Gastroesophageal reflux, allergy and chronic tubotympanal disorders in children

Relationship between sleep position and otitis media in infants: The Japan environment and children's study

OBJECTIVE

Otitis media is a disease that commonly occurs in infants. Various risk factors have been reported. Sleep position has been reported to be associated with various diseases. There is no report on the relationship between otitis media and sleep position. We examined the incidence of otitis media and sleep position in infants.

METHODS

We used data from the Japan Environment Children's Study. We used multivariate logistic analysis to examine the relationship between sleep position and the incidence of otitis media in infants aged up to 6 months. In addition, we conducted a stratified analysis based on whether the child was able to turn over in bed at 6 months of age.

RESULTS

The study population comprised 85,731 participants. The incidence of otitis media by sleep position was significantly higher when the infant was in the prone position compared to any other position (adjusted odds ratio, 1.206; 95 %CI, 1.038-1.401). Stratified analysis of turning showed that otitis media was more common in the prone position in all groups.

CONCLUSION

In the current study, infants aged 6 months or younger who slept in the prone position were more likely to have otitis media. Sleep position interview and guidance on changing sleep position may be useful for the prevention of otitis media.

Factors affecting the occurrence of otitis media with effusion in preschool and elementary school children: a comparative cross-sectional study

OBJECTIVE

Identify the risk factors for otitis media with effusion (OME), especially laryngopharyngeal reflux (LPR), adenoid hypertrophy and allergic rhinitis, that could be used to develop prevention strategies in children.

DESIGN

A comparative cross-sectional study was conducted to make sure the adequacy of proportions of OME and non-OME cases in finding the related factors.

SETTING

History taking, ear/nose/throat (ENT) examination, and tympanometry were performed in preschool and elementary schools. Flexible fibreoptic nasopharyngolaryngoscopy was performed in a bronchoesophagology outpatient clinic in a tertiary referral hospital in Jakarta, Indonesia.

PARTICIPANTS

Preschool and elementary children in East Jakarta, Indonesia were recruited for this study. A total of 2016 participants underwent history taking, ENT examination and tympanometry. The case group was 46 children with OME, and the control group was 46 children without OME. The number of subjects fulfilled the minimum sample size for two proportions comparison.

MAIN OUTCOME MEASURES

A type B tympanogram indicated OME. A Reflux Finding Score of more than 7 indicated LPR. Adenoid hypertrophy was diagnosed using flexible fibreoptic nasopharyngolaryngoscopy. Allergic rhinitis was diagnosed using a questionnaire based on the International Study of Asthma and Allergies in Childhood phase III that has been validated for Indonesians.

RESULTS

The proportion of LPR in the OME group was significantly higher than in the non-OME group, at 78.3% and 52.2%. The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR (OR 3.3; 95% CI 1.33 to 8.189; p=0.01). There was no significant relationship between adenoid hypertrophy and OME (p=0.211; 95% CI 0.71 to 3.97), and also between allergic rhinitis and OME (p=0.463; 95% CI 0.61 to 4.28).

CONCLUSION

The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR. LPR should be considered in patients with OME and vice versa.

Association Between Laryngopharyngeal Reflux and Media Otitis: A Systematic Review

OBJECTIVES

To investigate the relationship between laryngopharyngeal reflux (LPR) and recurrent (ROM) or chronic otitis media with effusion (COME).

DATABASES

PubMed, Scopus, and Cochrane Library.

METHODS

Three authors searched articles published between January 1980 and September 2020 about the association between LPR and the development of recurrent or chronic otitis media. Inclusion, exclusion, diagnostic criteria, and clinical outcome evaluation of included studies were analyzed using PRISMA criteria. The bias analysis of included studies was evaluated with the Tool to assess Risk of Bias of the CLARITY group.

RESULTS

Twenty-six clinical and three experimental articles met our inclusion criteria, accounting for 1,624 children and 144 adults with COME or ROM. According to the pH study type, the prevalence of LPR and gastroesophageal reflux disease (GERD) in OM patients were 28.7% (range, 8-100%) and 40.7 (range, 18-64%), respectively. The majority of studies identified pepsin or pepsinogen in middle ear effusion, with a range of mean concentrations depending on the technique used to measure pepsin. There was an important heterogeneity between studies regarding definition of COME, ROM, and LPR, exclusion criteria, methods used to measure pepsin/pepsinogen in middle ear secretions and outcome assessments.

