Airway reflux

Postnasal Drip

Postnasal drip (PND) is a common symptom encountered when evaluating subjects with sinonasal disease; it may be present without sinonasal disease or as a symptom of laryngopharyngeal reflux. It is postulated that PND stems from dysfunction of normal mucus clearance mechanisms; however, there is no definitive evidence elucidating an exact pathophysiology. Compounding the uncertainties surrounding PND is the lack of an objective assessment tool. Instead, treating physicians must rely on subjective complaints and investigators utilize validated patient-reported outcome instruments, such as the Sino-Nasal Outcome Test, to determine treatment efficacy. This review seeks to discuss the current understanding of PND and evidence regarding effective treatment strategies.

Pepsin-mediated inflammation in laryngopharyngeal reflux via the ROS/NLRP3/IL-1β signaling pathway

BACKGROUND

Laryngopharyngeal reflux (LPR) is one of the most common disorders in otorhinolaryngology, affecting up to 10% of outpatients visiting otolaryngology departments. In addition, 50% of hoarseness cases are related to LPR. Pepsin reflux-induced aseptic inflammation is a major trigger of LPR; however, the underlying mechanisms are unclear. The nucleotide-binding domain and leucine-rich repeat protein 3 (NLRP3) inflammasome has become an important bridge between stimulation and sterile inflammation and is activated by intracellular reactive oxygen species (ROS) in response to danger signals, leading to an inflammatory cascade. In this study, we aimed to determine whether pepsin causes LPR-associated inflammatory injury via mediating inflammasome activation and explore the potential mechanism.

METHODS

We evaluated NLRP3 inflammasome expression and ROS in the laryngeal mucosa using immunofluorescence and immunohistochemistry. Laryngeal epithelial cells were exposed to pepsin and analyzed using flow cytometry, western blotting, and real-time quantitative PCR to determine ROS, NLRP3, and pro-inflammatorycytokine levels.

RESULTS

Pepsin expression was positively correlated with ROS as well as caspase-1 and IL-1β levels in laryngeal tissues. Intracellular ROS levels were elevated by increased pepsin concentrations, which were attenuated by apocynin (APO)-a ROS inhibitor-in vitro. Furthermore, pepsin significantly induced the mRNA and protein expression of thioredoxin-interacting protein, NLRP3, caspase-1, and IL-1β in a dose-dependent manner. APO and the NLRP3 inhibitor, MCC950, inhibited NLRP3 inflammasome formation and suppressed laryngeal epithelial cell damage.

CONCLUSION

Our findings verified that pepsin could regulate the NLRP3/IL-1β signaling pathway through ROS activation and further induce inflammatory injury in LPR. Targeting the ROS/NLRP3 inflammasome signaling pathway may help treat patients with LPR disease.

Diagnosis of Laryngopharyngeal Reflux Disease Based on Gray and Texture Changes of Laryngoscopic Images

OBJECTIVE

This study aimed to compare the changing trends of gray and texture values of laryngoscopic images in patients with laryngopharyngeal reflux (LPR) and non-LPR.

METHODS

A total of 3428 laryngoscopic images were selected and divided into two groups, non-LPR and LPR groups based on the reflux symptom index. Gray histogram and gray-level co-occurrence matrix (GLCM) were used to quantify gray and texture features, and the model was trained based on these features. The total laryngoscopic images dataset was proportionally split into two parts including the training set and the test set according to the ratio of 7:3. Four different machine learning algorithms, including decision tree, naive Bayes, linear regression, and K-nearest neighbors, were applied to classify non-LPR or LPR laryngoscopic images.

RESULTS

The results showed that different classification algorithms are used to classify laryngoscopic image dataset and promising classification accuracy are obtained. Specifically, the accuracy of K-nearest neighbors was 83.38% for the gray histogram-only classification, that of linear regression was 88.63% for the GLCM-only classification, and that of the decision tree was 98.01% for the combined gray histogram and GLCM analysis.

CONCLUSION

Gray histogram and GLCM analysis of the laryngoscopic images may be used as auxiliary tools to detect laryngopharyngeal mucosal damage in patients with LPR. Measurement of gray and texture feature values is an objective and convenient method, which may serve as a reference baseline for clinicians and have potential clinical usefulness.

