for the AF9 non-SAR region, no significant difference in cleavage frequency was detected between untreated and BA-treated cells. A few breakpoints detected in the SAR region were mapped within the AF9 region that was previously reported to translocate with the mixed lineage leukaemia (MLL) gene in an acute lymphoblastic leukaemia (ALL) patient.

Conclusions

Our findings suggest that MAR/SAR may be involved in defining the positions of chromosomal breakages induced by BA. Our report here, for the first time, unravelled the relation of these BA-induced chromosomal breakages to the AF9 chromatin structure.

Electronic supplementary material

The online version of this article (10.1186/s12920-018-0465-4) contains supplementary material, which is available to authorized users.

Bile acids at neutral and acidic pH induce apoptosis and gene cleavages in nasopharyngeal epithelial cells: implications in chromosome rearrangement

BACKGROUND

Chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC) while nasopharyngeal reflux is known to be one of the major aetiological factors of CRS. Bile acid (BA), the component of gastric duodenal contents, has been recognised as a carcinogen. BA-induced apoptosis was suggested to be involved in human malignancies. Cells have the potential and tendency to survive apoptosis. However, cells that evade apoptosis upon erroneous DNA repair may carry chromosome rearrangements. Apoptotic nuclease, caspase-activated deoxyribonuclease (CAD) has been implicated in mediating translocation in leukaemia. We hypothesised that BA-induced apoptosis may cause chromosome breaks mediated by CAD leading to chromosome rearrangement in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is one of the most common deletion sites in NPC.

METHODS

We tested the ability of BA at neutral and acidic pH in inducing phosphatidylserine (PS) externalisation, reactive oxygen species (ROS) production, mitochondrial membrane potential (MMP) disruption, and caspase 3/7 activity in normal nasopharyngeal epithelial (NP69) and NPC (TWO4) cells. Inverse-PCR (IPCR) was employed to detect AF9 gene cleavages. To investigate the role of CAD in mediating these cleavages, caspase inhibition was performed. IPCR bands representing AF9 cleaved fragments were sequenced.

RESULTS

BA-treated cells showed higher levels of PS externalisation, ROS production, MMP loss and caspase 3/7 activity than untreated control cells. The effect of BA in the induction of these intracellular events was enhanced by acid. BA at neutral and acidic pH also induced significant cleavage of the AF9 gene. These BA-induced gene cleavages were inhibited by Z-DEVD-FMK, a caspase-3 inhibitor. Intriguingly, a few chromosome breaks were identified within the AF9 region that was previously reported to participate in reciprocal translocation between the mixed lineage leukaemia (MLL) and AF9 genes in an acute lymphoblastic leukaemia (ALL) patient.

CONCLUSIONS

These findings suggest a role for BA-induced apoptosis in mediating chromosome rearrangements in NPC. In addition, CAD may be a key player in chromosome cleavages mediated by BA-induced apoptosis. Persistent exposure of sinonasal tract to gastric duodenal refluxate may increase genomic instability in surviving cells.

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review

Introduction

The relationship between gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) is still a controversial issue in literature.

Objective

A systematic review of the association between these two diseases in adult patients.

Methods

Systematic review in PubMed and Cochrane Database with articles published between 1951 and 2015. We included all articles that specifically studied the relationship between CRS and GERD.

Results

Of the 436 articles found, only 12 met the inclusion criteria. Eight cross-sectional articles suggest a relation between CRS and GERD, especially on CRS that is refractory to clinical or surgical treatment. However, the groups are small and methodologies are different. Four other longitudinal studies have assessed the effect of treatment with proton pump inhibitors (PPIs) on the improvement of symptoms of CRS, but the results were conflicting.

Conclusions

There seems to be relative prevalence of reflux with intractable CRS. There is still a lack of controlled studies with a significant number of patients to confirm this hypothesis. Few studies specifically assess the impact of treatment of reflux on symptom improvement in patients with CRS.

Helicobacter Pylori and Laryngopharyngeal Reflux in Chronic Rhinosinusitis

OBJECTIVES: Investigation of the potential role of several laryngopharyngeal reflux contents in sinus disease.

STUDY DESIGN AND SETTING: A controlled cohort analysis of Helicobacter pylori, pepsin and pepsinogen I in inflamed and non-inflamed sinonasal tissue. Fifteen patients, selected for surgery due to chronic medically refractory rhinosinusitis, had their pathologic sinus tissue analyzed for polymerase chain reaction detection of H. pylori DNA and assayed for pepsin and pepsinogen I tissue concentration levels. A control group of 5 patients undergoing surgery for anatomic sinonasal abnormalities provided non-inflammatory mucosa specimens for comparison.

RESULTS: H. pylori was found scattered in inflamed and non-inflamed mucosa, whereas sinonasal tissue pepsin/pepsinogen never rose above blood levels in both groups.