CONCLUSION

The association between LPR and OM is still unclear. Future clinical and experimental studies are needed to investigate the association between LPR and OM in both children and adults through extensive gastric content analysis in middle ear suppurations and impedance-pH monitoring considering acid, weakly acid, and alkaline reflux events.

The Relationship Between Otitis Media With Effusion and Gastroesophageal Reflux Disease: A Meta-analysis

OBJECTIVE

Recent studies have investigated the mechanism by which refluxed gastric materials reach the middle ear, to establish otitis media with effusion (OME) causal relation between them in both children and adults. Therefore, the relationship between OME and gastro-esophageal reflux disease (GERD) should be further studied extensively.

METHODS

To identify eligible original articles, we searched a range of computerized databases, including Medline via PubMed, EMBASE, CNKI, and Web of Science with a systematic searching strategy. Subgroup analysis was performed to analyze heterogeneity and Egger and Begg funnel plot to assess the publication bias of the included articles.

RESULTS

The meta-analysis had an overall sample size of 1961. We identified a significant relationship between OME and GERD, with a pooled odds ratio (OR) of 4.52 (95% confidence interval [CI]: 2.42-8.44; p < 0.001). The pooled data were calculated with the random-effects model as a high significant heterogeneity was found among the studies and there was no significant publication bias observed.

CONCLUSIONS

The meta-analysis suggested that there was a significant association between otitis media with effusion and gastroesophageal reflux disease.

Outcome of Gastroesophageal Reflux Therapy in Children with Persistent Otitis Media with Effusion

Introduction Otitis media with effusion (OME) is considered one of the most common disorders that affect children during the first years of life. There are many risk factors of persistent middle ear effusion; one of these risk factors is gastroesophageal reflux. Association between persistent OME and gastroesophageal reflux diseases (GERDs) could be explained by respiratory tract infections, insufficient ciliary clearance, and poor drainage of the Eustachian tube.

Objective To investigate whether the control of gastroesophageal reflux plays a role in the management of persistent OME and decreases tympanostomy tube insertion

Method A cross-sectional study was conducted on 50 children complaining of persistent OME. Their ages ranged between 5 and 12 years old. All children were subjected to full history taking, audiological assessment and 24-hour esophageal pH monitoring. The study group was divided according to pH results into two groups: GERD positives and GERD negatives.

Result The prevalence of GERD in persistent OME was 58%. There were statistically significant differences in the hearing levels and middle ear condition before and after the treatment (p < 0.05). The percentage of improvement of children complaining of persistent OME after antireflux treatment was 52%.

Conclusion Gastroesophageal reflux disease should be considered in patients with persistent OME. The administration of proton pump inhibitor (PPI) can set aside superfluous surgical treatment (such as tympanostomy).

Laryngopharyngeal Reflux in Children with Chronic Otitis Media with Effusion

BACKGROUND/AIMS

To evaluate the characteristic properties of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GER) in children with otitis media with effusion (OME) using 24-hour multichannel intraluminal impedance combined with dual-probe (pharyngeal and esophageal) pH-metry.

METHODS

Children aged 7-10 years of age with OME underwent 24-hour multichannel intraluminal impedance pH-metry. The upper pH sensor was situated 1 cm above the upper esophageal sphincter, and the lower pH sensor was placed 3-5 cm above the lower esophageal sphincter. Parents were asked to complete the gastroesophageal reflux assessment of symptoms in a pediatrics questionnaire.

RESULTS

Twenty-eight children were enrolled; LPR was detected in 19 (67.9%) children. The criteria of the LPR diagnosis was the presence of at least one supraesophageal episode with a pH < 5.0 and a change in the pH value measured from the initial level at the upper sensor of > 0.2. In total, 64 episodes were observed. Assessment of all LPR episodes showed the presence of 246 episodes in the entire study. A considerable predominance of weakly acidic episodes (87.8%) was noted; there were 6.5% acidic episodes, and weakly alkaline episodes reached 5.7%. Pathological GER was noted in 10 (35.7%) subjects. Acid GER was detected in 8 children, 2 of whom demonstrated non-acidic reflux. In the LPR-negative patients, no pathological GER was confirmed with the exception of a single case of non-acidic reflux.

