Effect of pepsin on laryngeal stress protein (Sep70, Sep53, and Hsp70) response: role in laryngopharyngeal reflux disease

Pepsin Inhibitors Prevent Inflammation and Loss of Laryngeal Barrier Function in Mice with Gastroesophageal Reflux

OBJECTIVE

This study aimed to evaluate the role of pepsin inhibitors in the inflammatory response and their effects on laryngeal mucosal integrity during gastroesophageal reflux (GERD) under in vivo conditions.

METHODS

A surgical model of GERD was used, in which mice were treated with pepstatin (0.3 mg/kg) or darunavir (8.6 mg/kg) for 3 days. On the third day after the experimental protocol, the laryngeal samples were collected to assess the severity of inflammation (wet weight and myeloperoxidase activity) and mucosal integrity (transepithelial electrical resistance and paracellular epithelial permeability to fluorescein).

RESULTS

The surgical GERD model was reproduced. It showed features of inflammation and loss of barrier function in the laryngeal mucosa. Pepstatin and darunavir administration suppressed laryngeal inflammation and preserved laryngeal mucosal integrity.

CONCLUSION

Pepsin inhibition by the administration of pepstatin and darunavir improved inflammation and protected the laryngeal mucosa in a mouse experimental model of GERD.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3080-3085, 2024.

Exploring the Substantive Significance of Laryngoscopic Observations as Reliable Prognostic Indicators for the Therapeutic Efficacy in Cases of Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) can be defined as the regurgitation of gastric acid and peptic substances into the laryngeal and hypopharyngeal regions, even in the case of a singular occurrence. A substantial body of recent research underscores the significance of non-acid reflux as a notable contributor to LPR symptoms. This current investigation delves into the assessment of laryngoscopic observations in their predictive capacity regarding the therapeutic outcomes of empirically administered proton pump inhibitor (PPI) therapy in the context of LPR. In this study, 145 patients who had received a clinical diagnosis of laryngopharyngeal reflux (LPR) underwent rigorous laryngoscopic examinations. These patients were subsequently categorized into three distinct groups based on the Belafsky reflux findings score, which included the criteria for normal (scores ranging from 0 to 7), mild to moderate (scores ranging from 8 to 16), and moderate to severe (scores ranging from 17 to 26). Among the participants, 12 individuals from the normal group, 44 from the mild to moderate group, and 31 from the moderate to severe group reported experiencing a noteworthy alleviation of symptoms following a three-month period of proton pump inhibitor (PPI) therapy and lifestyle adjustments. It is important to note that these findings yielded statistically significant results. Preliminary laryngoscopic observations hold significant potential as predictors of favourable treatment outcomes in the context of empirical proton pump inhibitor (PPI) therapy for laryngopharyngeal reflux (LPR).

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

The importance of laryngoscopic findings as predictors of the treatment outcomes of laryngopharyngeal reflux: a retrospective review of 143 cases

Background

Laryngopharyngeal reflux can be described as even a single episode of reflux of gastric acid peptic contents into the larynx and hypopharynx. A large number of new researches show non-acid reflux to be an important cause of LPR symptoms. The present study explores the role of laryngoscopic findings in predicting the treatment outcomes of empirical PPI therapy for LPR.

Methods

A total of 143 patients diagnosed clinically with LPR were evaluated by rigid laryngoscopy and classified into 3 groups based on the Belafsky reflux findings score, as normal (0–7), mild to moderate (8–16), and moderate to severe (17–26).

Results

Twelve out of 39 patients in the normal group, 44 out of 61 patients in the mild to moderate group, and 31 out of 43 patients in the moderate to severe group reported symptomatic improvement after 3 months of PPI therapy and lifestyle modifications. The results were statistically significant.

Conclusion

Pretherapy laryngoscopic findings can be an important predictor of successful treatment outcomes of empirical PPI therapy for LPR.

Airway Impedance: A Novel Diagnostic Tool to Predict Extraesophageal Airway Inflammation

OBJECTIVE

To validate a novel biomarker, airway impedance for extraesophageal disease.

STUDY DESIGN

We prospectively recruited patients with respiratory symptoms undergoing combined endoscopy and direct laryngoscopy for the evaluation of symptoms. The direct laryngoscopy was performed and videotaped for blinded scoring by 3 otolaryngologists and an impedance catheter was placed onto the posterior larynx to obtain measurements. Following this, an endoscopy was performed and impedance measurements and biopsies were taken at 3 esophageal heights. Impedance values were compared within and between patients.

RESULTS

Eighty-eight patients were recruited, of which 73 had complete airway and endoscopic exams. There was no significant correlation between airway impedance values and mean reflux finding scores (r² = 0.45, P = .07). There was no significant positive correlation between airway impedance and esophageal impedance values (r² = 0.097-0.138, P > .2). Patients taking proton pump inhibitors had significantly lower mean airway impedance values (706 ± 450 Ω) than patients not taking them (1069 ± 809 Ω, P = .06). Patients who had evidence of aspiration on video fluoroscopic swallow studies had lower airway impedance (871 ± 615 Ω) than patients without aspiration (1247 ± 360 Ω, P = .008). Inhaled steroids did not impact airway impedance levels (P = .7).

CONCLUSIONS

Airway impedance may be an important diagnostic tool to diagnose gastroesophageal reflux or aspiration, eliminating the subjectivity of airway appearance alone.