A Prospective Controlled Study Investigating Odor Identification in Laryngopharyngeal Reflux

OBJECTIVE

To psychophysically evaluate olfaction in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective controlled study.

SETTING

Tertiary medical center.

METHODS

From January 2021 to January 2022, patients with LPR diagnosed with hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring underwent psychophysical evaluation of the sense of smell. Reflux symptoms and findings were assessed with the Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA). Nasal symptoms were assessed through the Sino-Nasal Outcome Test 22 (SNOT-22). From pre- to posttreatment, patients underwent identification Sniffin' Sticks test and olfactory cleft examination. Clinical outcomes were compared between LPR patients and healthy individuals.

RESULTS

In total, 107 patients and 76 healthy individuals completed the evaluations. LPR patients reported significant higher RSS, RSA, and SNOT-22 scores. Psychophysical olfactory evaluations were significantly lower in reflux patients compared with controls, while there were no significant differences in olfactory cleft score. RSS and RSA significantly improved from baseline to 3 months posttreatment. SNOT-22, olfactory cleft endoscopy scale, and psychophysical olfactory evaluations did not change throughout treatment. Patients with higher number of acid pharyngeal reflux events reported lower psychophysical olfactory scores (P = .025).

CONCLUSION

LPR disease was associated with low odor identification results in patients without olfactory cleft abnormalities. The sense of smell did not improve after 3-month therapy. Future controlled studies using threshold, discrimination, and identification testing are needed.

[Current possibilities and challenges in the treatment of laryngopharyngeal reflux]

Laryngopharyngeal reflux (LPR) is characterized by backflow of gastric or gastroduodenal content and gases into the upper aerodigestive tract, which can damage the mucus membranes of the larynx and pharynx. It is associated with a variety of symptoms such as retrosternal burning and acid regurgitation, or other unspecific symptoms such as hoarseness, globus sensation, chronic cough, or mucus hypersecretion. Due to the lack of data and the heterogeneity of studies, diagnosis of LPR is problematic and challenging, as recently discussed. Moreover, the different therapeutic approaches are also discussed controversially in the face of the poor evidence base, and include pharmacologic and conservative dietary measures. Hence, in the following review, the available options for treatment of LPR are critically discussed and summarized for daily clinical use.

Laryngeal and Esophageal Mucosal Protection Using the Angico Gum Biopolymer in a Mouse Model of Reflux

OBJECTIVE

This study aimed to evaluate the in vivo protective effect of the angico gum biopolymer in reducing the inflammatory response and preserving the integrity of the laryngeal and esophageal mucosa.

STUDY DESIGN

Animal study.

METHODS

A murine surgical model of gastroesophageal reflux disease was accomplished and subsequently treated with angico gum or omeprazole. On days 3 and 7 post surgery, samples of the larynx and esophagus, respectively, were collected to measure the level of inflammation (wet weight and myeloperoxidase activity) and mucosal integrity (transepithelial electrical resistance and mucosal permeability to fluorescein).

RESULTS

Angico gum and omeprazole decreased laryngeal inflammation (wet weight and myeloperoxidase activity) and dramatically improved the integrity of the laryngeal mucosa. It also reduced inflammation (decreased wet weight and myeloperoxidase activity) of the esophagus and preserved the barrier function (inferred by assessing the integrity of the mucosa).

CONCLUSION

This study demonstrates the protective effect of angico gum in an experimental gastroesophageal reflux disease model. Angico gum attenuates inflammation and impairment of the mucosal barrier function not only in the larynx but also in the esophagus.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:162-168, 2023.

Changes of Pepsin Concentration in Saliva Sample According to Storage Period

OBJECTIVES

To determine whether the concentration of pepsin in the saliva sample changes according to the storage period of the sample.

METHODS

Forty eight patients with suspected laryngopharyngeal reflux were included in this study. Saliva samples were collected from each patient and each sample divided into six and stored for different period of time. Pepsin concentration was measured using enzyme-linked immunosorbent assay. A comparison was made between the pepsin concentration measured immediately and the concentration measured after storage for 1 week, 2 weeks, 1 month, 3 months, and 6 months.