CONCLUSIONS

LPR was frequently noted in the group of children with OME, and it might be an important risk factor in this common disease.

Information on co-morbidities collected by history is useful for assigning Otitis Media risk to children

OBJECTIVES

Determine if a 2-Step multivariate analysis of historical symptom/sign data for comorbid diseases can abstract high-level constructs useful in assigning a child's "risk" for different Otitis Media expressions.

METHODS

Seventeen items related to the symptom/sign expression of hypothesized Otitis Media comorbidities were collected by history on 141 3-year-old children. Using established criteria, the children were assigned to 1 of 3 groups: Control (no significant past Otitis Media, n=45), Chronic Otitis Media with Effusion (n=45) and Recurrent Acute Otitis Media (n=51). Principal Component Analysis was used to identify factors representing the non-redundant shared information among related items and Discriminant Analysis operating on those factors was used to estimate the best predictor equation for pairwise group assignments.

RESULTS

Six multivariate factors representing the assignable comorbidities of frequent colds, nasal allergy, gastroesophageal disease (specific and general), nasal congestion and asthma were identified and explained 81% of the variance in the 17 items. Discriminant Analysis showed that, for the Control-Chronic Otitis Media with Effusion comparison, a combination of 3 factors and, for the Control-Recurrent Acute Otitis Media comparison, a combination of 2 factors had assignment accuracies of 74% and 68%, respectively. For the contrast between the two disease expressions, a 2-factor combination had an assignment accuracy of 61%.

CONCLUSION

These results show that this analytic methodology can abstract high-level constructs, comorbidities, from low-level data, symptom/sign scores, support a linkage between certain comorbidities and Otitis Media risk and suggest that specific comorbidity combinations contain information relevant to assigning the risk for different Otitis Media expressions.

Helicobacter Pylori: A Possible Association with Otitis Media with Effusion

OBJECTIVE: Evaluate possible role of Helicobacter Pylori in pathogenesis of otitis media with effusion (OME).

STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center.

STUDY GROUP: Middle ear fluid was aspirated, a biopsy was taken from the promontorium of 22 children with OME.

CONTROL GROUP: A small biopsy was taken from the promontorium of 20 children with normal otologic findings. For both groups, 5 mm deep tissue specimens were obtained from tonsil and adenoid.

RESULTS: H pylori presence in the middle ear, the tonsillar and adenoid tissues by culture and PCR was significantly more frequent in the study group compared to the control group ( P < 0.05).

CONCLUSIONS: This study is the first to grow H pylori in middle ear in OME. Significantly increased colonization by H pylori of the middle ear, and tonsillar and adenoid tissue in patients with OME indicates that the bacteria might be involved in the pathogenesis of OME.

EBM rating: A-1b

Impacts of endoscopic gastroesophageal flap valve grading on pediatric gastroesophageal reflux disease

BACKGROUND

Gastroesophageal flap valve (GEFV) endoscopic grading is reported to be associated with gastroesophageal reflux disease (GERD) in adults; however its role in pediatric groups remains unknown. This study aimed to investigate the significance of GEFV grading and the associations to multichannel intraluminal impedance and pH monitoring (MII-pH) in children with GERD.

METHODS

A total of 48 children with GERD symptoms who received esophagogastroduodenoscopy and MII-pH monitoring were enrolled. The degree of GEFV was graded from I to IV according to the Hill classification, and classified into two groups: normal GEFV (Hill grades I and II), and abnormal GEFV (Hill grades III and VI). Endoscopic findings and MII-pH monitoring were analyzed among the groups.

RESULTS

Thirty-six patients had normal GEFV while 12 had abnormal GEFV. The presence of erosive esophagitis was significantly more common in the patients with abnormal GEFV (p = 0.037, OR 9.84, 95% CI 1.15-84.42). Pathological acidic gastroesophageal reflux (GER) determined by MII-pH was more prevalent in the patients with loosened GEFV geometry (p = 0.01, OR 7.0, 95% CI 1.67-27.38). There were significant positive correlations between GEFV Hill grading I to IV and the severity of erosive esophagitis (r = 0.49, p<0.001), percentage of supine acid reflux (r = 0.37, p = 0.009), percentage of total acid reflux (r = 0.3284, p = 0.023), and DeMeester score (r = 0.36, p = 0.01) detected by pH monitoring. In the impedance study, GEFV Hill grading also positively correlated to median number of acid reflux events (r = 0.3015, p = 0.037).