CONCLUSIONS: Evidence of intra-operative peptic reflux into the sinuses was not found. As H. pylori was similarly encountered in healthy and diseased sinus mucosa, it seemingly fails to support a pathogenic role for this organism in the sinuses.

EBM rating: B-2b

An evaluation of olfactory function in adults with gastro-esophageal reflux disease

CONCLUSION

To the best of the authors' knowledge, this study is the first to evaluate the olfactory function of adult patients diagnosed with GERD. The results revealed that adults with GERD have diminished olfactory function.

OBJECTIVE

This study aimed to evaluate the olfactory abilities of subjects using the 'Sniffin' Sticks' olfactory test.

METHODS

A total of 35 men and women aged 18-60 years with a diagnosis of GERD and 45 healthy controls were included in the study. The Sniffin' Sticks olfactory test results of the two groups were compared, and the relationship between the study findings and the olfactory parameters was evaluated.

RESULTS

The odor threshold (10.1; 9.5, p = 0.016), odor identification (9.6; 8.1, p < 0.001), and odor discrimination (10.7; 8.9, p < 0.001) of the GERD group were significantly lower than those of the control group. A statistically significant positive correlation was detected between the accompanying chronic pharyngitis, chronic sinusitis, and odor parameters. A significant correlation was not detected between the laryngeal findings and the olfactory parameters.

[pH values in the pharynx of the patients presenting with compromised nasal breathing of inflammatory and non-inflammatory genesis concomitant with gastroesophageal reflux disease]

The objective of the present study was to estimate the influence of gastroesophageal reflux disease (GERD) on the pH values in the pharynx and nose. It included 87 patients at the age varying from 18 to 81 years admitted to the Irkutsk-based Railway Clinical Hospital and allocated to four groups. Group 1 was comprised of 25 patients presenting with gastroesophageal reflux disease and chronic rhinosinusitis (CRS), group 2 consisted of 29 patients with CRS in the absence of GERD, group 3 included 22 patients with nasal septum deformations (NSD) and GERD, group 4 included 11 patients with NSD and motor rhinitis without GERD. The control group was formed from 10 volunteers. pH was measured by the contact method with the use ofEkokhim indicator paper. Gastroesophageal reflux disease was diagnosed following the recommendations of the Montreal consensus. It was shown that pH values in the pharynx of the patients with compromised nasal breathing of any origin in combination with GERD were lower than in the absence of GERD and in the healthy volunteers. The study groups did not differ in terms of pH values in the nasal cavity. It is concluded that pH values 4 or lower may serve as the criterion for pharyngo-laryngeal reflux (PLR) concomitant with HERD while pH 5 occurs more frequently in the patients with compromised nasal breathing of any etiology, regardless of the presence or absence of GERD.Disordered nasal breathing of any genesis in the patients presenting with gastroesophageal reflux disease was associated with the feeling of the lump in the throat, congestion of the respiratory tract and the nose, pain in the ears, cardialgia, and irregular heartbeat. It isrecommended to use pH measurements as a criterion for diagnostics of pharyngo-laryngeal reflux in the patients presenting with gastroesophageal reflux disease.

Zolpidem Use Associated With Increased Risk of Pyogenic Liver Abscess: A Case-Control Study in Taiwan

The purpose of this study was to explore the association between zolpidem use and pyogenic liver abscess in Taiwan.This was a population-based case-control study using the database of the Taiwan National Health Insurance Program since 2000 to 2011. We identified 1325 patients aged 20 to 84 years with the first-attack of pyogenic liver abscess as the cases, and 5082 patients without pyogenic liver abscess matched with sex, age, comorbidities, and index year of hospitalization for pyogenic liver abscess as the controls. Patients whose last remaining 1 tablet for zolpidem was noted ≤7 days before the date of admission for pyogenic liver abscess were defined as current use of zolpidem. Patients whose last remaining 1 tablet for zolpidem was noted >7 days before the date of admission for pyogenic liver abscess were defined as late use of zolpidem. Patients who never received 1 prescription for zolpidem were defined as never use of zolpidem. A multivariable unconditional logistic regression model was used to measure the odds ratio (OR) and 95% confidence interval (CI) to explore the association between zolpidem use and pyogenic liver abscess.After adjustment for possible confounding variables, the adjusted OR of pyogenic liver abscess was 3.89 for patients with current use of zolpidem (95% CI 2.89, 5.23), when compared with those with never use of zolpidem. The adjusted OR decreased to 0.85 for those with late use of zolpidem (95% CI 0.70, 1.03), but without statistical significance.Current use of zolpidem is associated with the increased risk of pyogenic liver abscess. Physicians should take the risk of pyogenic liver abscess into account when prescribing zolpidem.

Alkaline pH in middle meatus in cases of chronic rhinosinusitis

STUDY TYPE

Prospective and observational study.