RESULTS

No significant difference in pepsin concentrations were detected between the sample analyzed immediately and those analyzed at 1 week, 2 weeks, 1 month, and 3 months after saliva collection. A significant difference in pepsin concentration was observed in the sample analyzed immediately and the sample analyzed 6 months after saliva collection.

CONCLUSIONS

Pepsin concentration in saliva samples did not demonstrate a significant difference between the concentration measured immediately and the concentration measured 3 months after saliva collection, although a significant difference was observed in the concentration measured 6 months after collection.

Effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases: physiopathology and therapeutic targets

PURPOSE

Laryngopharyngeal reflux disease (LPRD) is a general term for the reflux of gastroduodenal contents into the laryngopharynx, oropharynx and even the nasopharynx, causing a series of symptoms and signs. Currently, little is known regarding the physiopathology of LPRD, and proton pump inhibitors (PPIs) are the drugs of choice for treatment. Although acid reflux plays a critical role in LPRD, PPIs fail to relieve symptoms in up to 40% of patients with LPRD. The influence of other reflux substances on LPRD, including pepsin, bile acid, and trypsin, has received increasing attention. Clarification of the substances involved in LPRD is the basis for LPRD treatment.

METHODS

A review of the effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases was conducted in PubMed.

RESULTS

Different reflux substances have different effects on LPRD, which will cause various symptoms, inflammatory diseases and neoplastic diseases of the laryngopharynx. For LPRD caused by different reflux substances, 24-h multichannel intraluminal impedance combined with pH-metry (MII-pH), salivary pepsin, bile acid and other tests should be established so that different drugs and treatment courses can be used to provide patients with more personalized treatment plans.

CONCLUSION

This article summarizes the research progress of different reflux substances on the pathogenesis, detection index and treatment of LPRD and lays a theoretical foundation to develop target drugs and clinical diagnosis and treatment.

How to Understand and Treat Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.

Bile reflux and hypopharyngeal cancer (Review)

Laryngopharyngeal reflux, a variant of gastroesophageal reflux disease, has been considered a risk factor in the development of hypopharyngeal cancer. Bile acids are frequently present in the gastroesophageal refluxate and their effect has been associated with inflammatory and neoplastic changes in the upper aerodigestive tract. Recent in vitro and in vivo studies have provided direct evidence of the role of acidic bile refluxate in hypopharyngeal carcinogenesis and documented the crucial role of NF-κB as a key mediator of early oncogenic molecular events in this process and also suggested a contribution of STAT3. Acidic bile can cause premalignant changes and invasive squamous cell cancer in the affected hypopharynx accompanied by DNA damage, elevated p53 expression and oncogenic mRNA and microRNA alterations, previously linked to head and neck cancer. Weakly acidic bile can also increase the risk for hypopharyngeal carcinogenesis by inducing DNA damage, exerting anti-apoptotic effects and causing precancerous lesions. The most important findings that strongly support bile reflux as an independent risk factor for hypopharyngeal cancer are presented in the current review and the underlying mechanisms are provided.

24-Hour Multichannel Intraluminal Impedance-pH in Proton Pump Inhibitor Nonresponders vs Responders in Patients With Laryngopharyngeal Reflux

OBJECTIVE

This study aimed to evaluate the characteristics of reflux in proton pump inhibitor (PPI) nonresponders vs responders in patients with laryngopharyngeal reflux (LPR) by using 24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring.

STUDY DESIGN

Prospective cohort study.

SETTING

A tertiary care otolaryngology clinic.

METHODS

Patients with typical LPR symptoms showing >1 proximal reflux episode were considered to have LPR and investigated prospectively. Patients were prescribed high-dose PPI twice daily and followed up for at least 2 months. Patients with LPR showing a ≥50% decrease in the follow-up reflux symptom index score during treatment periods as compared with pretreatment were defined as responders; others were defined as nonresponders. Various parameters in 24-hour MII-pH monitoring between nonresponders and responders with LPR were compared with Student's t test and receiver operating characteristic curve.

RESULTS

Eighty patients were diagnosed with LPR and categorized as nonresponders (n = 19) and responders (n = 61). Proximal all reflux time and proximal longest reflux time in various MII parameters were higher in responders than in nonresponders (P = .0040 and .0216, respectively). Proximal all reflux time >0.000517% was a better cutoff value to predict responders with LPR as compared with the proximal longest reflux time >0.61 minutes (sensitivity + specificity: 1.317 vs 1.291).