NF-κB: A novel therapeutic pathway for gastroesophageal reflux disease?

Although gastroesophageal reflux disease (GERD), a common chronic disease in clinical practice, has been widely studied, its potential adverse impact on patients is still a significant clinical concern. It is necessary to understand the pathogenesis of the disease and choose appropriate treatment according to its mechanism. The pathogenesis of GERD is diverse and complex. As the traditional treatment methods are expensive and ineffective in alleviating symptoms in some patients, new treatment options need to be explored. Our previous study suggested that the activation of nuclear factor-kappa beta (NF-κB) in esophageal mucosa may be related to the injury of epithelial barrier function caused by reflux. Based on the literature and our previous study results, it is speculated that inhibition of NF-κB activation may block the insult of GERD on the esophageal mucosal barrier. NF-κB may play an important role in the development of GERD. This article reviews the pathogenesis of GERD and the relationship between NF-κB and GERD, in order to provide new strategies for the treatment of GERD.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role and mechanism of Glut-1 and H+/K+-ATPase expression in pepsin-induced development of vocal cord leukoplakia

PURPOSE

We investigated the role of Glut-1 and H⁺/K⁺-ATPase expression in pepsin-induced development of human vocal cord leukoplakia cells (HVCLCs). Next, we analyzed the relationship between Glut-1 and H⁺/K⁺-ATPase expression with the clinicopathological features of laryngeal carcinoma.

METHODS

Glut-1 and H⁺/K⁺-ATPase expression levels in HVCLCs were determined after treatment with artificial gastric juice containing pepsin and laryngeal carcinoma tissues.

RESULTS

Exposure to pepsin-containing artificial gastric juice significantly enhanced the migration and proliferation of VSCLCs in a time-dependent manner. The apoptotic rate of VSCLCs decreased over time after exposure to pepsin and reached a nadir on day 7 (p < 0.01). With increasing duration of exposure to pepsin, the proportion of VSCLCs in G0/G1 phase decreased and the proportions in the S and G2/M phases significantly increased (p < 0.05). After treatment with pepsin-containing artificial gastric juice, RT-PCR and Western blotting showed that the expression of Glut-1 and H⁺/K⁺-ATPase α, β significantly increased in HVCLCs compared to in the absence of pepsin (p < 0.05). The expression of Glut-1 and H⁺/K⁺-ATPase α, β gradually increased from vocal cord leukoplakia (VLC) to laryngeal carcinoma (p < 0.05). Lentivirus-mediated inhibition of Glut-1 expression in VCL significantly inhibited the cells' migration and proliferation (p < 0.05) but enhanced their apoptosis (p < 0.05). Also, inhibition of Glut-1 expression resulted in an increased proportion of cells in G0/G1 phase and a significantly decreased proportion in G2/M phase (p < 0.05).

CONCLUSIONS

Elevated Glut-1 expression may promote the development of VCL by upregulating laryngeal H⁺/K⁺-ATPase expression to reactivate absorbed pepsin, thus damaging the laryngeal mucosa.

Evaluation of the effects of isoniazid and rifampin on the structure and activity of pepsin enzyme by multi spectroscopy and molecular modeling methods

Pepsin is an aspartic protease that is involved in the digestion of food in the stomach of mammals. Continuous and long-term use of therapeutic agents will cause chronic contact of the drug with pepsin, and as a result, the structure and function of enzyme may change. In this regard the interactions of isoniazid and rifampin as the first line treatments of tuberculosis with pepsin were investigated by various methods such as fluorescence spectroscopy, FTIR, molecular docking and molecular dynamics simulation. Based on the results obtained in this study, the mentioned drugs can form stable complexes with pepsin and the structure of protein changes slightly. According to the results, the major forces in the formation of the protein-drug complex are electrostatic and hydrophobic forces for isoniazid and rifampin respectively and isoniazid shows to form a stronger binding with protein. The FTIR spectrum of the protein shows that little change was occurred in the structure of pepsin in the presence of the drugs. Molecular modeling results of the binding of isoniazid and rifampin to the pepsin confirm laboratory results and show that the binding site of drugs is close to the active site of the enzyme. Also, the activity of pepsin in the presence of both drugs has significantly increased.

Pathophysiology and treatment options for gastroesophageal reflux disease: looking beyond acid

Gastroesophageal reflux disease (GERD) is a disorder due to the retrograde flow of refluxate into the esophagus. Although GERD is a common clinical diagnosis, its pathogenesis is quite complex. As a result of its multifactorial development, many patients continue to experience adverse symptoms due to GERD despite prolonged acid suppression with proton pump inhibitor therapy. The pathogenesis of GERD involves an interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment. As such, GERD should be approached as a disorder beyond acid. This review will investigate the major factors that contribute to the development of GERD, including factors related to the refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus. In reviewing GERD pathogenesis, this paper will highlight therapeutic advances, with mention of future opportunities of study when approaching GERD.

Impact of bile acids on the severity of laryngo-pharyngeal reflux

OBJECTIVES

The primary end point of this study was to evaluate the impact of bile acids on severity of laryngo-pharyngeal reflux (LPR) and the possible correlation with esophagitis and upper airway malignancies. The second end point was to evaluate if salivary bile acids and molecules other than pepsin might serve as diagnostic biomarkers of LPR.

