Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux

Proton pump inhibitors are still overprescribed for hospitalized children

OBJECTIVE

The use of proton pump inhibitors has increased exponentially over the past 20 years. Several side effects have been reported and concerns exist about the consequences of long-term proton pump inhibitors on health, leading to limitation of their use. The present study analyzed prescriptions of proton pump inhibitors at inpatient units and assessed their compliance with current recommendations.

METHODS

This single-center, observational, retrospective study reviewed medical file of patients hospitalized at the pediatric medical departments of the Bordeaux University Hospital between April 1 and September 30, 2019. Patients younger than 18 years, hospitalized in the pediatric hospital units and treated with proton pump inhibitors were included. Prescriptions of proton pump inhibitors were compared with French and international guidelines.

RESULTS

Proton pump inhibitors were prescribed for 251 of 2237 children (11%), mainly for gastroesophageal reflux disease (47%) and prevention of peptic ulcer disease (32.7%). Proton pump inhibitor prescription complied to recommendations in 34.5% of cases, less often in children aged younger than 1 year (13.5%) than in older children. Compliance to recommendations was lower when proton pump inhibitors were indicated for the prevention of peptic disease (5%) than for gastroesophageal reflux disease (48%).

CONCLUSIONS

Proton pump inhibitors are frequently prescribed for hospitalized children, and indications comply with recommendations in only 35% of the cases. Efforts in spreading awareness of the recommendations on the use of proton pump inhibitors in children are mandatory among hospital pediatricians.

Gastroesophageal Reflux Disease and Aerodigestive Disorders

This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance.

Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) is a normal physiologic process. It is important to distinguish GER from GER disease (GERD) since GER does not require treatment. Although a diagnosis of GERD can largely be based on history and physical alone, endoscopy and pH impedance studies can help make the diagnosis when there in atypical presentation. In children and adolescents, lifestyle changes and acid suppression are first-line treatments for GERD. In infants, acid suppression is not effective, but a trial of hydrolyzed formula can be considered, as milk protein sensitivity can be difficult to differentiate from GER symptoms.

Management of dysphonia in children

Background:

Dysphonia is common in children, but practice varies considerably regarding what, if any, investigations are performed and how the condition is managed. Although childhood dysphonia is mostly due to non-serious causes such as voice misuse, very serious pathology such as papillomatosis or malignancy needs occasionally to be excluded, and treatable congenital anomalies such as webs and cysts can be missed. Voice clinics and voice therapy services are now well established in most adult health services in the developed world, but equivalent services for children are less common, at least in the UK.

Methods:

We retrospectively reviewed the records of all children presenting to our large children's hospital with a primary complaint of dysphonia between January 2001 and October 2007, in order to determine their management, investigations and final diagnosis.

Results:

We identified 142 children. Case records were found for 137 (97 per cent). Eight-three children were male (61 per cent) and 54 female (39 per cent). Ages ranged from two months to 15 years (median 5.3 years). In 10 children (7 per cent), hoarseness was congenital, presenting as a hoarse, weak cry at birth. In 15 children (11 per cent), onset of hoarseness was related to a specific surgical procedure. The larynx was visualised by mirror alone in 23 children (17 per cent), by awake fibre-optic laryngoscopy in 27 (20 per cent) and by microlaryngoscopy-bronchoscopy under anaesthesia in 42 (31 per cent). Forty children (29 per cent) did not undergo laryngeal visualisation at any time and were diagnosed based on history alone. A further five (4 per cent) were scheduled for direct laryngoscopy but this was not performed due to resolution of symptoms. Voice abuse accounted for 62 (45 per cent) of all diagnoses.

Conclusions:

Childhood dysphonia accounts for a large number of referrals. There is considerable variation in how these children are managed. A more structured approach to diagnosis and investigation would be beneficial, perhaps within the setting of a dedicated paediatric voice clinic.

Oropharyngeal 24-Hour pH Monitoring in Children With Airway-Related Problems

Objectives

Diagnosis and clinical presentation of pediatric laryngopharyngeal reflux (LPR) is still controversial. The aims of this work were to study the possibility of performing 24-hour oropharyngeal pH monitoring for children in the outpatient clinic setup and to explore the results of this test in correlation to airway-related problems.

Methods

In this descriptive qualitative study, 26 children suffering from airway-related problems were included. Oropharyngeal 24-hour pH monitoring was performed for all subjects in the outpatient clinic setting. The distribution of airway diagnoses among the study group was studied versus the results of the pH monitoring.