CONCLUSION

Proximal all reflux time in various 24-hour MII-pH monitoring parameters can be helpful to predict the response to PPI therapy in patients with LPR. These findings will help establish a personalized therapeutic scheme for patients with LPR.

Laryngeal Chemoreflex in Health and Disease: A Review

The larynx plays a key role in airway protection via the laryngeal chemoreflex (LCR). This involuntary reflex can be evoked when hazardous substances activate mucosal receptors, which send signals to be processed within the brainstem. Although the LCR is meant to be protective, the reflex can become hyperstimulated, even to benign stimuli, which can result in pathological disorders, such as chronic cough and inducible laryngeal obstruction. In this review, we will outline the mechanism of the LCR and its associated pathological disorders.

Association between gastroesophageal reflux disease and vocal fold polyps

The aim of this study is to explore the relationship between gastroesophageal reflux disease (GERD) and vocal fold polyps (VFPs).This is a Case-Control study and was performed with the help of The Second Affiliated Hospital of Chongqing Medical University.Twenty-seven patients with VFP and 20 controls without VFP were recruited between May and October 2018. All the subjects underwent a saliva pepsin test, completed the GerdQ questionnaire and 24-hour multichannel intraluminal impedance with pH (24-h MII-pH) monitoring. Twenty-five resected VFP specimens were examined with immunohistochemical (IHC) and double immunofluorescence (IF) staining.The incidence of GERD in the VFP group was significantly higher than that in the control group (P = .003). Patients with VFP had significantly higher GerdQ scores, pepsin concentrations, and pepsin-positive rates (P < .05). Moreover, the number of proximal and upright reflux events was significantly higher in the VFP group (P < .05). The pepsin concentration in saliva showed a significant positive correlation with the pepsin levels in tissues (r2 = 0.50, P = .011). Pepsin and TGF-β1-positive cells were colocalized with CD45RO-positive cells. IHC staining showed that the majority of VFP patients had a positive expression of pepsin (20/25, 80%) and pepsin-positive cells were found in both the squamous epithelium and mesenchymal tissues. IHC staining of TGF-β1 in VFP revealed findings similar to those of pepsin staining.GERD is an important risk factor for VFP. Pepsin may promote the aggregation of immune cells, increase the local cytokines, and promote inflammatory reaction, suggesting a potential new pathogenesis for VFP. The saliva pepsin test is a reliable method for GERD diagnosis.

Management of Laryngopharyngeal Reflux Around the World: An International Study

OBJECTIVE

To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR).

METHODS

An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment.

RESULTS

A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR.

CONCLUSIONS

LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world.

LEVEL OF EVIDENCE

N.A. Laryngoscope, 131:E1589-E1597, 2021.

Presence of Gastric Pepsinogen in the Trachea Is Associated with Altered Inflammation and Microbial Composition

Gastroesophageal reflux is a common gastrointestinal issue that can lead to aspiration and contribute to respiratory problems. Little is known about how reflux can alter the respiratory microenvironment. We aimed to determine if the presence of gastric pepsinogen in the trachea was associated with changes in the microbial and inflammatory microenvironment. A pediatric cohort at high risk of reflux aspiration was prospectively recruited, and the tracheal microenvironment was examined. Pepsinogen A3 (PGA3) and cytokines were measured. The microbiome (bacterial and fungal) was profiled using 16S rRNA and internal transcribed spacer 2 (ITS2) amplicon sequencing. Increased bacterial richness and an altered composition driven by an enrichment of Prevotella correlated with high PGA3 levels. Fungal richness increased with PGA3, with higher Candida relative abundances observed in a subset of samples with high PGA3 levels. Source tracking of tracheal microbial taxa against taxa from matched oral and gastric samples revealed a significantly greater contribution of oral than of gastric taxa with higher PGA3 levels. Tracheal cytokines were differentially produced when stratified according to PGA3, with higher levels of interleukin-1 (IL-1)-related cytokines and IL-8 being associated with high PGA3 levels. Network analysis across cytokine and microbiome measures identified relationships between IL-1-related proteins and microbial taxa, with the presence of respiratory issues associated with higher levels of IL-1β, IP-10, and Prevotella In conclusion, PGA3 levels in the trachea are correlated with increases in specific microbial taxa and inflammatory molecules, with an increase in oral microbes with increasing PGA3.

