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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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Lechien JR, Vaezi MF, Chan WW, Allen JE, Karkos PD, Saussez S, Altman KW, Amin MR, Ayad T, Barillari MR, Belafsky PC, Blumin JH, Johnston N, Bobin F, Broadhurst M, Ceccon FP, Calvo-Henriquez C, Eun YG, Chiesa-Estomba CM, Crevier-Buchman L, Clarke JO, Dapri G, Eckley CA, Finck C, Fisichella PM, Hamdan AL, Hans S, Huet K, Imamura R, Jobe BA, Hoppo T, Maron LP, Muls V, O'Rourke AK, Perazzo PS, Postma G, Prasad VMN, Remacle M, Sant'Anna GD, Sataloff RT, Savarino EV, Schindler A, Siupsinskiene N, Tseng PH, Zalvan CH, Zelenik K, Fraysse B, Bock JM, Akst LM, Carroll TL. The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus. Laryngoscope 2024; 134:1614-1624. [PMID: 37929860 DOI: 10.1002/lary.31134] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/18/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR. METHODS Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician. RESULTS After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h. CONCLUSION A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR. LEVEL OF EVIDENCE 5 Laryngoscope, 134:1614-1624, 2024.
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Affiliation(s)
- Jerome R Lechien
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Brussels, Belgium
- Department of Laryngology and Broncho-Esophagology (Anatomy Department), EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, Paris Saclay University, Research Committee of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
- Department of Otorhinolaryngology and Head and Neck Surgery, Polyclinic of Poitiers, Poitiers, France
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacqueline E Allen
- Department of Otolaryngology, Head and Neck Surgery, University of Auckland, Auckland, New Zealand
| | - Petros D Karkos
- Department of Otorhinolaryngology and Head and Neck Surgery, Thessaloniki Medical School, Thessaloniki, Greece
| | - Sven Saussez
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Brussels, Belgium
- Department of Laryngology and Broncho-Esophagology (Anatomy Department), EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
| | - Kenneth W Altman
- Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Milan R Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, USA
| | - Tareck Ayad
- Department of Otolaryngology-Head Neck Surgery, Montreal Hospital, Montreal, Canada
| | - Maria R Barillari
- Division of Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive Medicine, L. Vanvitelli University, Naples, Italy
| | - Peter C Belafsky
- Department of Otolaryngology, UC Davis Medical Center, Sacramento, California, USA
| | - Joel H Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Francois Bobin
- Department of Otorhinolaryngology and Head and Neck Surgery, Polyclinic of Poitiers, Poitiers, France
| | | | - Fabio P Ceccon
- Department of Otolaryngology-Head and Neck Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christian Calvo-Henriquez
- Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Young-Gyu Eun
- Department of Otolaryngology Head & Neck Surgery, Department of Biomedical Science and Technology, Graduate School, Kyung Hee University, Kyung Hee University School of Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Carlos M Chiesa-Estomba
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Donostia, San Sebastian, Spain
| | - Lise Crevier-Buchman
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, Paris Saclay University, Research Committee of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Redwood City, California, USA
| | - Giovanni Dapri
- International School Reduced Scar Laparoscopy, Minimally Invasive General and Oncologic Surgery Center, Humanitas Gavazzeni University Hospital, Bergamo, Italy
| | - Claudia A Eckley
- Divisão de Otorrinolaringologia, Fleury Medicina e Saúde Laboratórios de Diagnóstico, São Paulo, Brazil
| | - Camille Finck
- Department of Otorhinolaryngology-Head and Neck Surgery, CHU de Liege, Liege, Belgium
| | | | - Abdul-Latif Hamdan
- Department of Otorhinolaryngology-Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Stephane Hans
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, Paris Saclay University, Research Committee of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
| | - Kathy Huet
- Department of Metrology and Langage Science, University of Mons, Mons, Belgium
| | - Rui Imamura
- Department of Otorhinolaryngology, Clinical Hospital, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Blair A Jobe
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA
| | - Toshitaka Hoppo
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA
| | - Lance P Maron
- Netcare Park Lane Hospital, Johannesburg, South Africa
| | - Vinciane Muls
- Department of gastroenterology, CHU Saint-Pierre, Brussels
| | - Ashli K O'Rourke
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paulo S Perazzo
- Department of Otolaryngology, School of Medicine, São Paulo Federal University, Sao Paulo, Brazil
| | - Gregory Postma
- Department of Otolaryngology, Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Vyas M N Prasad
- ENT Centre and Singapore Medical Specialist Centre, Singapore, Singapore
| | - Marc Remacle
- Department of Otolaryngology, Centre Hospitalier du Luxembourg, Luxembourg, Luxembourg
| | - Geraldo D Sant'Anna
- Disciplina de Otorrinolaringologia, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Nora Siupsinskiene
- Department of Otolaryngology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Faculty of Health Sciences, Klaipeda university, Klaipeda, Lithuania
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Craig H Zalvan
- Department of Otolaryngology-New York Medical College, School of Medicine, Valhalla, NY; Institute for Voice and Swallowing Disorders, Sleepy Hollow, NY, USA
| | - Karol Zelenik
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | | | - Jonathan M Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lee M Akst
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Thomas L Carroll
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Brigham and Women's Hospital and Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Olmos JA, Pandolfino JE, Piskorz MM, Zamora N, Valdovinos Díaz MA, Remes Troche JM, Guzmán M, Hani A, Valdovinos García LR, Pitanga Lukashok H, Domingues G, Vesco E, Rivas MM, Ovalle LFP, Cisternas D, Vela MF. Latin American consensus on diagnosis of gastroesophageal reflux disease. Neurogastroenterol Motil 2024; 36:e14735. [PMID: 38225792 DOI: 10.1111/nmo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. METHODS This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. KEY RESULTS A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. CONCLUSIONS Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.
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Affiliation(s)
- Jorge A Olmos
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - María M Piskorz
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Miguel A Valdovinos Díaz
- UNAM, Ciudad de Mexico, Mexico
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José M Remes Troche
- Institute of Medical Biological Research, Universidad Veracruzana, Veracruz, Mexico
| | - Mauricio Guzmán
- Neurogastroenterology Unit, Gastroenterology Service, Hospital San Martín de La Plata, Buenos Aires, Argentina
| | - Albis Hani
- Hospital San Ignacio-Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Hannah Pitanga Lukashok
- Digestive Motility Service, Instituto Ecuatoriano de Enfermedades Digestivas-IECED, Guayaquil, Ecuador
| | | | - Eduardo Vesco
- Neuromotility Unit, Clínica Angloamericana, Lima, Peru
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Mariel Mejia Rivas
- Internal Medicine, Gastroenterology and Digestive Endoscopy Service, Hospital Vivian Pellas, Managua, Nicaragua
| | - Luis F Pineda Ovalle
- Neurogastroenterology and Motility Service Motility Instituto Gut Médica, Bogotá, Colombia
| | - Daniel Cisternas
- Clínica Alemana de Santiago, School of Medicine, Universidad del Desarrollo, Clínica Alemana, Vitacura, Chile
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Lechien JR, Bobin F. Diagnostic Value of Fasting and Bedtime Saliva Pepsin Measurements in Laryngopharyngeal Reflux. Biomedicines 2024; 12:398. [PMID: 38398000 PMCID: PMC10886472 DOI: 10.3390/biomedicines12020398] [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: 11/23/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The pepsin test is an emerging non-invasive diagnostic approach for laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of multiple salivary pepsin tests for detecting LPR. METHODS Patients with suspected LPR and asymptomatic individuals were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and fasting and bedtime saliva collections to measure oral pepsin. The sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated considering fasting, bedtime, and the highest values of the pepsin tests at ≥16, ≥36, ≥45, and ≥100 ng/mL cutoffs. RESULTS The pepsin test was adequately performed in 147 LPR patients and 32 controls. The pepsin tests were 81.6%, 74.8%, and 61.5% sensitive at cutoffs of ≥16, ≥45, and ≥100 ng/mL, respectively. The PPVs were 93.0%, 94.0%, and 94.8%, respectively. The highest specificity (81.8%) was found for the fasting pepsin test at a cutoff of 100 ng/mL. The highest sensitivity (81.6%) was found by considering the highest measured pepsin test at the ≥16 ng/mL threshold. The measurement of fasting saliva pepsin was associated with the highest sensitivity and specificity value. At ≥16 ng/mL, 27 patients had negative findings, indicating that 18.4% (27/147) of the true positive cases were missed by considering the highest pepsin test. The receiver operating characteristic curve reported that a cutoff of 21.5 was 76.9% sensitive and 62.5% specific, while the PPV and NPV were 91.1% and 38.2%, respectively. CONCLUSIONS The consideration of the highest concentration of the fasting and bedtime saliva pepsin collections at a cutoff of 21.5 was associated with the best detection rate and sensitivity of the pepsin tests.
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Affiliation(s)
- Jerome R. Lechien
- Division of Laryngology and Broncho-Esophagology, Department of Otolaryngology-Head Neck Surgery, EpiCURA Hospital, B7000 Baudour, Belgium
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Avenue du Champ de Mars, 6, B7000 Mons, Belgium
- Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), 92150 Paris, France
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, F64000 Brussels, Belgium
- Polyclinique Elsan de Poitiers, 86000 Poitiers, France;
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5
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Ren QW, Lei G, Zhao YL, Zhou L, Luo XL, Peng SL. Laryngopharyngeal Reflux and Benign Vocal Fold Lesions: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 170:309-319. [PMID: 37727944 DOI: 10.1002/ohn.529] [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: 06/07/2023] [Revised: 08/04/2023] [Accepted: 08/26/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE There is a link between laryngopharyngeal reflux (LPR) and the formation of benign vocal fold lesions (BVFLs). However, previous studies have mainly focused on LPR suggested by symptoms and signs, rather than objectively diagnosed LPR via pharyngeal pH monitoring. We, therefore, conducted a Meta-analysis to evaluate the association between pharyngeal pH monitoring diagnosed LPR and the odds of BVFLs. DATA SOURCES Relevant observational studies were identified by searching PubMed, Embase, Cochrane Library, and Web of Science. REVIEW METHODS We evaluated between-study heterogeneity using the Cochrane Q test and estimated the I2 statistic. Random-effects models were used when significant heterogeneity was observed; otherwise, fixed-effects models were used. RESULTS Thirteen datasets from 9 studies were included. Among them, 493 were diagnosed with LPR and 344 had BVFLs. LPR was related to a higher odds of BVFLs (odds ratio: 3.26, 95% confidence interval: 1.84-5.76, P < .001) with moderate heterogeneity (P for Cochrane Q test = .006, I2 = 57%). Subgroup analyses showed that the association was similar in studies with only pharyngeal pH monitoring (Restech), with double-probe or 3-site pH monitoring, and with 24-hour multichannel intraluminal impedance-pH monitoring (P for subgroup difference = .15). In addition, subgroup analysis showed consistent results in studies from Asia and Europe (P for subgroup analysis = .12), and the association seemed to be consistent for vocal Reinke's edema, nodules, and polyps (P for subgroup difference = .09). CONCLUSION Pharyngeal pH monitoring diagnosed LPR is associated with the formation of BVFLs.
