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Lechien JR, De Marrez LG, Hans S, Muls V, Spinato L, Briganti G, Saussez S, De Vos N. Digestive Biomarkers of Laryngopharyngeal Reflux: A Preliminary Prospective Controlled Study. Otolaryngol Head Neck Surg 2024; 170:1364-1371. [PMID: 38353373 DOI: 10.1002/ohn.674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 04/30/2024]
Abstract
OBJECTIVE To investigate the digestive enzymes and biomarkers in the saliva of patients with laryngopharyngeal reflux (LPR) and asymptomatic individuals. STUDY DESIGN Prospective controlled study. SETTING Multicenter study. METHODS Patients with LPR at the hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and asymptomatic individuals were consecutively recruited from January 2020 to April 2023 from 2 University Hospitals. The saliva of patients (off PPIs) and asymptomatic individuals was collected to measure pH, elastase, bile salts, cholesterol, gastric, and pancreatic lipases. Anxiety, symptoms, and findings were studied through perceived stress scale (PSS), reflux symptom score (RSS), and reflux sign assessment (RSA). RESULTS Sixty-seven LPR patients and 57 asymptomatic individuals completed the evaluations. LPR patients reported higher PSS, RSS, and RSA than asymptomatic individuals. The mean saliva pH was more alkaline in LPR patients (7.23: 95% confidence interval [CI]: 7.08, 7.38) compared to controls (6.13; 95% CI: 5.95, 6.31; P = .001). The mean concentration of elastase was higher in patients (51.65 µg/mL; 95% CI: 44.47, 58.83 µg/mL) versus asymptomatic individuals (25.18 µg/mL; 95% CI: 21.64, 28.72 µg/mL; P = .001). The saliva cholesterol reported higher concentration in healthy individuals (3.43 mg/dL; 95% CI: 3.21, 3.65 mg/dL) compared to patients (1.16 mg/dL; 95% CI: 1.05, 1.27 mg/dL; P = .001). The saliva pH, and elastase concentration were significantly associated with the baseline RSS, while saliva cholesterol was negatively associated with the severity of RSS and RSA. CONCLUSION Cholesterol, bile salts, and elastase are biomarkers of LPR and should be considered to develop future non-invasive saliva device for the detection of LPR.
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Affiliation(s)
- Jerome R Lechien
- Division of Laryngology and Broncho-esophagology, Department of Otolaryngology-Head Neck Surgery, EpiCURA Hospital, Baudour, Belgium
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, School of Medicine, Paris Saclay University, Phonetics and Phonology Laboratory, (UMR 7018 CNRS, Université Sorbonne Nouvelle/Paris 3), Paris, France
- Department of Otolaryngology-Head and Neck Surgery, CHU Saint-Pierre, Brussels, Belgium
- Polyclinique Elsan de Poitiers, Poitiers, France
| | - Lisa G De Marrez
- Department of Otorhinolaryngology-Head and Neck Surgery, CHU Brugmann, Brussels, Belgium
| | - Stephane Hans
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, School of Medicine, Paris Saclay University, Phonetics and Phonology Laboratory, (UMR 7018 CNRS, Université Sorbonne Nouvelle/Paris 3), Paris, France
| | - Vinciane Muls
- Department of Gastroenterology, CHU Saint-Pierre, Brussels, Belgium
| | - Linda Spinato
- Department of Otorhinolaryngology-Head and Neck Surgery, CHU Brugmann, Brussels, Belgium
| | | | - Sven Saussez
- Division of Laryngology and Broncho-esophagology, Department of Otolaryngology-Head Neck Surgery, EpiCURA Hospital, Baudour, Belgium
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, School of Medicine, Paris Saclay University, Phonetics and Phonology Laboratory, (UMR 7018 CNRS, Université Sorbonne Nouvelle/Paris 3), Paris, France
| | - Nathalie De Vos
- Department of Clinical Chemistry, LHUB-ULB, Brussels, Belgium
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2
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Johnston N, Samuels TL, Goetz CJ, Arnold LA, Smith BC, Seabloom D, Wuertz B, Ondrey F, Wiedmann TS, Vuksanovic N, Silvaggi NR, MacKinnon AC, Miller J, Bock J, Blumin JH. Oral and Inhaled Fosamprenavir Reverses Pepsin-Induced Damage in a Laryngopharyngeal Reflux Mouse Model. Laryngoscope 2023; 133 Suppl 1:S1-S11. [PMID: 35678265 PMCID: PMC9732152 DOI: 10.1002/lary.30242] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE More than 20% of the US population suffers from laryngopharyngeal reflux. Although dietary/lifestyle modifications and alginates provide benefit to some, there is no gold standard medical therapy. Increasing evidence suggests that pepsin is partly, if not wholly, responsible for damage and inflammation caused by laryngopharyngeal reflux. A treatment specifically targeting pepsin would be amenable to local, inhaled delivery, and could prove effective for endoscopic signs and symptoms associated with nonacid reflux. The aim herein was to identify small molecule inhibitors of pepsin and test their efficacy to prevent pepsin-mediated laryngeal damage in vivo. METHODS Drug and pepsin binding and inhibition were screened by high-throughput assays and crystallography. A mouse model of laryngopharyngeal reflux (mechanical laryngeal injury once weekly for 2 weeks and pH 7 solvent/pepsin instillation 3 days/week for 4 weeks) was provided inhibitor by gavage or aerosol (fosamprenavir or darunavir; 5 days/week for 4 weeks; n = 3). Larynges were collected for histopathologic analysis. RESULTS HIV protease inhibitors amprenavir, ritonavir, saquinavir, and darunavir bound and inhibited pepsin with IC50 in the low micromolar range. Gavage and aerosol fosamprenavir prevented pepsin-mediated laryngeal damage (i.e., reactive epithelia, increased intraepithelial inflammatory cells, and cell apoptosis). Darunavir gavage elicited mild reactivity and no discernable protection; aerosol protected against apoptosis. CONCLUSIONS Fosamprenavir and darunavir, FDA-approved therapies for HIV/AIDS, bind and inhibit pepsin, abrogating pepsin-mediated laryngeal damage in a laryngopharyngeal reflux mouse model. These drugs target a foreign virus, making them ideal to repurpose. Reformulation for local inhaled delivery could further improve outcomes and limit side effects. LEVEL OF EVIDENCE NA. Laryngoscope, 133:S1-S11, 2023.
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Affiliation(s)
- Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
- Department of Microbiology and Immunology, Medical College of Wisconsin
| | - Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
| | | | - Leggy A. Arnold
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | - Brian C. Smith
- Department of Biochemistry, Medical College of Wisconsin
| | - Donna Seabloom
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | - Beverly Wuertz
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | - Frank Ondrey
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | | | - Nemanja Vuksanovic
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | - Nicholas R. Silvaggi
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | | | - James Miller
- Department of Pathology, Medical College of Wisconsin
| | - Jonathan Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Joel H. Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
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Jain S, Gupta S, Ramalingam WVBS. To Compare and Evaluate Laryngeal Changes in Patients with Dysphonia in Laryngopharyngeal Reflux (LPR) before and after Treatment with Proton Pump Inhibitors (PPI) and Prokinetic Drugs. Indian J Otolaryngol Head Neck Surg 2022; 74:4933-4947. [PMID: 36742570 PMCID: PMC9895181 DOI: 10.1007/s12070-020-02323-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023] Open
Abstract
To evaluate and compare pre and post treatment results using the following parameters by (a) Dual probe pH monitoring. (b) Laryngeal mucosal changes as assessed by direct video laryngoscopy/stroboscopy using Belafsky scores. (c) Voice changes by using GRBAS and Dr Speech software for speech analysis. In our study we have evaluated and compared voice and laryngeal changes in patients with dysphonia and RSI > 10 (which is suggestive of LPR) before treatment and after 6 months of treatment with Tab. Pantoprazole and Tab. Mosapride. This prospective study was carried out on 50 patients attending the ENT OPD of a tertiary care referral centre over a period of 18 months i.e. from Nov 2008 to Apr 2010. The study showed that prolonged therapy (> 6 months) is required to treat LPR effectively and 24 h ambulatory dual probe pH metry and videolaryngoscopy to assess RFS are the most preferred diagnostic tools in LPR. Dr Speech software for voice analysis can give an objective assessment of voice changes in LPR before and after treatment. The treatment consisting of PPI and prokinetic drugs proved to be effective in laryngopharyngeal reflux disease as improvement was seen in all the parameters including reflux findings score, subjective and objective voice assessment. According to results of our study, 24 h ambulatory dual probe pH metry, Reflux Finding Score (RFS), subjective and objective acoustic parameters can be used as indicators of efficacy of treatment.