CONCLUSIONS

GEFV dysfunction highly associated with acid GER and severe erosive esophagitis. An abnormal GEFV is a sign of acid GER in children.

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.

Otitis media with effusion: an effort to understand and clarify the uncertainties

Otitis media with effusion--defined as the accumulation of middle-ear effusion behind an intact tympanic membrane without signs or symptoms of acute infection--is one of the most common causes of hearing loss in children in developed countries, potentially leading to language deficits. Although treatment of chronic or relapsing otitis media with effusion is considered imperative, none of the preventative or nonsurgical management measures currently available have proven effective. Tympanostomy tube placement remains the recommended treatment option for high-risk children or for cases of unresponsive otitis media with effusion. This can be attributed to the uncertainties surrounding its pathogenesis. Multiple factors and several possible pathogenetic models have been proposed to explain the production and persistence of middle-ear effusion; only a few of them are supported by sufficient evidence. In this review, the authors will present current knowledge on the pathogenesis, consequences, diagnosis and management of otitis media with effusion. An effort will be made to clarify those aspects sufficiently supported by evidence-based studies, and to underline those that remain unfounded.

The Role of Helicobacter pylori in Upper Respiratory System Infections: Is it More Than Colonization?

Helicobacter pylori (HP) is recognized as a common chronic human bacterial infection and is the most common cause of gastritis. Recent studies suggest an increased HP prevalence in patients with various extra-digestive inflammatory diseases. Since many respiratory diseases are characterized by chronic inflammation as well as increased immune response, and HP may enter the nasopharyngeal cavity by gastroesophageal reflux, an association between respiratory disorders and HP infection has been suggested. Several studies discover HP in clinical samples from the patients with upper respiratory system infections. Even some of them revealed a relief after the treatment directed to HP eradication. However some studies do not support this theory and whether this association means a definite proof of a causal relationship between HP and respiratory diseases needs to be clarified. In this study, we aimed to review the reports about the role of HP in upper respiratory system infections.

Role of GERD in children with otitis media with effusion

OBJECTIVES

To establish whether Gastroesophageal reflux disease (GERD) plays a significant role in the etiopathogenesis of otitis media with effusion (OME) patients and to find if there is any association between GERD symptoms and OME. Also, to detect presence of pepsinogen in the middle ear aspirate and to demonstrate pepsinogen band by electrophoresis.

METHODS

This is a prospective study conducted in a tertiary care hospital. Middle ear effusion samples were collected from 32 children undergoing surgery for OME.The samples were measured for pepsinogen level as well as total protein content. Samples were subjected to electrophoresis study by SDS PAGE (Sodium Dodecyl Sulphate Polyacrylamide Gel Electrophoresis).

RESULTS

A total of 21 patients out of 32 were found to have higher pepsinogen level in their middle ear effusion samples than the cut off value of 90 mg/ml.The lack of symptoms associated with GERD among the children in this study corroborates with other similar studies in the world literature. It was also statistically shown that the association between GERD score and pepsinogen level was insignificant (P = 0.512).

CONCLUSIONS

OME appears to be multifactorial disease.GERD may be one of the contributing factors in the etiopathogenisis of OME.

Incidence of Helicobacter pylori infection and their clarithromycin-resistant strains in otitis media with effusion regarding phenotypic and genotypic studies