METHODS

The study group was divided in two groups consisted of 50 normal subjects (100 meati) and 50 patients (100 meati) of chronic rhinosinusitis (CRS). All subjects underwent nasal endoscopy along with measurement of the pH of the middle meatus using a portable pH monitoring device. Statistical analysis was done to compare mean pH of normal middle meatus with the diseased one.

RESULTS

The mean pH of normal 100 middle meati was measured to be 7.35(±0.82). The mean pH of 100 middle meatii in CRS patients was higher 7.81(±0.83) and was found to be statistically significant (p=0.00011).

CONCLUSION

Alkaline pH (7.81) was observed in the middle meatus of CRS patients.

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.

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.

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.

Recurrent respiratory infections

The child who has recurrent infections poses one of the most difficult diagnostic challenges in pediatrics. The clinician faces a two-fold challenge in determining first whether the child is normal or has a serious disease, and then, in the latter case, how to confirm or exclude the diagnosis with the minimum number of the least invasive tests. It is hoped that, in the absence of good-quality evidence for most clinical scenarios, the experience-based approach described in this article may prove a useful guide to the clinician.

Correlation between nasal mucociliary clearance time and gastroesophageal reflux disease: our experience on 50 patients

OBJECTIVES

It is increasingly suggested that gastroesophageal reflux disease (GERD) could play an important role in chronic rhinosinusitis. The aim of our study was to evaluate the nasal mucociliary clearance time in GERD patients and if any correlations could be assumed.

METHODS

Fifty GERD patients endoscopically diagnosed underwent an ear, nose and throat evaluation. The saccharin test and the 20-Item Sino-nasal Outcome Test (SNOT-20) were administered to 50 participants who correspond to our inclusion criteria. The saccharin test is a validated proof to verify the nasal mucociliary clearance time and the SNOT-20 is a disease-specific, health-related quality of-life questionnaire widely used for the assessment of rhinosinusitis.

RESULTS

Thirty-seven (74%) patients showed a significant increment in their saccharin test values in comparison with the others subjects (23.79+/-5.58 vs 8.15+/-2.06min; P=0.0001). This group of patients reported only typical gastroesophageal symptoms (GES) without any other complaint. Gastroesophageal endoscopic findings revealed some interesting and unexpected results in this subgroup. The remainder of patients considered (13/50; 26%) showed normal values for nasal mucociliary clearance time and they referred only typical extraesophageal symptoms (EES). In any case and in both groups rhinosinusitis complaints were present. The SNOT-20 test results were normal in all patients even if a significant difference for GES group could be highlighted (19.3 vs 7.4; P<0.005).

CONCLUSION

This study supports the assumption of possible and important correlations between nasal mucociliary clearance time and GERD. GERD could be an altering factor for nasal function also in absence of laryngo-pharyngeal symptoms although to verify this interesting hypothesis more validated data are necessary.

Nasal pepsin assay and pH monitoring in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to determine the relationship between chronic rhinosinusitis (CRS) and laryngopharyngeal reflux (LPR). We also investigated the diagnostic value of pepsin in nasal lavage by means of fluorometric assay as compared with 24-hour dual-probe pH monitoring.

STUDY DESIGN AND METHODS

This is a controlled, prospective study from a retrospective dataset of 33 patients recruited for endoscopic sinus surgery between 2005 and 2006 in a tertiary care referral center (Hacettepe University Medical Center). All patients underwent 24-hour dual-probe pH monitoring and nasal lavage fluid investigation for pepsin. A fluorometric pepsin assay using casein-fluorescein isothiocyanate in nasal lavage fluid was used to detect LPR. The control group included 20 patients who were proven not to have sinusitis.

RESULTS

A higher incidence of pharyngeal acid reflux events was found in patients with CRS (29 of 33, 88%) compared with the control patients (11 of 20, 55%). The difference was statistically significant (P = .01). The fluorometric pepsin assay was correlated to the results of 24-hour dual-probe monitoring for LPR diagnosis with a 100% sensitivity and 92.5% specificity. These data suggest that an association between CRS and LPR is present and that the detection of pepsin in nasal lavage fluid may provide a noninvasive and feasible method of LPR screening.

Nonallergic rhinitis in children

Nonallergic rhinitis in children is a medical condition that has not been well defined and the true incidence is unknown. Current treatment recommendations are based on data obtained from adult studies. The mechanisms of pediatric nonallergic rhinitis are also unclear. The concept that laryngopharyngeal reflux (LPR) events may play a critical role in the pathogenesis of upper airway disease is presently under investigation. Although LPR is being better delineated and appropriate methods of diagnosis and treatment are being studied, substantial evidence links LPR with several disease states including rhinitis, sinus disease, and middle ear disease. Due to the lack of information concerning the etiology of nonallergic rhinitis in children, LPR should be considered in the differential diagnosis of a child with negative skin tests and chronic rhinitis symptoms. The clinician should especially give attention to this diagnosis when a child presents with recurrent co-morbid conditions such as chronic sinusitis or persistent middle ear disease.