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Affiliation(s)
- Shalini Jain
- Dr. RML Hospital, A-103, Krishan Kunj Appartments, Nasirpur, Dwarka Sector 1A, New Delhi, 110045 India
| | - Sarita Gupta
- Kanachur Institute of medical sciences Mangalore, Mangalore, Karnataka 575018 India
| | - W. V. B. S. Ramalingam
- Departmnet of ENT and Head and Neck Surgery, Army Hospital (Research and Referral), Delhi Cantt – 10, New Delhi, India
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Wang X, Zhang J, Wang J, Liu Z, Zhang C, Zhao J, Zou S, Ma X, Li J. Laryngopharyngeal Reflux Disease and Gastroesophageal Reflux Disease Can Mutually Influence. J Voice 2022:S0892-1997(22)00313-7. [PMID: 36347736 DOI: 10.1016/j.jvoice.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the mutually relationship between gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD). METHODS All included patients completed simultaneous 24-hour hypopharyngeal intraluminal multichannel impedance pH monitoring (24h-MII-pH), Reflux Symptom Index (RSI), and Reflux Finding Score (RFS). The LPRD diagnosis was based on the occurrence of ≥1 acid or non-acid hypopharyngeal proximal reflux episode(HRE), GERD was defined as a length of time >4.0% of the 24-hour recording spent below pH 4.0 or a DeMeester score >14.72. Patients with both positive LPRD and GERD were classified as LPRD & GERD group, patients with positive LPRD and negative GERD were classified as ILPRD group, patients with negative LPRD and positive GERD were classified as IGERD group, and patients with both negative LPRD and GERD were classified as N group. The differences in clinical characteristics of reflux between the groups were statistically analyzed. RESULTS A total of 437 patients were included, including 248 (56.75%) in the ILPRD group, 98 (22.43%) in the LPRD & GERD group, 23 (5.26%) in the IGERD group, and 68 (15.56%) in the N group. There was no significant difference between the types of gastroesophageal reflux in patients with GERD. The number of weak acid/acid/gas/liquid HREs was significantly more in LPRD & GERD patients than in ILPRD patients (P < 0.01), and the number of distal acid reflux events and Longest distal acid clearance time were significantly higher in LPRD & GERD patients than in IGERD patients (P > 0.01). CONCLUSION GERD and LPRD are not the same disease but can mutually influence. Combined GERD increased all types of laryngopharyngeal reflux events in patients with LPRD, whereas combined LPRD only increased acidic distal reflux events and acid clearance time in patients with GERD.
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Affiliation(s)
- Xiaoyu Wang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China; Navy Clinical College, the Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui Province, China
| | - Jinhong Zhang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jiasen Wang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Zhi Liu
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China; Navy Clinical College, the Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui Province, China
| | - Chun Zhang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jing Zhao
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Shizhen Zou
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Xin Ma
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jinrang Li
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China; Navy Clinical College, the Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui Province, China.
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Sartori AJ, Dewes R, Madazio G, Moreti F, Behlau M. Vocal deviation in individuals with suggestive signs and symptoms of laryngopharyngeal reflux. Codas 2022; 34:e20190065. [PMID: 35239772 PMCID: PMC9886118 DOI: 10.1590/2317-1782/20212019065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/22/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Verify and compare vocal deviation in quality, vocal symptoms and reflux symptom index in patients with clinical diagnosis of laryngopharyngeal reflux (LPR). METHODS 100 individuals of both genders participated in this prospective study, aged between 18 and 60 years old, who presented signs of LPR in the nasofibrolaryngological exam. Participants answered the Reflux Symptom Index (RSI) questionnaire to determine the reflux index and the Voice Symptom Scale (VoiSS). Their voices were recorded for the auditory-perceptual assessment. Three speech therapists with voice experience were contacted and the most reliable one was maintained. RESULTS 100 examined voices, 34 were classified as adapted and 66 as deviated. The predominant vocal quality type was rough and a slight degree of deviation. The average score on VoiSS and RSI of individuals with deviated voice is significantly higher than the adapted voice group on both protocols (p<0.01). The symptom reported with most frequency and intensity, in both analyses, was throat clearing. There were statistically significant differences once analyzed the vocal quality types by pairs: rough-adapted (p=0.0021) and tense-adapted (p=0.0075) on VoiSS, and rough-adapted (p=0.001) on RSI. CONCLUSION Individuals with deviated voice reported higher occurrence of LPR related vocal signals and symptoms measured by VoiSS and RSI. The numerous theories about the disease do not make possible a single conclusion on the subject. Further studies are needed in the area to assist the professional in the diagnosis and treatment of the RLF patient.
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Affiliation(s)
- Ana Julia Sartori
- Centro de Estudos da Voz – CEV - São Paulo (SP), Brasil.
- RD Serviços Médicos - Lajeado (RS), Brasil.
| | | | | | - Felipe Moreti
- Centro de Estudos da Voz – CEV - São Paulo (SP), Brasil.
| | - Mara Behlau
- Centro de Estudos da Voz – CEV - São Paulo (SP), Brasil.
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Samuels TL, Khampang P, Espahbodi M, McCormick CA, Chun RH, McCormick ME, Yan K, Kerschner JE, Johnston N. Association of Pepsin With Inflammatory Signaling and Effusion Viscosity in Pediatric Otitis Media. Laryngoscope 2021; 132:470-477. [PMID: 34272879 DOI: 10.1002/lary.29749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/11/2021] [Accepted: 07/06/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Otitis media (OM) is a common inflammatory disease spectrum. Cytokine signaling, neutrophil activity, and mucin hypersecretion during recurrent and chronic OM contribute to persistent, viscous middle ear (ME) effusions, hearing loss, and potential for developmental delay. Extraesophageal reflux (EER), specifically pepsin, triggers inflammatory signaling in respiratory mucosa and is associated with OM. The objective of this study was to investigate the association of pepsin with ME inflammatory signaling and the outcomes and examine causality in vitro. STUDY DESIGN Cross-sectional study. METHODS ME fluid (MEF) and preoperative audiometric data were collected from 30 pediatric subjects undergoing tympanostomy tube placement for recurrent OM or OM with effusion. MEF viscosity was characterized by the surgeon. Pepsin, inflammatory molecules, and mucin were assayed by enzyme-linked immunosorbent assay (ELISA). ME epithelial primary culture was exposed to 0.1 to 1 mg/ml pepsin at pH 5, 6, and 7 for 30 minutes, and cytokine expression was assayed via qPCR. RESULTS Pepsin was observed in the MEF of 77% of patients (range 71-2,734 ng/ml). Pepsin correlated with effusion viscosity, interleukins -6 and -8, neutrophil elastase, and mucin 5B (P < .05). Pepsin-negative MEF was more frequently absent of interleukin 8 or mucin 5B (P < .05). Weak acid was generally insufficient to elicit cytokine expression in ME cells in vitro, however, pepsin induced IL6, IL8, and TNF at pH 7 (P < .05) and weak acid (pH 6) facilitated a response at lower pepsin concentration. CONCLUSIONS Pepsin may contribute to inflammatory signaling, persistent viscous effusion, and poorer OM outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Tina L Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Pawjai Khampang
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Mana Espahbodi
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Caroline A McCormick
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Robert H Chun
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Michael E McCormick
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Ke Yan
- Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Joseph E Kerschner
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.,Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.,Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Wang SM, Freedman ND, Katki HA, Matthews C, Graubard BI, Kahle LL, Abnet CC. Gastroesophageal reflux disease: A risk factor for laryngeal squamous cell carcinoma and esophageal squamous cell carcinoma in the NIH-AARP Diet and Health Study cohort. Cancer 2021; 127:1871-1879. [PMID: 33615447 PMCID: PMC8406665 DOI: 10.1002/cncr.33427] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prior studies have suggested that gastroesophageal reflux disease (GERD) may be associated with risk of squamous cancers of the larynx and esophagus; however, most of these studies have had methodological limitations or insufficient control for potential confounders. METHODS We prospectively examined the association between GERD and esophageal adenocarcinoma (EADC), esophageal squamous cell carcinoma (ESCC), and laryngeal squamous cell carcinoma (LSCC) in 490,605 participants of the NIH-AARP Diet and Health Study cohort who were 50-71 years of age at baseline. Exposure to risk factors were obtained from the baseline questionnaire. GERD diagnosis was extracted among eligible participants via linkage to Medicare diagnoses codes and then multiply imputed for non-Medicare-eligible participants. Hazard ratios (HRs) and 95% CIs of GERD were computed using Cox regression. RESULTS From 1995 to 2011, we accrued 931 cases of EADC, 876 cases of LSCC, and 301 cases of ESCC in this cohort and estimated multivariable-adjusted HRs of 2.23 (95% CI, 1.72-2.90), 1.91 (95% CI, 1.24-2.94), and 1.99 (95% CI, 1.39-2.84) for EADC, LSCC, and ESCC, respectively. The associations were independent of sex, smoking status, alcohol intake, and follow-up time periods. We estimated that among the general population in the United States, 22.04% of people aged 50-71 years suffered from GERD. Using risk factor distributions for the United States from national survey data, 16.92% of LSCC cases and 17.32% of ESCC cases among individuals aged 50-71 years were estimated to be associated with GERD. CONCLUSION GERD is a common gastrointestinal disorder, but future prospective studies are needed to replicate our findings. If replicated, they may inform clinical surveillance of GERD patients and suggest new avenues for prevention of these malignancies.