Helicobacter pylori (H. pylori) are pathogenic bacteria that infect a half of the human population, colonize gastric mucosa and can be found in gastric juice. Reflux of gastric juice has been suggested to be associated with glue ear in children. It has been suggested that tonsil and adenoid tissues are potential reservoirs of H. pylori infection. These observations raise the question as to whether H. pylori infection might have a role in otitis media with effusion (OME) in children. The objectives of this research were to evaluate the incidence and possible role of H. pylori in the pathogenesis of OME in children and to evaluate the clarithromycin-resistant strains. Molecular assessment was done to evaluate the culture results vs. molecular study. A total of 60 children, who were prone to ventilation tube insertion, adenoidectomy and/or tonsillectomy were included in the study. The control group consisted of 40 children who underwent adenoidectomy and/or tonsillectomy without the history of OME. Samples of the middle ear fluid and mucosa, adenoid tissue, tonsillar tissue and gastric lavage were cultured and underwent polymerase chain reaction (PCR) analysis then were assembled by using QIAxcel System as capillary electrophoresis for H. pylori detection. There was significant difference between the results of cultures and PCR (P < 0.05). Middle ear fluid culture was positive for H. pylori in 40% of the patients vs. 56.7% PCR results while middle ear mucosa culture was positive in 20% vs. 26.7% PCR results. Gastric lavage culture was positive in 46.6% of the patients and PCR was positive in 63.3% of the patients. Adenoid culture and PCR were positive in 56.3% for each, while tonsil culture was positive in 70% and PCR was positive in 90%. H. pylori presence in the gastric lavage, the tonsillar and adenoid tissues by culture and PCR was significantly more frequent in the study group compared to the control group. The minimum inhibitory concentration (MIC) values of clarithromycin-resistant isolates ranged from 1.5 to 8 μg/ml. This study showed the presence of H. pylori in around 50% of the patients with OME. PCR revealed its sensitivity than culture techniques. The incidence of clarithromycin resistance was found to be high among the isolates (39.6%).

Association between Otitis Media and Gastroesophageal Reflux

Objective. To systematically review the association between otitis media and gastroesophageal/laryngopharyngeal reflux in children.

Data Sources. Cochrane library, MEDLINE (1966–September 2011), EMBASE (1974–September 2011), proceedings of International Symposia on Recent Advances in Otitis Media, and reference lists of relevant selected articles.

Review Methods. Studies with planned data collection, in children with chronic otitis media with effusion/recurrent acute otitis media, assessing gastroesophageal/laryngopharyngeal reflux, pepsin/pepsinogen in middle ear, or antireflux therapy, were included.

Results. Of 242 initial studies, 15 met inclusion criteria. The authors found a mean prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion of 48.4% (range, 17.6%-64%) and in children with recurrent acute otitis media of 62.9% (range, 61.5%-64.3%). A mean prevalence of laryngopharyngeal reflux of 48.6% (range, 27.3%-70.6%) was found in children with otitis media. Mean pepsin/pepsinogen presence in otitis media was 85.3% (range, 60%-100%) and of enzymatic activity was 34.2% (range, 14.5%-73%). Two randomized trials could not find benefit after antireflux treatment for 3 months, with an absolute rate difference (95% confidence interval) of 0.23 (0.023-0.42) and 0.13 (−0.086 to 0.34), respectively. Reporting of adverse events was limited, or absent, in most studies.

Conclusion. The prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion/recurrent acute otitis media may be higher than the overall prevalence for children. Presence of pepsin/pepsinogen in the middle ear could be related to physiologic reflux. A cause-effect relationship between pepsin/pepsinogen in the middle ear and otitis media is unclear. Antireflux therapy for otitis media cannot be endorsed based on existing research.

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.

Detection of gastric pepsin in middle ear fluid of children with otitis media

OBJECTIVE

We sought to confirm the finding of pepsin/pepsinogen in the middle ear fluid of children with otitis media in a larger sample size using a sensitive and specific pepsin assay.

STUDY DESIGN AND SETTING

We evaluated 152 children (225 ear samples) in a prospective study at a tertiary care children's hospital. The presence of pepsin in middle ear aspirates was determined using enzymatic assay.

RESULTS

Of the patients, 14.4 percent (22 of 152) had detectable pepsin activity in one or both of the ear samples with no pepsin activity detected in control serum. Average pepsin concentration in the samples was 96.6 +/- 170.8 ng/ml, ranging from 13 to 687 ng/ml. Pepsin concentration in the middle ear of children younger than 1.0 year was significantly higher than in older age groups.

CONCLUSION AND SIGNIFICANCE

Results indicate that pepsin/pepsinogen is present in the middle ears of children with otitis media, although not at the high rate previously reported. Gastric reflux may be one causative factor in the pathogenesis of otitis media.

Chronic otitis media with effusion and Helicobacter pylori

OBJECTIVE

The aim of this study is to investigate the presence of Helicobacter pylori (HP) in the middle ear effusion by Campylobacter-like organism (CLO) test and whether it has a role in the ethiopathogenesis of chronic otitis media with effusion (OME).

STUDY DESIGN

A prospective randomized and controlled study.