Results

There were 16 males and 10 females participated in the study with a mean age of 6.88 (SD, ±5.77) years. Thirty-five percent of the patients were under the age of 3 years (range, 11 months to 3 years). Eight-five percent of the patients tolerated the pH probe insertion and completed 24-hour of pH recording. Laryngomalacia and subglottic stenosis (SGS) were more frequently reported in the positive LPR patients (77%).

Conclusion

Oropharyngeal 24-hour pH monitoring can be conducted for children in the outpatient setup even in young age children below 3 years old. Among the positive LPR group, SGS and laryngomalacia were the most commonly reported airway findings.

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

The assessment of pediatric laryngopharyngeal reflux (LPR) is controversial. Otorhinolaryngologists may play a role in the evaluation of children with suspected LPR detecting typical airway endoscopic findings and/or associated diseases and may help in the selection of children to be subjected to further instrumental tests. In this perspective the present review aims at examining the available evidence in the literature regarding the assessment of LPR in children. After careful literature search there are no current validated symptoms assessment questionnaires for LPR evaluation in children; flexible fiberoptic nasopharyngolaryngoscopy remains controversial as a diagnostic tool in suspect LPR cases; even though the multichannel intraluminal impedance with pH monitoring has been proposed as the instrumental gold standard, further evidence need to be found for validation in children with typical features of LPR.

Eosinophilic Laryngitis in Children with Aerodigestive Dysfunction

Objective

To describe the presence of laryngeal eosinophils and associated symptomatology in patients with aerodigestive dysfunction.

Study Design

Case series with chart review.

Setting

Single tertiary pediatric referral center.

Subjects

Eighty-one consecutive pediatric patients referred to a multidisciplinary aerodigestive clinic with upper airway concerns.

Methods

Microlaryngoscopy and posterior arytenoid biopsy, flexible bronchoscopy, esophagogastroduodenoscopy and esophageal biopsy, and impedance probe testing were performed as indicated by clinical symptoms. Positive versus negative posterior arytenoid biopsy for eosinophils and the presence or absence of concomitant histopathological laryngitis and/or esophagitis were measured.

Results

Nine of 81 (11%) patients had positive laryngeal biopsy for eosinophils (range, 1-29 eosinophils/high-powered field [HPF]). Three of these 9 patients also had concurrent biopsy-proven eosinophilic esophagitis, while 8 of 81 total patients had biopsy-proven eosinophilic esophagitis. The frequency of biopsy-proven eosinophilic esophagitis was higher in patients with posterior arytenoid eosinophils versus patients without laryngeal eosinophils (33% versus 6.9%, P = .0408).

Conclusions

Eosinophilic inflammation in the larynx has not been described in children with complex aerodigestive complaints. Posterior arytenoid eosinophils may serve as a marker of chronic laryngeal inflammation in children with aerodigestive dysfunction, although their exact role in this inflammation remains unclear. In our population, >15 eosinophils/HPF within posterior arytenoid biopsies was associated with concomitant eosinophilic esophagitis.

The utility of endoscopy and multichannel intraluminal impedance testing in children with cough and wheezing

BACKGROUND

Gastroesophageal reflux (GER) has been implicated as a causal factor in respiratory disease but prior studies have focused on the role of acid alone in the genesis of symptoms. Prior studies have relied on pH probe testing but this is blind to non-acid reflux which has been implicated in the genesis of extraesophageal symptoms. The objective of this prospective, cross-sectional study is to determine the utility of gastroesophageal reflux testing, including multichannel intraluminal impedance with pH (pH-MII) and upper gastrointestinal endoscopy (EGD), in the child with intractable cough and wheezing. We hypothesize that there is a high rate of pathologic reflux testing in these patients.

METHODS

Children ages 1-18 with chronic cough and wheezing who were undergoing bronchoscopy for the evaluation of cough and wheezing were recruited into this prospective, cross-sectional study. They underwent identical reflux testing with pH-MII and EGD at the time of bronchoscopy. Reflux burden, symptom association, and rates of esophageal pathology were determined. Results 58% of patients had abnormal reflux testing; 67% of patients had an abnormal pH-MII test and 32% of patients had abnormal esophageal biopsies. The most common pH-MII abnormality was an abnormal symptom association between cough and reflux and the most common endoscopic abnormality was reflux esophagitis. Seven percent of patients presenting only with cough were diagnosed with eosinophilic esophagitis.