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Affiliation(s)
- Quan-Wei Ren
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Department of Otolaryngology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Gang Lei
- Department of Otolaryngology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Yan-Li Zhao
- Department of Otolaryngology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Li Zhou
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiao-Li Luo
- Department of Otolaryngology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Shun-Lin Peng
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Lesnick A, Samuels TL, Seabloom D, Wuertz B, Ojha A, Seelig D, Ondrey F, Wiedmann TS, Hogan C, Torii E, Ouyang H, Yan K, Garcia GJM, Bock JM, Johnston N. Inhaled fosamprenavir for laryngopharyngeal reflux: Toxicology and fluid dynamics modeling. Laryngoscope Investig Otolaryngol 2024; 9:e1219. [PMID: 38362183 PMCID: PMC10866582 DOI: 10.1002/lio2.1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/20/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024] Open
Abstract
Objectives Approximately 25% of Americans suffer from laryngopharyngeal reflux (LPR), a disease for which no effective medical therapy exists. Pepsin is a predominant source of damage during LPR and a key therapeutic target. Fosamprenavir (FOS) inhibits pepsin and prevents damage in an LPR mouse model. Inhaled FOS protects at a lower dose than oral; however, the safety of inhaled FOS is unknown and there are no inhalers for laryngopharyngeal delivery. A pre-Good Lab Practice (GLP) study of inhaled FOS was performed to assess safety and computational fluid dynamics (CFD) modeling used to predict the optimal particle size for a laryngopharyngeal dry powder inhaler (DPI). Methods Aerosolized FOS, amprenavir (APR), or air (control) were provided 5 days/week for 4 weeks (n = 6) in an LPR mouse model. Organs (nasal cavity, larynx, esophagus, trachea, lung, liver, heart, and kidney) were assessed by a pathologist and bronchoalveolar lavage cytokines and plasma cardiotoxicity markers were assessed by Luminex assay. CFD simulations were conducted in a model of a healthy 49-year-old female. Results No significant increase was observed in histologic lesions, cytokines, or cardiotoxicity markers in FOS or APR groups relative to the control. CFD predicted that laryngopharyngeal deposition was maximized with aerodynamic diameters of 8.1-11.5 μm for inhalation rates of 30-60 L/min. Conclusions A 4-week pre-GLP study supports the safety of inhaled FOS. A formal GLP assessment is underway to support a phase I clinical trial of an FOS DPI for LPR. Level of Evidence NA.
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Affiliation(s)
- Alexandra Lesnick
- Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Tina L. Samuels
- Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Donna Seabloom
- Otolaryngology Head and Neck SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Beverly Wuertz
- Otolaryngology Head and Neck SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Abhilash Ojha
- Mechanical EngineeringUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Davis Seelig
- Comparative Pathology Shared ResourceMasonic Cancer Center, University of MinnesotaMinneapolisMinnesotaUSA
| | - Frank Ondrey
- Otolaryngology Head and Neck SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Chris Hogan
- Mechanical EngineeringUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Emma Torii
- Comparative Pathology Shared ResourceMasonic Cancer Center, University of MinnesotaMinneapolisMinnesotaUSA
| | - Hui Ouyang
- Mechanical EngineeringUniversity of Texas‐DallasDallasTexasUSA
| | - Ke Yan
- Pediatrics Quantitative Health SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Guilherme J. M. Garcia
- Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
- Biomedical EngineeringMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Jonathan M. Bock
- Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Nikki Johnston
- Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsinUSA
- Microbiology and ImmunologyMedical College of WisconsinMilwaukeeWisconsinUSA
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Lukaschyk J, Abel J, Brockmann-Bauser M, Clausen JF, Reiter R, Wessel J, Rohlfs AK. The Relation Between Endoscopic and Subjective Laryngopharyngeal Reflux Signs, Vocal Tract Discomfort, Voice Handicap, and Voice Disorder Type: Same Yet Different? J Voice 2024:S0892-1997(23)00381-8. [PMID: 38182496 DOI: 10.1016/j.jvoice.2023.11.021] [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: 08/30/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVES This study aimed to investigate the relation between subjective voice-related symptoms and endoscopic findings in patients with different etiology of voice disorder and vocally healthy subjects with and without laryngopharyngeal reflux (LPR). STUDY DESIGN Retrospective cross-sectional study. METHODS The study involved 149 participants (106 female, 43 male) including 125 with various voice disorders (functional, structural, and neurogenic) and 24 vocally healthy individuals. For self-rating the German versions of the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) Scale, and Reflux Symptom Index (RSI) were applied, while endoscopic evaluations utilized the Reflux Finding Score (RFS) and Reflux Sign Assessment (RSA). Statistical analyses incorporated ANOVA with Bonferroni posthoc tests to identify group variations. Correlations between VTD Scale, VHI, RSI, RFS, and RSA were evaluated using Pearson's correlation coefficient. To examine test sensitivity and specificity for the VTD Scale and RSA, we performed a receiver operating characteristics analysis. Youden's-Index was applied to determine the cut-off-value with best discriminatory abilities. The diagnosis of LPR was assumed when the criteria of RFS > 7 AND RSI > 13 was met. RESULTS Significant differences for all voice diagnosis groups and vocally healthy individuals for RFS and all three self-rating questionnaires were found. Moreover, there was significant correlation between VTD Scale and VHI and RSI as well as RSI and RFS, which was moderate, negative in the group of persons with LPR. However, there was no significant difference for RSA results between the vocally healthy or any diagnosis group. CONCLUSION Thus, the RFS may be more suitable to predict reflux and voice-related symptoms. The VTD Scale is a useful instrument in screening voice disorders but also LPR and can therefore be used as a tool for decision-making when transferring to a specialist.
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Affiliation(s)
- Julia Lukaschyk
- ENT, Phoniatrics and Pedaudiology - Klosterstern, Hamburg, Germany.
| | - Jakob Abel
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Meike Brockmann-Bauser
- Department of Phoniatrics and Speech Pathology, Clinic for Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jacob Friedrich Clausen
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rudolf Reiter
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Julian Wessel
- ENT, Phoniatrics and Pedaudiology - Klosterstern, Hamburg, Germany
| | - Anna-Katharina Rohlfs
- ENT, Phoniatrics and Pedaudiology - Klosterstern, Hamburg, Germany; Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lechien JR. Personalized Treatments Based on Laryngopharyngeal Reflux Patient Profiles: A Narrative Review. J Pers Med 2023; 13:1567. [PMID: 38003882 PMCID: PMC10671871 DOI: 10.3390/jpm13111567] [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: 09/23/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE To review the current findings of the literature on the existence of several profiles of laryngopharyngeal reflux (LPR) patients and to propose personalized diagnostic and therapeutic approaches. METHODS A state-of-the art review of the literature was conducted using the PubMED, Scopus, and Cochrane Library databases. The information related to epidemiology, demographics, clinical presentations, diagnostic approaches, and therapeutic responses were extracted to identify outcomes that may influence the clinical and therapeutic courses of LPR. RESULTS The clinical presentation and therapeutic courses of LPR may be influenced by gender, age, weight, comorbidities, dietary habits and culture, anxiety, stress, and saliva enzyme profile. The clinical expression of reflux, including laryngopharyngeal, respiratory, nasal, and eye symptoms, and the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring profile of patients are important issues to improve in patient management. The use of more personalized therapeutic strategies appears to be associated with better symptom relief and cures over the long-term. The role of pepsin in LPR physiology is well-established but the lack of information about the role of other gastrointestinal enzymes in the development of LPR-related mucosa inflammation limits the development of future enzyme-based personalized diagnostic and therapeutic approaches. CONCLUSION Laryngopharyngeal reflux is a challenging ear, nose, and throat condition associated with poor therapeutic responses and a long-term burden in Western countries. Artificial intelligence should be used for developing personalized therapeutic strategies based on patient features.
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Affiliation(s)
- Jerome R. Lechien
- Division of Laryngology and Broncho-Esophagology, Department of Otolaryngology-Head Neck Surgery, EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Baudour, Belgium;
- Phonetics and Phonology Laboratory (UMR 7018 CNRS, Université Sorbonne Nouvelle/Paris 3), Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, (Paris Saclay University), 92150 Paris, France
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU Saint-Pierre, School of Medicine, B1000 Brussels, Belgium
- Research Committee of the Young Otolaryngologists of the International Federation of Otorhinolaryngological Societies (YO-IFOS), 92150 Paris, France
- Department of Otolaryngology, Elsan Hospital, 92150 Paris, France
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Lechien JR, Bobin F. Variability and accuracy of multiple saliva pepsin measurements in laryngopharyngeal reflux patients. J Otolaryngol Head Neck Surg 2023; 52:66. [PMID: 37794462 PMCID: PMC10548621 DOI: 10.1186/s40463-023-00670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE To study the variability and diagnostic value of multiple salivary pepsin measurements in the detection of laryngopharyngeal reflux (LPR). METHODS Patients with LPR symptoms were consecutively recruited from December 2019 to Augustus 2022. Twenty-one asymptomatic individuals completed the study. The diagnostic was confirmed with hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH). Patients collected three saliva samples during the 24-h testing period. Symptoms and findings were studied with reflux symptom score-12 and reflux sign assessment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin measurements were calculated considering morning, post-lunch and post-dinner samples. The consistency and relationship between HEMII-pH, pepsin measurements, and clinical features were investigated. RESULTS Morning, post-lunch and post-dinner saliva pepsin concentrations were measured in 42 patients. Pepsin measurements were 64.9%, 59.5%, and 59.0% sensitive for morning, post-lunch and post-dinner collections at cutoff ≥ 16 ng/mL. Considering the highest concentration of the three pepsin saliva collections, the accuracy, sensitivity, specificity and PPV were 70.5%, 73.0%; 66.7% and 78.9%, respectively. Morning pepsin measurements reported higher consistency, sensitivity, and specificity than post-dinner and post-lunch pepsin measurements. CONCLUSION The collection of several saliva pepsin samples improves the detection rate of LPR. In case of high clinical LPR suspicion and negative pepsin test, a HEMII-pH study could provide further diagnostic information.
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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), Avenue du Champ de Mars, 6, 7000, Mons, Belgium.
- Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France.
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium.
- Polyclinique Elsan de Poitiers, Poitiers, France.