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Affiliation(s)
- Shao-Ming Wang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Neal D Freedman
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Hormuzd A Katki
- Biostatistics Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Charles Matthews
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Barry I Graubard
- Biostatistics Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lisa L Kahle
- Information Management Services Inc, Calverton, Maryland
| | - Christian C Abnet
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
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Liu D, Qian T, Sun S, Jiang JJ. Laryngopharyngeal Reflux and Inflammatory Responses in Mucosal Barrier Dysfunction of the Upper Aerodigestive Tract. J Inflamm Res 2021; 13:1291-1304. [PMID: 33447069 PMCID: PMC7801919 DOI: 10.2147/jir.s282809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/16/2020] [Indexed: 12/29/2022] Open
Abstract
The upper aerodigestive tract (UAT) is the first line of defense against environmental stresses such as antigens, microbes, inhalants, foods, etc., and mucins, intracellular junctions, epithelial cells, and immune cells are the major constituents of this defensive mucosal barrier. Laryngopharyngeal reflux (LPR) is recognized as an independent risk factor for UAT mucosal disorders, and in this review, we describe the components and functions of the mucosal barrier and the results of LPR-induced mucosal inflammation in the UAT. We discuss the interactions between the refluxate and the mucosal components and the mechanisms through which these damaging events disrupt and alter the mucosal barriers. In addition, we discuss the dynamic alterations in the mucosal barrier that might be potential therapeutic targets for LPR-induced disorders.
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Affiliation(s)
- Danling Liu
- Otorhinolaryngology Department, ENT Institute, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, NHC Key Laboratory of Hearing Medicine Research, Fudan University, Shanghai 200032, People's Republic of China
| | - Tingting Qian
- Otorhinolaryngology Department, ENT Institute, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, NHC Key Laboratory of Hearing Medicine Research, Fudan University, Shanghai 200032, People's Republic of China
| | - Shan Sun
- Otorhinolaryngology Department, ENT Institute, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, NHC Key Laboratory of Hearing Medicine Research, Fudan University, Shanghai 200032, People's Republic of China
| | - Jack J Jiang
- Otorhinolaryngology Department, ENT Institute, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, NHC Key Laboratory of Hearing Medicine Research, Fudan University, Shanghai 200032, People's Republic of China.,Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Wisconsin Medical School, Madison, WI 53792-7375, USA
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9
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Parsel SM, Iarocci AL, Gastañaduy M, Winters RD, Marino JP, McCoul ED. Response to “The Association Between Reflux and Laryngeal Neoplasia Is Still Not Demonstrated”. Otolaryngol Head Neck Surg 2020; 163:1285-1286. [DOI: 10.1177/0194599820938320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hutnik R, Zlatopolsky A, Mehraban-Far S, Alrassi J, McMillan N, Amadi C, Fujita K, Mortensen M. Laryngopharyngeal reflux: Comparing improvements in reflux symptom index with reflux finding score. Am J Otolaryngol 2020; 41:102730. [PMID: 32956939 DOI: 10.1016/j.amjoto.2020.102730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/30/2020] [Accepted: 09/08/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE The objective of this study was to determine the correlation of reported symptom improvement in laryngopharyngeal reflux (LPR) with physical findings on laryngoscopic examination following medical therapy. MATERIALS AND METHODS This IRB-approved, retrospective, single-institution study included all patients who were diagnosed and medically treated for LPR from Jan. 1, 2015-October 21st, 2019. Only patients who received at least six weeks of treatment with a proton pump inhibitor and those with pre- and post-treatment Reflux Symptom Index; RSI (n = 91) and Reflux Finding Score; RFS (n = 33) were included in the study. RESULTS A total of 91 patients were included in the analysis (61.54% female). There was a 19.99% improvement in total RSI (p = 0.0034) and a 25.20% improvement in total RFS (p = 0.0011) following at least six weeks of treatment (average = 253 ± 213 SD days). RSI symptoms were significantly decreased between pre- and post-treatment for hoarseness (p = 0.0005), clearing of the throat (p = 0.0066), excess throat mucus or postnasal drip (p = 0.0004), troublesome cough (p = 0.0231), and heartburn/chest pain (p = 0.0053). RFS demonstrated a statistically significant decrease in only subglottic edema (p < 0.0001) and ventricular obliteration (p = 0.0295). Pearson's correlation test did not demonstrate a relationship between RSI and RFS in the pre- and post-treatment analyses alone, but did demonstrate a statistically significant relationship when analyzed across all captured pre and post data (r = 0.265, p = 0.006). CONCLUSIONS RSI and RFS are complimentary to one another when assessing for treatment response, but improvement in RSI does not correlate with that in RFS.
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Affiliation(s)
- Robert Hutnik
- Stony Brook Medicine, Department of Surgery, Stony Brook, NY, United States of America
| | - Aaron Zlatopolsky
- Stony Brook Medicine, Department of Surgery, Stony Brook, NY, United States of America
| | - Sina Mehraban-Far
- Stony Brook Medicine, Department of Surgery, Stony Brook, NY, United States of America
| | - James Alrassi
- SUNY Downstate Health Sciences University, Department of Otolaryngology, Brooklyn, NY, United States of America
| | - Nadia McMillan
- Beth Israel Deaconess Medical Center, Department of Neurology, Boston, MA, United States of America
| | - Chima Amadi
- Stony Brook Medicine, Department of Surgery, Stony Brook, NY, United States of America
| | - Kevin Fujita
- Yale School of Medicine, Department of Surgery, Division of Otolaryngology, New Haven, CT, United States of America
| | - Melissa Mortensen
- Albany Medical College, Department of Otolaryngology, Albany, NY, United States of America.
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11
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Does our swallow go to sleep? Changes in swallow function during sleep and implications for symptoms. Curr Opin Otolaryngol Head Neck Surg 2020; 28:392-400. [DOI: 10.1097/moo.0000000000000670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Swain S, Choudhury J. Experience with the management of pediatric laryngopharyngeal reflux in an Indian teaching hospital. JOURNAL OF CLINICAL SCIENCES 2020. [DOI: 10.4103/jcls.jcls_38_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Gastroesophageal and Laryngopharyngeal Reflux Associated With Laryngeal Malignancy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:1253-1264.e5. [PMID: 30366155 DOI: 10.1016/j.cgh.2018.10.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastric reflux may lead to chronic mucosal inflammation and contribute to development of laryngeal malignancies, although there is controversy over this association. We performed a systematic review and meta-analysis to assess this relationship and determine the risk of laryngeal malignancy in patients with reflux disease. METHODS We performed a systematic review and meta-analysis, searching MEDLINE, EMBASE, and Web of Science databases from 1900 through April 9, 2018, for observational studies of adults reporting associations between gastroesophageal reflux disease (GERD) and/or laryngopharyngeal reflux and the risk of having or developing laryngeal malignancies. An itemized assessment of the risk of bias was conducted for each study that met inclusion criteria. The meta-analysis was performed using the Mantel-Haenszel method with random effects to account for heterogeneity. We performed subgroup analyses to determine the effect of reflux type, study design, diagnostic method, and confounding variables on the overall risk. RESULTS Of the 957 studies that were identified during systematic review, 18 case-control studies met the criteria for analysis. Our meta-analysis showed that reflux disease significantly increased the risk of laryngeal malignancy (odds ratio, 2.47; 95% CI, 1.90-3.21; P < .00001; I2 = 94%). This association remained when controlling for patient smoking and drinking (odds ratio, 2.07; 95% CI, 1.26-3.41). There was no statistically significant difference in risk of laryngeal malignancies between patients with GERD vs laryngopharyngeal reflux (P = .44). CONCLUSIONS In a systematic review and meta-analysis, we found a significant association between reflux disease and the presence of laryngeal malignancy. Prospective studies should be performed to examine this relationship.
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Lechien JR, Saussez S, Nacci A, Barillari MR, Rodriguez A, Le Bon SD, Crevier-Buchman L, Harmegnies B, Finck C, Akst LM. Association between laryngopharyngeal reflux and benign vocal folds lesions: A systematic review. Laryngoscope 2019; 129:E329-E341. [PMID: 30892725 DOI: 10.1002/lary.27932] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/14/2019] [Accepted: 02/25/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF). METHODS PubMed, Cochrane Library, and Scopus were searched by three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinke's edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. RESULTS Of the 155 relevant publications, 42 studies were included. Thirty-five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (pH monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinke's edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell-to-cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma. CONCLUSIONS Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinke's edema. However, the heterogeneity and the low number of high-quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF. Laryngoscope, 129:E329-E341, 2019.