CONCLUSIONS

There is a high yield to reflux testing in children with chronic cough and wheezing.

Histologic versus pH probe results in pediatric laryngopharyngeal reflux

OBJECTIVE

A comparison of histologic findings from the post-cricoid region versus nasopharyngeal pH probe results in the diagnosis of laryngopharyngeal reflux (LPR) in the pediatric patient.

STUDY DESIGN

Retrospective review.

SETTING

Outpatient pediatric otolaryngology private practice.

SUBJECT AND METHODS

63 consecutive patients, age 6-months to 17-years between June 1, 2009 and October 6, 2010, tested by simultaneous post cricoid biopsy and nasopharyngeal pH probe monitoring using the Restech Dx-pH Measurement System (Respiratory Technology Corporation, San Diego, CA).

RESULTS

Of the 63 total patients (age 6-months to 17-years), 11 (17%) were excluded due to a pulled probe, one additional patient did not have a biopsy taken and one probe failed after insertion making a total of 50 patients with complete data sets. Thirty-six of those 50 patients had a positive probe with a negative biopsy (72%). Four (8%) had both a positive probe and biopsy and 10 (16%) had a negative probe and negative biopsy. No patients had a negative probe and positive biopsy. Symptoms used to identify patients suspected of reflux included: throat clearing, nasal congestion, cough, history of recurrent sinusitis with negative radiographic findings, halitosis, culture negative sore throat, post nasal drip, otalgia, poor appetite and stomach ache.

CONCLUSION

Eighty percent of our patients (40) were either positive for reflux by pH probe or by pH probe and biopsy. The Restech Dx-pH Measurement System appeared to be well tolerated in all age groups. There were no complications. We found this a useful tool in confirming clinical suspicion of LPR.

[The possibilities of reflux disease diagnosis by the ear, nose and throat specialist]

Reflux disease has gained in importance over the last decade since we know that many of the symptoms and diseases of the upper aerodigestive tract might be associated with reflux. However, a distinction needs to be made between extraesophageal reflux (EER) and gastroesophageal reflux disease (GERD). There are several techniques available for the diagnosis of EER. Furthermore, there are various pH monitoring devices to determine acid contamination of the larynx and the pharynx. In addition, flexible transnasal esophagoscopy is a practicable technique for the rapid examination of reflux, its cause as well as the diagnosis of reflux-induced mucosal changes in the esophagus. The present article describes the instruments used for the diagnosis of reflux against the background of our own experience and the international literature.

Effect of different pH criteria on dual-sensor pH monitoring in the evaluation of supraesophageal gastric reflux in children

BACKGROUND AND AIM

Existing tests for supraesophageal gastric reflux (SEGR) that focus on pH drops <4 in the proximal esophagus have had limited sensitivity and specificity. The aim of the present study was to evaluate the effect of newly proposed pH criteria on SEGR detection.

PATIENTS AND METHODS

Twenty-four-hour dual-sensor pH tracings of 32 patients were reviewed. Proximal esophageal pH data were evaluated according to the conventional definition of pH drop <4 and 2 proposed definitions: pH drop <5.5 while upright and <5.0 while supine and pH drop of >10% from a running baseline. For each potential SEGR event, the preceding 1-minute window was examined for corresponding distal acid reflux.

RESULTS

Of the 542 distal acid reflux events detected, 200 were associated with a proximal pH drop <4; this number increased to 295 using the definition of proximal pH drop <5.5 (upright)/<5.0 (supine) and 301 using the definition of proximal pH drop >10%. A proportion of proximal events, however, was not associated with distal acid reflux: 21 of 200 (10.5%) proximal pH <4 events, 119 of 414 (29%) proximal pH <5.5 (upright)/<5.0 (supine) events, and 272 of 573 (47%) proximal pH drop >10% events lacked a preceding or simultaneous drop in distal pH <4.

CONCLUSIONS

Although the use of more liberal pH criteria increased the diagnostic yield for SEGR events with dual-sensor monitoring, a significant proportion of proximal pH events did not correlate with distal acid reflux. These events could represent either false-positive measurements or association with weakly acid reflux.