- Research Committee of Young Otolaryngologists of the International Federation of Oto-Rhinolaryngological Societies (YO-IFOS), Paris, France.
| | - Francois Bobin
- Polyclinique Elsan de Poitiers, Poitiers, France
- Research Committee of Young Otolaryngologists of the International Federation of Oto-Rhinolaryngological Societies (YO-IFOS), Paris, France
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Al-Momani H, Mashal S, Al Balawi D, Almasri M, Al-Shudifat AE, Khasawneh AI, Pearson J, Ward C. A prospective study of extraesophageal reflux and potential microaspiration in patients hospitalized with COVID-19 in Jordan. BMC Pulm Med 2023; 23:341. [PMID: 37697259 PMCID: PMC10496175 DOI: 10.1186/s12890-023-02638-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lung infection has represented a global challenge. Intriguingly, it has been shown that the alveolar lung epithelium expresses little Angiotensin Converting Enzyme receptor protein (ACE2), the entry receptor for SARS-CoV-2. Upper airway establishment of infection and translocation to the lung is well documented but other anatomical niches may be relevant to potentially serious lung infection. ACE2 is heavily expressed in the gastrointestinal tract and gastrointestinal symptoms support a clinical diagnosis of Coronavirus disease 2019 (COVID-19). This suggests a research question and the need to gather patient data exploring potential aerodigestive links in SARS-CoV-2 tranlocation and infection which may be relevant in the peripheral lung. This recognizes anatomical proximity and concepts of bi-directional movement between the Gastrointestinal and lung systems in normal physiology and disease. We have therefore explored the potential for gastro oesophageal reflux disease (GORD) micro aspiration and aeorodigestive pathophysiology in a novel prospective investigation of patients hospitalized with COVID-19. METHODS This is a prospective descriptive cohort study of 210 patients who were hospitalized with a confirmed diagnosis of COVID-19. The cohort was divided into three groups of patients based on symptom severity and radiological results. The Reflux Symptom Index (RSI) was used to evaluate the presence and severity of GOR. An RSI greater than 13 is considered to be abnormal. Patients' saliva samples were tested using enzyme-linked immunosorbent assay (ELISA) to determine the level of salivary pepsin among the cohort of patients. RESULTS A total of 210 patients with COVID-19 were enrolled in the study with 55.2% (116/210) classified as mildly ill, 31.9% (67/210) moderately ill and 12.9% (27/210) as severely ill. 34% (72/210) of the patients had an RSI score of over 13 and a median salivary pepsin value of 54 ± 29 ng/ml which suggested an incidence of extraesophageal reflux (EOR) in around a third of patients. The presence of respiratory comorbid conditions, an RSI score of over 13 and a salivary pepsin level of > 76ng/ml increased the risk of developing a more severe COVID-19 infection. CONCLUSION The study showed a high prevalence of EOR among the study cohort and provide the first prospective evidence suggesting the potential for aerodigestive pathophysiology including microaspiration in COVID-19 disease. We believe that the results of our study support the need for more extensive research.
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Affiliation(s)
- Hafez Al-Momani
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan.
| | - Safaa Mashal
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Dua'a Al Balawi
- Faculty of Applied Medical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Muna Almasri
- Faculty of Applied Medical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Abdel-Ellah Al-Shudifat
- Department of Internal and family Medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Ashraf I Khasawneh
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Jeffrey Pearson
- Translational and clinical research and Biosciences institutes, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Christopher Ward
- Translational and clinical research and Biosciences institutes, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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Rao YF, Wang J, Cheng DN, Xu Y, Ren X, Yang W, Liu G, Xu W, Yan XH, Song Y, Zheng YB, An P, Zhong DL, He ZP, Ren JJ, Zhao Y. The Controversy of Pepsinogen A/Pepsin A in Detecting Extra-Gastroesophageal Reflux. J Voice 2023; 37:748-756. [PMID: 34090740 DOI: 10.1016/j.jvoice.2021.04.009] [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: 01/27/2021] [Revised: 03/31/2021] [Accepted: 04/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pepsinogen A (PGA)/pepsin A is often used as a diagnostic marker of extra-gastroesophageal reflux. We aimed to explore whether its positivity in upper aerodigestive tract (UADT) was specific enough to diagnose reflux. METHODS PGA/pepsin A protein levels were examined in 10 types of tissues and 10 types of body fluid by immunological staining, western blot or Elisa, using three different commercially available brands simultaneously. Liquid chromatography-tandem mass spectrometry parallel reaction monitoring (LC-MS/MS PRM) served as a gold reference for the detection of PGA/pepsin A proteins. PGA gene expression was analyzed by reverse transcriptase sequencing methods for tissue samples. Specifically, 24 hour pH monitoring technique was conducted for patients who donated saliva samples. RESULTS Eight out of ten types of human tissue samples (stomach, esophagus, lung, kidney, colon, parotid gland, nasal turbinate and nasal polyps) were confirmed positive for PGA/pepsin A gene and protein by genetic and PRM technique, respectively. Two out of ten types of body fluid samples (gastric fluid, urine) were confirmed positive for PGA/pepsin A protein by PRM technique. The consistence rates of PGA/pepsin A positivity among three commercial antibody brands and Elisa kit were poor, and Elisa results of salivary did not match with 24-hour pH monitoring. CONCLUSIONS Multiple tissues and body fluid could be detected baseline expression levels of PGA/pepsin A gene and protein. However, those commercially available PGA/pepsin A antibodies achieved poor sensitivity and specificity, therefore, relying on the detection of PGA/pepsin A in UADT by single antibodies to diagnose extra-gastroesophageal reflux without a specific positive cut-off value is unreliable.
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Affiliation(s)
- Yu-Fang Rao
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Dan-Ni Cheng
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xue Ren
- Institute of statistics and management, Shanghai University of Finance and Economics, Shanghai, China
| | - Wen Yang
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Geoffrey Liu
- Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON, Canada.; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wei Xu
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Xiao-Hong Yan
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yao Song
- Institute of statistics and management, Shanghai University of Finance and Economics, Shanghai, China
| | - Yong-Bo Zheng
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Ping An
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Da-Lin Zhong
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhao-Ping He
- Department of Biomedical Research, Nemours/Alfred I.duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jian-Jun Ren
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.; Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON, Canada..
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China..
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12
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Lechien JR, Hamdan AL. Diagnostic Value of Pepsin Measurements in Dysphonia Attributed to Laryngopharyngeal Reflux Disease. J Voice 2023:S0892-1997(23)00229-1. [PMID: 37625902 DOI: 10.1016/j.jvoice.2023.07.020] [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: 05/21/2023] [Revised: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE To investigate the diagnostic value of pepsin test in detecting laryngopharyngeal reflux (LPR) in patients with suspected LPR-induced dysphonia. METHODS Dysphonic and non-dysphonic patients with LPR at the 24-hour hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were recruited from January 2019 to November 2022. Patients collected saliva/sputum samples to measure pepsin concentrations. Symptoms and findings were studied through reflux symptom score (RSS) and reflux sign assessment (RSA). Voice quality was assessed with maximum phonation time, GRBAS, voice handicap index (VHI), and acoustic parameters at baseline and 3-month post-treatment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin tests for dysphonia-related to LPR were calculated at ≥16 ng/mL cutoff. The relationship between HEMII-pH, clinical features, voice quality outcomes, and pepsin measurement was investigated. RESULTS Sixty-seven patients with LPR at the HEMII-pH completed the evaluations accounting for 30 patients consulting for dysphonia. Dysphonic patients reported higher RSS than non-dysphonic patients. RSS, RSA, laryngeal findings, VHI, and grade of dysphonia significantly improved from baseline to 3-month posttreatment. Pepsin test detected LPR in 73% of dysphonic cases. The pepsin test was 73.3 sensitive and 18.9 specific when considering the highest pepsin level of morning, postlunch, and postdinner sputum collections. Sensitivity, specificity, PPV, and NPV varied regarding the time of sputum collections. There was a strong significant association between the concentration of the morning pepsin test and the severity of laryngeal RSA score (P = 0.018). The morning pepsin saliva test concentration was predictive of the 3-month otolaryngological RSS (P = 0.014). CONCLUSION Pepsin test is a sensitive but poorly specific diagnostic approach for patients with dysphonia attributed to LPR. Multiple pepsin measurements may increase the sensitivity and predictive value of pepsin test. Future large-cohort studies are needed to investigate the accuracy of pepsin test in this population.
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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 Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium; Polyclinique Elsan de Poitiers, Poitiers, France.
| | - Abdul-Latif Hamdan
- Department of Otolaryngology, Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Samuels TL, Blaine‐Sauer S, Yan K, Johnston N. Amprenavir inhibits pepsin-mediated laryngeal epithelial disruption and E-cadherin cleavage in vitro. Laryngoscope Investig Otolaryngol 2023; 8:953-962. [PMID: 37621274 PMCID: PMC10446255 DOI: 10.1002/lio2.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
Background Laryngopharyngeal reflux (LPR) causes chronic cough, throat clearing, hoarseness, and dysphagia and can promote laryngeal carcinogenesis. More than 20% of the US population suffers from LPR and there is no effective medical therapy. Pepsin is a predominant source of damage during LPR which disrupts laryngeal barrier function potentially via E-cadherin cleavage proteolysis and downstream matrix metalloproteinase (MMP) dysregulation. Fosamprenavir (FDA-approved HIV therapeutic and prodrug of amprenavir) is a pepsin-inhibiting LPR therapeutic candidate shown to rescue damage in an LPR mouse model. This study aimed to examine amprenavir protection against laryngeal monolayer disruption and related E-cadherin proteolysis and MMP dysregulation in vitro. Methods Laryngeal (TVC HPV) cells were exposed to buffered saline, pH 7.4 or pH 4 ± 1 mg/mL pepsin ± amprenavir (10-60 min). Analysis was performed by microscopy, Western blot, and real time polymerase chain reaction (qPCR). Results Amprenavir (1 μM) rescued pepsin acid-mediated cell dissociation (p < .05). Pepsin acid caused E-cadherin cleavage indicative of regulated intramembrane proteolysis (RIP) and increased MMP-1,3,7,9,14 24-h postexposure (p < .05). Acid alone did not cause cell dissociation or E-cadherin cleavage. Amprenavir (10 μM) protected against E-cadherin cleavage and MMP-1,9,14 induction (p < .05). Conclusions Amprenavir, at serum concentrations achievable provided the manufacturer's recommended dose of fosamprenavir for HIV, protects against pepsin-mediated cell dissociation, E-cadherin cleavage, and MMP dysregulation thought to contribute to barrier dysfunction and related symptoms during LPR. Fosamprenavir to amprenavir conversion by laryngeal epithelia, serum and saliva, and relative drug efficacies in an LPR mouse model are under investigation to inform development of inhaled formulations for LPR.
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Affiliation(s)
- Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Simon Blaine‐Sauer
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of WisconsinMilwaukeeWisconsinUSA
- Department of Microbiology and ImmunologyMedical College of WisconsinMilwaukeeWisconsinUSA
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Lechien JR, Bobin F. Saliva pepsin measurements in the detection of gastroesophageal reflux disease in laryngopharyngeal reflux patients: a cohort study. Eur Arch Otorhinolaryngol 2023:10.1007/s00405-023-08000-1. [PMID: 37140740 DOI: 10.1007/s00405-023-08000-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To study the diagnostic value of salivary pepsin measurement (Peptest) for detecting gastroesophageal reflux disease (GERD) in laryngopharyngeal reflux (LPR) patients. METHODS Patients with reflux symptoms were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH), fasting and bedtime saliva collections to measure pepsin. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were evaluated for GERD and LPR patients considering the highest values of pepsin tests at ≥ 16, ≥ 75, and ≥ 216 ng/mL cutoffs. The relationship between HEMII-pH, endoscopic and clinical findings, and pepsin measurements was studied. RESULTS Saliva was collected in 109 LPR patients and 30 individuals with both LPR and GERD. The total number of pharyngeal reflux events was significantly higher in GERD-LPR patients compared with LPR patients (p = 0.008). The mean fasting and bedtime pepsin saliva concentrations were similar between groups. The sensitivity of Peptest in LPR patients was 30.5%, 70.2%, and 84.0% at cutoffs ≥ 16, ≥ 75 and ≥ 216 ng/mL. In GERD-LPR group, Peptest was 80.0%, 70.0%, and 30.0% sensitive. At cutoff 16 ng/mL, Peptest reported PPV of 20.7% and 94.8% in LPR-GERD and LPR groups, respectively. NPV were 73.9% and 8.7% in GERD-LPR and LPR groups, respectively. The consistency analysis between Peptest and HEMII-pH was not significant. Peptest was significantly associated with the number of acid pharyngeal reflux events (rs = 0.182; p = 0.032). CONCLUSION Pepsin saliva measurements appear to be not a reliable diagnostic tool for the detection of GERD in LPR patients. Future studies are needed to determine the place of Peptest in laryngopharyngeal reflux and gastroesophageal reflux diseases.