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Affiliation(s)
- Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Laboratory of Anatomy and Cell Biology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Laboratory of Phonetics, Faculty of Psychology, Research Institute for Language Sciences and Technology, University of Mons, Mons, Belgium.,Department of Otorhinolaryngology-Head and Neck Surgery, CHRU de Lille, Université de Lille, Lille, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Sven Saussez
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Laboratory of Anatomy and Cell Biology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrea Nacci
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,ENT Audiology and Phoniatric Unit, University of Pisa, Pisa, Italy
| | - Maria Rosaria Barillari
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Division of Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive Medicine, University of Luigi Vanvitelli, Naples, Italy
| | - Alexandra Rodriguez
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge D Le Bon
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Lise Crevier-Buchman
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Department of Otorhinolaryngology-Head and Neck Surgery, Foch Hospital, Paris, France
| | - Bernard Harmegnies
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Laboratory of Phonetics, Faculty of Psychology, Research Institute for Language Sciences and Technology, University of Mons, Mons, Belgium
| | - Camille Finck
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Laboratory of Anatomy and Cell Biology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Liège, Faculty of Medicine, University of Liège, Liège, Belgium
| | - Lee M Akst
- Laryngopharyngeal Reflux Study Group of the Young Otorhinolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Marseille, France.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
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15
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Kibar E, Erdur O, Ozturk K. Evaluation of upper esophageal sphincter in benign vocal lesions. Eur Arch Otorhinolaryngol 2018; 275:3033-3037. [PMID: 30349954 DOI: 10.1007/s00405-018-5175-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/16/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE To evaluate upper esophageal sphincter (UES) activity in patients with benign glottic lesions. METHODS Twenty-three patients with benign vocal fold (VF) lesions scheduled for manometric evaluation were enrolled as the study group (SG); 20 healthy subjects without vocal pathology or dysphagia were included as the control group (CG). UES residual, basal, relaxation time and peak pharyngeal pressures were evaluated by manometry. The reflux symptom index (RSI) and reflux finding score (RFS) were used to estimate the clinical findings of laryngopharyngeal reflux, and the voice handicap index (VHI) was measured in both groups. The patients' data were compared using the Mann-Whitney test and t test. RESULTS The diagnoses in the SG were vocal nodules, vocal polyps, vocal cysts, sulcus vocalis, or Reinke's edema. The evaluation scores (RSI, RFS, and VHI) were significantly higher in the SG than in the CG (P < 0.05). UES basal and relaxation pressures, relaxation time, and peak pharyngeal pressures did not differ between the SG and the CG (P > 0.05). CONCLUSION UES manometric pressure was similar in patients with VF mucosal lesions and controls. Studies involving larger populations are necessary to confirm the manometric changes in the UES and to elucidate the pathogenesis of benign VF lesions.
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Affiliation(s)
- Ertugrul Kibar
- Department of Otolaryngology, Selcuk University Medical School, Alaeddin Keykubad Campus, 42075 Yeni Istanbul caddesi, Konya, Turkey
| | - Omer Erdur
- Department of Otolaryngology, Selcuk University Medical School, Alaeddin Keykubad Campus, 42075 Yeni Istanbul caddesi, Konya, Turkey.
| | - Kayhan Ozturk
- Department of Otolaryngology, Selcuk University Medical School, Alaeddin Keykubad Campus, 42075 Yeni Istanbul caddesi, Konya, Turkey
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16
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Loehrl TA, Smith TL, Merati A, Torrico-Brusky L, Hoffman RG, Toohill RJ. Pharyngeal pH Probe Findings in Patients with Postnasal Drainage. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240501900403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Patients commonly present with complaints of postnasal drainage (PND). This study reports the pharyngeal pH probe findings in patients without rhinitis/rhinosinusitis who present with complaints of PND. Methods This is a prospective study of patients presenting with PND but no historical or endoscopic evidence of rhinitis/rhinosinusitis. Twenty-four-hour pharyngeal pH probe studies were done on 32 consecutive patients and compared with historical controls. Results There were a total of 32 patients with PND (mean age, 54 years) and 51 controls (mean age, 49 years). The proportion of patients with positive pH probe studies was higher in PND (28.1%) versus controls (17.6%) but did not reach statistical significance (p = 0.27). However, when comparing the mean number of pharyngeal acid exposure events, patients with PND had significantly more events (1.6) than controls (0.3; p < 0.002). In addition, the mean acid exposure time was significantly higher in PND (0.18%) versus controls (0.01%; p < 0.004). Conclusion The proportion of patients with PND displaying positive pharyngeal 24 pH probe studies is not significantly greater than controls. However, patients with PND do exhibit a statistically greater degree of pharyngeal acid exposure as compared with controls. Additional research is required to delineate the role of pharyngeal reflux in patients with PND.
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Affiliation(s)
- Todd A. Loehrl
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
| | - Timothy L. Smith
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
| | - Albert Merati
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
| | - Laura Torrico-Brusky
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
| | - Raymond G. Hoffman
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
| | - Robert J. Toohill
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin Supported by a Grant from Janssen Pharmaceuticals
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17
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Wang J, Yu Z, Ren J, Xu Y, Zhang Y, Lei L, Zheng Y, Huang L, He Z. Effects of pepsin A on heat shock protein 70 response in laryngopharyngeal reflux patients with chronic rhinosinusitis. Acta Otolaryngol 2017; 137:1253-1259. [PMID: 28784015 DOI: 10.1080/00016489.2017.1360515] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We investigated the relationship between laryngopharyngeal reflux (LPR) and chronic rhinosinusitis (CRS), and explored the effects of pepsin A on the level of heat shock protein 70 (HSP70) in CRS. METHODS We included 23 CRS patients with nasal polyps (CRSwNP), 26 CRS patients without nasal polyps (CRSsNP) and nine normal controls to measure pepsin A levels in nasal secretions, blood plasma and nasal tissues, to measure HSP70 levels in nasal tissues, and to detect pepsinogen A, HSPA5, cyclo-oxygenase-2 (COX-2), and carbonic anhydrase III (CAIII) mRNA expression levels in nasal tissues. RESULTS Pepsin A levels in nasal secretions were significantly higher in CRSwNP/CRSsNP patients than in controls. HSP70 levels were significantly increased in pepsin A-positive turbinate mucosa compared to controls (p < .001). Similarly, HSP70 levels were significantly increased in pepsin A-positive polyp tissues than in pepsin A-negative polyp tissues (p = .016). Furthermore, no association was found between the presence of pepsin A and HSPA5, COX-2, and CAIII mRNA expression levels. CONCLUSIONS These results suggest that LPR may play a role in the development of CRS through pepsin A reflux, and increased HSP70 expression may be associated with the pathogenic mechanism of mucosal injury in CRS.
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Affiliation(s)
- Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Zhao Yu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Jianjun Ren
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yuke Zhang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Lei Lei
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yongbo Zheng
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Ligao Huang
- Department of Otolaryngology, Chengdu Renpin Otorhinolaryngological Hospital, Chengdu, Sichuan, China
| | - Zhaoping He
- Department of Biomedical Research, Nemours/Alfred I.duPont Hospital for Children, Wilmington, DE, USA
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18
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Lechien JR, Saussez S, Harmegnies B, Finck C, Burns JA. Laryngopharyngeal Reflux and Voice Disorders: A Multifactorial Model of Etiology and Pathophysiology. J Voice 2017; 31:733-752. [DOI: 10.1016/j.jvoice.2017.03.015] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 12/14/2022]
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19
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Wood J, Hussey D, Woods C, Astill D, I Watson D, Lee B, Carney A. Does gene expression in laryngeal subsites differ between patients with laryngopharyngeal reflux and controls? Clin Otolaryngol 2017. [DOI: 10.1111/coa.12918] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- J.M. Wood
- Flinders ENT; Adelaide SA Australia
- Flinders University Department of Surgery; Flinders Centre for Cancer Prevention and Control; Adelaide SA Australia
| | - D.J. Hussey
- Flinders University Department of Surgery; Flinders Centre for Cancer Prevention and Control; Adelaide SA Australia
| | - C.M. Woods
- Flinders ENT; Adelaide SA Australia
- Flinders University Department of Surgery; Flinders Centre for Cancer Prevention and Control; Adelaide SA Australia
| | - D. Astill
- Department of Anatomical Pathology; Flinders University and Flinders Medical Centre; Adelaide SA Australia
| | - D. I Watson
- Flinders University Department of Surgery; Flinders Centre for Cancer Prevention and Control; Adelaide SA Australia
| | - B. Lee
- Flinders ENT; Adelaide SA Australia
| | - A.S. Carney
- Flinders ENT; Adelaide SA Australia
- Flinders University Department of Surgery; Flinders Centre for Cancer Prevention and Control; Adelaide SA Australia
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20
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Ren JJ, Zhao Y, Wang J, Ren X, Xu Y, Tang W, He Z. PepsinA as a Marker of Laryngopharyngeal Reflux Detected in Chronic Rhinosinusitis Patients. Otolaryngol Head Neck Surg 2017; 156:893-900. [PMID: 28457223 DOI: 10.1177/0194599817697055] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives We aimed to confirm the presence of pepsinA in the nasal secretions and tissues of chronic rhinosinusitis (CRS) patients and reveal the relationship between CRS and laryngopharyngeal reflux (LPR). Study Design Cross-sectional study. Setting The study was conducted at the Department of Oto-Rhino-Laryngology, West China Hospital, Sichuan University. Subjects and Methods A total of 32 CRS patients with or without nasal polyps (CRSwNP and CRSsNP, respectively) and 10 normal controls were enrolled in our study. We investigated the expression of pepsinA in the nasal tissues, secretions, and blood plasma from the subjects by immunohistochemical staining, Western blot, or ELISA. Additionally, the expressions of MUC4, MUC5AC, MUC5B, MUC8, and pepsinogenA in nasal tissue were evaluated by quantitative real-time polymerase chain reaction. Results Immunohistochemistry and Western blot revealed that the pepsinA expression levels in the turbinate mucosa in CRSwNP/CRSsNP patients, which were largely restricted to the epithelial layer or glandular mucous cells in nasal tissues, were significantly higher than those in controls and in the polyp tissues of CRSwNP patients ( P < .05). In addition, the concentration of pepsinA in nasal secretions was significantly increased in the CRSwNP (147.85 ± 53.69 ng/mL, P < .001) and CRSsNP (134.12 ± 36.23 ng/mL, P < .001) groups as compared with the controls (68.69 ± 19.28 ng/mL). Although MUC5AC, MUC5B, and MUC8 expression differed among the groups, no correlation between pepsinA and mucin genes was found. Conclusion The results of this study provided evidence of an association between LPR and CRS, although no correlation was found to exist between LPR and mucin genes in CRS patients.