DESIGN

Observational prospective comparative study.

SETTING

Otorhinolaryngology unit of a tertiary hospital.

PARTICIPANTS

Sixty-two consecutive adult outpatients suspected of LPR.

MAIN OUTCOME MEASURES

Bile acids, bilirubin and pepsinogen I-II were measured in saliva. Patients underwent pH metry and based on the results of bile acids were subdivided as acid, mixed and alkaline LPR.

RESULTS

Significantly higher Reflux Findings Score (RFS) and Reflux Symptoms Index (RSI) were seen in patients with alkaline and mixed LPR compared to acid LPR. Salivary bile acids >1 µmol/L seem to be a reliable indicator of the severity of LPR. Compared to those without, patients with esophagitis or a history of upper airway malignancy have high concentrations of bile acids in saliva. Among the molecules studied, bile acids were the most suitable for diagnosis of LPR, with a sensitivity of 86% and a positive predictive value of 80.7%.

CONCLUSIONS

Our data suggest that high concentrations of bile acids are associated with higher values of RSI and RFS in LPR as well as a higher risk of esophagitis and history of upper airway malignancies. We finally observed that bile acids provided the best biometric parameters for diagnosis of LPR among the molecules tested.

Pepsin and Laryngeal and Hypopharyngeal Carcinomas

Laryngeal and hypopharyngeal carcinomas are common malignant tumors of the head and neck, and the incidence of both is increasing. Laryngopharyngeal reflux refers to the retrograde flow of gastric contents into the larynx, oropharynx, and/or nasopharynx. It remains controversial whether laryngopharyngeal reflux is a risk factor for laryngeal and hypopharyngeal cancers. The refluxing substances mainly include hydrochloric acid, pepsin, and occasionally bile acids and bile salts, as well as bacteria that colonize the gastrointestinal tract. Loss of epithelium in the mucous membrane of the larynx and hypopharynx is thought to be caused by pepsin. Here, we review the relationships between laryngopharyngeal reflux and both laryngeal and hypopharyngeal carcinomas, as well as the significance of pepsin, methods of clinical detection, and the mechanism of carcinogenesis.

Relationship Between Pepsin Expression and Dysplasia Grade in Patients With Vocal Cord Leukoplakia

OBJECTIVE

To measure pepsin expression in patients with vocal fold leukoplakia and elucidate its clinical significance.

STUDY DESIGN

Retrospective analysis of pathologic archive specimens.

SETTING

Affiliated university hospital.

SUBJECTS AND METHODS

The study included 45 patients with vocal fold leukoplakia and 19 with vocal fold polyps who underwent surgical treatment between December 2013 and July 2016. Masses were detected on both vocal cords in 5 patients with vocal fold leukoplakia and in 1 patient with vocal fold polyps. Immunohistochemistry was used to assess pepsin expression. In addition, the relationship of pepsin expression level with clinical characteristics of vocal fold leukoplakia was assessed.

RESULTS

The rate of pepsin expression was high in the polyp group (75%) and the leukoplakia group (68%); however, the difference between groups was not significant (P > .05). Pepsin expression significantly increased according to grade of dysplasia (mild, 57.1%; moderate, 88.9%; severe, 100.0%; P = .034). Similarly, the percentage of lesions that exhibited strongly positive pepsin expression increased with the grade of dysplasia (mild, 37.1%; moderate, 66.7%; severe, 100.0%; P = .005). The leukoplakia recurrence rate was higher in patients with positive pepsin expression than in patients with negative pepsin expression but without a significant difference (P > .05).

CONCLUSION

Our study suggests that pepsin was associated with the grade of dysplasia of vocal cord leukoplakia. Further investigation with appropriate control groups and controlling for other risk factors, such as smoking or alcohol consumption, is needed.

Duodenogastroesophageal reflux and its effect on extraesophageal tissues: A review

We conducted a literature review to identify elements of duodenogastroesophageal reflux (DGER)—namely pancreatic fluids, hydrochloric acid, pepsin, and bile—as to the effects each has when refluxed to the extraesophageal structures. Further, we wished to acquaint clinicians with the possibilities that, in addition to hydrochloric acid, the other components of DGER are likewise contributing to disease in the extraesophageal areas. Our review included studies that have indicated reflux of the above mentioned components of DGER to the pharynx, larynx, tracheobronchial tree, oral cavity, nasopharynx, nose and sinuses, eustachian tube, and middle ear. Findings demonstrate that injury to the upper aerodigestive tract can occur from a variety of substances secreted from the stomach and duodenum. Treatment for DGER is nonspecific. We conclude that patients with an incomplete response to acid suppression may have significant involvement of pepsin, bile, or both. Future studies are needed to clarify the importance of these elements and to suggest more precise treatments.

Gastroesophageal and Laryngopharyngeal Reflux Associated With Laryngeal Malignancy: A Systematic Review and Meta-analysis

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.