METHODS

This study was performed with 45 patients with the diagnosis of chronic OME and adenoid hypertrophy, between the ages 3 and 13 (median 6). Thirty patients constituted the study group (18 male (60%) and 12 (40%) female). Adenoidectomy with myringotomy with ventilation tube insertion were performed to this group. Middle ear effusion and adenoid tissue pieces were collected and H. pylori presence was investigated by "CLO" testing. Fifteen patients of the matching age group (9 male (66.7%) and 6 (33.3%) female) constituted the control group to whom adenoidectomy with myringotomy were performed but no middle ear effusion could be determined (empty myringotomy patients). The wash out liquid of middle ear and pieces of adenoid tissue samples were also collected from the control group. By using CLO testing, the presence of H. pylori was investigated in the adenoid tissues and middle ear of the empty myringotomy patients.

RESULTS

In 20 (66.6%) patients of the study group, CLO testing was positive in the middle ear effusions. None of the patients demonstrated positive CLO test in the wash out liquid of middle ear. There was significant difference of positive CLO testing in the middle ear effusions of two groups (p<0.001).

CONCLUSIONS

These findings showed us that presence of HP in the middle ear effusion using CLO testing and this may be responsible for the ethiopathogenesis of chronic OME.

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.

Should otolaryngologists perform pH probe studies?

PURPOSE OF REVIEW

This commentary discusses recent developments in the methods available to pediatric otolaryngologists in the diagnosis of laryngopharyngeal reflux.

RECENT DEVELOPMENTS

The development of detachable wireless monitoring allows the otolaryngologists to perform their own pH monitoring. It can be deployed while performing other procedures, such as laryngoscopy and bronchoscopy. The procedure to insert the probe and collect data is described.

SUMMARY

It is hoped that the pH probe will play an important role in understanding the pathological role of pharyngeal reflux in terms of laryngeal, pharyngeal, sinus and ear pathology.

Chronic suppurative otitis media: a review

OBJECTIVES

Chronic suppurative otitis media (CSOM) remains one of the most common childhood chronic infectious diseases worldwide. Although microbial, immunological, and genetically determined factors, as well as Eustachian tube characteristics, are supposed to be involved in the pathogenesis of CSOM, many aspects of the pathogenesis of CSOM still need to be clarified. Optimal treatment strategy has not been established yet. The objective of this review is to present and evaluate the current state of knowledge of CSOM.

DESIGN

Systematic narrative review.

METHODS

A PubMed search (1966-January 2005) was performed for studies on epidemiology, pathogenesis, clinical management, and complications of CSOM. All included articles were categorized according to level of evidence.

RESULTS

Five hundred and fifty papers were identified, of which 79 were found to be relevant for this review. The definition of CSOM was found to vary. CSOM is a multifactorial disease. Regarding management of CSOM, there is no consensus as to what the optimal management strategy should entail. No convincing evidence is available for most medical and surgical therapies. Topical quinolones have proven effective, but need further monitoring regarding adverse effects.

CONCLUSIONS AND RECOMMENDATIONS

Important goals in research of CSOM should be achieving consensus about the definition of CSOM and gaining more in-depth knowledge of the pathogenesis of CSOM, especially the role of innate and adaptive immunity. There is also a need for further well-designed studies on the effectiveness of various management strategies for CSOM.

Pharyngeal reflux in children with chronic otitis media with effusion

OBJECTIVE

To investigate whether there is an association between chronic otitis media (COM) with effusion and pharyngeal reflux in children by using 24-h pH monitoring with a dual probe.

MATERIAL AND METHODS

This was a prospective study. The study group consisted of 25 children with COM with effusion and the control group comprised 12 healthy children. All children underwent 24-h esophageal pH monitoring with a dual probe (distal and proximal esophageal pH monitoring).

RESULTS

In the study group, the frequencies of pharyngeal and gastroesophageal reflux (GER) were 48% and 64%, respectively, and the corresponding values in the control group were 8.3% and 25%. Both of these differences were significant (p <0.05). In the study group, 28% of patients were positive for at least 1 symptom of GER; 72% of the patients did not have any symptoms but 56% of these patients had silent GER.

CONCLUSIONS

These findings indicate that pharyngeal reflux may play an important role in the etiology of COM with effusion. If patients have typical symptoms of GER, such as pyrosis, regurgitation, dysphagia and emesis, the presence of GER should be considered. The presence of silent GER and pharyngeal reflux should also be considered.