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Affiliation(s)
- Jerome R Lechien
- Division of Laryngology and Broncho-Esophagology, Department of Otolaryngology-Head Neck Surgery, EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium.
- Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France.
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium.
- Polyclinique Elsan de Poitiers, Poitiers, France.
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Pediatric Laryngopharyngeal Reflux in the Last Decade: What Is New and Where to Next? J Clin Med 2023; 12:jcm12041436. [PMID: 36835970 PMCID: PMC9962831 DOI: 10.3390/jcm12041436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Laryngopharyngeal reflux may affect people of any age; still, most of the accumulated knowledge concerns adults, and evidence regarding pediatric populations remains relatively restricted. This study aims to review the most recent and emerging aspects of pediatric laryngopharyngeal reflux from the last ten years. It also attempts to identify gaps in knowledge and highlight discrepancies that future research should urgently address. METHODS An electronic search of the MEDLINE database was conducted, limited to January 2012 through December 2021. Non-English language articles, case reports, and studies that concerned a purely or predominantly adult population were excluded. The information from the articles with the most relevant contribution was initially categorized by theme and subsequently synthesized into a narrative form. RESULTS 86 articles were included, of which 27 were review articles, eight were surveys, and 51 were original articles. Our review systematically maps the research done in the last decade and provides an updated overview and the current state-of-the-art in this subject. CONCLUSIONS Despite discrepancies and heterogeneity in accumulating research, evidence gathered so far endorses a need for refining an escalating multiparameter diagnostic approach. A step-wise therapeutic plan appears to be the most reasonable management approach, starting with behavioral changes for mild to moderate, uncomplicated cases and escalating to personalized pharmacotherapy options for severe or nonresponsive cases. Surgical options could be considered in the most severe cases when potentially life-threatening symptoms persist despite maximal medical therapy. Over the past decade, the amount of available evidence has been gradually increasing; however, its strength remains low. Several aspects remain markedly under-addressed, and further adequately powered, multicenter, controlled studies with uniformity in diagnostic procedures and criteria are urgently needed.
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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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17
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Yu L, Li R, Du L, Zhao Y. The diagnostic value of pepsin concentration in saliva for laryngopharyngeal reflux disease. Eur Arch Otorhinolaryngol 2022; 279:5783-5789. [PMID: 35689682 DOI: 10.1007/s00405-022-07472-x] [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: 01/06/2022] [Accepted: 05/27/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To explore the diagnostic efficacy of pepsin concentration in saliva for laryngopharyngeal reflux (LPR) disease. METHODS In this study, we recruited 40 participants with abnormal sensation of throat into the study who visited our hospital from March 2020 to December 2020. The 24 h multichannel intraluminal impedance and pH monitoring (24 h MII-pH), reflux symptom index (RSI) and reflux finding score (RFS), pepsin concentration in saliva were collected. The Cohen's kappa test and receiver-operating characteristic (ROC) curves were performed to determine and compare the sensitivity and specificity of five diagnostic methods: RSI; RFS, pepsin concentration, RSI + RFS, RSI + RFS + pepsin concentration. RESULTS The area under the curve (AUC) of RSI, RFS, pepsin concentration, RSI + RFS, RSI + RFS + pepsin concentration were 0.767, 0.733, 0.870, 0.750,0.867, respectively. That is, the pepsin concentration has maximum AUC (the cutoff point is 219.47 (ng/mL); the sensitivity and 1-specificity is 0.300, 0.933, respectively.). The positive predictive value was 90.3% (28/31), and the negative predictive value was 77.8% (7/9). The Cohen's kappa coefficients of the five diagnostic subgroups were: RSI 0.486 (95% CI 0.207-0.764, P = 0.001); RFS 0.333 (95% CI 0.021-0.644, P = 0.032); RSI + RFS: 0.517 (95% CI 0.205-0.829, P = 0.001); pepsin concentration: 0.699 (95% CI 0.379-0.931, P = 0.001); RSI + RFS + pepsin concentration: 0.500 (95% CI 0.181-0.819, P < 0.001). CONCLUSION The pepsin concentration has the maximum AUC area and highest consistency with the 24 h MII-pH. Therefore, it has certain value in the screening and diagnosis of diseases related to LPR disease.
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Affiliation(s)
- Lei Yu
- Department of Otorhinolaryngology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Rui Li
- Department of Otorhinolaryngology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Linnan Du
- Chemical Engineering Institute, Shijiazhuang University, Shijiazhuang, China
| | - Yuliang Zhao
- Department of Otorhinolaryngology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China.
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18
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Yang R, Liang F, Tian R, Yao Y, Zhang M, Li X. There is a Good Consistency Between Reflux Symptom Score-12 and Reflux Symptom Index in Chinese Population. J Voice 2022:S0892-1997(22)00373-3. [PMID: 36460539 DOI: 10.1016/j.jvoice.2022.11.021] [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: 11/03/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the consistency between the Reflux Symptom Score-12 (RSS-12) and Reflux Symptom Index (RSI) in Chinese people. METHODS Patients with symptoms of LPR from the outpatient otorhinolaryngology-head and neck surgery clinic were included. All included patients completed the RSS-12 and RSI. The patient with RSS-12>11 or RSI>13 suggested possible LPR. For the patients with RSI >13 or RSS-12>11, they were treated using diet recommendations and were prescribed a twice-daily pantoprazole for 12 weeks. The consistency between the RSS-12 and RSI was compared with the weighted Cohen's kappa statistic. RESULTS A total of 258 patients were included. The mean scores for RSS-12 and RSI were 13.21±17.31 and 12.86±6.15, respectively. The positive rate of LPR was 17.44% based on the RSI, and 24.42% based on the RSS-12. The kappa value between the RSS-12 and RSI was 0.736 (P < 0.001). Following 12 weeks of treatment, there was a significant reduction in both RSI and RSS-12. Based on the RSI, 73% of patients had a good treatment response, whereas according to the RSS-12, 85% of patients had a good treatment response. CONCLUSION There is a good consistency between RSS-12 and RSI, meaning that the RSS-12 is a feasible LPR initial screening tool. The RSS-12 provides a more comprehensive evaluation of reflux symptoms and treatment effect than RSI in patients with LPR.
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Affiliation(s)
- Ruimin Yang
- Department of Otolaryngology, Hebei Langfang people's Hospital, Hebei, China.
| | - Fangfang Liang
- Department of Otolaryngology, Hebei Langfang people's Hospital, Hebei, China
| | - Ru Tian
- Department of Otolaryngology, Langfang Hospital of traditional Chinese medicine, Hebei, China
| | - Yang Yao
- Department of Otolaryngology, Hebei Langfang people's Hospital, Hebei, China
| | - Ming Zhang
- Department of Otolaryngology, Hebei Langfang people's Hospital, Hebei, China
| | - Xiaowen Li
- Department of Otolaryngology, Hebei Langfang people's Hospital, Hebei, China
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19
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Zhang J, Wang X, Wang J, Zhao J, Zhang C, Liu Z, Li J. Optimal Timing of the Salivary Pepsin Test for the Diagnosis of Laryngopharyngeal Reflux. Laryngoscope 2022. [PMID: 36149876 DOI: 10.1002/lary.30408] [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: 07/19/2022] [Revised: 08/13/2022] [Accepted: 08/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the optimal time point for diagnosing laryngopharyngeal reflux (LPR) through combining 24-h hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-h HEMII-pH) monitoring and the multi-time point salivary pepsin test (MTPSPT). STUDY DESIGN Prospective uncontrolled trial. METHOD Patients with and without LPR symptoms were included as the test group and the control group, respectively. The patients in the test group underwent 24-h HEMII-pH and MTPSPT. The results of 24-h HEMII-pH were used as a diagnostic criterion for LPR, and the diagnostic value of salivary pepsin tests performed at different time points was compared by receiver operating characteristic (ROC) analysis. RESULTS A total of 153 patients were included. Based on 24-h HEMII-pH, the positive rate of LPR in the test group of patients was 84.00%. In the control group, only one person (3.57%) had a positive salivary pepsin test result. The area under the curve (AUC) of the MTPSPT was 0.827. In addition, we separately calculated the AUC of the combined salivary pepsin test at different time points, and found good diagnostic value (AUC = 0.799) when the test was combined with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests. However, when the number of tests were further increased, the diagnostic value did not improve significantly. CONCLUSION Salivary pepsin testing combined with waking, 1 h and 2 h after breakfast and lunch, and 1 h after dinner has almost the same diagnostic value as MTPSPT, and testing at these time points can be an effective method for diagnosing LPR. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Jinhong Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China.,Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xiaoyu Wang
- 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
| | - Jing Zhao
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Chun Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China.,Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, China
| | - Zhi Liu
- 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.,Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, China
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20
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Zhang J, Wang X, Wang J, Zhao J, Zhang C, Liu Z, Li J. Does hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring for the diagnosis of laryngopharyngeal reflux have to be 24 h? Eur Arch Otorhinolaryngol 2022; 279:5323-5329. [PMID: 35864359 DOI: 10.1007/s00405-022-07554-w] [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: 05/02/2022] [Accepted: 07/11/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the diagnostic value of combined multi-timepoint salivary pepsin testing (MTPSPT) and hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) for laryngopharyngeal reflux (LPR) and whether an appropriate reduction in the duration of HEMII-pH would affect the accuracy of diagnosis of LPR. METHODS Recruited patients were studied with both MTPSPT and HEMII-pH. The diagnosis of LPR was based on the occurrence of > 1 reflux event and/or positive results on any of the MTPSPT. The diagnostic value of combined diagnosis was studied through combining a breakdown of the 24-h HEMII-pH finding and the results of the MTPSPT. The diagnostic value was expressed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS Based on 24-h HEMII-pH and MTPSPT, the positive rate of LPR was 83.33% and 74.69%, respectively. According to the combined diagnosis, the positive rate of LPR was 90.74%. The sensitivity and specificity of the combined diagnosis both were 89.51% and 100%, when the HEMII-pH intervals were 7 a.m.-6 p.m. and 7 a.m.-7 p.m., respectively. However, when the monitoring time was extended to 8 p.m. and bedtime, the sensitivity, specificity, PPV and NPV of the combined diagnosis both were 100%. CONCLUSIONS The combination of MTPSPT and HEMII-pH increased the sensitivity and accuracy of diagnosis of LPR. For patients with positive MTPSPT results, the duration of HEMII-pH can be appropriately shortened to reduce patient sufferings.
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Affiliation(s)
- Jinhong Zhang
- Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, 510006, China.,Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Xiaoyu Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jiasen Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jing Zhao
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Chun Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Zhi Liu
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jinrang Li
- Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, 510006, China. .,Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China.