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Affiliation(s)
- Jian-jun Ren
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Xue Ren
- School of Mathematics and Statistics, Chongqing Technology and Business University, Chongqing, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Wenlong Tang
- Shenzhen Key Laboratory of ENT, Institute of ENT & Longgang ENT Hospital, Shenzhen, China
| | - Zhaoping He
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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21
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Questioning the Utility of Laryngoscopy in the Evaluation of Pediatric Gastroesophageal Reflux. J Pediatr 2017; 183:9-11. [PMID: 28161203 DOI: 10.1016/j.jpeds.2017.01.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/12/2017] [Indexed: 11/22/2022]
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22
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Min HJ, Hong SC, Yang HS, Mun SK, Lee SY. Expression of CAIII and Hsp70 Is Increased the Mucous Membrane of the Posterior Commissure in Laryngopharyngeal Reflux Disease. Yonsei Med J 2016; 57:469-74. [PMID: 26847302 PMCID: PMC4740542 DOI: 10.3349/ymj.2016.57.2.469] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/25/2015] [Accepted: 07/21/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We tried to evaluate the difference in the expression of carbonic anhydrase (CA) III and heat shock protein (Hsp) 70 between laryngopharyngeal reflux disease (LPRD) and non-LPRD patients. MATERIALS AND METHODS The study involved 28 patients who underwent laryngeal microsurgery due to benign laryngeal disease from March to August 2008. Reflux symptom index (RSI) and reflux finding score (RFS) were measured for each person, and they were assigned either to the LPRD group (n=10) or non-LPRD group (n=18). Tissue samples were obtained from the mucosa of posterior commissure, and immunohistochemistry (IHC) staining of CAIII and Hsp70 was performed. The IHC scores were measured and compared with clinical features including RSI and RFS. RESULTS Total 10 patients were assigned as LPRD group, and 18 patients were as control group. The mean IHC score of CAIII and Hsp70 was 1.70 ± 1.06 and 1.90 ± 0.88, respectively, in LPRD patients, whereas the mean IHC score of CAIII and Hsp70 was 0.78 ± 0.73 and 0.94 ± 0.87, respectively, in non-LPRD patients. The difference between two groups was statistically significant (p<0.05). CONCLUSION CAIII and Hsp70 expressions were higher in LPRD patients that in non-LPRD patients, suggesting the possibility as one of biomomarker in LPRD diagnosis.
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Affiliation(s)
- Hyun Jin Min
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seok Chan Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hoon Shik Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seog Kyun Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sei Young Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.
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Samuels T, Hoekzema C, Gould J, Goldblatt M, Frelich M, Bosler M, Lee SH, Johnston N. Local Synthesis of Pepsin in Barrett's Esophagus and the Role of Pepsin in Esophageal Adenocarcinoma. Ann Otol Rhinol Laryngol 2015; 124:893-902. [PMID: 26077392 DOI: 10.1177/0003489415590657] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Despite widespread use of proton pump inhibitors (PPIs), the incidence of esophageal adenocarcinoma (EAC) continues to rise. PPIs reduce reflux acidity, but only transiently inactivate gastric enzymes. Nonacid reflux, specifically nonacid pepsin, contributes to carcinogenesis in the larynx. Given the carcinogenic potential of pepsin and inefficacy of PPIs to prevent EAC, the presence and effect of pepsin in the esophagus should be investigated. METHODS Normal and Barrett's biopsies from 8 Barrett's esophagus patients were collected for pepsin analysis via Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR). Human esophageal cells cultured from healthy patients were treated with pepsin (0.01-1 mg/mL; 1-20 hours), acid (pH 4)±pepsin (5 minutes); real-time RT-PCR, ELISA, and cell migration were assayed. RESULTS Pepsin was detected in all 8 Barrett's and 4 of 8 adjacent normal specimens. Pepsinogen mRNA was observed in 22 Barrett's, but not in normal adjacent samples. Pepsin induced PTSG2 (COX-2) and IL-1β expression and cell migration in vitro. CONCLUSIONS Pepsin is synthesized by metaplastic, Barrett's esophageal mucosa. Nonacid pepsin increases metrics of tumorigenicity in esophageal epithelial cells in vitro. These findings implicate refluxed and locally synthesized pepsin in development and progression of EAC and, in part, explain the inefficacy of PPIs in the prevention of EAC.
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Affiliation(s)
- Tina Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig Hoekzema
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Goldblatt
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Frelich
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Bosler
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sang-Hyuk Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Liu BY, Lin YJ, Lee HF, Ho CY, Ruan T, Kou YR. Menthol suppresses laryngeal C-fiber hypersensitivity to cigarette smoke in a rat model of gastroesophageal reflux disease: the role of TRPM8. J Appl Physiol (1985) 2014; 118:635-45. [PMID: 25539933 DOI: 10.1152/japplphysiol.00717.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients with gastroesophageal reflux disease (GERD) display enhanced laryngeal reflex reactivity to stimuli that may be due to sensitization of the laryngeal C-fibers by acid and pepsin. Menthol, a ligand of transient receptor potential melastatin-8 (TRPM8), relieves throat irritation. However, the possibility that GERD induces laryngeal C-fiber hypersensitivity to cigarette smoke (CS) and that menthol suppresses this event has not been investigated. We delivered CS into functionally isolated larynxes of 160 anesthetized rats. Laryngeal pH 5-pepsin treatment, but not pH 5-denatured pepsin, augmented the apneic response to CS, which was blocked by denervation or perineural capsaicin treatment (a procedure that blocks the conduction of C fibers) of the superior laryngeal nerves. This augmented apnea was partially attenuated by capsazepine [an transient receptor potential vanilloid 1 (TRPV1) antagonist], SB-366791 (a TRPV1 antagonist), and HC030031 [a transient receptor potential ankyrin 1 (TRPA1) antagonist] and was completely prevented by a combination of TRPV1 and TRPA1 antagonists. Local application of menthol significantly suppressed the augmented apnea and this effect was reversed by pretreatment with AMTB (a TRPM8 antagonist). Our electrophysiological studies consistently revealed that laryngeal pH 5-pepsin treatment increased the sensitivity of laryngeal C-fibers to CS. Likewise, menthol suppressed this laryngeal C-fiber hypersensitivity and its effect could be reversed by pretreatment with AMTB. Our results suggest that laryngeal pH 5-pepsin treatment increases sensitivity to CS of both TRPV1 and TRPA1, which are presumably located at the terminals of laryngeal C-fibers. This sensory sensitization leads to enhanced laryngeal reflex reactivity and augmentation of the laryngeal C-fiber responses to CS, which can be suppressed by menthol acting via TRPM8.
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Affiliation(s)
- Bi-Yu Liu
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Jung Lin
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Fu Lee
- Department of Neurosurgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Ching-Yin Ho
- Department of Otolaryngology, Taipei Veteran General Hospital, Taipei, Taiwan; Department of Otolaryngology, National Yang-Ming University, Taipei, Taiwan; and
| | - Ting Ruan
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yu Ru Kou
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan;
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Waxman J, Yalamanchali S, Valle ES, Pott T, Friedman M. Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg 2014; 150:1010-7. [PMID: 24647643 DOI: 10.1177/0194599814525577] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/05/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the effect of twice-daily proton pump inhibitor (PPI) treatment on the relationship between laryngopharyngeal pH environment and symptoms in patients with laryngopharyngeal reflux (LPR). STUDY DESIGN AND SETTING Retrospective analysis of records from consecutive patients seen at a single clinical site between 2009 and 2012. SUBJECTS AND METHODS Forty-three records of patients diagnosed with LPR who underwent pre- and posttreatment pH studies were included. Prior to treatment, all had a Reflux Symptom Index (RSI) > 13 and an abnormal pH study. Patients were treated for ≥ 4 weeks with twice-daily PPIs. Following treatment, patients completed a second RSI and pH study. RESULTS Most patients (67.4%) had symptom normalization; however, most patients (60.5%) did not have pH normalization. For all patients whose symptoms did not normalize, pH scores also did not normalize; 32.6% of patients showed no subjective or objective treatment response. For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score. For the entire group, pretreatment symptom and upright pH scores were strongly positively correlated. Improvements in symptom and upright pH scores following treatment were moderately positively correlated. CONCLUSION Laryngopharyngeal pH failed to normalize for most individuals after PPI treatment; only pH improvement was necessary for symptom normalization. Many patients had no treatment response. Laryngopharyngeal reflux patients may make up a heterogeneous group, and PPI responsivity may help explain conflicting results from previous studies. Posttreatment pH monitoring is recommended in studies investigating the efficacy of PPI therapy for LPR.