A comparison of rating scales used in the diagnosis of extraesophageal reflux

OBJECTIVE

To evaluate the level of agreement between reflux area index scores, the reflux symptom index (RSI), and the reflux finding score (RFS). Inter- and intrarater reliability of the RFS was assessed. A criterion of pH 5 was used to evaluate its effects on agreement.

STUDY DESIGN

Adult participants were enrolled in this prospective study.

METHODS

Eighty-two participants (72 patients and 10 controls) completed the RSI, videoendoscopy, and 24-hour pH probe monitoring. The reflux area index for extraesophageal reflux (EER) events was calculated at pH 4 and 5. Two speech-language pathologists and one otolaryngologist independently rated 36 endoscopic examinations using the RFS through a web-based system. A repeated rating of six examinations was completed.

RESULTS

Chi-square revealed poor agreement between the diagnostic tools, regardless of which pH criterion was used. Intraclass correlation coefficients revealed fair interrater reliability of the RFS and moderate intrarater reliability. Independent-sample t tests for the RFS and reflux area index (RAI) scores failed to identify patients from normal controls.

CONCLUSIONS

The results of this study highlight the lack of agreement among the current available diagnostic tools for EER. Raters were not in agreement regarding the presence and severity of physical findings of EER. Results support the need for greater consensus among the clinical tools used in the diagnosis of EER. Physical rating scales may overidentify patients and would benefit from uniform scales and training. Assessing EER occurring at pH 5 may also yield important diagnostic information. Further research is needed to verify normative RAI cutpoints.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

OBJECTIVES

To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.

METHODS

Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.

RESULTS

There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.

CONCLUSIONS

The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.

Aspiration following CO(2) laser-assisted supraglottoplasty

OBJECTIVE

To review the incidence, risk factors, and treatment of aspiration following CO(2) laser-assisted supraglottoplasty for severe laryngomalacia (LM).

DESIGN

IRB approved retrospective study of pediatric patients with severe LM treated with CO(2) laser supraglottoplasty over a 5-year period.

SETTING

Tertiary pediatric hospital.

PATIENTS

Fifty-two patients met inclusion criteria. Indication for supraglottoplasty was respiratory distress in 90% of patients and/or failure to thrive in 19%.

INTERVENTIONS

All children underwent bilateral CO(2) laser supraglottoplasty and were assessed postoperatively with swallow evaluation by a speech pathologist. Videoflouroscopic evaluation was utilized to confirm aspiration and guide management.

MAIN OUTCOME MEASURES

Aspiration, treatment required to manage aspiration, duration of treatment required.

RESULTS

Thirty-seven percent (20/52) of patients had postoperative aspiration. Aspiration was demonstrated on videoflouroscopic swallow study (VFSS) after supraglottoplasty is 28% (12/43). All patients with newly diagnosed aspiration had treatment with thickened and/or nasogastric feedings with mean resolution time of 6 months. In nine children with preoperative aspiration, eight (89%) had postoperative aspiration and seven required gastrostomy tube placement for feeding management. All individuals requiring gastrostomy for aspiration management had neurological conditions. In the absence of preoperative clinically evident aspiration, children with neurological conditions have an equivalent rate of postoperative aspiration as healthy children. The only risk factor for postoperative aspiration was preoperative aspiration.

CONCLUSION

Aspiration is more common after CO(2) laser-assisted supraglottoplasty than previously recognized. In otherwise healthy children, postoperative aspiration is of short duration and can be treated with conservative measures. Optimal treatment after supraglottoplasty includes screening for and management of aspiration in conjunction with a speech pathologist.

Multilevel esophageal biopsy in children with airway manifestations of extraesophageal reflux disease

OBJECTIVES

Extraesophageal reflux disease (EERD) is a recognized cause of upper airway symptoms in children. Direct microlaryngoscopy and bronchoscopy (MLB) is performed for diagnostic information as to the extent and severity of the inflammation caused by gastric refluxate. Esophagoscopy with multilevel biopsy performed at the time of MLB may provide the clinician with additional information to assist in the management of EERD. We undertook to determine the role of multilevel esophageal biopsy in children who have airway manifestations secondary to EERD.

METHODS

We performed a retrospective chart review of 139 esophagoscopies with multilevel biopsy done at the time of MLB by a single provider for evaluation of symptoms highly associated with EERD at a tertiary care children's hospital. The histopathologic presence of esophagitis was analyzed by site and compared to the presence and location of tracheolaryngeal abnormalities.