Proximal reflux: biochemical mediators, markers, therapeutic targets, and clinical correlations

Airway reflux is implicated in the pathophysiology of a wide range of adult and pediatric upper and lower airway diseases. However, the diagnosis of proximal reflux-associated disease remains challenging due to evolving clinical criteria and institutional and regional variances in diagnostic practices. Evidence suggests that nonacidic contents of reflux may serve as both pathologic mediators of and biomarkers for reflux in the upper airway. Furthermore, they offer potential pharmaceutical and surgical intervention targets and are the focus of novel clinical diagnostic tools currently under investigation.

Management of Laryngopharyngeal Reflux in Asia

OBJECTIVES

This study was conducted to investigate the current practices of Asian otolaryngologists for laryngopharyngeal reflux (LPR).

METHODS

An online survey about LPR was sent to 2,000 members of Asian otolaryngological societies, and a subgroup analysis was performed between Western and Eastern Asian otolaryngologists. The survey was conducted by the Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the International Federation of Oto-rhino-laryngological Societies.

RESULTS

Among approximately 1,600 Asian otolaryngologists, 146 completed the survey (62 from Western Asian countries, 84 from Eastern Asian countries). A substantial majority (73.3%) of the otolaryngologists considered LPR and gastroesophageal reflux disease to be different diseases. The symptoms thought to be closely related to LPR were coughing after lying down, throat clearing, and globus sensation. The findings thought to be closely related to LPR were posterior commissure granulations and hypertrophy, arytenoids, and laryngeal erythema. The respondents indicated that they mostly diagnosed LPR (70%) after an empirical therapeutic trial of proton pump inhibitors (PPIs). Although multichannel intraluminal impedance-pH (MII-pH) monitoring is a useful tool for diagnosing nonacid or mixed LPR, 78% of Asian otolaryngologists never or very rarely used MII-pH. Eastern Asian otolaryngologists more frequently used once-daily PPIs (64.3% vs. 45.2%, P=0.021), whereas Western Asian otolaryngologists preferred to use twice-daily PPIs (58.1% vs. 39.3%, P=0.025). The poor dietary habits of patients were considered to be the main reason for therapeutic failure by Asian otolaryngologists (53.8%). Only 48.6% of Asian otolaryngologists considered themselves to be adequately knowledgeable and skilled regarding LPR.

CONCLUSION

Significant differences exist between Western and Eastern Asian otolaryngologists in the diagnosis and treatment of LPR. Future consensus statements are needed to establish diagnostic criteria and therapeutic regimens.

The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

OBJECTIVE

This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR.

METHODS

In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains.

RESULTS

A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003).

CONCLUSION

Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

Laryngeal Mucosa Alterations in Mice Model of Gastroesophageal Reflux: Effects of Topical Protection

OBJECTIVES/HYPOTHESIS

The objectives of this study were to evaluate laryngeal inflammation and mucosal integrity in a murine model of reflux disease and to assess the protective effects of topical agents including alginate, hyaluronic acid, and cashew gum.

STUDY DESIGN

Animal study.

METHODS

A surgical murine model of reflux disease was evaluated at 3 or 7 days postsurgery, and laryngeal samples were collected to measure inflammation (wet weight and myeloperoxidase [MPO]) and mucosal integrity (transepithelial resistance [TER] and mucosal permeability to fluorescein). Additional groups of animals were administered one of several topical agents (alginate, hyaluronic acid, or cashew gum) daily, and laryngeal inflammation and mucosal integrity were evaluated at 3 days postsurgery.

RESULTS

At 3 days, and not 7 days postsurgery, we observed increased laryngeal wet weight and MPO, decreased laryngeal TER, and increased laryngeal mucosa permeability. Alginate partially decreased laryngeal inflammation (wet weight and not MPO) and dramatically improved laryngeal mucosal integrity. Conversely, hyaluronic acid eliminated the inflammation; however, it had no effect on laryngeal mucosal integrity impairment. Cashew gum eliminated laryngeal inflammation as well as the impairment in laryngeal mucosal integrity.