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21
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Clinical Update Findings about pH-Impedance Monitoring Features in Laryngopharyngeal Reflux Patients. J Clin Med 2022; 11:jcm11113158. [PMID: 35683545 PMCID: PMC9181144 DOI: 10.3390/jcm11113158] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023] Open
Abstract
Purpose: The diagnosis of laryngopharyngeal reflux (LPR) is commonly based on non-specific symptoms and findings and a positive response to an empirical therapeutic trial. The therapeutic response is, however, unpredictable, and many patients need pH-impedance monitoring to confirm the diagnosis. Methods: A review of the recent literature was conducted in PubMED, Scopus, and Embase about the pH-study features of LPR patients. A summary of last evidence was proposed. Results: The awareness of otolaryngologists about indications and interpretation of pH-impedance monitoring is low. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is the most reliable examination determining the type and composition of hypopharyngeal reflux events (HRE) and the LPR features. The use of HEMII-pH is important to confirm the diagnosis in selected patients because non-specificity of symptoms and findings. There are no international consensus guidelines for the LPR diagnosis at the HEMII-pH. However, most studies supported the occurrence of >1 acid/weakly acid/nonacid HRE as diagnostic threshold. HREs are more frequently gaseous, weakly/nonacid compared with reflux events of gastroesophageal reflux. HREs occurred as daytime and upright, which does not support the value of double proton pump inhibitors or bedtime alginate. Oropharyngeal pH-monitoring is another approach reporting different sensitivity and specificity outcomes from HEMII-pH. The use of Ryan score for the LPR diagnosis at the oropharyngeal pH monitoring may be controversial regarding the low consideration of alkaline HREs. Conclusions: The awareness of otolaryngologists about HEMII-pH indication, features, and interpretation is an important issue regarding the high prevalence of LPR in outpatients consulting in otolaryngology. The HEMII-pH findings may indicate a more personalized treatment considering type and occurrence time of HREs.
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22
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Sabry M, Yosef TM, Mahmoud AM, George Michael TMA. Fasting salivary pepsin level as a reliable non-invasive method of screening for laryngopharyngeal reflux in Egyptian patients. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Laryngopharyngeal reflux (LPR) is caused by the regurgitation of gastric contents above the upper esophageal sphincter. Diagnostic gold standard tests like multichannel intraluminal impedance (MII) and 24-h dual-probe pH-metry are invasive and expensive which limits their accessibility especially in resource-limited settings. Since pepsin is only produced in the stomach, detecting pepsin in the laryngopharynx would make it a specific marker for reflux.
Therefore, in this study, we measured fasting salivary pepsin in patients with symptoms suggestive of LPR. We aimed to confirm the role of fasting salivary pepsin as a non-invasive diagnostic tool of LPR, to detect a cut-off value for it in Egyptian patients and to study predictors of changes in its level.
Methods
We conducted a prospective case control study at the gastroenterology clinic in Ain Shams University Hospitals. After testing with esophageal pH-metry, 25 symptomatic patients with confirmed LPR and 25 healthy controls were enrolled in the study. Patients diagnosed with organic upper gastrointestinal disorders, autoimmune diseases, diabetes, malignancy or organ failure were excluded. Patients on PPI were advised to stop 2 weeks before testing. All patients were tested for fasting salivary pepsin levels, esophageal pH-metry, and indirect laryngoscopy in addition to routine laboratory parameters.
Results
Out of the 25 LPR patients, 16% of patients had laryngoscope abnormality in the form of mucosal hyperemia and inflammation, and the average percentage of time pH < 4 in esophageal pH-metry testing was 29.14 ± 39.5%.
Comparative study between the 2 groups revealed a significant increase in salivary pepsin in LPR group compared to control group (p < 0.001). By using ROC-curve analysis, salivary pepsin at a cut-off point > 5 ng/ml diagnosed patients with LPR, with fair (77.9%) accuracy, sensitivity = 100% and specificity = 56% (p = 0.0001) while pH-metry (% Time pH < 4) at a cut-off point > 14% diagnosed patients with LPR, with good (87%) accuracy, sensitivity = 80%, and specificity = 100% (p < 0.0001)
Conclusion
Fasting salivary pepsin level at a cut-off value of > 5 ng/ml is a reliable, non-invasive method for detection of LPR especially in resource-limited settings.
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23
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 260] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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24
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Lechien JR, Scifo L, Hans S, Mayo-Yanez M. In Reference to Association of Dry Eye with Laryngopharyngeal Reflux in Clinical Practice. Curr Eye Res 2021; 47:325-326. [PMID: 34802346 DOI: 10.1080/02713683.2021.2008981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jerome R Lechien
- Department of Otolaryngology, Elsan Hospital, Paris, France.,Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, Paris Saclay University, Paris, France.,Department of Otolaryngology-Head & Neck Surgery, Chu Saint-Pierre, Belgium
| | - Lisa Scifo
- Department of Ophtalmology, Chu Saint-Pierre, Brussels, Belgium
| | - Stéphane Hans
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, Paris Saclay University, Paris, France
| | - Miguel Mayo-Yanez
- Otorhinolaryngology - Head and Neck Surgery Department, Complexo Hospitalario Universitario a Coruña (Chuac), A Coruña, Spain.,Clinical Research in Medicine, International Center for Doctorate and Advanced Studies (Ciedus), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Spain
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25
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张 青, 谢 萌, 郭 瑞, 马 思, 刘 小, 杨 敏, 李 娜, 刘 海, 任 晓, 罗 花. [Effect of proton pump inhibitort on salivary pepsin concentration in patients with laryngopharyngeal reflux]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2021; 35:965-970. [PMID: 34886597 PMCID: PMC10128359 DOI: 10.13201/j.issn.2096-7993.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 06/13/2023]
Abstract
Objective:To investigate the effect of proton pump inhibitor(PPI) treatment on salivary pepsin concentration in laryngopharyngeal reflux(LPR). Methods:152 patients with suspected LPR complaining non-specific symptoms such as foreign body sensation, dry throat, phlegm and other non-specific symptoms were enrolled, in the Second Affiliated Hospital of Xi'an Jiaotong University from August 2019 to December 2020. According to the scores of reflux symptom index(RSI) and reflux finding score(RFS), all the patients were divided into LPR (+) group and LPR (-) group, RSI (+) group and RSI (-) group, RFS (+) group and RFS (-) group . Patients in the LPR (+) group were reassessed after 1 month of PPI treatment. Saliva samples were collected from all the patients at initial diagnosis and follow-up diagnosis after treatment. The salivary pepsin concentration was determined by enzyme linked immunosorbent assay (ELISA). The differences of RSI, RFS scores and salivary pepsin concentrations before and after treatment were compared. Results:The median concentration of salivary pepsin in LPR (+) group was significantly higher than that in LPR (-) group, and (73.01 ng/mL vs 25.66 ng/mL, P<0.01), the median concentration of salivary pepsin in RFS (+) group were significantly higher than that in RFS (-) group(78.00 ng/mL vs 35.79 ng/mL, P<0.01) Furthermore, the median scores of RSI (11.00 vs 7.00, P<0.05) and RFS (9.00 vs 7.00, P<0.01) of LPR (+) patients notably decreased after PPI treatment for 1 month, and the salivary pepsin median concentration was memorably lower than that before treatment(53.60 ng/mL vs 46.49 ng/mL, P<0.05). Meanwhile, the scores of symptoms such as pharyngeal paraesthesia, heartburn, chest pain, stomachache, and the scores of signs such as false vocal fold, erythema or congestion, vocal fold edema, posterior commissure hypertrophy and thick endolaryngeal mucus were conspicuously lower after treatment than those before treatment(P<0.05). Conclusion:After 1 month of PPI treatment, the scores of partial symptoms and signs, and the salivary pepsin concentrations of LPR patients decreased significantly, suggesting that pepsin plays an important role in the pathogenesis of LPR, and pepsin may be closely related to the symptoms and signs such as pharyngeal paraesthesia and vocal fold edema.
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Affiliation(s)
- 青青 张
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 萌 谢
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 瑞昕 郭
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 思敬 马
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 小红 刘
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 敏娟 杨
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 娜 李
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 海琴 刘
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 晓勇 任
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - 花南 罗
- 西安交通大学第二附属医院耳鼻咽喉头颈外科病院(西安,710004)Department of Otolaryngology Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
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Lechien JR, Mouawad F, Bobin F, Bartaire E, Crevier-Buchman L, Saussez S. Review of management of laryngopharyngeal reflux disease. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138:257-267. [DOI: 10.1016/j.anorl.2020.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Guo Z, Jiang J, Wu H, Zhu J, Zhang S, Zhang C. Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26756. [PMID: 34397878 PMCID: PMC8360476 DOI: 10.1097/md.0000000000026756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/06/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A rapid lateral flow test (Peptest) to detect pepsin in saliva/sputum has been considered as a valuable method for diagnosing laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD). The aim of this meta-analysis is to analyze the utility of Peptest for diagnosis of LPR and GERD. METHODS PubMed, EMBASE, and the Cochran Library (from January 1980 to 26 January 2020) were searched for pepsin in saliva for LPR/GERD diagnosis. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve data were summarized to examine the accuracy. RESULTS A total of 16 articles that included 2401 patients and 897 controls were analyzed. The pooled sensitivity and specificity for the diagnosis of GERD/LPR with Peptest were 62% (95% confidence interval [CI] 49%-73%) and 74% (95% CI 50%-90%), respectively. The summarized diagnostic odds ratio and area under the curve were 5.0 (95% CI 2-19) and 0.70 (95% CI 0.66-0.74), respectively. CONCLUSION Peptest shows moderate diagnostic value for LPR and GERD. More studies with standard protocols should be done to verify its usefulness.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jiali Jiang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Cardiovascular diseases, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jinxia Zhu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing, China
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
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Wlodarczyk E, Domeracka-Kolodziej A, Miaskiewicz B, Skarzynski H, Skarzynski PH. A simple qualitative scale for diagnosis of laryngopharyngeal reflux: high correlations with pH measurements and disease severity. The usefulness of the Warsaw Scale in LPR diagnostics compared to other diagnostic tools. Eur Arch Otorhinolaryngol 2021; 278:4883-4892. [PMID: 34357461 PMCID: PMC8553686 DOI: 10.1007/s00405-021-06989-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/08/2021] [Indexed: 12/26/2022]
Abstract
Purpose Diagnosis and monitoring of laryngopharyngeal reflux (LPR) is a constant challenge in otolaryngological practice, chiefly because there are no specific symptoms characteristic of the disease. In this paper, we present the validation of a simple, 6-level qualitative scale to gauge the clinical findings of LPR. It has been previously published in Polish as the Warsaw Scale. Methods In the study, we enrolled 100 patients with voice problems who had registered in our clinic, and we performed an extended battery of diagnostic tests for LPR, together with 24-h pH monitoring. Results The Warsaw Scale significantly outperformed other instruments in both predicting LPR status and correlating with pH measurements. Moreover, the rating provided by the scale showed a strong association with patient-reported symptoms. Conclusion The data indicate that the Warsaw Scale could be used as an affordable, consistent, and effective diagnostic and monitoring tool for LPR.
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Affiliation(s)
- E Wlodarczyk
- World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland
| | - A Domeracka-Kolodziej
- World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland
| | - B Miaskiewicz
- World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland
| | - H Skarzynski
- World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland
- Institute of Sensory Organs, Kajetany, Poland
- Oto-Rhino-Laryngology Surgery Clinic, World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland
| | - P H Skarzynski
- World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland.