Making the call: the diagnosis of acute community-acquired bacterial sinusitis

BACKGROUND

Although one of the most common illnesses encountered in the primary care setting, acute community-acquired bacterial sinusitis (ACABS) can be a challenge to diagnose.

METHODS

Existing diagnostic modalities ranging from clinical history to imaging studies used to diagnose ACABS are discussed.

RESULTS

Numerous methods exist but they do not distinguish well between viral and bacterial illness.

CONCLUSION

Diagnosis of ACABS should primarily be made based on the clinical history. Other modalities provide useful information in select cases.

Long-Term Follow-Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study is to retrospectively compare the long-term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

STUDY DESIGN

This is a retrospective, age-matched, cohort outcome study performed at a tertiary-care hospital.

METHODS

Two groups of young children (2-5 yr old) with chronic rhinosinusitis were treated with endoscopic sinus surgery or medically managed and evaluated 10 years after their initial therapy. Of the 131 eligible patients, 67 could be located and consented to participate in the study. Six symptoms (day cough, night cough, irritability or crankiness, headaches, nasal airway obstruction, and purulent rhinorrhea) were used to assess the outcome of their treatment.

RESULTS

Children undergoing endoscopic sinus surgery had more significant disease as noted on the computed tomography (CT) scans. Their symptom severity, however, was similar. When individual symptoms were compared, there were no statistically significant differences between the surgically and medically managed groups. When the mean was controlled for baseline symptom severity and CT severity, there was statistical improvement in nasal airway obstruction and decreased rhinorrhea. There was a trend toward improvement in cough, but this was not statistically significant. Parenteral assessment of improvement (change) in symptoms (P = .001) and their degree of satisfaction with treatment (P = .005) was significantly higher in the surgically managed group.

CONCLUSIONS

Children who have chronic rhinosinusitis improve in their symptoms of nasal airway obstruction and purulent discharge if they undergo surgery. Parents of young children with chronic rhinosinusitis appear to be more satisfied with the outcome of surgical management than medical management when assessed 10 years later.

Oesophageal replacement in children with indolent stricture of the oesophagus

OBJECTIVE

To evaluate the indications for and results of oesophageal replacement for acquired oesophageal stricture in children.

METHODS

This was a descriptive interventional study. Between 1987 and 2003, patients who had peptic or corrosive stricture were included in the study. Age and gender were analysed and any history of ingestion of caustic agents or untreated reflux was noted. Types of symptoms such as progressive dysphagia to solids and liquids and extent of respiratory infections were evaluated. Nutritional deprivation was also measured. Success or failure of dilatation at the time of endoscopy was taken into account. The criterion for oesophageal replacement was recurrence of stricture within 3 weeks of the previous dilatation. Patients were prepared with general supportive care. Feeding gastrostomy was performed in 12 patients who were severely malnourished. No patients underwent oesophagectomy of the strictured oesophagus. Short- and long-term complications were recorded.

RESULTS

Of the 54 patients, 34 were male and 20 were female. Colonic conduit and reverse gastric tube were used in 27 patients each. Three patients had leak and were treated conservatively. Six patients developed anastomotic stricture but benefited remarkably from periodic dilatation and, in the long-term, remained symptom-free. Results were generally very gratifying.

CONCLUSION

Most patients who require oesophageal conduit do well and catch up with their growth and development.

Diagnostic and management problems of laryngopharyngeal reflux disease in children

OBJECTIVE

Reflux is a common pediatric disorder and an association between reflux and otolaryngological conditions has been described. However, to prove a causal relationship a pathophysiological pathway must be identified, diagnostic test with high specificity and sensitivity must be developed and conservative or surgical treatment of reflux should be shown to predictably improve the otolaryngological problems. This review study aims at examining the available evidence for the above controversial issues.

METHODS

Articles on pediatric laryngopharyngeal reflux published in English during the last decade were searched using Ovid and PubMed.

RESULTS

A lack of consensus was found in four separate but interdependent areas: clinical manifestations, diagnostic testing, interpretation of findings and treatment. Although clinical experience and uncontrolled case series suggest that laryngopharyngeal reflux may possibly contribute to apnea, recurrent upper respiratory infections, laryngeal symptoms (mainly laryngomalacia and subglottic stenosis), sinusitis and otitis convincing data are lacking. For pediatric studies, the diagnostic role of pH monitoring, barium esophagram, scintigraphy, impedance monitoring, laryngoscopic examination, laryngeal biopsy and symptom assessment questionnaires remain to be defined. Interpretation of pharyngeal reflux events is controversial and the lack of established normative values as well as the existing variability in the diagnostic criteria (reflux definition, duration and number of pathological reflux events) limits the ability to directly compare results. Proposed laryngopharyngeal reflux treatment (lifestyle modification, medical or surgical therapy) is mostly empiric, with no significant placebo-controlled trials of treatment and outcomes.