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Affiliation(s)
- Jonathan Waxman
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA ChicagoENT, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Sreeya Yalamanchali
- ChicagoENT, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Elizabeth Shay Valle
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA ChicagoENT, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Thomas Pott
- ChicagoENT, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Michael Friedman
- ChicagoENT, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA Rush University Medical Center, Chicago, Illinois, USA
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Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assunção AR. Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol 2013; 18:184-91. [PMID: 25992088 PMCID: PMC4297018 DOI: 10.1055/s-0033-1352504] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 06/06/2013] [Indexed: 12/19/2022] Open
Abstract
Introduction Laryngopharyngeal reflux (LPR) is a highly prevalent disease and commonly encountered in the otolaryngologist's office. Objective To review the literature on the diagnosis and treatment of LPR. Data Synthesis LPR is associated with symptoms of laryngeal irritation such as throat clearing, coughing, and hoarseness. The main diagnostic methods currently used are laryngoscopy and pH monitoring. The most common laryngoscopic signs are redness and swelling of the throat. However, these findings are not specific of LPR and may be related to other causes or can even be found in healthy individuals. Furthermore, the role of pH monitoring in the diagnosis of LPR is controversial. A therapeutic trial with proton pump inhibitors (PPIs) has been suggested to be cost-effective and useful for the diagnosis of LPR. However, the recommendations of PPI therapy for patients with a suspicion of LPR are based on the results of uncontrolled studies, and high placebo response rates suggest a much more complex and multifactorial pathophysiology of LPR than simple acid reflux. Molecular studies have tried to identify biomarkers of reflux such as interleukins, carbonic anhydrase, E-cadherin, and mucin. Conclusion Laryngoscopy and pH monitoring have failed as reliable tests for the diagnosis of LPR. Empirical therapy with PPIs is widely accepted as a diagnostic test and for the treatment of LPR. However, further research is needed to develop a definitive diagnostic test for LPR.
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Affiliation(s)
- Andrea Maria Campagnolo
- Department of Otolaryngology, Hospital Universitário Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro/RJ, Brazil
| | - Jaqueline Priston
- Department of Speech-Language Pathology (SLP), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro/RJ, Brazil
| | - Rebecca Heidrich Thoen
- Department of Otolaryngology, Hospital Universitário Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro/RJ, Brazil
| | - Tatiana Medeiros
- Department of Speech-Language Pathology (SLP), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro/RJ, Brazil
| | - Aída Regina Assunção
- Department of Otolaryngology, Hospital Universitário Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro/RJ, Brazil
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Neri G, Pugliese M, Castriotta A, Mastronardi V, Pasqualini P, Colasante A, Cazzato F, Talamonti R, Del Boccio G. White-line: A new finding in laryngopharyngeal reflux objective evaluation. Med Hypotheses 2013; 80:769-72. [DOI: 10.1016/j.mehy.2013.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 03/09/2013] [Indexed: 11/28/2022]
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Vardar R, Sweis R, Anggiansah A, Wong T, Fox MR. Upper esophageal sphincter and esophageal motility in patients with chronic cough and reflux: assessment by high-resolution manometry. Dis Esophagus 2013; 26:219-25. [PMID: 22591118 DOI: 10.1111/j.1442-2050.2012.01354.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The pathophysiology of chronic cough and its association with dsymotility and laryngopharyngeal reflux remains unclear. This study applied high-resolution manometry (HRM) to obtain a detailed evaluation of pharyngeal and esophageal motility in chronic cough patients with and without a positive reflux-cough symptom association probability (SAP). Retrospective analysis of 66 consecutive patients referred for investigation of chronic cough was performed. Thirty-four (52%) were eligible for inclusion (age 55 [19-77], 62% female). HRM (ManoScan 360, Given/Sierra Scientific Instruments, Mountain View, CA) with 10 water swallows was performed followed by a 24-hour ambulatory pH monitoring. Of this group, 21 (62%) patients had negative reflux-cough SAP (group A) and 13 (38%) had positive SAP (group B). Results from 23 healthy controls were available for comparison (group C). Detailed analysis revealed considerable heterogeneity. A small number of patients had pathological upper esophageal sphincter (UES) function (n=9) or esophageal dysmotility (n=1). The overall baseline UES pressure was similar, but average UES residual pressure was higher in groups A and B than in control group C (-0.2 and -0.8mmHg vs. -5.4mmHg; P<0.018 and P<0.005). The percentage of primary peristaltic contractions was lower in group B than in groups A and C (56% vs. 79% and 87%; P=0.03 and P<0.002). Additionally, intrabolus pressure at the lower esophageal sphincter was higher in group B than in group C (15.5 vs. 8.9; P=0.024). HRM revealed changes to UES and esophageal motility in patients with chronic cough that are associated with impaired bolus clearance. These changes were most marked in group B patients with a positive reflux-cough symptom association.
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Affiliation(s)
- R Vardar
- Ege University School of Medicine, Division of Gastroenterology, Izmir, Turkey
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Abstract
It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options.
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Affiliation(s)
- Ian D Molyneux
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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Koufman JA, Johnston N. Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol 2012; 121:431-4. [PMID: 22844861 DOI: 10.1177/000348941212100702] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES At the cellular level, tissue-bound pepsin is fundamental to the pathophysiologic mechanism of reflux disease, and although the thresholds for laryngeal damage in laryngopharyngeal reflux and for esophageal damage in gastroesophageal reflux disease differ, both forms of damage are due to pepsin, which requires acid for its activation. In addition, human pepsin remains stable at pH 7.4 and may be reactivated by hydrogen ions from any source. Thus, most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability. The purposes of these in vitro studies were to investigate whether artesian well water containing natural bicarbonate (pH 8.8) might irreversibly denature (inactivate) human pepsin, and to establish its potential acid-buffering capacity. METHODS Laboratory studies were performed to determine whether human pepsin was inactivated by pH 8.8 alkaline water. In addition, the buffering capacity of the alkaline water was measured and compared to that of the two most popular commercially available bottled waters. RESULTS The pH 8.8 alkaline water irreversibly inactivated human pepsin (in vitro), and its hydrochloric acid-buffering capacity far exceeded that of the conventional-pH waters. CONCLUSIONS Unlike conventional drinking water, pH 8.8 alkaline water instantly denatures pepsin, rendering it permanently inactive. In addition, it has good acid-buffering capacity. Thus, the consumption of alkaline water may have therapeutic benefits for patients with reflux disease.
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Rosen R, Johnston N, Hart K, Khatwa U, Nurko S. The presence of pepsin in the lung and its relationship to pathologic gastro-esophageal reflux. Neurogastroenterol Motil 2012; 24:129-33, e84-5. [PMID: 22141343 PMCID: PMC3307906 DOI: 10.1111/j.1365-2982.2011.01826.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Pepsin has been proposed as a biomarker of reflux-related lung disease. The goal of this study was to determine (i) if there is a higher reflux burden as measured by pH-MII in patients that are pepsin positive in the lung, and (ii) the sensitivity of pepsin in predicting pathologic reflux by pH, MII, and EGD. METHODS We recruited children between the ages of 1-21 with chronic cough or asthma undergoing bronchoscopy, esophagogastroduodenoscopy (EGD), and multichannel intraluminal impedance (pH-MII) probe placement. The reflux profiles were compared between those patients who were pepsin positive and negative; proportions were compared using Chi-squared analyses and means were compared using t-testing. KEY RESULTS Only the mean number of non-acid reflux events was associated with pepsin positivity (0.04). The sensitivity and specificity of pepsin in predicting pathologic reflux by pH-MII or EGD was 57% and 65%, respectively. The positive predictive value of pepsin in predicting pathologic reflux by pH, MII or EGD was 50% (11/22), and the negative predictive value was 71% (20/28). There was a significantly higher mean LLMI in patients who were pepsin positive compared with pepsin negative patients (81 ± 54 vs 47 ± 26, P = 0.001). CONCLUSIONS & INFERENCES Lung pepsin cannot predict pathologic reflux in the esophagus, but its correlation with lung inflammation suggests that pepsin may be an important biomarker for reflux-related lung disease.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, Boston, MA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Services, Medical College of Wisconsin, Milwaukee, WI
| | - Kristen Hart
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, Boston, MA
| | - Umakanth Khatwa
- Division of Pulmonary Medicine, Children’s Hospital Boston, Boston, MA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, Boston, MA
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Erickson-Levendoski E, Sivasankar MP. Role for ion transport in porcine vocal fold epithelial defense to acid challenge. Otolaryngol Head Neck Surg 2011; 146:272-8. [PMID: 22086905 DOI: 10.1177/0194599811428273] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The vocal fold epithelium is routinely exposed to gastric contents, including acid and pepsin, during laryngopharyngeal reflux events. The epithelium may possess intrinsic defenses to reflux. The first objective of the current study was to examine whether vocal fold epithelial ion transport is one potential mechanism of defense to gastric contents. The second objective was to determine whether ion transport in response to gastric contents is associated with the secretion of bicarbonate. STUDY DESIGN Prospective design in excised porcine larynges. SETTING Laboratory. SUBJECTS AND METHODS Porcine vocal folds (N = 56) were exposed on the luminal surface to acid, pepsin, or sham challenges. Ion transport at baseline and following challenge exposure was measured using electrophysiological techniques. To examine specific ion transport mechanisms, vocal folds were pretreated with either a sodium channel blocker or bicarbonate channel blocker. RESULTS Within 60 seconds of acid but not pepsin exposure, there was a significant increase in ion transport. This rapid increase in ion transport was transient and related to bicarbonate secretion. CONCLUSION The current data suggest that porcine vocal folds immediately increase bicarbonate secretion following exposure to acid. Bicarbonate secretion may act to neutralize acid. These findings contribute to the identification of the mechanisms underlying vocal fold defense to reflux and offer implications for the development of treatments for reflux-induced vocal fold injury.