- Institute of Sensory Organs, Kajetany, Poland.
- Oto-Rhino-Laryngology Surgery Clinic, World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland.
- Heart Failure and Cardiac Rehabilitation Department, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland.
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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 J, Li J, Nie Q, Zhang R. Are Multiple Tests Necessary for Salivary Pepsin Detection in the Diagnosis of Laryngopharyngeal Reflux? Otolaryngol Head Neck Surg 2021; 166:477-481. [PMID: 34253110 DOI: 10.1177/01945998211026837] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the necessity of multiple salivary pepsin tests within a day when diagnosing laryngopharyngeal reflux. STUDY DESIGN Prospective cohort study. SETTING Tertiary hospitals. METHODS A total of 138 patients with signs and/or symptoms associated with laryngopharyngeal reflux were included. Salivary pepsin was detected on the day of 24-hour pH monitoring, and the results of salivary pepsin detected once in the morning and multiple times in 1 day were compared with the results of pH monitoring. RESULTS Among the 138 patients, pH monitoring results were positive in 112. Salivary pepsin was positive in 47 cases in the morning, which was not consistent with the results of pH monitoring (kappa value = 0.117). With the pH monitoring results as the standard, the salivary pepsin detected once in the morning had a sensitivity of 38.4% (43/112) and a specificity of 84.6% (22/26) for the diagnosis of laryngopharyngeal reflux. When salivary pepsin was detected multiple times per day, 102 patients tested positive. The consistency with pH monitoring was moderate (kappa value = 0.587). The sensitivity was 86.6% (97/112), and the specificity was 80.8% (21/26). Of the 97 patients with positive results from pH monitoring and salivary pepsin detected multiple times a day, 54 had negative findings for a single detection in the morning, indicating that 55.7% (54/97) of the true positive cases were missed. CONCLUSION Although a single detection of salivary pepsin in the morning is more economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.
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Affiliation(s)
- Jiasen Wang
- Department of Otolaryngology-Head and Neck Surgery, The Sixth Medical Centre of Chinese PLA General Hospital, Beijing, China
| | - Jinrang Li
- Department of Otolaryngology-Head and Neck Surgery, The Sixth Medical Centre of Chinese PLA General Hospital, Beijing, China
| | - Qian Nie
- Department of Otolaryngology-Head and Neck Surgery, The Sixth Medical Centre of Chinese PLA General Hospital, Beijing, China
| | - Ran Zhang
- Department of Otolaryngology-Head and Neck Surgery, The Sixth Medical Centre of Chinese PLA General Hospital, Beijing, China
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Diagnostic Value of the Peptest TM in Detecting Laryngopharyngeal Reflux. J Clin Med 2021; 10:jcm10132996. [PMID: 34279479 PMCID: PMC8268930 DOI: 10.3390/jcm10132996] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The PeptestTM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR. METHODS Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes. RESULTS Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively. CONCLUSIONS A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.
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Involvement of Laryngopharyngeal Reflux in Ocular Diseases: A State-of-the-Art Review. J Voice 2021:S0892-1997(21)00106-5. [PMID: 33849761 DOI: 10.1016/j.jvoice.2021.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laryngopharyngeal reflux-associated symptoms embrace a wide variety of head and neck manifestations. Its participation in eye disorders has recently been postulated, and there is currently no consensus in this regard. The aim of this manuscript is to review the role of reflux in the development of ocular signs and symptoms, and its physio-pathological mechanisms. METHODS A systematic approach based on the preferred reporting Items for a systematic review and meta-analysis checklist with a modified population, intervention, comparison, and outcome framework was used to structure the review process of studies that evaluated the possible association, with clear diagnostic methods, of laryngopharyngeal reflux and ocular signs and symptoms. Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through the meta-searcher Trip Database with the keywords: reflux, laryngitis, laryngopharyngeal, gastroesophageal, ocular, eye, symptoms, signs, conjunctivitis, keratitis, dacryocystitis, dry eye. RESULTS Seven studies met the inclusion criteria, in which the primary acquired nasolacrimal duct obstruction and the ocular surface disease were evaluated. The local increase of eye pepsin concentration (>2.5 ng/mL) may affect ocular surface though its direct proteolytic activity and the local expression of proinflammatory cytokines. The H. Pylori, with a similar mechanism to reach the lacrimonasal duct, would be associated with the release of proinflammatory and vasoactive substances that would lead to a mucosa injury and chronic inflammation. Ocular Surface Disease Index seems to correlate directly with the reflux severity, with cut-off of 41.67 score as predictor for disease. DISCUSSION The role of laryngopharyngeal reflux in the development of ocular disorders has not yet been demonstrated and data are limited and heterogeneous. It seems theoretically conceivable that pepsin may reach lachrymal duct area through hypopharyngeal-nasal gaseous reflux events. Future studies using objective testing for diagnosis and pepsin detection into the tear and nasal mucosa are needed in order to explore this potential relationship.
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Li XP, Dai YF, Tan JJ, Deng CQ, Liu X, Lv ZH. Preliminary study on the relationship between pepsin and vocal fold polyp. Am J Otolaryngol 2021; 42:102835. [PMID: 33272715 DOI: 10.1016/j.amjoto.2020.102835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Xiang-Ping Li
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.
| | - Yuan-Feng Dai
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jia-Jie Tan
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chao-Qun Deng
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xiong Liu
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Ze-Hong Lv
- Department of Otolaryngology - Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Abstract
Laryngopharyngeal reflux (LPR) is defined as backflow of gastral or gastroduodenal content into the upper aerodigestive tract and characterized by a variety of unspecific symptoms such as chronic cough, globus sensation, or mucus hypersecretion. Due to the lack of a gold standard and the heterogeneity of studies, the diagnosis of LPR is still problematic and challenging. However, in patients with characteristic symptoms and endoscopic findings, with an increased reflux symptom index, a pathologic reflux finding score (RFS), pathologic 24 h esophageal or oropharyngeal pH monitoring, and without any other underlying condition, the diagnosis of LPR is probable. In the following review, we critically discuss the abovementioned methods as well as more recent tools such as measurements of pepsin concentrations in the saliva for diagnosis of LPR.
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Analysis of Pepsin Concentration and Influencing Factors in Saliva of Elderly Nasal Feeding Patients. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4721812. [PMID: 33564676 PMCID: PMC7850846 DOI: 10.1155/2021/4721812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/12/2020] [Accepted: 12/18/2020] [Indexed: 12/05/2022]
Abstract
Background Elderly patients receiving nasal feeding have weaker physiological function, and placement of a nasogastric tube weakens the natural barrier of the cardia-esophageal sphincter; therefore, the risk of gastroesophageal reflux (GER) is higher. Many studies have shown that pepsin is extremely sensitive in predicting GERD, so this study intends to investigate the level of pepsin in saliva of elderly patients with nasal feeding and analyze its influencing factors. Methods This was a cross-sectional study. Patients admitted to the Chinese PLA General Hospital from April 2018 to October 2018 who received nasal feeding were included. One ml of saliva was collected from each patient in while sitting during fasting in the morning and 1 hour after lunch for 3 consecutive days. Pepsin was quantified by enzyme-linked immunosorbent assay (ELISA). The patients were predivided into two groups (≥7.75μg/ml or <7.75μg/ml) based on the median pepsin. Baseline and clinical factors were compared. Results The mean age of the patients was 91.09 ± 4.91 years. There were statistical differences in diabetes and feeding methods between the two groups. There was a positive correlation between the morning and postprandial pepsin levels (r = 0.442, P < 0.001), and has no statistical difference (P = 0.175). Multivariate analysis showed that the risk factors for higher pepsin levels were diabetes (odds ratio (OR): 2.67; 95% CI: 1.225-5.819, P = 0.013) and nasal feeding methods (OR: 2.475; 95% CI: 1.183-5.180, P=0.016). Conclusions For patients undergoing nasal feeding who are older than 80 years, the fasting and 1-hour postprandial pepsin concentration were consistent. Diabetes and feeding methods are risk factors for high pepsin levels. For the elderly over 80 years old, age has no influence on pepsin concentration.
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Lechien JR, Bobin F, Dequanter D, Rodriguez A, Le Bon S, Horoi M, Thill MP, Salem C, Muls V, Saussez S. Does Pepsin Saliva Concentration (Peptest™) Predict the Therapeutic Response of Laryngopharyngeal Reflux Patients? Ann Otol Rhinol Laryngol 2021; 130:996-1003. [PMID: 33467863 DOI: 10.1177/0003489420986347] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study the profile and the therapeutic response of patients with laryngopharyngeal reflux (LPR) at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) according to the initial pepsin saliva concentration. METHODS From January 2018 to January 2020, patients with positive LPR diagnosis at the HEMII-pH were consecutively recruited from 3 European Hospitals. Saliva pepsin concentration (Peptest™) was measured during the HEMII-pH testing period and patients were classified into 2 groups: negative versus positive Peptest. The clinical outcomes, that is, gastrointestinal and HEMII-pH findings, reflux symptom score-12 (RSS-12), and 3-month therapeutic response, were compared between groups. RESULTS A total of 124 patients completed the study. Among them, 30 patients had negative Peptest. Pharyngeal reflux events occurred outside 1-hour post-meal time in 74.0%, after the meals in 20.5% and nighttime in 5.5%. The pepsin saliva level was not significantly associated with the reflux events preceding the sample collection. Patients with positive Peptest had better improvement of RSS-12 digestive and respiratory subscores and oral, pharyngeal, and laryngeal findings compared with patients with negative Peptest. CONCLUSION Patients with high saliva pepsin concentration had no stronger gastrointestinal, HEMII-pH, or clinical outcomes compared with those with low or undetectable saliva pepsin concentration.
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Affiliation(s)
- Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.,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 Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Francois Bobin
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.,Polyclinique Elsan de Poitiers, Poitiers, France
| | - Didier Dequanter
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandra Rodriguez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, 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 Le Bon
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Mihaela Horoi
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Marie-Paule Thill
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Charelle Salem
- Department of Gastroenterology and Endoscopy, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Vinciane Muls
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.,Department of Gastroenterology and Endoscopy, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Sven Saussez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.,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 Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
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Lechien JR, De Vos N, Everard A, Saussez S. Laryngopharyngeal reflux: The microbiota theory. Med Hypotheses 2020; 146:110460. [PMID: 33359943 DOI: 10.1016/j.mehy.2020.110460] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 02/06/2023]
Abstract
Laryngopharyngeal reflux (LPR) is a prevalent disease associated with non-specific symptoms and findings. Many gray areas persist in the pathogenesis of LPR, the diagnosis and the treatment. Symptoms are poorly correlated with fiberoptic signs or hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring findings. The therapeutic response remains uncertain with some resistant patients to medical or surgical treatment. The development of LPR-symptoms and findings may be related to the refluxate of a myriad of gastroduodenal enzymes, which may modify the laryngopharyngeal and oral microbiome leading to mucosa maintenance and recovery impairments. The diet of patient is important because it may impact the microbiome composition and some foods are known to increase the number of hypopharyngeal reflux events. The number of hypopharyngeal reflux events may be increased by autonomic nerve dysfunction that may have an important role in the persistence of LPR-symptoms.