CONCLUSIONS

Limited evidence exists to support a causative relationship between reflux and any otorhinolaryngological condition or the effectiveness of treatment. Epidemiological and large-scale prospective controlled studies are required to clarify these issues.

Possible role of Helicobacter pylori in the etiopathogenesis of chronic otitis media

OBJECTIVE

To investigate a possible contribution from Helicobacter pylori to the etiopathogenesis of chronic otitis media.

STUDY DESIGN

Prospective clinical trial.

METHODS

Tympanomastoidectomy, radical mastoidectomy, and modified radical mastoidectomy procedures were performed according to the pathology of ear disease. Biopsy specimens were taken from middle ear, mastoid antrum, and tympanic orifice of eustachian tube. Helicobacter pylori DNA was extracted from these biopsy specimens by using nested polymerase chain reaction.

RESULTS

Helicobacter pylori DNA was detected in 3 (7.9%) of 38 chronic otitis media patients.

CONCLUSION

Even though it is possible to detect Helicobacter pylori in middle ear cleft in chronic otitis media, its role in the etiopathogenesis of the issue is controversial.

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

OBJECTIVE

Gastroesophageal reflux disease (GERD) has been implicated in various extra-gastroesophageal diseases, especially in the upper and lower airways (atypical GERD). The objective of the present study was to determine the frequency of gastroesophageal and extra-gastroesophageal symptoms in pediatric patients with GERD and their response to the general treatment.

MATERIAL AND METHODS

A retrospective study was conducted on 45 children of both sexes aged 3 months-12 years with GERD diagnosed by clinical examination and 24h single-channel pHmetry. The gastroesophageal and extra-gastroesophageal symptoms, the treatment instituted and the response of the patients to the latter were determined.

RESULTS

Five symptomatologic groups were identified: gastroesophageal (51.11%), pulmonary (recurrent pneumonia, 40%, and bronchial asthma, 46.67%), chronic cough (64.44%), rhinologic (chronic nasal obstruction, 68.88%, nasal secretion, 55.55%, and nose itching, 46.66%), and pharyngo-otologic (recurrent acute middle ear infection, 35.56%, and recurrent tonsillitis, 24.44%). The response to treatment (antireflux drugs, antiallergic drugs, and surgical procedures) resulted in cure in 24 patients (53.34%), while 21 continued to be symptomatic. The cure rate was 69.56% for the gastroesophageal group, 100% for the recurrent pneumonia group, 80.95% for the bronchial asthma group, 68.96% for the chronic cough group, 83.87% for the chronic nasal obstruction group, 80% for the nasal secretion group, 85.71% for the nose itching group, 100% for the recurrent acute middle ear infection group, and 90.90% for the recurrent tonsillitis group. Total treatment time was 1.8 times longer for the remission of extra-gastroesophageal symptoms. Exclusive antireflux treatment promoted full remission of the otorhinolaryngologic symptoms in 38.89% of patients (nasal-41.17%, recurrent acute middle ear infection-12.5%, and recurrent tonsillitis-18.18%).

CONCLUSION

GERD can cause otorhinolaryngologic symptoms in children and remission of these symptoms can be obtained with antireflux therapy.

Pediatric sinusitis

Sinusitis remains one of the most prevalent but clinically challenging disease processes in pediatrics. Lack of appropriate culture evidence makes the diagnosis difficult, and increasing microbial resistance presents a therapeutic dilemma. This article examines causative factors, appropriate diagnostic measures, and effective medical and surgical treatment options for sinusitis in the pediatric population.

Acute histologic effects of extraesophageal reflux on vocal fold healing

This study evaluates how extraesophageal reflux affects membranous vocal fold healing in a canine model. We created membranous vocal fold injuries in the animals and randomly assigned them to topical application of acid and pepsin at pH 2 or pH 6 or of normal saline solution every other day for 12 days. The experimental vocal folds were compared to uninjured, control vocal folds from animals painlessly sacrificed for other reasons. Hematoxylin and eosin, fibronectin, and procollagen I staining were performed for histologic analysis. The injured specimens had three times greater cellular infiltrate (p < or = .001, analysis of variance) and twice as much fibronectin and procollagen I (p < or = .001, analysis of variance) as did the specimens from the control animals. No significant differences or trends were identified for cellular infiltrate, fibronectin, or procollagen I within the injured groups (p > .05, Bonferroni t-test). Acute wound healing did not appear to be influenced by the presence of acid and pepsin at pH 2 or 6 as compared to saline solution.

