Patterns of laryngopharyngeal and gastroesophageal reflux

Proton pump inhibitors and histamine 2 blockers are associated with improved overall survival in patients with head and neck squamous carcinoma

It has been postulated that gastroesophageal reflux plays a role in the etiology of head and neck squamous cell carcinomas (HNSCC) and contributes to complications after surgery or during radiotherapy. Antacid medications are commonly used in patients with HNSCC for the management of acid reflux; however, their relationship with outcomes has not been well studied. Associations between histamine receptor-2 antagonists (H2RA) and proton pump inhibitors (PPI) use and treatment outcomes were determined in 596 patients with previously untreated HNSCC enrolled in our SPORE epidemiology program from 2003 to 2008 (median follow-up 55 months). Comprehensive clinical information was entered prospectively in our database. Risk strata were created on the basis of possible confounding prognostic variables (age, demographics, socioeconomics, tumor stage, primary site, smoking status, HPV16 status, and treatment modality); correlations within risk strata were analyzed in a multivariable model. Patients taking antacid medications had significantly better overall survival (OS; PPI alone: P < 0.001; H2RA alone, P = 0.0479; both PPI + H2RA, P = 0.0133). Using multivariable Cox models and adjusting for significant prognostic covariates, both PPIs and H2RAs used were significant prognostic factors for OS, but only H2RAs use for recurrence-free survival in HPV16-positive oropharyngeal patients. We found significant associations between the use of H2RAs and PPIs, alone or in combination, and various clinical characteristics. The findings in this large cohort study indicate that routine use of antacid medications may have significant therapeutic benefit in patients with HNSCC. The reasons for this association remain an active area of investigation and could lead to identification of new treatment and prevention approaches with agents that have minimal toxicities.

Salivary Concentration of Epidermal Growth Factor in Adults with Reflux Laryngitis before and after Treatment

Objectives:

The diagnosis of laryngopharyngeal reflux (LPR) is controversial. There is no correlation between the number of reflux episodes and the severity of the inflammatory response at the esophagus or the laryngopharyngeal segment. Some authors have suggested that decreased salivary epidermal growth factor (EGF) concentrations in patients with gastroesophageal reflux disease and LPR point to a breakdown in the local defenses. Our objective was to establish whether treatment of the disease influences low salivary EGF concentrations.

Methods:

The spontaneous whole saliva of 20 adults with LPR was sampled at a tertiary teaching hospital before and after a 16-week course of full-dose proton pump inhibitor and compared to that of 12 healthy controls. Salivary EGF concentrations were established with a commercially available enzyme-linked immunosorbent assay kit.

Results:

Although the mean salivary EGF concentrations were higher before treatment than after treatment and control of the disease (25,083 versus 19,359 pg/mL), this difference was not statistically significant (p = 0.065). The mean salivary EGF concentration of healthy control subjects was significantly higher (54,509 pg/mL; p < 0.0001).

Conclusions:

Both before and after treatment, patients with reflux laryngitis present lower salivary EGF concentrations than healthy control subjects, suggesting a primary deficit in their protective mechanisms.

Globus pharyngeus and extraesophageal reflux: simultaneous pH <4.0 and pH <5.0 analysis

OBJECTIVES/HYPOTHESIS

Weakly acid refluxes seem to play an important role in the pathogenesis of extraesophageal reflux. The aim of this study was to evaluate how proportional representation of patients with extraesophageal reflux in a group of patients with globus pharyngeus changes when we use both pH <4.0 as well as pH <5.0 as a pathological threshold for an extraesophageal reflux episode.

STUDY DESIGN

Prospective pH monitoring study of 46 patients.

METHODS

Patients with pure globus pharyngeus lasting more than 3 months were included in the study. The pH monitoring was performed (Smit technique) with double probes (fixed distance of 15 cm). The recorded data using only pH <4.0 and using both pH <4.0 along with pH <5.0 as thresholds for extraesophageal reflux episode were analyzed simultaneously. The reflux area index 4 >6.3 and reflux area index 5 >72.6 were considered as clear pathological extraesophageal reflux.

RESULTS

Extraesophageal reflux was proven in 23.9% patients with pure globus pharyngeus when standard analysis using only pH <4.0 was used as pathological threshold. If both pH <4.0 and pH <5.0 were used as the pathological threshold, clear extraesophageal reflux was found in four more (8.7%) patients.

CONCLUSIONS

This study indicates the possible role of weakly acid extraesophageal reflux episodes in some patients with globus pharyngeus. Other studies on this issue, including the use of biological markers such as signs of inflammation, are warranted.

Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines

OBJECTIVE

To review the literature on the most common causes of chronic cough.

METHODS

MEDLINE was searched (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms "cough," "causes of cough," and "etiology of cough." Case series and prospective descriptive clinical trials were selected for review. Also obtained were any references from these studies that were pertinent to the topic

RESULTS

Upper airway cough syndrome (UACS) due to a variety of rhinosinus conditions, previously referred to as postnasal drip syndrome, asthma, nonasthmatic eosinophilic bronchitis (NAEB), and gastroesophageal reflux disease (GERD) are the most common causes of chronic cough. Each of these diagnoses may be present alone or in combination and may be clinically silent apart from the cough itself.

CONCLUSION

In the absence of evidence for the presence of another disorder, an approach focused on detecting the presence of UACS, asthma, NAEB, or GERD, alone or in combination, is likely to have a far higher yield than routinely searching for relatively uncommon or obscure diagnoses.