Detection of pepsin and IL-8 in saliva of adult asthmatic patients

Objective: Asthma and gastric reflux disease are widespread and often coexisting diseases with complex interactions, leading some to suspect that asthma symptoms of patients with reflux may improve with anti-reflux therapy. The objective of this study was to determine whether pepsin in saliva, indicative of airway reflux, could be detected in patients with asthma of varying severity and test the requirement of citric acid as a pepsin preservative. Methods: Saliva samples were collected in the clinic (with/without citric acid) and upon waking the following morning from 25 asthmatic patients. Enzyme-linked immunosorbent assay was performed for pepsin and interleukin-8 (IL-8), an inflammatory cytokine induced by pepsin in other airway epithelia. Pepsin induction of IL-8 was tested in a lung epithelial cell culture model. Results: Pepsin was detected in saliva from 14/25 patients (56%; mean concentration of pepsin in specimens where observed ±SD =80.3±87.5 ng/mL); significant agreement was found between samples collected in the presence/absence of citric acid. No significant associations were found with pepsin and clinical measures of asthma severity. IL-8 was detected in saliva from 22/25 patients (88%; mean IL-8 in all specimens where observed =3.27±3.91 ng/mL). IL-8 was significantly upregulated in human lung epithelial cells exposed to pepsin at pH7 in vitro (P=0.041). Conclusion: In summary, more than half of the asthma patients in this study were found to have pepsin in their saliva, indicative of airway reflux. These data support the use of salivary pepsin as a noninvasive tool for future investigation of airway reflux in a larger cohort. The data further suggest that collection in citric acid as a sample preservative is not warranted and that pooling of multiple saliva samples collected at various timepoints may improve sensitivity of pepsin detection and reduce costs incurred by multiple sample analysis in future studies.

Pepsin promotes IL-8 signaling-induced epithelial-mesenchymal transition in laryngeal carcinoma

Background

Laryngopharyngeal reflux (LPR), with its increasing morbidity, is attracting considerable attention. In recent years, the causal role between LPR and laryngeal carcinoma has been debated. The main harmful component of LPR is pepsin, which has been shown to induce mucosal inflammation by damaging the mucous membrane. Thus, pepsin is linked to an increased risk of laryngeal carcinoma, although the potential mechanism remains largely unknown.

Methods

The human laryngeal carcinoma cell lines Hep-2 and Tu212 were exposed to different pepsin concentrations and the morphology, proliferation, migration, secretion of inflammatory cytokines, and epithelial–mesenchymal transition (EMT) of the cells were assessed. To evaluate whether interleukin-8 (IL-8) had a causal relationship with pepsin and EMT, an IL-8 inhibitor was used to suppress IL-8 secretion during pepsin exposure and the expression of EMT markers, cell proliferation, and migration were analyzed.

Results

Pepsin promoted proliferation, colony formation, migration, and IL-8 secretion of Hep-2 and Tu212 cells in vitro. Furthermore, increased pepsin concentrations changed the morphology of Hep-2 and Tu212 cells; levels of the epithelial marker E-cadherin were reduced and those of mesenchymal markers vimentin and β-catenin and the transcription factors snail and slug were elevated. A similar effect was observed in laryngeal carcinoma tissues using immunohistochemistry. IL-8 level was reduced and EMT was restored when pepsin was inhibited by pepstatin. EMT was weakened after exposure to the IL-8 inhibitor, with significant reduction in pepsin-induced cell proliferation and migration.

Conclusions

Pepsin may induce EMT in laryngeal carcinoma through the IL-8 signaling pathway, which indicates that it has potential role in enhancing cell proliferation and metastasis of laryngeal carcinoma.

Electronic supplementary material

The online version of this article (10.1186/s12935-019-0772-7) contains supplementary material, which is available to authorized users.

Heat shock protein 70 is induced by pepsin via MAPK signaling in human nasal epithelial cells

BACKGROUND

Recent studies have shown that laryngopharyngeal reflux is associated with chronic rhinosinusitis. Pepsin may be a key factor involved in the injury of nasal mucosal epithelial cells, but the pathogenesis remains unclear. We are to investigate whether a mitogen-activated protein kinase (MAPK) pathway regulates heat shock protein 70 (HSP70) expression in primary cultures of human nasal epithelial cells (HNEpCs) in response to pepsin stimulation.

METHODS

HSP70 protein expression levels in HNEpCs were estimated by Western blot analysis after treatment with pepsin. MAPK pathway activity levels were also evaluated to elucidate the mechanism underlying the effects of pepsin on HSP70 in HNEpCs. Inhibitors of signaling pathways were used to determine the contribution of MAPKs in HSP70 response after pepsin stimulation. Cellular apoptosis and cell viability in HNEpCs after treatment with pepsin were measured.

RESULTS

The expression of HSP70 increased after stimulation with pepsin and decreased after the removal of pepsin. Pepsin induced activation of p38, extracellular signal-regulated kinase 1/2, and c-Jun N-terminal kinase (JNK) 1/2. Inhibition of JNK1/2 reduced HSP70 expression in HNEpCs. The apoptosis in HNEpCs at 12 h after treatment with pepsin at pH 7.0 increased significantly when compared with the control and pH 7.0 groups. Cell viability decreased following exposure to pepsin at pH 7.0.

CONCLUSION

Pepsin, even under neutral pH 7.0, increases the expression of HSP70 in HNEpCs by activating the JNK/MAPK signaling pathway. Increased HSP70 may be the protective mechanism when pepsin presents in the other parts of the body.

Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications

OBJECTIVE

To determine if an anti-reflux induction program relieves laryngopharyngeal reflux (LPR) symptoms more effectively than medication and behavioral changes alone.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care academic center.