Pediatric middle ear infections and gastroesophageal reflux

OBJECTIVES

The pathogenesis of middle ear infections in children is multifactorial and includes infection, anatomical factors, impaired immunologic status, allergy, familial predisposition, male sex, method of feeding and environmental factors. Glue ear remains the commonest cause of deafness in childhood. Gastroesophageal reflux (GOR) is a common problem in the newborn and preschool periods. Recent research suggests that it may be related to eustachian tube dysfunction and otitis media.

METHODS

We review the literature and discuss the possible relationship between Gastroesophageal reflux and otitis media in children.

CONCLUSIONS

The current data are not enough to support antireflux treatment in children with refractory middle ear infections. More prospective randomised placebo-controlled studies are needed.

Gastroesophageal reflux and sequelae of chronic tubotympanal disorders in children

OBJECTIVE

To compare sequelae of chronic tubotympanal disorders in children with and without gastroesophageal reflux (GER).

MATERIAL AND METHODS

In 32 patients with chronic tubotympanal disorders GER was studied by means of 24-h continuous esophageal pH monitoring. After a period of 2-6 years (mean 4 years) sequelae of the tubotympanal disorders were examined, together with the clinical status of the ears and hearing status. The criteria for classification into mild, moderate and severe sequelae were based on the clinical status of the ear. Hearing was determined using tonal audiograms. Conductive hearing loss was classified as either slight (< or = 35 dB hearing loss in speech frequencies) or severe (>35 dB hearing loss in speech frequencies).

RESULTS

In the group of 16 patients (mean age 6.1 years) with GER, sequelae were observed in 29 ears (mild, n=11; moderate, n=5; severe, n=13). Hearing impairment was determined in 20 ears (mild, n=8; severe, n=12). In the group of 16 patients (mean age 7.1 years) without GER, sequelae were observed in 17 ears (mild, n=11; moderate, n=1; severe, n=5). Hearing impairment was determined in 10 ears (mild, n=6; severe, n=4).

CONCLUSION

The total number of ears with sequelae and the total number of ears with conductive hearing impairment were significantly higher in patients with GER.

Association between gastroesophageal reflux and sinusitis, otitis media, and laryngeal malignancy: a systematic review of the evidence

This study was conducted to review and evaluate the published evidence for an association between gastroesophageal reflux (GER) and 3 supraesophageal pathologies: sinusitis, otitis media, and laryngeal malignancy. Relevant articles were located using MEDLINE (search limits: 1966-2001, English language, human studies). Only new data or new analyses of previous data were included. Relevant articles were designated by their level of evidence, based on published standards, and grouped by pathology. An overall grade was assigned to each group for the strength of evidence for or against an association. The search produced 152 articles, 42 of which met inclusion criteria and were reviewed in detail. There is grade C evidence for a positive association between GER and sinusitis (57 articles screened, 14 articles included); for a negative association between GER and otitis media (28 articles screened, 10 articles included); and for a positive association between GER and laryngeal malignancy (67 articles screened, 18 articles included). The published literature weakly supports a positive association between GER and both sinusitis and laryngeal malignancy, and a negative association between GER and otitis media.

Reliability of radionuclide gastroesophageal reflux studies using visual and time-activity curve analysis: inter-observer and intra-observer variation and description of minimum detectable reflux

Radionuclide studies have gained wide acceptance in the evaluation of infants and children with gastroesophageal reflux (GER). For correct interpretation of scan results, knowledge of inter-observer and intra-observer variability and minimum detectable reflux volume is essential. In this study, we evaluated the methodological issues underlying the visual assessment of GER and time activity curve analysis. An in vitro model of stomach and oesophagus was established to determine the minimum detectable reflux by placing various volumes and concentrations representing the diluted activity in the stomach. In the clinical part 99 patients were imaged for 1 h after oral administration of 99mTc sulfur colloid. Eleven patients were excluded from the study either due to incomplete clinical data or suboptimal image quality. Frames of 16 s each, and time-activity curves which were generated after drawing regions of interest from the oesophagus, were read three times by an experienced nuclear medicine physician and a resident in training. On the phantom study, the concentration, volume and duration were the determining factor for the visualization of reflux. In the clinical part, the overall incidence of GER in 88 patients was 69%. The mean intra- and inter-observer reproducibility (kappa values) was 0.76 and 0.7065, respectively. Agreement was slightly higher in the analysis of time-activity curves (0.767 and 0.731). Our results indicate that GER may be reproducibly analysed on scintigraphy by the same and different observers with varying levels of training. Its visualization is associated with reflux duration, volume and dilution factor of radioactivity.