RESULTS

Tracheolaryngeal abnormalities associated with EERD were found in 97% of patients when evaluated by MLB. Concomitant esophagitis was found in 59% of these patients. Of patients who had 0, 1, 2, 3, 4, or 5 positive findings on MLB, 75% (3 of 4), 58% (7 of 12), 57% (20 of 35), 62% (32 of 51), 56% (18 of 32), and 80% (4 of 5), respectively, had at least 1 positive biopsy.

CONCLUSIONS

We found that EERD that affects the pediatric upper airway was associated with esophagitis in more than half of the patients. The usefulness of 4-level biopsies during esophagoscopy and concomitant airway endoscopy will be discussed.

Extraesophageal reflux in children

PURPOSE OF REVIEW

To summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children.

RECENT FINDINGS

Extraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions.

SUMMARY

Pediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.

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.

Laryngeal examination is superior to endoscopy in the diagnosis of the laryngopharyngeal form of gastroesophageal reflux disease

OBJECTIVE

The laryngopharyngeal form of gastroesophageal reflux disease (LF GERD) is a frequent manifestation of supraesophageal GERD. Diagnosis of LF GERD is difficult: most of the common diagnostic methods of GERD have insufficient accuracy in establishing LF GERD. The purpose of this study was to evaluate the role of endoscopic and laryngologic examination in the diagnosis of LF GERD and to create a laryngoscopic reflux index (LRI).

MATERIAL AND METHODS

A total of 108 LF GERD patients and 90 controls were investigated. The criteria for LF GERD were: complaints, reflux-laryngitis, and esophagitis (endoscopically or histologically proven). Lesions in four laryngeal regions were evaluated: arytenoids (A), intraarytenoid notch (IAN), vestibular folds (VF), and vocal cords (VC). Three types of mucosal lesions were evaluated on a points basis: alterations of the epithelium, erythema, and edema. Total LRI was calculated by summing-up the indices in the separate laryngeal areas.

RESULTS

The LRI mean value (11.48+/-3.78 points) of LF GERD patients was statistically significantly greater than that (1.64+/-1.93 points) of the controls. The most significant laryngoscopic changes of LF GERD were: mucosal lesions of IAN, mucosal lesions of VC, and edema of VC. A combination of these three findings reliably distinguishes the LF GERD patients from controls in 95.9% of cases. The mucosal lesions of IAN have the greatest importance in diagnosing LF GERD: the odds ratio to LF GERD - 21.32, p<0.001. Endoscopic esophagitis was established in 36 (33.3%) cases. The severity of esophagitis did not correlate with the severity of the laryngeal findings.

CONCLUSIONS

Laryngoscopy is superior to endoscopy in diagnosing LF GERD. Endoscopy has limited value in the diagnosis of LF GERD. Establishing the LRI could be helpful in the differential diagnosis of the disease in the everyday clinical practice.

Are proton pump inhibitors indicated for the treatment of gastroesophageal reflux in infants and children?

Randomized controlled trials in the pediatric population that support the efficacy of proton pump inhibitors for the treatment of gastroesophageal reflux (GER) are lacking. Studies are needed to establish the safety of long-term acid suppression in infants and children, as well as to confirm a causal relationship between GER and extraesophageal symptoms and signs.

Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment

Gastroesophageal reflux (GER) occurs throughout the day in healthy infants, children, and adolescents, as well as in adults. However, regurgitation into the pharynx and vomiting are more common in infants than in adults. This places the infant at particular risk for supraesophageal complications of GER. Despite recognition of this risk, a lack of good control data in children and an absence of placebo-controlled treatment trials provide only marginal evidence to support GER as a cause of any supraesophageal disorder in infants or children. An association of GER with "awake apnea," reactive airway disease, and recurrent pneumonia has been demonstrated. Although there is no good evidence to support the efficacy of medical therapy, surgical therapy for GER has been demonstrated to improve symptoms in selected cases with each of these symptom presentations. Although clinical experience and case series suggest that GER may possibly contribute to laryngeal disorders, sinusitis, and otitis media, convincing data are lacking. No studies have definitively demonstrated symptom improvement with medical or surgical therapy for the latter symptom presentations.