CONCLUSIONS

This study shows that a surgical model of reflux disease induced laryngeal inflammation and impairment in laryngeal barrier function. These observed alterations were partially attenuated by alginate and hyaluronic acid and completely reversed by cashew gum.

LEVEL OF EVIDENCE

NA Laryngoscope, 2020.

Treatment of laryngopharyngeal reflux disease: A systematic review

BACKGROUNG

For a long time, laryngopharyngeal reflux disease (LPRD) has been treated by proton pump inhibitors (PPIs) with an uncertain success rate.

AIM

To shed light the current therapeutic strategies used for LPRD in order to analysis the rationale in the LPRD treatment.

METHODS

Three authors conducted a PubMed search to identify papers published between January 1990 and February 2019 about the treatment of LPRD. Clinical prospective or retrospective studies had to explore the impact of medical treatment(s) on the clinical presentation of suspected or confirmed LPRD. The criteria for considering studies for the review were based on the population, intervention, comparison, and outcome framework.

RESULTS

The search identified 1355 relevant papers, of which 76 studies met the inclusion criteria, accounting for 6457 patients. A total of 64 studies consisted of empirical therapeutic trials and 12 were studies where authors formally identified LPRD with pH-monitoring or multichannel intraluminal impedance-pH monitoring (MII-pH). The main therapeutic scheme consisted of once or twice daily PPIs for a duration ranged from 4 to 24 wk. The most used PPIs were omeprazole, esomeprazole, rabeprazole, lansoprazole and pantoprazole with a success rate ranging from 18% to 87%. Other composite treatments have been prescribed including PPIs, alginate, prokinetics, and H₂ Receptor antagonists.

CONCLUSION

Regarding the development of MII-pH and the identification of LPRD subtypes (acid, nonacid, mixed), future studies are needed to improve the LPRD treatment considering all subtypes of reflux.

Pepsin Triggers Neutrophil Migration Across Acid Damaged Lung Epithelium

Pepsin represents a potential biomarker for extraesophageal reflux disease when detected in airways, however a direct role for pepsin in lung dysfunction has not been clearly established. Children experiencing gastroesophageal and extraesophageal reflux are often prescribed proton pump inhibitors (PPIs) to reduce gastric acid associated damage to esophageal and airway mucosa. The potential of pepsin and gastric fluid, from children that were either on or off PPI therapy, to cause inflammation and damage using a human in vitro co-culture model of the airway mucosa was evaluated herein. Exposure of the airway model to acidic solutions caused cellular damage and loss of viability, however, acid alone did not disrupt barrier integrity or instigate neutrophil trans-epithelial migration without pepsin. Gastric fluid from patients on PPI therapy exhibited only a slightly higher pH yet had significantly higher concentrations of pepsin and elicited more barrier disruption and neutrophil trans-epithelial migration compared to gastric fluid from patients off PPIs. Inflammatory and damaging responses observed with gastric fluid from patients on PPIs were largely driven by pepsin. These results indicate the potential for PPI usage to raise concentrations of pepsin in gastric fluid, which may enhance the pathological impact of micro-aspirations in children with extraesophageal reflux.

Saliva pepsin level of laryngopharyngeal reflux patients is not correlated with reflux episodes

OBJECTIVE

To investigate the relationship between the laryngopharyngeal reflux (LPR) episodes at the multichannel intraluminal impedance-pH monitoring (MII-pH) and the concentration of pepsin in the saliva of LPR patients.

METHODS

Patients with LPR were enrolled from the polyclinic of Poitiers, France. Patients benefited from 24-hour MII-pH that allowed a correlation study between reflux episodes and symptoms. Patients reported the occurrence of the critical symptoms during the testing period through a recording device. Simultaneously, they collected a first saliva sample 30 minutes after the symptoms and a second saliva collection a few hours after the first collection. The patient symptoms were assessed with reflux symptom score (RSS). The relationship between pepsin concentration in the saliva, symptoms, and the reflux episode characteristics at the MII-pH was investigated through multiple linear regression.