Direct Nasopharyngeal Reflux of Gastric Acid is a Contributing Factor in Refractory Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

To determine whether there is a difference in the prevalence of reflux in patients with refractory chronic rhinosinusitis (CRS) compared with control patients, including whether direct nasopharyngeal reflux (NPR) occurs in CRS patients. It is hypothesized that refractory CRS patients have a greater incidence of laryngopharyngeal reflux and NPR events and that NPR is a significant etiologic factor for CRS in these patients.

STUDY DESIGN

Prospective study.

METHODS

The study group consisted of 38 patients with a history of at least one endoscopic sinus surgery (ESS) with continued CRS symptoms and mucosal inflammation on endoscopy. The first control group consisted of 10 patients who had at least one ESS procedure and had no symptoms of CRS or mucosal inflammation a minimum of 1 year postoperatively. The second control group consisted of 20 subjects with no history of CRS or sinus surgery. All patients completed reflux symptom scales, a 20 item sinonasal outcome test, and a sinusitis symptom scale and underwent nasal endoscopy to grade the nasal mucosal findings. Patients underwent a 24 hour pH study with a specially designed probe with sensors located in the nasopharynx, 1 cm above the upper esophageal sphincter (UES), and the distal esophagus. The pH recordings were evaluated for NPR events less than pH 4 and 5. Reflux at the UES probe was considered pathologic if there were more than 6.9 episodes for the entire study or the reflux area index (RAI) exceeded 6.3. Esophageal reflux was defined as abnormal if greater than 4% of the study time was spent at pH less than 4. Statistical analysis was performed with Fisher's exact test to compare the reflux parameters and with analysis of variance and Tukey's post hoc analysis for the symptom and examination scores.

RESULTS

No statistical difference was found between the two control groups for any parameters at any sites. When a single outlier was dropped from the nonCRS control group, less NPR was found in the nonCRS group compared with the successful ESS control group (P = .03). Because these groups were statistically homogenous, they were collapsed into a single control group. Compared with the control group, the study group had significantly more patients with NPR events pH less than 4 (39% vs. 7%, P = .004) and an even greater difference in the number of patients with NPR events pH less than 5 (76% vs. 24%, P = .00003). At the UES, 74% of the study group had greater than 6.9 reflux episodes, compared with 38% of control patients (P = .006). The UES RAI was abnormal for 58% of the study group compared with 21% of the control group (P = .007). The study group also had more gastroesophageal reflux (66% vs. 31%, P = .007). For nasopharynx and UES reflux parameters, the differences between study and control groups increased when the patients with isolated frontal recess disease were removed from the dataset. The study group also had higher scores on all symptom and examination scores (P = .001 for each scale).

CONCLUSIONS

Patients with persistent CRS after ESS have more reflux at the nasopharynx, UES, and distal esophagus than controls. The greatest difference is in NPR, especially pH less than 5. This is the first study to document NPR in CRS patients, and it is likely to represent an important causative factor of refractory CRS in adults.

Clinical manifestations and complications of gastroesophageal reflux disease (GERD)

Gastroesophageal reflux-induced diseases are among the most common disorders and are associated with classical oesophageal manifestations of gastroesophageal reflux disease (GERD) including a range of symptoms such as heartburn, acid regurgitation and chest pain, and also organic manifestations such as oesophagitis, oesophageal strictures and ulcerations, Barrett's oesophagus and oesophageal adenocarcinoma. Recognition of its impact on other organ systems, extra-oesophageal reflux diseases, such as the ear, nose and throat (ENT) region and the bronchopulmonary system, as well as its contribution to symptoms such as chest pain and sleep disturbances, is also increasing. This paper addresses the symptoms, diseases and complications in which the abnormal reflux of gastric content to the oesophagus and adjacent organ systems is believed to be a frequent contributory factor.

Twenty-four-hour esophageal pH monitoring in children and adolescents with chronic and/or recurrent rhinosinusitis

Gastroesophageal reflux (GER) disorder was studied in children and adolescents with chronic and/or recurrent rhinosinusitis not associated with bronchial asthma. Ten children with a clinical and radiological diagnosis of chronic and/or recurrent rhinosinusitis, consecutively attended at the Pediatric Otolaryngology Outpatient Clinic, Federal University of São Paulo, were evaluated. Prolonged esophageal pH monitoring was used to investigate GER disorder. The mean age of the ten patients evaluated (eight males) was 7.4 +/- 2.4 years. Two patients presented vomiting as a clinical manifestation and one patient presented retrosternal pain with a burning sensation. Twenty-four-hour esophageal pH monitoring was performed using the Sandhill apparatus. An antimony probe electrode was placed in the lower third of the esophagus, confirmed by fluoroscopy and later by a chest X-ray. The parameters analyzed by esophageal pH monitoring included: total percent time of the presence of acid esophageal pH, i.e., pH below 4 (<4.2%); total number of acid episodes (<50 episodes); number of reflux episodes longer than 5 min (3 or less), and duration of the longest reflux episode (<9.2 min). One patient (1/10, 10%) presented a 24-h esophageal pH profile compatible with GER disorder. This data suggest that an association between chronic rhinosinusitis not associated with bronchial asthma and GER disorder may exist in children and adolescents, especially in those with compatible GER disorder symptoms. In these cases, 24-h esophageal pH monitoring should be performed before indicating surgery, since the present data suggest that 10% of chronic rhinosinusitis surgeries can be eliminated.