SUBJECTS AND METHODS

A database was populated with patients treated for LPR. Patients were included in the study group if they completed a two-week anti-reflux program (diet, alkaline water, medications, behavioral modifications). Patients were included in the control group if they completed anti-reflux medications and behavioral modifications only. Patients completed the voice handicap index (VHI), reflux symptom index (RSI), cough severity index (CSI), dyspnea index (DI) and eating assessment tool (EAT-10) surveys and underwent laryngoscopy for examination and reflux finding score (RFS) quantification.

RESULTS

Of 105 study group patients, 96 (91%) reported subjective improvement in their LPR symptoms after an average 32-day first follow-up and their RSI and CSI scores improved significantly. No significant differences were found in VHI, DI, or EAT-10 scores. Fifteen study patients who had previously failed adequate high-dose medication trials reported improvement and their CSI and EAT-10 scores improved significantly. Ninety-five percent of patients with a chief complaint of cough reported improvement and their CSI scores improved significantly from 12.3 to 8.2. Among 81 controls, only 39 (48%) patients reported improvement after an average 62-day first follow-up. Their RSI scores did not significantly change.

CONCLUSION

The anti-reflux program yielded rapid and substantial results for a large cohort of patients with LPR. It compared favorably with medication and behavioral modification alone. It was effective in improving cough and treating patients who had previously failed medications alone.

Sep70/Pepsin expression in hypopharynx combined with hypopharyngeal multichannel intraluminal impedance increases diagnostic sensitivity of laryngopharyngeal reflux

BACKGROUND

Improved methods of diagnosis of laryngopharyngeal reflux (LPR) would enable surgeons to better identify patients who may benefit from antireflux surgery (ARS). The objective of the present study was to assess if hypopharyngeal Pepsin and Sep70 expression combined with hypopharyngeal multichannel intraluminal impedance (HMII) has the potential to increase diagnostic sensitivity of LPR.

METHODS

This study was performed on patients who underwent unsedated transnasal endoscopy with hypopharyngeal biopsy and 24-h HMII to determine abnormal proximal exposure (APE) and DeMeester score (DMS) from 2013 to 2016. Pepsin and Sep70 protein expression was assessed by Western blots of biopsy specimens. The outcomes of ARS were assessed using reflux symptom index (RSI). HMII APE classification, Sep 70, and Pepsin protein levels were compared in normative and symptomatic LPR patients and further analyzed alongside quality of life changes following ARS.

RESULTS

Of 30 subjects enrolled, 23 were excluded for abnormal HMII results or endoscopic evidence of esophagitis. Seven subjects and 105 patients were included in the normative and symptomatic groups, respectively. Compared to the normative group, only Pepsin expression was significantly higher in the symptomatic group [APE+/LPR+ (p = 0.000), APE+/LPR- (p = 0.001), and APE- (p = 0.047)]. Further, the ratio of Sep70/Pepsin was significantly lower in the symptomatic group [APE+/LPR+ (p = 0.008), APE+/LPR- (p = 0.000), and APE- (p = 0.050)], and a cutoff ratio for a diagnosis of LPR was established as < 158. Of 105 symptomatic patients, 48 patients underwent ARS. Of these, 17 patients had complete pre- and post-RSI questionnaires. LPR symptoms improved in 15 (88%), of whom 2 were APE- but met criteria for a diagnosis of LPR based on the Sep70/Pepsin cutoff.

CONCLUSIONS

The identified Sep70/Pepsin ratio may serve as a reliable biomarker for the diagnosis of LPR. As a result, this may help identify additional patients who have a false-negative HMII result due to the 24-h testing window.

Effects of pepsin A on heat shock protein 70 response in laryngopharyngeal reflux patients with chronic rhinosinusitis

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.

Is Pepsin a Reliable Marker of Laryngopharyngeal Reflux? A Systematic Review

Objective

Laryngopharyngeal reflux (LPR) is a common illness of otolaryngology visits. Over the past few years, pepsin has become a promising marker of LPR. The objective of the present research is to analyze the existing literature using pepsin as a diagnostic tool of LPR through a systematic review.

Data Sources

PubMed (Medline), Trip Database, Cochrane Library, EMBASE, SUMsearch, and Web of Science.

Review Methods

The outcome assessed was the presence of pepsin in LPR patients. We included articles in which pepsin was studied in LPR patients (clinically suspected or with confirmed diagnosis). Studies with no control group, comparison group, and/or a sample size lower than 20 patients were excluded.

Results

Twelve studies were included. All included studies, with the exception of 2, found statistically significant differences for pepsin in cases compared with healthy controls.

Conclusion

Pepsin might be a reliable marker in LPR patients, although questions remain about optimal timing, location, nature, and threshold values for pepsin testing. Future investigations are necessary to clarify the best method to use pepsin in the diagnostic process of LPR.