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Reflux revisited: advancing the role of pepsin. Int J Otolaryngol 2011; 2012:646901. [PMID: 22242022 PMCID: PMC3216344 DOI: 10.1155/2012/646901] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 09/09/2011] [Indexed: 12/30/2022] Open
Abstract
Gastroesophageal reflux disease is mediated principally by acid. Today, we recognise reflux reaches beyond the esophagus, where pepsin, not acid, causes damage. Extraesophageal reflux occurs both as liquid and probably aerosol, the latter with a further reach. Pepsin is stable up to pH 7 and regains activity after reacidification. The enzyme adheres to laryngeal cells, depletes its defences, and causes further damage internally after its endocytosis. Extraesophageal reflux can today be detected by recognising pharyngeal acidification using a miniaturised pH probe and by the identification of pepsin in saliva and in exhaled breath condensate by a rapid, sensitive, and specific immunoassay. Proton pump inhibitors do not help the majority with extraesophageal reflux but specifically formulated alginates, which sieve pepsin, give benefit. These new insights may lead to the development of novel drugs that dramatically reduce pepsinogen secretion, block the effects of adherent pepsin, and give corresponding clinical benefit."For now we see through a glass, darkly."-First epistle, Chapter 13, Corinthians.
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Abstract
Laryngopharyngeal reflux is a controversial but increasingly made diagnosis used in patients with a collection of often non-specific laryngeal symptoms. It is a clinical diagnosis, and its pathophysiology is currently poorly understood. Previous reflux research has focused on injurious agents, acid, pepsin and biomarker expression. Failure of intrinsic defences in the larynx may cause changes in laryngeal epithelia, particularly alterations in carbonic anhydrases and E-cadherin. Carbonic anhydrase III levels vary in the larynx in response to laryngopharyngeal reflux, depending on location. Expression of E-cadherin, a known tumour suppressor, is reduced in the presence of reflux. Mucin expression also varies according to the severity of reflux. Further research is required to define the clinical entity of laryngopharyngeal reflux, and to identify a definitive mechanism for mucosal injury. Understanding this mechanism should allow the development of a comprehensive model, which would enable future diagnostic and therapeutic interventions to be developed.
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Jiang A, Liang M, Su Z, Chai L, Lei W, Wang Z, Wang A, Wen W, Chen M. Immunohistochemical detection of pepsin in laryngeal mucosa for diagnosing laryngopharyngeal reflux. Laryngoscope 2011; 121:1426-30. [DOI: 10.1002/lary.21809] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 02/25/2011] [Accepted: 03/02/2011] [Indexed: 12/17/2022]
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Asaoka D, Nagahara A, Oguro M, Mori H, Nakae K, Izumi Y, Osada T, Hojo M, Otaka M, Watanabe S. Establishment of a reflux esophago-laryngitis model in rats. Dig Dis Sci 2011; 56:1299-308. [PMID: 20936353 DOI: 10.1007/s10620-010-1431-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/09/2010] [Indexed: 01/10/2023]
Abstract
BACKGROUND To investigate the pathophysiology of reflux laryngitis, an experimental model is required. AIM The aim of this study is to establish an animal model of reflux esophago-laryngitis, modifying our previously reported model of chronic acid reflux esophagitis. METHODS The modified chronic acid reflux esophagitis (m-RE) group (n = 10), in which the duodenum was wrapped with 2.5 mm of Nelaton catheter, was not treated with any drugs. Also postoperatively, two treatment groups (n = 10 in each) received different dosages of rabeprazole (RPZ): 1.0 mg/kg/day (RPZ 1.0 group) or 10.0 mg/kg/day (RPZ 10.0 group). As a control group (n = 5), other rats underwent sham operation. The esophagus and larynx were resected on day 14 after the operation, and ulcer score of the esophagus was assessed. The epithelial thickness and leukocyte infiltration of the supraglottic and subglottic laryngeal mucosae were investigated. The number of interleukin (IL)-1β-positive cells was also counted and defined as the IL-1β labeling index. RESULTS In the m-RE group, the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of the supraglottic and subglottic laryngeal mucosae were increased compared with controls (P < 0.01). In the RPZ groups, not only the ulcer score of esophagus but also the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of both the supraglottic and subglottic laryngeal mucosae were decreased dose-dependently relative to the m-RE group (P < 0.05). CONCLUSIONS Our modified chronic acid reflux esophagitis model proved useful in establishing a rat reflux esophago-laryngitis model, with both pathological laryngeal findings and reflux esophagitis shown to be improved by administration of a proton pump inhibitor.
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Affiliation(s)
- Daisuke Asaoka
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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Koufman JA. Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications. Ann Otol Rhinol Laryngol 2011; 120:281-7. [DOI: 10.1177/000348941112000501] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bock JM, Brawley MK, Johnston N, Samuels T, Massey BL, Campbell BH, Toohill RJ, Blumin JH. Analysis of Pepsin in Tracheoesophageal Puncture Sites. Ann Otol Rhinol Laryngol 2010; 119:799-805. [DOI: 10.1177/000348941011901203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objectives: Tracheoesophageal puncture (TEP) and prosthesis insertion is a well-established method of voice rehabilitation after laryngectomy. Maintenance of the prosthesis and tract can be challenging, and reflux to the TEP site has been proposed as a cause. The sites of TEP were evaluated for the presence of pepsin in tissue biopsy specimens and tract secretions to explore this association. Methods: Patients with TEP were interviewed for a history of symptoms related to reflux, medication use history, TEP voice quality, and incidence of TEP complications. Tissue biopsy specimens and tract secretions were obtained from TEP sites and analyzed for the presence of pepsin via sodium dodecyl sulfate–polyacrylamide gel electrophoresis Western blot analysis. Results: Twelve of 17 patients (47%) had some history of preoperative or postoperative symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux. Pepsin was present within the TEP site in a total of 10 of 17 patients (58%; 7 of 17 tissue biopsy specimens and 6 of 7 secretion samples). There were no statistically significant associations between the presence of pepsin and sex, reflux history, use of acid suppressive medicine, or time since laryngectomy. Conclusions: Reflux with subsequent pepsin deposition into the TEP tract occurs in a majority of laryngectomy patients. Further studies on the effect of reflux on the health and function of the TEP tract are warranted.
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Tetra-probe, 24-hour pH monitoring for laryngopharyngeal reflux: a technique for simultaneous study of hypopharynx, oesophagus and stomach. The Journal of Laryngology & Otology 2009:117-22. [DOI: 10.1017/s0022215109005222] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:This study aimed to introduce the technique of tetra-probe, 24-hour pH monitoring for laryngopharyngeal reflux disease.Methods:Tetra-probe, 24-hour pH monitoring was performed for 30 suspected cases of laryngopharyngeal reflux. The proximal probe was placed in the hypopharynx, just above the upper oesophageal sphincter, the second probe was placed in the middle oesophagus, the third probe was placed a few centimetres above the lower oesophageal sphincter, and the distal probe was placed in the stomach.Results:As the pH at the four sensor sites could be monitored simultaneously, gastric acid levels and gastroesophageal and laryngopharyngeal reflux could be examined. This pH monitoring technique enabled the pH relationship between the four sensor locations to be well documented, enabling gastric acid levels and patterns of reflux to be assessed. This procedure was also able to be used as a functional examination to evaluate anti-reflux medication efficacy.Conclusions:Tetra-probe, 24-hour pH monitoring is a reliable functional examination for laryngopharyngeal reflux.
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Patterns of laryngopharyngeal and gastroesophageal reflux. The Journal of Laryngology & Otology 2009:42-7. [DOI: 10.1017/s0022215109005076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectives:Double-probe, 24-hour pH monitoring remains the ‘gold standard’ for the diagnosis of laryngopharyngeal reflux disease, even though there is no consensus on how to interpret the data collected.Methods:Tetra-probe, 24-hour pH monitoring was performed in 56 patients with suspected laryngopharyngeal reflux, in order to investigate patterns of laryngopharyngeal and gastroesophageal reflux.Results:The number of reflux episodes and the total and percentage time periods spent with pH < 4.0 were correlated with the distance of the probe from the lower oesophageal sphincter. The number of reflux episodes and the total and percentage time periods with pH < 4.0 were greater when patients were upright (i.e. during the daytime). There were few laryngopharyngeal reflux events recorded for pH levels of <4.0; however, there were a significant number of laryngopharyngeal reflux events recorded for pH levels of <5.0, a level capable of causing laryngopharyngeal reflux disease. When a pH level of <5.0 was used, the number, total time and percentage time of laryngopharyngeal reflux episodes was greater during the supine period (i.e. during sleeping) in a quarter of the cases, compared with results when a pH of <4.0 was used.Conclusions:It is valid to use a pH level of 5.0 as indicative of laryngopharyngeal reflux in the hypopharynx.