Laryngopharyngeal Reflux: Trends in Diagnostic Interpretation Criteria

Laryngopharyngeal reflux (LPR) is becoming recognized as a clinical entity with a variety of presentations distinct from those of gastroesophreflux disease (GERD). However, much uncertainty remains as to what is considered pathologic versus physiologic reflux. The aim of the study was to determine the normal range of pharyngeal reflux (PR) occurring in healthy adults based on pH-monitoring parameters utilized in the DeMeester scoring system for GERD. We have reviewed the current pool of prospective literature examining ambulatory dual-channel pH-monitoring study data derived from hypopharyngeal proximal probes in normal adults. From our review we have identified trends in several monitoring parameters based on the DeMeester scoring system for GERD. Our discussion recognizes and accepts the limitations imposed by small sample sizes and the number of healthy individuals that would be required to determine the general adult physiologic range of PR. We also explore the possible need for separate normal PR reference intervals based on age or gender disparities. Additional discussion and the summary address future directions for LPR research notably, (1) identification of the most appropriate research paradigm for LPR (i.e., pH 4 vs. 5), (2) establishing reproducibility for the appropriate LPR research paradigm, and (3) complementary modalities to ambulatory dual-channel pH monitoring for the study of acid and nonacid bolus movement within the esophagus

Chronic sinusitis and gastroesophageal reflux: are they related?

PURPOSE OF REVIEW

Gastroesophageal reflux has been implicated in many disorders affecting the upper airway over the past three decades. This article reviews the recent literature regarding the relationship of chronic rhinosinusitis to gastroesophageal reflux.

RECENT FINDINGS

Recent studies have demonstrated that patients with chronic rhinosinusitis have an increased prevalence of gastroesophageal reflux. In addition, many patients (especially children) have had improvement in their chronic sinonasal symptoms after therapeutic trials of antireflux therapy.

SUMMARY

It is possible that gastroesophageal reflux plays a role in some patients with chronic rhinosinusitis; thus, evaluation and treatment should be considered in this patient population.

The role of 24 h pH-recording in pediatric otolaryngologic gastro-esophageal reflux disease

The purpose of this study was to investigate the role of 24 h pH monitoring for the diagnosis of otolaryngologic including rhinologic manifestations of gastro-esophageal reflux (GER) in children and if possible to correlate the results with the efficacy of medical treatment. This is a retrospective study of 72 children from January 1997 to December 1999. The children were separated into three groups according to the main symptoms (although association of symptoms was frequent): rhinologic (n=28), laryngotracheal (n=28) and pharyngeal-otologic (n=16). With the classical gastroenterologic criterion (> or =4.2% of total time at pH < 4), the pH monitoring was positive in 56% of the patients. However, this criterion does not seem to be sensitive for otolaryngologic gastro-esophageal reflux disease (GERD) because multiple daytime short reflux episodes are often involved. Indeed, the pH monitoring was positive in 75% of the patients (82% in the rhinologic group) when a number of 40 episodes in 24h was also taken into account. The success rate of medical treatment was about 80% in case of positive pH recording. This study underlines that GER is an important factor in pediatric otolaryngologic diseases.

Reflux of nasopharyngeal content into middle ear through the eustachian tube

Whether nasopharyngeal content passes into the middle ear in patients without any head and neck pathology during the recovery phase of anesthesia is shown with an objective and prospective method. Thirty-eight patients, 21 female and 17 male, aged between 17 and 76, were included in the study. During the recovery phase of general anesthesia, 10 ml of 5 mCi Tc-99m-MAA was administered intranasally to the patients with a 10-F catheter. A manometer-adapted cuffed intubation tube was placed in the nasal passage so that the cuff was located at the choana. The pressure changes reflecting to the nasopharynx were recorded. The patients were extubated 10 min after the radionuclide was applied. The scintigraphic evaluation was done at the end of the 1st hour of the application of radionuclide. Transmission and emission views were taken with a gamma camera. Passage of nasopharyngeal content into the middle ear via the eustachian tube was not a statistically significant observation. The mean value of maximum pressure reflecting from the nasopharynx did not differ significantly between patients. Our study does not support the hypothesis that nasopharyngeal content passes directly through the eustachian tube into the middle ear and causes deleterious effects.