Histologic features of reflux-attributed laryngeal lesions

The purpose of this study was to compare the histologic appearance of the normal larynx and the larynx presumably affected by reflux. A secondary objective was to determine the safety of performing laryngeal biopsies. Biopsy specimens from the interarytenoid area of 15 patients with reflux laryngitis were compared with specimens from 9 control subjects. Control subjects were asymptomatic, had normal 24-hour pH studies, and had a normal videostroboscopic laryngeal examination. Patients with reflux laryngitis had abnormal pH studies and videostroboscopic examinations. There were no consistent changes in mucosal detail or cellular infiltration that distinguished the biopsies from normal patients and those with reflux laryngitis. In this small sample of subjects it was not possible to define any characteristic histologic features of reflux laryngitis.

Pediatric otolaryngologic manifestations of gastroesophageal reflux disease

In adults, an estimated 4% to 10% of chronic, nonspecific laryngeal disease seen in otolaryngologic clinics is associated with gastroesophageal reflux disease (GERD). Although no such estimates exist in children, many investigators have reported extraesophageal manifestations of GERD, of which the most common is the association of GERD with asthma and chronic cough. A variety of signs and symptoms of otolaryngologic disease also have been attributed to GERD, including hoarseness, laryngitis, chronic rhinitis, sinusitis, globus pharyngeus, recurrent croup, laryngomalacia, stridor, subglottic stenosis, otalgia, vocal cord granulomas, and oropharyngeal dysphagia. However, proof of the association between these manifestations of otolaryngologic disease and GERD is sparse. Furthermore, the manifestations of otolaryngologic disease often occur in the absence of such classic systems of GERD as heartburn or chest pain. This review explores the role of GERD in otolaryngologic disease in children.

[Vocal fold nodules. Risk factors in teachers. A case control study design]

Vocal nodules are structural lesions very common amongst professional voice users such as teachers. We have studied the risk factors that predispose the development of vocal nodules in teachers. Two hundred and forty-two teachers were selected: 120 with vocal nodules and 120 with normal vocal folds. Professional and personal factors as well as classroom environment were studied. A complete evaluation of the voice was performed, aerodynamic measures, tone and extension of the voice, acoustic analysis, perceptual evaluation of the voice as well as a videolaryngostroboscopy which was definitive in the diagnosis. Younger teachers with less years of teaching experience a greater have tendency to develop vocal nodules than the rest. Class-room's dryness, loudness and echo are correlated with the pathological group. The most relevant personal factors in the pathological group were previous vocal pathology, laryngeal surgery, nasal surgery and gastroesophageal reflux. Vocal intensity and vocal frequency ranks were shorter in the pathological group. We could also see that, fonatory flow was less effective in the pathological group.

Disorders of phonation in children

Vocal disturbances in children are surprisingly common. Typical pathologic conditions differ, however, from those that are seen commonly in adults. Disturbances in the vibratory characteristic of the vocal folds cause dysphonia. The most common causes for dysphonia are infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, or iatrogenic in nature. A child who presents with hoarseness demands a rapid and thorough assessment. Fine points during the history may provide the clinician with clues as to the correct etiologic category. Proper treatment requires an accurate diagnosis. Although some conditions are similar in the adult larynx, treatment of the pediatric larynx often differs. An understanding of the changing and growing pediatric larynx is necessary for treatment and satisfactory results.

Histological insight into the pathogenesis of severe laryngomalacia

OBJECTIVE

To correlate clinical and histological findings in patients with laryngomalacia who required surgical intervention.

METHODS

Retrospective study of all patients undergoing supraglottoplasty by a single surgeon (MEG) for severe laryngomalacia between October, 1999 and November, 2000.

RESULTS

Nine patients were identified, of which seven had clinical evidence of GER. Seven patients had co-existing abnormalities or delays of neuromuscular development including seizure disorder, agenesis of the corpus callosum, obstructive sleep apnea, primary aspiration, a history of apparent life-threatening events, and craniosynostosis. Varying degrees of subepithelial edema and significant dilation of the subepithelial lymphatics were noted in all specimens. Submucosal inflammation was minimal to mild, and intraepithelial inflammation was rare to absent in all sections. No submucosal gland hyperplasia was seen in the samples from any patient. Two specimens contained cuneiform cartilage, both of which were histologically characterized as fibrocartilage.

CONCLUSIONS

In this series, the histopathology of tissue excised during the treatment of severe laryngomalacia was dominated by submucosal edema and lymphatic dilation. Further study is needed to investigate comorbidities that may contribute to the need for intervention in children with laryngomalacia.