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Molecular pathways and genetic factors in the pathogenesis of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol 2009; 266:795-801. [DOI: 10.1007/s00405-009-0966-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Accepted: 03/17/2009] [Indexed: 10/20/2022]
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Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA. Activity/Stability of Human Pepsin: Implications for Reflux Attributed Laryngeal Disease. Laryngoscope 2009; 117:1036-9. [PMID: 17417109 DOI: 10.1097/mlg.0b013e31804154c3] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS Exposure of laryngeal epithelia to pepsin during extra-esophageal reflux causes depletion of laryngeal protective proteins, carbonic anhydrase isoenzyme III (CAIII), and squamous epithelial stress protein Sep70. The first objective of this study was to determine whether pepsin has to be enzymatically active to deplete these proteins. The second objective was to investigate the effect of pH on the activity and stability of human pepsin 3b under conditions that might be found in the human esophagus and larynx. STUDY DESIGN Prospective translational research study. METHODS An established porcine in vitro model was used to examine the effect of active/inactive pepsin on laryngeal CAIII and Sep70 protein levels. The activity and stability of pepsin was determined by kinetic assay, measuring the rate of hydrolysis of a synthetic pepsin-specific substrate after incubation at various pH values for increasing duration. RESULTS Active pepsin is required to deplete laryngeal CAIII and Sep70. Pepsin has maximum activity at pH 2.0 and is inactive at pH 6.5 or higher. Although pepsin is inactive at pH 6.5 and above, it remains stable until pH 8.0 and can be reactivated when the pH is reduced. Pepsin is stable for at least 24 hours at pH 7.0, 37 degrees C and retains 79% +/- 11% of its original activity after re-acidification at pH 3.0. CONCLUSIONS Detectable levels of pepsin remain in laryngeal epithelia after a reflux event. Pepsin bound there would be enzymatically inactive because the mean pH of the laryngopharynx is pH 6.8. Significantly, pepsin could remain in a form that would be reactivated by a subsequent decrease in pH, such as would occur during an acidic reflux event or possibly after uptake into intracellular compartments of lower pH.
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Affiliation(s)
- Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee 53226, USA.
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Perry KA, Enestvedt CK, Lorenzo CSF, Schipper P, Schindler J, Morris CD, Nason K, Luketich JD, Hunter JG, Jobe BA. The integrity of esophagogastric junction anatomy in patients with isolated laryngopharyngeal reflux symptoms. J Gastrointest Surg 2008; 12:1880-7. [PMID: 18677538 DOI: 10.1007/s11605-008-0607-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 07/08/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Distortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms. METHOD In a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett's esophagus within each group. RESULTS There were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett's esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett's esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology. CONCLUSION This indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett's esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer.
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Affiliation(s)
- Kyle A Perry
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
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Kantas I, Balatsouras DG, Kamargianis N, Katotomichelakis M, Riga M, Danielidis V. The influence of laryngopharyngeal reflux in the healing of laryngeal trauma. Eur Arch Otorhinolaryngol 2008; 266:253-9. [DOI: 10.1007/s00405-008-0744-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2007] [Accepted: 06/02/2008] [Indexed: 12/14/2022]
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Belafsky PC, Rees CJ. Laryngopharyngeal reflux: the value of otolaryngology examination. Curr Gastroenterol Rep 2008; 10:278-282. [PMID: 18625139 DOI: 10.1007/s11894-008-0056-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Laryngopharyngeal reflux (LPR) is the disease process by which gastric contents affect the extraesophageal structures of the head and neck. The symptoms of LPR include intermittent dysphonia, excessive throat clearing, globus pharyngeus, cough, and dysphagia. These symptoms can be assessed with the Reflux Symptom Index. Signs of LPR, as determined with laryngoscopy, can be described with the Reflux Findings Score, which includes assessment of site-specific laryngeal edema and other inflammatory changes. This article discusses the current understanding of LPR pathophysiology, taking into account pepsin stability and reactivation.
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Affiliation(s)
- Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology Head and Neck Surgery, University of California, Davis School of Medicine, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817, USA.
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Abstract
PURPOSE OF REVIEW Laryngopharyngeal reflux should no longer be underestimated because of its negative impact on the lives of patients and its potentially dangerous long-term complications. RECENT FINDINGS Both laryngopharyngeal reflux and gastroesophageal reflux disease are caused by mucosal injury from acid and pepsin exposure, but the esophagus has intrinsic antireflux defenses that prevent mucosal injury (bicarbonate production, mucosal tissue resistance and esophageal motor function with acid clearance) whereas the pharynx and the larynx do not. Symptoms felt to be most related to reflux (>or= 95%) are throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in the throat) and voice-quality change, while the physical examination findings include (>or= 95%) arytenoid erythema, vocal-cord erythema and edema, posterior commissure hypertrophy, and arytenoid edema. In this regard, the reflux symptom index and the reflux finding score are very useful clinical tools. Patients are proposed an empirical therapeutic trial including behavioural and dietary recommendations and a 3-month twice-daily proton-pump inhibitor therapy. The proton-pump inhibitor should be taken 30-60 min before meals. Nonresponders undergo an assessment, ideally based on esogastroduodenoscopy and ambulatory multichannel intraluminal impedance and pH monitoring. Transnasal esophagoscopy in the outpatient setting is a safe alternative. When medical management fails, patients with demonstrable high-volume reflux and lower sphincter incompetence are often candidates for surgical intervention. SUMMARY The algorithm proposed by Ford has structured and confirmed our attitude on a day-to-day basis.
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Affiliation(s)
- Marc Remacle
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Louvain at Mont-Godinne, Yvoir, Belgium.
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Rees CJ, Belafsky PC. Laryngopharyngeal reflux: Current concepts in pathophysiology, diagnosis, and treatment. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2008; 10:245-253. [PMID: 20840040 DOI: 10.1080/17549500701862287] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Laryngopharyngeal reflux (LPR) is the backflow of gastric contents into the pharynx and larynx. The diagnosis of LPR is primarily based on symptoms, including dysphonia, dysphagia, globus, throat-clearing, and post-nasal drip. The gold standard for diagnosis is dual-probe 24-hour pH testing with the upper probe positioned above the upper oesophageal sphincter. Treatment may require 3 months or more of twice-daily proton pump inhibitors along with lifestyle modifications. This review details the pathophysiology, symptoms, findings, treatment, and current controversies in LPR.
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Mahieu HF. Review article: The laryngological manifestations of reflux disease; why the scepticism? Aliment Pharmacol Ther 2007; 26 Suppl 2:17-24. [PMID: 18081645 DOI: 10.1111/j.1365-2036.2007.03474.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment. AIM Proper understanding of laryngopharyngeal reflux disease (LPRD). METHOD Review of literature. RESULTS Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials. CONCLUSIONS LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.
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Affiliation(s)
- H F Mahieu
- Department of Otorhinolaryngology, Meander Medical Centre, Amersfoort, The Netherlands.
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Franco RA, Andrus JG. Common Diagnoses and Treatments in Professional Voice Users. Otolaryngol Clin North Am 2007; 40:1025-61, vii. [PMID: 17765694 DOI: 10.1016/j.otc.2007.05.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Common problems among all patients seen by the laryngologist are also common among professional voice users. These include laryngopharyngeal reflux, muscle tension dysphonia, fibrovascular vocal fold lesions (eg, nodules and polyps), cysts, vocal fold scarring, changes in vocal fold mobility, and age-related changes. Microvascular lesions and their associated sequelae of vocal fold hemorrhage and laryngitis due to voice overuse are more common among professional voice users. Much more common among professional voice users is the negative impact that voice problems have on their ability to work, on their overall sense of well-being, and sometimes on their very sense of self. This article reviews the diagnosis and treatment options for these and other problems among professional voice users, describing the relevant roles of medical treatment, voice therapy, and surgery. The common scenario of multiple concomitant entities contributing to a symptom complex is underscored. Emphasis is placed on gaining insight into the "whole" patient so that individualized management plans can be developed. Videos of select diagnoses accompany this content online.
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Affiliation(s)
- Ramon A Franco
- Division of Laryngology, Massachusetts Eye & Ear Infirmary, Department of Otology and Laryngology, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA.
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Crapko M, Kerschner JE, Syring M, Johnston N. Role of extra-esophageal reflux in chronic otitis media with effusion. Laryngoscope 2007; 117:1419-23. [PMID: 17585281 DOI: 10.1097/mlg.0b013e318064f177] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES/HYPOTHESIS Otitis media with effusion (OME) is the most common cause of childhood hearing loss. Despite its prevalence, the enormous health care expenditures resulting from its treatment, and the increasing therapeutic challenges imposed by antimicrobial resistance, very little is known regarding the cellular and molecular immunologic and inflammatory events in this disease process. Extra-esophageal reflux (EER) has been implicated in the pathogenesis of chronic OME. The objective of this study was to confirm that children with OME have EER into the middle ear as measured by the presence of pepsin in middle ear effusions (MEE) removed during tympanostomy tube (TT) placement. STUDY DESIGN Prospective, translational, cell biological research study. METHODS MEE were obtained from children undergoing TT placement for OME. The fluid was lysed in a urea buffer and the presence of pepsin quantitatively determined by Western blot analysis using a specific antipepsin antibody. The pH of the samples was recorded before lysis. RESULTS Pepsin protein was detected in 18 of 32 (56%) samples analyzed, with 12 of 20 (60%) patients having at least one positive sample for pepsin. Pepsin levels ranged from 80 to 1,000 ng/mL. The pH of the samples ranged from 6.0 to 7.6, with a mean pH of 6.8. CONCLUSIONS Pepsin was detected in 60% of patients with OME, confirming that EER into the middle ear occurs in these children. The pepsin present would have little or no activity at pH 6.0 to 7.6; however, pepsin is stable below pH 8.0 and thus could be reactivated after a decrease in pH.
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Affiliation(s)
- Matthew Crapko
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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