Pepsin as a Marker of Extraesophageal Reflux

Diagnosis of extraesophageal reflux (EER) currently relies on tools designed for diagnosis of gastroesophageal reflux. Such tools lack the sensitivity and reproducibility to detect the less frequent and mildly acidic reflux associated with upper airway disease. Pepsin has been posited to be a reliable biological marker of EER. Our aim was to present a comprehensive literature review of the use of pepsin as a diagnostic marker of EER. Two methods are typically used for detection of pepsin in the airways: enzymatic and immunologic. The limitations, advantages, and examples of use of each are discussed. Pepsin assay has been used to identify refluxate in trachea, lung, sinus, middle ear, combined sputum and saliva, and breath condensate. An immunologic pepsin assay of combined sputum and saliva was determined to be 100% sensitive and 89% specific for detection of EER (based on pH-metry), and an enzymatic test of nasal lavage fluid (100% sensitivity and 92.5% specificity) demonstrated an increased incidence of EER in patients with chronic rhinosinusitis. Pepsin assay identified tracheal pepsin to be an indicator of bronchopulmonary dysplasia and related mortality risk in ventilated preterm infants. Pepsin assay is a useful tool for correlation of reflux with airway disease and is a reliable diagnostic marker of EER.

PepsinA as a Marker of Laryngopharyngeal Reflux Detected in Chronic Rhinosinusitis Patients

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.

The Role of Helicobacter pylori in Laryngopharyngeal Reflux

Objective The primary objective was to determine the prevalence of Helicobacter pylori among patients with laryngopharyngeal reflux. The secondary objective was determining if H pylori eradication leads to greater symptom improvement in patients with laryngopharyngeal reflux as compared with standard proton pump inhibitor therapy alone. Data Sources EMBASE, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov. Review Methods A systematic review was performed of studies assessing the diagnosis or treatment of H pylori among patients with laryngopharyngeal reflux. Randomized controlled trials, cohort studies, case-control studies, and case series were included. A meta-analysis of prevalence data and assessment of heterogeneity was performed on relevant studies. Results Fourteen studies were analyzed in the review, with 13 eligible for the meta-analysis. We determined that the prevalence of H pylori among patients with laryngopharyngeal reflux was 43.9% (95% confidence interval, 32.1-56.5). The heterogeneity of studies was high, with an overall I² value of 92.3%. We were unable to quantitatively assess findings for our secondary outcome, since H pylori identification and treatment were not the primary focus of the majority of studies. Conclusion There is a high rate of H pylori infection among patients with laryngopharyngeal reflux. The infection rate in North America and Western Europe has not been adequately studied. There is insufficient evidence to make a recommendation regarding the testing and treatment of H pylori infection among patients with laryngopharyngeal reflux.

Airway reflux

An ever-increasing number of adult and pediatric disorders have been shown to be influenced or caused by airway reflux. This has become a controversial and complicated aspect of medicine that requires a multidisciplinary approach. Evidence indicates that it is not only the acidic components of gastric refluxate that injure extraesophageal tissues but also the nonacidic components, such as pepsin and bile. There is a realization that proton pump inhibitors will not be effective when nonacidic components of refluxate are causing the problem. New in vitro and in vivo models for the study of airway reflux and new therapeutic and surgical approaches are discussed in this review article.

Expression of CAIII and Hsp70 Is Increased the Mucous Membrane of the Posterior Commissure in Laryngopharyngeal Reflux Disease

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.

Local Synthesis of Pepsin in Barrett's Esophagus and the Role of Pepsin in Esophageal Adenocarcinoma

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.

Upper esophageal and pharyngeal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on laryngopharyngeal reflux as a risk factor for laryngeal cancer; the role of pepsin in laryngopharyngeal neoplasia; natural fruit and vegetable compounds for the prevention and treatment of pharyngeal and esophageal cancers; and evaluation of cranberry constituents as inhibitors of esophageal adenocarcinoma utilizing in vitro assay and in vivo models.

Bicarbonate availability for vocal fold epithelial defense to acidic challenge

OBJECTIVES

Bicarbonate is critical for acid-base tissue homeostasis. In this study we investigated the role of bicarbonate ion transport in vocal fold epithelial defense to acid challenges. Acidic insults to the larynx are common in gastric reflux, carcinogenesis and metastasis, and acute inflammation.

METHODS

Ion transport was measured in viable porcine vocal fold epithelium. First, 18 vocal folds were exposed to either the carbonic anhydrase antagonist acetazolamide or to vehicle. Second, 32 vocal folds were exposed to either a control buffer or a bicarbonate-free buffer on their luminal or basolateral surface or both. Third, 32 vocal folds were challenged with acid in the presence of bicarbonate-free or control buffer.

RESULTS

The vocal fold transepithelial resistance was greater than 300 Ω*cm(2), suggesting robust barrier integrity. Ion transport did not change after exposure to acetazolamide (p > 0.05). Exposure to bicarbonate-free buffer did not compromise vocal fold ion transport (p > 0.05). Ion transport increased after acid challenge. This increase approached statistical significance and was the greatest for the control buffer and for the bicarbonate-free buffer applied to the basolateral surface.

CONCLUSIONS

Bicarbonate secretion may contribute to vocal fold defense against acid challenge. Our data offer a potential novel role for bicarbonate as a therapeutic agent to reduce pH abnormalities in the larynx and prevent associated pathological changes.

Hypopharyngeal pepsin and Sep70 as diagnostic markers of laryngopharyngeal reflux: preliminary study

INTRODUCTION

The management of laryngopharyngeal reflux (LPR) has been challenging. Hypopharyngeal multichannel intraluminal impedance (HMII) has shown to increase the sensitivity in diagnosing LPR. The objective of this study is to investigate the potential use of pepsin and Sep70 as diagnostic tools for detection of LPR in combination with HMII.