Gastroesophageal reflux and the upper airway

EER is a disorder commonly seen in otolaryngologic practice and differs from GERD in its clinical manifestations, pathophysiology, and response to treatment. Its association with numerous disorders in children should lead otolaryngologists to consider this diagnosis in all patients with voice, airway, and swallowing complaints.

Role of GERD in chronic resistant sinusitis: a prospective, open label, pilot trial

OBJECTIVE

The objective of this study was to determine whether aggressive medical therapy of gastroesophageal reflux disease (GERD) could improve both subjective and objective features of chronic resistant sinusitis (CRS).

METHODS

Consecutive patients with CRS underwent assessment of GERD and sinus symptoms, esophageal motility testing, dual-channel esophageal pH testing, and laryngoscopy and nasal endoscopy at baseline. The results were compared to those of a group of GERD patients without sinus problems. The CRS patients alone then received omeprazole 20 mg b.i.d. for 3 months with symptom follow-up at monthly intervals. Laryngoscopy and nasal endoscopy were repeated at 3 months.

RESULTS

Eleven patients with CRS and 19 GERD patients participated. Eight CRS patients experienced heartburn at least once weekly. Esophageal manometry and pH test results were similar between the two groups. Nine CRS patients had an abnormal pH test. All 11 CRS patients completed the 3-month course of omeprazole. Individual sinus symptoms (nasal congestion, nasal drainage, sinus pressure, facial headache, malaise) and global satisfaction were modestly improved in 25-89% and 91%, respectively, at 12 wk. Resolution of symptoms occurred infrequently. We identified no baseline variable that could predict symptom improvement. Although laryngoscopy and nasal endoscopy were abnormal in most CRS patients at baseline and improved in some after treatment, these changes did not parallel symptom improvement.

CONCLUSION

In this small, prospective, open label study, we demonstrated a high prevalence of GERD in patients with CRS, many of whom experienced modest sinus symptom improvement after using omeprazole b.i.d. for 3 months. These findings warrant further randomized, controlled study in a larger patient population.

Pediatric gastroesophageal reflux and laryngopharyngeal reflux

Pediatric gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) have gained better recognition over the past few years. GER and LPR usually present as regurgitation, emesis, epigastric pain, failure to thrive, esophagitis, or stricture. Many patients suffer respiratory disorders associated with reflux. Classification of reflux, pathophysiology, manifestations of reflux, diagnosis, and management of the disease are discussed in this article.

Outcome of reflux therapy on pediatric chronic sinusitis

OBJECTIVE

The cause of pediatric chronic sinusitis is multifactorial, but nasal edema appears to be the initial pathologic step. The objective of this study is to evaluate gastronasal reflux as a possible cause of pediatric sinusitis.

METHODS

Thirty children with chronic sinusitis were believed to be appropriate candidates for functional endoscopic sinus surgery. Children were evaluated retrospectively for their response to reflux therapy with regard to their sinus symptoms and avoidance of sinus surgery.

RESULTS

Two of the 30 children were eventually excluded because they were taken to surgery for the specific purpose of contact point release. Chart review at 24-month follow-up indicated that 25 of the 28 children (89%) avoided sinus surgery.

CONCLUSION

After reflux treatment, the number of children requiring sinus surgery was dramatically reduced. The results of this preliminary pediatric study indicate that gastronasal reflux should be evaluated and treated before sinus surgical intervention.

Possible relationship of gastroesophagopharyngeal acid reflux with pathogenesis of chronic sinusitis

Gastroesophagopharyngeal reflux (GEPR) has been suggested as a cause of pediatric sinusitis. However, its contribution to the pathogenesis of chronic sinusitis in adults has not been systematically investigated. We evaluated the prevalence of GEPR in 11 CT confirmed chronic sinusitis patients (51 +/- 4 years) who had not responded to conventional therapy, and 11 normal healthy controls (44 +/- 7 years). A 3-site ambulatory esophagopharyngeal pH monitoring technique (probe location: 2 cm proximal, 3-4 cm distal to UES and 5 cm proximal to LES high pressure zones) was used. A pharyngeal pH drop was accepted as a true reflux event only if it was coincident with or preceded by esophageal pH declines of a similar or larger magnitude. Studies were performed while subjects were on a uniform 2500 calorie diet (provided).

RESULTS

Ambulatory pH monitoring documented GEPR in seven of 11 patients (1-12 episodes) and two of 11 normal volunteers (1,2 episodes) (p < 0.05). A total of 34 nonbelch related pharyngeal acid reflux events were identified in patients, but none was associated with coughing. In both groups, all pharyngeal acid events occurred in the upright position. Compared to normal controls prevalence of pharyngeal reflux of gastric acid is significantly higher in patients with chronic sinusitis unresponsive to conventional therapy and suggests a different esophagopharyngeal distribution pattern of gastric refluxate in this patient group; these findings suggest that GEPR may contribute to the pathogenesis of chronic sinusitis in some adult patients.