Prolonged esophageal pH monitoring in the evaluation of gastroesophageal reflux in children with chronic tubotympanal disorders

BACKGROUND

Children with ear, nose and throat disorders are believed to have a high incidence of pathologic gastroesophageal reflux (GER). This study was designed to establish the frequency and ratio of pathologic GER in the development of chronic tubotympanal disorders.

METHODS

Twenty-seven children with chronic tubotympanal disorders (mean age, 2 to 13 years; average age, 6.8 years) underwent 24-hour continuous pH monitoring. Fourteen of the examined patients had secretory otitis, whereas 13 patients had recurrent otitis. From each 24-hour pH monitoring, 12-hour daytime and nighttime periods were selected. Eleven patients were tested using simultaneous dual pH monitoring (distal and proximal pH monitoring).

RESULTS

Fifteen (55.6%) of 27 patients had pathologic GER. The authors did not find a relation between pathologic GER and different types of ear disorders. Daytime pH monitoring yielded significantly more episodes of reflux than did nighttime monitoring. The reflux index was substantially higher during the day. In the current study, distal pH monitoring showed that 6 of 11 patients had pathologic GER, whereas proximal pH monitoring showed that only only 3 of 11 patients had pathologic GER.

CONCLUSIONS

The authors recommend that a pH study be performed in children with chronic tubotympanal disorders when standard treatment is ineffective. The method of choice for the diagnosis of pathologic GER in patients with chronic tubotympanal disorders should be pH monitoring of the esophagus and throat.

Extraesophageal associations of gastroesophageal reflux disease in children without neurologic defects

BACKGROUND & AIMS

The potential association between gastroesophageal reflux disease (GERD) and extraesophageal manifestations remains unknown in children without neurological defects. We conducted a large case-control study to examine the association between GERD and several upper and lower respiratory disorders in these children.

METHODS

We identified all patients between 2 and 18 years of age with GERD who were seen at Texas Children's Hospital between 1996 and 2000. Patients seen during the same time period without GERD were randomly selected as controls (4:1 ratio). Patients with mental retardation, cerebral palsy, or congenital esophageal anomalies were excluded. We compared the presence of several predefined upper and lower respiratory disorders in cases and controls.

RESULTS

We identified 1980 patients with GERD and 7920 controls without GERD. Cases and controls were without neurological deficits or congenital esophageal anomalies. Cases were older than controls (9.2 years +/- 4.6 vs. 8.6 +/- 4.9, P < 0.0001), and were more likely to be female (51.2% vs. 47.2%, P = 0.0028) and white (60.2% vs. 41.2%, P < 0.0001). Compared with controls in univariate analyses, cases with GERD had more sinusitis (4.2% vs. 1.4%, P < 0.0001), laryngitis (0.7% vs. 0.2%), asthma (13.2% vs. 6.8%, P < 0.0001), pneumonia (6.3% vs. 2.3%, P < 0.0001), and bronchiectasis (1.0% vs. 0.1%, P < 0.0001). However, otitis media was less common in cases than controls (2.1% vs. 4.6%, P < 0.0001). After adjusting for differences in age, gender, and ethnicity in the regression analyses, GERD remained a significant risk factor for sinusitis (adjusted odds ratio [OR], 2.3; 95% confidence intervals [CI], 1.7-3.2; P < 0.0001), laryngitis (OR, 2.6; CI, 1.2-5.6; P = 0.0228), asthma (OR, 1.9; CI, 1.6-2.3; P < 0.0001), pneumonia (OR, 2.3; CI, 1.8-2.9; P < 0.0001), and bronchiectasis (OR, 2.3; CI, 1.1-4.6; P = 0.0193).

CONCLUSIONS

GERD in children without neurological defects is associated with a several-fold increase in the risk of sinusitis, laryngitis, asthma, pneumonia, and bronchiectasis. Further studies are needed to examine whether a cause-effect relationship exists between GERD and these disorders in children.