RESULTS

A total of 65 patients with LPR were recruited. The mean concentrations of the first and the second pepsin samples were 92.0 ± 108.1 and 101.8 ± 131.0, respectively. Peptest (RD Biomed, Milan, Italy) was positive in 51 LPR patients (78.5%). Concentrations of both pepsin samples were significantly correlated (P = 0.019). There was no significant association between pepsin concentrations in saliva samples, RSS, key symptoms during the test period, and MII-pH findings.

CONCLUSION

The level of pepsin saliva concentration is not associated with the reflux episodes at the MII-pH. Future studies are needed to better understand the relationship between the extracellular pepsin concentration, mucosal inflammation, and related laryngopharyngeal symptoms.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1278-1281, 2020.

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review

OBJECTIVE

To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients-those who do not respond to anti-reflux medical treatment.

METHODS

A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated.

RESULTS

Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non-acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy.

CONCLUSION

To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients.

LEVEL OF EVIDENCE

2a.

Optimized Generation of Primary Human Epithelial Cells from Larynx and Hypopharynx: A Site-Specific Epithelial Model for Reflux Research

Laryngopharyngeal reflux (LPR) induces a differential damage effect on several anatomic sites within the larynx and hypopharynx; therefore, an in vitro model is needed for each anatomic site. This study aimed to establish a primary culture method for human laryngeal and hypopharyngeal epithelial cells derived from multiple anatomic sites. Surgical mucosa specimens were treated with a two-step enzymatic strategy to establish a primary culture. Of the 46 samples, primary cultivation was achieved successfully with 36 samples, and the positive ratio was 78.3%. In addition, flow cytometry revealed that these primary cells were epithelial cells with a purity of 94.9%. The proliferative ability was confirmed by positive staining for Ki-67. Laryngeal and hypopharyngeal epithelial cells from multiple sites exhibited similar epithelial morphology and positive cytokeratin expression. These cells can be cultured to passage 4. In summary, we successfully established the in vitro epithelial model of larynx and hypopharynx subsites, which may potentially be used as a platform for reflux research, especially for site-specific damage effect.

Perspectives on the interlinked nature of systemic sclerosis and reflux disease

Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.

Evaluation and Management of Laryngopharyngeal Reflux Disease: State of the Art Review

OBJECTIVE

To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR).

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

METHODS

A comprehensive review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature.

CONCLUSIONS

The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance-pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved.

IMPLICATIONS FOR PRACTICE

The development of multichannel intraluminal impedance-pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR.

Aerodigestive Approach to Chronic Cough in Children

Purpose of review

Chronic cough is the most common presenting complaint in a pediatric aerodigestive clinic. The etiology of chronic cough is varied and often includes more than one organ system. This review aims to summarize the current literature for a multidisciplinary approach when evaluating a child with chronic cough.

Recent findings

There is very little medical literature focused on a multidisciplinary approach to chronic cough. In the limited data available, multidisciplinary clinics have been shown to be more cost-efficient for the families of children with complex medical problems, and also increase the likelihood of successfully obtaining a diagnosis.

Summary

There is no consensus in the literature on how to work-up a child with chronic cough presenting to an aerodigestive clinic. Current studies from these clinics have shown improved outcomes related to cost-effectiveness and identifying definitive diagnoses. Future studies evaluating clinical outcomes are necessary to help delineate the utility of testing routinely performed, and to demonstrate the impact of interventions from each specialty on quality of life and specific functional outcome measures.