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Affiliation(s)
- Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France; Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium.
| | - Nathalie De Vos
- Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Amandine Everard
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, WELBIO, Walloon Excellence in Life Sciences and BIOtechnology, UCLouvain, Université Catholique de Louvain, Brussels, Belgium
| | - Sven Saussez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France
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Lechien JR, Saussez S, Muls V, Barillari MR, Chiesa-Estomba CM, Hans S, Karkos PD. Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians. J Clin Med 2020; 9:E3618. [PMID: 33182684 PMCID: PMC7697179 DOI: 10.3390/jcm9113618] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/24/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.
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Affiliation(s)
- Jerome R. Lechien
- Department of Human Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Mons, Belgium;
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), 92150 Paris, France;
- Department of Otolaryngology-Head & Neck Surgery, Ambroise Paré Hospital, APHP, Paris Saclay University, 92150 Paris, France
- Department of Otolaryngology-Head & Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Sven Saussez
- Department of Human Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Mons, Belgium;
- Department of Otolaryngology-Head & Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Vinciane Muls
- Division of Gastroenterology and Endoscopy, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium;
| | - Maria R. Barillari
- Division of Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive Medicine, University of Naples SUN, 34103 Naples, Italy;
| | - Carlos M. Chiesa-Estomba
- Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Universitario Donostia, 00685 San Sebastian, Spain;
| | - Stéphane Hans
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), 92150 Paris, France;
- Department of Otolaryngology-Head & Neck Surgery, Ambroise Paré Hospital, APHP, Paris Saclay University, 92150 Paris, France
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Petros D. Karkos
- Department of Otorhinolaryngology and Head and Neck Surgery, AHEPA University Hospital, Thessaloniki Medical School, 54621 Thessaloniki, Greece;
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Zikos TA, Triadafilopoulos G, Kamal A, Podboy A, Sonu IS, Regalia KA, Nandwani MC, Nguyen LA, Fernandez-Becker NQ, Clarke JO. Baseline impedance via manometry and ambulatory reflux testing are not equivalent when utilized in the evaluation of potential extra-esophageal gastroesophageal reflux disease. J Thorac Dis 2020; 12:5628-5638. [PMID: 33209395 PMCID: PMC7656325 DOI: 10.21037/jtd-20-1623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Esophageal baseline impedance (BI) shows promise for the diagnosis of gastroesophageal reflux disease (GERD), but means of acquisition and relevance to extra-esophageal manifestations of GERD (EE-GERD) remain unclear. In this study we aim to (I) evaluate concordance between BI as measured by 24-hour pH-impedance (pH-MII) and high-resolution impedance manometry (HRIM), and (II) assess relationship to potential EE-GERD symptoms. Methods In this prospective open cohort study, patients presenting for outpatient HRIM and pH-MII studies were prospectively enrolled. All patients completed the GERD-HRQL, NOSE, and respiratory symptom index questionnaire (RSI), plus questions regarding wheezing and dental procedures. HRIM and pH-MII were evaluated with calculation of BI. Correlations were assessed using either Pearson’s correlation or Spearman’s rank coefficients. Results 70 HRIM patients were enrolled, 35 of whom underwent pH-MII. There was no correlation between BI measurements as assessed by HRIM and pH-MII proximally, but there was moderate-weak correlation distally (r=0.34 to 0.5). Distal acid exposure time correlated with distal BI only for measurements by pH-MII (rho= −0.5 to −0.65), and not by HRIM. There was no relationship between proximal acid exposure time and proximal BI. There were no correlations when comparing proximal or distal BI measurements, acid exposure times, and impedance events to symptoms. Conclusions Concordance between BI as measured by HRIM and pH-MII is poor, especially proximally, suggesting that these two methods are not interchangeable. There is no correlation between BI both distally/proximally and symptoms of either GERD/EE-GERD, suggesting that many symptoms are unrelated to acid or that BI is not an adequate marker to assess EE-GERD symptoms.
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Affiliation(s)
- Thomas A Zikos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Afrin Kamal
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexander Podboy
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Irene S Sonu
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kirsten A Regalia
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica C Nandwani
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Linda A Nguyen
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Nielsen Q Fernandez-Becker
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Plateroti R, Sacchetti M, Magliulo G, Plateroti AM, Pace A, Moramarco A, Lambiase A, Bruscolini A. Evidence of Pepsin-Related Ocular Surface Damage and Dry Eye (PROD Syndrome) in Patients with Laryngopharyngeal Reflux. Life (Basel) 2020; 10:life10090202. [PMID: 32942541 PMCID: PMC7554736 DOI: 10.3390/life10090202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background: patients with laryngopharyngeal reflux (LPR) showed detectable levels of tear pepsin that explain the nasolacrimal obstruction. The purpose of this study was to determine whether patients with LPR show ocular surface changes and to investigate the relationship between lacrimal pepsin concentration and ocular alterations. Methods: Fifty patients with positive endoscopic signs for LPR and an equal or higher score of 13 and 7 for Reflux Symptom Index and Reflux Finding Score were enrolled. Twenty healthy patients with no reflux disease and dry eye were included as the control group. After evaluation of ocular discomfort symptoms, the tear break-up time test, corneal staining, and tear sampling were performed. Tear pepsin levels were measured using Pep-testTM kit. Results: Patients with LPR showed ocular surface changes including epithelial damage (48%) and impairment of lacrimal function (72%). Tear pepsin levels were detectable in 32 out of 50 (64%) patients with LPR (mean ± SD: 55.4 ± 67.5 ng/mL) and in none of the control subjects. Most of the LPR patients complained of ocular discomfort symptoms, including itching (38%), redness (56%), or foreign body sensation (40%). Tear pepsin levels were significantly correlated with the severity of LPR disease and with ocular surface changes. Conclusions: A multidisciplinary approach, including ophthalmological evaluation, should be considered in order to improve the management of patients with LPR.
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Affiliation(s)
- Rocco Plateroti
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Marta Sacchetti
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Giuseppe Magliulo
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Andrea Maria Plateroti
- NESMOS Department, S. Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy;
| | - Annalisa Pace
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Antonietta Moramarco
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
- Correspondence: ; Tel.: +39-06-4997-5300
| | - Alice Bruscolini
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
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Choi YS, Na HG, Bae CH, Song SY, Kim YD. Pepsin exposure in a non-acidic environment upregulates mucin 5AC (MUC5AC) expression via matrix metalloproteinase 9 (MMP9)/nuclear factor κB (NF-κB) in human airway epithelial cells. Int Forum Allergy Rhinol 2020; 11:894-901. [PMID: 32846027 DOI: 10.1002/alr.22685] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric reflux (GR) is a backflow of gastric content to the aerodigestive tract. GR was previously found to be associated with inflammatory airway diseases and a potential cause of airway remodeling. Chronic exposure to gastric content may induce damage from nose to lung, because digestive enzymes and acidity are toxic to airway epithelial cells. Recently, the toxicity of pepsin in a non-acidic environment was found to increase proinflammatory cytokines and receptors in the epithelium of the aerodigestive tract. However, the effect of pepsin in non-acidic conditions on mucin expression has not been investigated in human airway epithelial cells. The purpose of this study was to evaluate the effect of pepsin on mucin 5AC (MUC5AC) expression in upper and lower airway epithelial cells as an important potential factor of non-acidic GR-related airway inflammation. METHODS In NCI-H292 cells and human nasal epithelial cells (HNEpCs), the effects and signaling pathways of pepsin on MUC5AC expression were examined using reverse-transcription polymerase chain reaction (RT-PCR), real-time PCR, enzyme immunoassay, zymography, Western blot, and immunofluorescence staining. RESULTS Pepsin increased MUC5AC expression in non-acidic condition of NCI-H292 cells and HNEpCs. Further, pepsin activated matrix metalloproteinase 9 (MMP9) and phosphorylated nuclear factor κB (NF-κB). Moreover, inhibitors of MMP9 and NF-κB significantly attenuated pepsin-induced MUC5AC expression, and the knockdown of NF-κB by small interfering RNA (siRNA) significantly blocked pepsin-induced MUC5AC expression in human airway epithelial cells. CONCLUSION These findings suggest that pepsin increased MUC5AC expression in non-acidic conditions via the activation of MMP9 and NF-κB in human airway epithelial cells.
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Affiliation(s)
- Yoon Seok Choi
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Hyung Gyun Na
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Chang Hoon Bae
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Si-Youn Song
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Yong-Dae Kim
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea.,Regional Center for Respiratory Diseases, Yeungnam University Medical Center, Daegu, Republic of Korea
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Wang J, Li J, Li X, Zhang S. Is the pepsin immunohistochemical staining of laryngeal lesions an available way for diagnosing laryngopharyngeal reflux. Acta Otolaryngol 2020; 140:702-705. [PMID: 32400239 DOI: 10.1080/00016489.2020.1758774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Backgound: Pepsin immunohistochemical (IHC) staining is a promising diagnostic approach of laryngopharyngeal reflux (LPR). The interarytenoid mucosa has been proved to be an effective biopsy area.Objectives: To investigate whether positive result of pepsin IHC staining in laryngeal lesions can predict LPR.Methods: The study included 136 patients with laryngeal cancer or vocal cord leukoplakia. 24 h multichannel intraluminal impedance-pH (MII-pH) was performed before operation, and pepsin IHC staining was performed on pathological sections after operation. The results of the two methods were compared.Results: Among the 136 patients, 101 with at least one LPR event were regarded as MII-pH positive group, and another 35 were negative. The positive rate of pepsin IHC staining was 93.1% in MII-pH positive group and 54.1% in MII-pH negative group (p < .05). If the MII-pH results were used as a reference, the sensitivity and specificity of pepsin IHC staining in the diagnosis of LPR were 93.1 and 45.7%, respectively. The consistency of pepsin IHC and MII-pH was moderate (Kappa value = 0.452).Conclusions: The sensitivity of pepsin IHC staining in laryngeal lesions for diagnosing LPR is satisfactory. The existence of false negative of MII-pH may be the main reason for the low specificity.
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Affiliation(s)
- Jiasen Wang
- Department of Otolaryngology Head and Neck Surgery, Chinese People’s Liberation Army General Hospital-Sixth Medical Centre, Beijing, China
| | - Jinrang Li
- Department of Otolaryngology Head and Neck Surgery, Chinese People’s Liberation Army General Hospital-Sixth Medical Centre, Beijing, China
| | - Xiaoyun Li
- Department of Otorhinolaryngology, Affiliated Hospital of Chengde Medical College, Chengde, China
| | - Shujun Zhang
- Department of Otorhinolaryngology, Affiliated Hospital of Chengde Medical College, Chengde, China
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43
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Lechien JR, Bobin F, Muls V, Horoi M, Thill MP, Dequanter D, Finck C, Rodriguez A, Saussez S. Saliva Pepsin Concentration of Laryngopharyngeal Reflux Patients Is Influenced by Meals Consumed Before the Samples. Laryngoscope 2020; 131:350-359. [PMID: 32510588 DOI: 10.1002/lary.28756] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess the impact of diet on the saliva pepsin concentration of patients with laryngopharyngeal reflux (LPR). STUDY DESIGN Non-controlled Prospective Study. METHODS Patients with positive LPR regarding hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were enrolled from three European Hospitals. Patients collected three saliva samples, respectively, in the morning (fasting), and 1 to 2 hour after lunch and dinner. Patients carefully detailed foods and beverages consumed during meals and before the pepsin samples. The 3-month treatment was based on the association of diet, proton pump inhibitors, alginate, or magaldrate regarding the HEMII-pH characteristics. Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were used for assessing the pre- to posttreatment clinical evolution. The Refluxogenic Diet Score and the Refluxogenic Score of a Dish (RESDI) were used to assess the refluxogenic potential of foods and beverages. The relationship between saliva pepsin concentration, HEMII-pH, RESDI, RSS, and RSA was investigated through multiple linear regression. RESULTS Forty-two patients were included. The saliva pepsin concentration of the 24-hour period of testing was significantly associated with foods and beverages consumed during the testing period and the evening dinner (rs = 0.973, P < .001). RSS and RSA significantly improved throughout treatment. The level of saliva pepsin in the morning was a negative predictive factor of the therapeutic response regarding RSA and RSS (P < .036). CONCLUSIONS Foods and beverages may significantly impact the saliva pepsin concentration of patients with LPR. Patients with high-level saliva pepsin in the morning had lower therapeutic response compared with those with low-level saliva pepsin. LEVEL OF EVIDENCE 4 Laryngoscope, 131:350-359, 2021.