MATERIALS AND METHODS

Tissue samples of hypopharynx, distal esophagus, and gastric cardia were collected from patients with LPR symptoms regardless of gastroesophageal reflux (GERD) diagnosis and underwent HMII to detect LPR and high esophageal reflux (HER: reflux 2 cm distal to upper esophageal sphincter) events. Patients were classified into two groups based on the presence of abnormal proximal exposure (APE), which was defined as LPR ≥1/day and/or HER ≥5/day: (1) positive-APE and (2) negative-APE. Patients with typical GERD symptoms without LPR symptoms who did not undergo HMII were used as a "control" GERD group. Protein was isolated from tissue samples and Western blot analysis of pepsin and Sep70 was performed. Pepsinogen was used as a control to differentiate pepsin from pepsinogen. Relative quantitation was performed using Image Studio Lite Software with normalization against the internal actin of each blot.

RESULTS

From October 2012 to September 2013, 55 patients underwent HMII. Of 55, 20 patients underwent biopsies from hypopharynx (17 positive-APE and 3 negative-APE). Ten patients with typical GERD symptoms were identified from tissue bank as a "control" GERD group. Pepsin was detected in distal esophagus and hypopharynx in all groups without significant difference among groups. However, Sep70 in distal esophagus and hypopharynx was significantly depleted in the positive-APE group compared to the other groups (p = 0.032 and 0.002, respectively).

CONCLUSION

Depletion of Sep70 with the presence of pepsin in the hypopharynx may indicate cellular injury in laryngopharynx due to constant proximal reflux. However, the normative data for these markers have to be validated.

Chronic pepsin exposure promotes anchorage-independent growth and migration of a hypopharyngeal squamous cell line

OUTCOME OBJECTIVES

(1) Investigate the role of reflux, specifically pepsin, in laryngopharyngeal carcinogenesis. (2) Evaluate effects of chronic pepsin exposure on cell migration, apoptosis, and colony-forming ability in hypopharyngeal cells.

STUDY DESIGN

Translation research.

SETTING

Academic research laboratory.

METHODS

Human hypopharyngeal squamous carcinoma FaDu cells were chronically exposed to nonacidic pepsin (exposed for 24 hours, 4 times over 2 weeks at the following concentrations: 0.01 mg/mL, 0.1 mg/mL, or 1 mg/mL). Precise wounds were created in confluent cell plates, and rates of cell migration into wounds were quantified. Separately, cell viability of chronic pepsin-exposed FaDu cells acutely treated with paclitaxel was measured. Finally, a clonogenic assay was performed on these cells to measure effects of chronic pepsin exposure on colony-forming ability.

RESULTS

An increased rate of relative wound density was observed in chronic pepsin-treated (0.01 mg/mL, 0.1 mg/mL) cells compared with control (P < .001), suggesting greater rates of cell migration. Pepsin-treated (0.1 mg/mL) cells demonstrated on average greater cell viability compared with control after exposure to paclitaxel, suggesting possible apoptotic resistance; however, this was not statistically significant. Chronic pepsin exposure (0.1 mg/mL, 1 mg/mL) was associated with a dose-dependent increase in colony-forming ability relative to control (P < .001).

CONCLUSION

Hypopharyngeal squamous cell line chronically exposed to pepsin demonstrated increased cell migration and colony-forming ability relative to control cells. These experiments indicate that chronic pepsin exposure acts as a promoter of tumorigenesis and metastasis of airway epithelium, suggesting a role for pepsin in laryngopharyngeal carcinogenesis attributed to gastric reflux.

Laryngopharyngeal reflux: diagnosis, treatment, and latest research

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.

Relationship between reflux and laryngeal cancer

Gastroesophageal reflux disease (GERD), or its variation known as laryngopharyngeal reflux (LPR), has been recognized as a potential cause of several laryngeal disorders. Patients with laryngeal cancer have lifestyle risk factors, especially tobacco and alcohol consumption, that play an etiological role in the development of their cancer but also places them at risk for reflux. The question then arises whether there is merely an association or a causal relationship between laryngeal cancer and reflux. However, despite a number of studies, a causal relationship with laryngeal cancer is uncertain. In this article, we address the current literature in a critical manner to evaluate the relationship between reflux and laryngeal cancer. From the review of the literature, we conclude that there is insufficient evidence to support a causal role of reflux in laryngeal cancer, mainly because of the confounding effect of tobacco and alcohol consumption and the inaccuracies in the diagnosis of reflux.

Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease

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.

The Value of Routine pH Monitoring in the Diagnosis and Treatment of Laryngopharyngeal Reflux

Objective. To assess the need for pH testing in diagnosing laryngopharyngeal reflux (LPR).

Study Design. Case series with planned data collection.

Setting. Tertiary care center.

Subjects and Methods. On the basis of symptoms and/or abnormal endoscopic findings, more than 500 patients underwent 24-hour pharyngeal pH testing at a single center (using the Dx-pH probe) between January 2009 and June 2011. A total of 163 patients not on proton-pump inhibitors at the time of study and with complete data available for analysis (pH results, body mass index, smoking status, pretest reflux symptom index) were divided into 2 groups by positive (n = 70) and negative (n = 93) Ryan Score. The Reflux Symptom Index (RSI) was compared between groups and assessed overall against Ryan Score parameters at different pH thresholds. The diagnostic utility of an RSI ≥ 13 for prediction of Ryan Score was assessed.