Effects of pepsin and pepstatin on reflux tonsil hypertrophy in vitro

There is evidence that pepsin can aggravate tonsil hypertrophy. Pepstatin is a potent inhibitor of pepsin activity and could protect patients against reflux tonsil hypertrophy by inhibiting pepsin. We examined the effects of pepstatin on the development of tonsil hypertrophy to investigate pepsin’s role in the pathogenesis of tonsil lesions. We investigated whether pepstatin suppresses pepsin-mediated lymphocyte proliferation in tonsil hypertrophy. Forty-nine children with tonsil hypertrophy and twenty-two adults with tonsillitis were recruited to the study prior to surgery. Tonsil tissue from each patient was harvested and assessed for changes in the number of lymphocytes and macrophages in the presence of pepsin and pepstatin. We found that the proportions of CD4- and CD14-positive cells were significantly lower (p < 0.05), but that the proportions of CD19- and CD68-positive cells were significantly higher (p < 0.05), in children than in adults. There were significantly more CD4-positive cells after pepsin treatment, but these numbers were reduced by pepstatin. The levels of both interleukin-2 (IL-2) and interferon gamma (IFN-γ) increased significantly in response to pepsin, but were reduced when pepsin was inhibited by pepstatin. The level of IL-10 is reduced in pepsin-treated CD4 cells and the level is restored by pepstatin. IL-2 blocking reduced the increased CD4 cell number by pepsin. But, an additive or a synergic effect is not founded in combined with IL-2 blocking and pepstatin. Pepsin-positive cells did not co-localize with CD20 and CD45 cells, but they were found surrounding CD20- and CD45-positive hypertrophic tonsil cells. Pepsin-positive cells co-localized with CD68-positive cells. It is probable that pepsin from extraesophageal reflux aggravates tonsil hypertrophy and pepstatin exerts a protective effect by inhibiting pepsin activity.

Saliva Pepsin Detection and Proton Pump Inhibitor Response in Suspected Laryngopharyngeal Reflux

OBJECTIVES/HYPOTHESIS

To evaluate the prediction value of saliva pepsin detection for an 8-week proton pump inhibitor (PPI) response in patients with a Reflux Symptoms Index (RSI) score ≥13, which indicates possible laryngopharyngeal reflux.

STUDY DESIGN

Prospective individual single-cohort study.

METHODS

Patients were recruited who had experienced chronic laryngopharyngeal symptoms (RSI score ≥13) for more than 3 months after excluding other etiologies. The patients received PPI (40 mg of esomeprazole once daily) treatment for 8 weeks. Prior to treatment, the patients submitted saliva/sputum samples that were collected during the time symptoms were observed. The samples were taken for pepsin detection, and performed using the commercially available Peptest lateral flow device. The association of the Peptest results and PPI response were statistically analyzed with the χ² test.

RESULTS

Seventy-four patients completed the study, and upon completion of PPI treatment, the mean RSI score was significantly reduced from 19.22 ± 5.18 to 8.99 ± 5.69. Forty-four (59.5%) patients exhibited a good response as defined by an RSI score reduction ≥50%. The results of the Peptest were semiquantitatively graded as 0, 1, 2, 3 (negative, weak positive, moderate positive and strong positive, respectively) based upon the visual intensity of the test sample line as compared to the control line. Twenty-four patients (32.4%) exhibited grade 3 strong positive results. The Peptest strong positive results (P < .05) were significantly associated with a good PPI response, with the positive predictive value being 79.2%.

CONCLUSIONS

Analysis of strong positive results for pepsin detection in saliva/sputum samples may be a useful, noninvasive method for predicting better PPI response in patients with suspected reflux induced chronic laryngopharyngeal symptoms.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:709-714, 2019.

The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China

Background

None of current diagnostic methods has been proven to be a reliable tool for gastro-esophageal reflux disease (GERD). Pepsin in saliva has been proposed as a promising diagnostic biomarker for gastro-esophageal reflux. We aimed to determine the diagnostic value of salivary pepsin detection for GERD.

Methods

Two hundred and fifty patients with symptoms suggestive of GERD and 35 asymptomatic healthy volunteers provided saliva on morning waking, after lunch and dinner for pepsin determination using the Peptest lateral flow device. All patients underwent 24-h multichannel intraluminal impedance pH (24-h MII-pH) monitoring and upper gastrointestinal endoscopy. Based on 24-h MII-pH and endoscopy study, patients were defined as GERD (abnormal MII-pH results and/or reflux esophagitis) and non-GERD otherwise.

Results

Patients with GERD had a higher prevalence of pepsin in saliva and higher pepsin concentration than patients with non-GERD and healthy controls (P < 0.001 for all). The pepsin test had a sensitivity of 73% and a specificity of 88.3% for diagnosing GERD using the optimal cut-off value of 76 ng/mL. Postprandial saliva samples collected when the symptoms occurred had a more powerful ability to identify GERD.

Conclusions

Salivary pepsin test had moderate diagnostic value for GERD. It may be a promising tool to replace the use of currently invasive tools with advantages of non-invasive, easy to perform and cost effective.

Trial registration

ChiCTR-DDD-16009506 (date of registration: October 20, 2016).