Results. No significant difference in RSI was seen between Ryan-positive (17.50 ± 11.47) and Ryan-negative (14.95 ± 11.43) patients ( P = .161). Overall, RSI correlated poorly with percentage time spent below pH thresholds 6.5, 6.0, 5.5, and 5.0 and upright and supine Ryan parameters at these thresholds (as determined by linear regression analysis). The sensitivity, specificity, positive predictive value, and negative predictive value of RSI ≥ 13 for Ryan positivity were 55.7%, 47.3%, 44.3%, and 58.7%, respectively.

Conclusion. Our findings show that in our population of otolaryngology patients, the diagnosis of LPR cannot be reliably made on the basis of symptoms alone. Diagnosis, and in particular treatment decisions, should ideally be made on the basis of a combination of symptoms, signs, and confirmatory testing.

Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms

The reliability of Nissen fundoplication for the successful treatment of laryngopharyngeal reflux (LPR) symptoms remains in question. The purpose of this study was to assess the effect that antireflux surgery has on a variety of LPR symptoms as well as the patient's perceived success of surgical intervention. A retrospective review of all antireflux surgeries between 1998 and 2008 provided a patient base for a survey in which patients ranked pre- and postoperative LPR symptoms in addition to patient satisfaction with the outcome. Of the 611 patients identified and sent the evaluation forms, 244 responses (40%) were obtained. The percentage of patients with symptom improvement after surgery were: heartburn (90.1%), regurgitation (92.6%), voice fatigue (75.2%), chronic cough (76.3%), choking episodes (83.1%), sore throat (82.9%), lump in throat (77.4%), repetitive throat clearing (72.8%), and adult-onset asthma (59.6%). Twenty per cent with repetitive throat clearing and 30 per cent with adult-onset asthma had no improvement in symptoms. Eighty-one per cent considered surgery to be a success. Comparison of those who claimed the operation was successful with those who claimed it was not revealed no difference in demographics, primary diagnosis, procedure type, or reflux symptom index score. There was a statistically significant difference in patient-perceived outcome according to the length of time since surgery. More than 88 per cent in the "not successful" group had an operation greater than 4 years prior as compared with only 70 per cent in the "successful" group (P = 0.020). Nissen fundoplication is an effective treatment for most LPR symptoms, although patients with adult-onset asthma and repetitive throat clearing appear to benefit least from surgical intervention.

Reflux revisited: advancing the role of pepsin

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.

Pepsin detection in patients with laryngopharyngeal reflux before and after fundoplication

BACKGROUND

Some patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR). There is no reliable diagnostic test for LPR as there is for GERD. We hypothesized that detection of pepsin (a molecule only made in the stomach) in laryngeal epithelium or sputum should provide evidence for reflux of gastric contents to the larynx, and be diagnostic of LPR. We tested this hypothesis in a prospective study in patients with LPR symptoms undergoing antireflux surgery (ARS).

METHODS

Nine patients undergoing ARS for LPR symptoms were studied pre- and postoperatively using a clinical symptom questionnaire, laryngoscopy, 24-h pH monitoring, biopsy of posterior laryngeal mucosa, and sputum collection for pepsin Western blot assay.

RESULTS

The primary presenting LPR symptom was hoarseness in six, cough in two, and globus sensation in one patient. Pepsin was detected in the laryngeal mucosa in eight of nine patients preoperatively. There was correlation between biopsy and sputum (+/+ or -/-) in four of five patients, both analyzed preoperatively. Postoperatively, pH monitoring improved in all but one patient and normalized in five of eight patients. Eight of nine patients reported improvement in their primary LPR symptom (six good, two mild). Only one patient (who had negative preoperative pepsin) reported no response to treatment of the primary LPR symptom. Postoperatively, pepsin was detected in only one patient.

CONCLUSIONS

Pepsin is often found on laryngeal epithelial biopsy and in sputum of patients with pH-test-proven GERD and symptoms of LPR. ARS improves symptoms and clears pepsin from the upper airway. Detection of pepsin improves diagnostic accuracy in patients with LPR.

Establishment of a reflux esophago-laryngitis model in rats

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.

Reevaluation of gastroesophageal reflux disease as a risk factor for laryngeal cancer

OBJECTIVES/HYPOTHESIS

The relationship between gastroesophageal reflux disease (GERD) and laryngeal cancer has not been fully elucidated. This case-control study investigates whether GERD increases the odds of developing these malignancies.

STUDY DESIGN

Case-control study.

METHODS

Rates of GERD among cases of laryngeal cancer identified in the Veterans Health Administration outpatient care files (year 2000-2006) were compared with controls. Cases (N = 14,449) were frequency matched 1:1 with controls. Multivariate logistic regression was used to determine the association between GERD and cancer.

RESULTS

After adjusting for tobacco and/or alcohol use, there was no association between GERD and laryngeal cancer (adjusted odds ratio, 1.01; 95% confidence interval, 0.92-1.12, P =.780). Although an association was found when time from GERD diagnosis to malignancy was less than 3 months, it disappeared when this period was extended further.

CONCLUSIONS

In this population, there was no increased risk of laryngeal cancer among patients with GERD. However, in subsite analysis, a possible relationship between GERD and glottic cancer was observed. Reverse causality must be considered in future studies assessing the relationship between reflux and laryngeal cancer to limit misclassification bias.