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Affiliation(s)
- Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Francois Bobin
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Otolaryngology, Polyclinique Elsan de Poitiers, Poitiers, France
| | - Vinciane Muls
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Gastroenterology, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Mihaela Horoi
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Marie-Paule Thill
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Didier Dequanter
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Camille Finck
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Liège, University of Liège, Liège, Belgium
| | - Alexandra Rodriguez
- Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, 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 Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France.,Department of Human Anatomy and Experimental Oncology, 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
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Nacci A, Bastiani L, Barillari MR, Lechien JR, Martinelli M, Bortoli ND, Berrettini S, Fattori B. Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques. Ann Otol Rhinol Laryngol 2020; 129:1020-1029. [PMID: 32468832 DOI: 10.1177/0003489420930034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). METHODS From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. RESULTS A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. CONCLUSIONS It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.
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Affiliation(s)
- Andrea Nacci
- ENT Audiology Phoniatric Unit, University of Pisa, Pisa, Italy.,Laryngopharyngeal Reflux Study Group of YO-IFOS, Paris, France
| | - Luca Bastiani
- Laryngopharyngeal Reflux Study Group of YO-IFOS, Paris, France.,CNR Institute of Clinical Physiology, Pisa, Italy
| | - Maria Rosaria Barillari
- Laryngopharyngeal Reflux Study Group of YO-IFOS, Paris, France.,Department of Mental and Physical Health and Preventive Medicine, Division of Phoniatrics and Audiology, Luigi Vanvitelli University, Naples, Italy
| | - Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of YO-IFOS, Paris, France.,Laboratory of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
| | - Massimo Martinelli
- CNR Institute of Information Science and Technologies, Signals & Images Lab, Pisa, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa, Italy
| | | | - Bruno Fattori
- ENT Audiology Phoniatric Unit, University of Pisa, Pisa, Italy
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45
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Barrett CM, Patel D, Vaezi MF. Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:361-376. [PMID: 32146951 DOI: 10.1016/j.giec.2019.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Laryngopharyngeal reflux and atypical manifestations of gastroesophageal reflux disease have a high economic and social burden in the United States. There is increasing research supporting the reflex theory and hypersensitivity syndrome underlying this disease pathophysiology. Novel diagnostic biomarkers have gained more traction in the search for a more reliable diagnostic tool, but further research is needed. Current standard-of-care treatment relies on proton pump inhibitor therapy. Antireflux surgery is usually not recommended. Neuromodulators and treatments targeting specific neuronal receptors are discussed. A diagnostic algorithm is proposed for the evaluation of laryngeal symptoms suspected to be related to extraesophageal reflux disease.
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Affiliation(s)
- Caroline M Barrett
- Department of Internal Medicine, Vanderbilt University Medical Center, 719 Thompson Lane, Suite 20400, Nashville, TN 37204, USA
| | - Dhyanesh Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA
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46
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Figueiredo AA, Sales TMAL, Nicolau LAD, Nunes AAA, Costa-Filho HB, Moreira RLR, Nascimento RR, Sousa MKA, Silva LD, Carmo-Neto JP, Sidou FMNO, Paula SM, Medeiros JVR, Silva DA, Sifrim D, Souza MHLP. Laryngeal Mucosa Alterations in Mice Model of Gastroesophageal Reflux: Effects of Topical Protection. Laryngoscope 2020; 130:E889-E895. [PMID: 32159864 DOI: 10.1002/lary.28597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/21/2020] [Accepted: 02/15/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objectives of this study were to evaluate laryngeal inflammation and mucosal integrity in a murine model of reflux disease and to assess the protective effects of topical agents including alginate, hyaluronic acid, and cashew gum. STUDY DESIGN Animal study. METHODS A surgical murine model of reflux disease was evaluated at 3 or 7 days postsurgery, and laryngeal samples were collected to measure inflammation (wet weight and myeloperoxidase [MPO]) and mucosal integrity (transepithelial resistance [TER] and mucosal permeability to fluorescein). Additional groups of animals were administered one of several topical agents (alginate, hyaluronic acid, or cashew gum) daily, and laryngeal inflammation and mucosal integrity were evaluated at 3 days postsurgery. RESULTS At 3 days, and not 7 days postsurgery, we observed increased laryngeal wet weight and MPO, decreased laryngeal TER, and increased laryngeal mucosa permeability. Alginate partially decreased laryngeal inflammation (wet weight and not MPO) and dramatically improved laryngeal mucosal integrity. Conversely, hyaluronic acid eliminated the inflammation; however, it had no effect on laryngeal mucosal integrity impairment. Cashew gum eliminated laryngeal inflammation as well as the impairment in laryngeal mucosal integrity. CONCLUSIONS This study shows that a surgical model of reflux disease induced laryngeal inflammation and impairment in laryngeal barrier function. These observed alterations were partially attenuated by alginate and hyaluronic acid and completely reversed by cashew gum. LEVEL OF EVIDENCE NA Laryngoscope, 2020.
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Affiliation(s)
- Aline A Figueiredo
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Thiago M A L Sales
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Lucas A D Nicolau
- Biotechnology and Biodiversity Center Research, Federal University of Parnaíba Delta, Parnaíba, Brazil
| | - André A A Nunes
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Humberto B Costa-Filho
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Rhubens L R Moreira
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Renata R Nascimento
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Maria K A Sousa
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Lorena D Silva
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - João P Carmo-Neto
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Flávio M N O Sidou
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Suliana M Paula
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
| | - Jand V R Medeiros
- Biotechnology and Biodiversity Center Research, Federal University of Parnaíba Delta, Parnaíba, Brazil
| | - Durcilene A Silva
- Biotechnology and Biodiversity Center Research, Federal University of Parnaíba Delta, Parnaíba, Brazil
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Marcellus H L P Souza
- Laboratory of Physiopharmacology Study of Gastrointestinal Tract, Federal University of Ceará, Fortaleza, Brazil
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Danic Hadzibegovic A, Kozmar A, Hadzibegovic I, Prgomet D, Danic D. Influence of proton pump inhibitor therapy on occurrence of voice prosthesis complications. Eur Arch Otorhinolaryngol 2020; 277:1177-1184. [PMID: 31953634 DOI: 10.1007/s00405-020-05784-4] [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: 09/27/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE It has been shown that the reflux of the gastric content to the proximal oesophagus influences incidence of voice prosthesis (VP) complications in laryngectomized patients. We conducted prospective randomised study to investigate the relationship between pepsin concentration in saliva and occurrence of VP complications before and after 3 months of proton pump inhibitor (PPI) therapy. METHODS 60 laryngectomized patients with VP and 30 controls were included in the study. Saliva samples were collected in the morning and concentration of pepsin were measured by Human Pepsin (PG) ELISA kit. Thirty-Four (57%) patients reported one or more VP complication and were randomised in two groups, with and without PPI therapy, 40 mg pantoprazole per day for 3 months. RESULTS Patients who had longer time since last VP change had higher incidence of periprosthetic and transprosthetic leakage and Candida colonisation. Pepsin was found in all saliva samples. Median saliva pepsin concentration level did not significantly differ between laryngectomized patients and control subjects, or between patients with and without VP complications, and there was no correlation between saliva pepsin concentration levels and type of VP complication. After 3 months therapy, there was no difference in median saliva pepsin level or incidence of VP complication between patients with and without PPI therapy. CONCLUSION Although reflux was proposed to be associated with VP complications and pepsin was proven as a most sensitive and specific marker of EER, we did not find any statistically significant correlation between pepsin levels and occurrence of VP complications. A 3 months 40 mg pantoprazole therapy was ineffective in reduction of VP complications in our study group.
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Affiliation(s)
- Ana Danic Hadzibegovic
- Clinical Department for Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia. .,Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia. .,Faculty of Dental Medicine and Health Care, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.
| | - Ana Kozmar
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Irzal Hadzibegovic
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Faculty of Dental Medicine and Health Care, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Department for Cardiology, University Hospital Dubrava, Zagreb, Croatia.,Department for Internal Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Drago Prgomet
- Clinical Department for Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.,School of Medicine, University Zagreb, Zagreb, Croatia
| | - Davorin Danic
- Faculty of Dental Medicine and Health Care, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Optimization of Saliva Collection and Immunochromatographic Detection of Salivary Pepsin for Point-of-Care Testing of Laryngopharyngeal Reflux. SENSORS 2020; 20:s20010325. [PMID: 31935973 PMCID: PMC6982828 DOI: 10.3390/s20010325] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 12/16/2022]
Abstract
Salivary pepsin is a promising marker for the non-invasive diagnosis of laryngopharyngeal reflux (LPR). For reliable results regarding pepsin in saliva, it is critical to standardize the collection, storage, and pre-processing methods. In this study, we optimized the saliva collection protocols, including storage conditions, i.e., solution, temperature, and time, and the pre-processing filter for pepsin. Moreover, we prepared a simple immunochromatographic strip for the rapid detection of pepsin and evaluated its sensing performance. As a result, we selected a polypropylene (PP) filter as the pre-processing filter for salivary pepsin in low resource settings, such as those where point of care testing (POCT) is conducted. This filter showed a similar efficiency to the centrifuge (standard method). Finally, we detected the pepsin using gold nanoparticles conjugated with monoclonal pepsin antibody. Under optimized conditions, the lower limit of detection for pepsin test strips was determined as 0.01 μg/mL. Furthermore, we successfully detected the salivary pepsin in real saliva samples of LPR patients, which were pre-processed by the PP filter. Therefore, we expect that our saliva collection protocol and pepsin immunochromatographic strip can be utilized as useful tools for a non-invasive diagnosis/screening of LPR in POCT.
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A Multicentre Study in UK Voice Clinics Evaluating the Non-invasive Reflux Diagnostic Peptest in LPR Patients. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractQuestionnaires and invasive diagnostic tests are established for diagnosing gastro-esophageal reflux disease (GERD) but shown not to be sensitive or specific for diagnosing laryngopharyngeal reflux (LPR) where vast majority of reflux events are weakly acidic or non-acidic. The research question addressed in the current multicentre study was to determine if the measurement of salivary pepsin is a sensitive, specific and reliable diagnostic test for LPR. Five UK voice clinics recruited a total of 1011 patients presenting with symptoms of LPR and a small group of subjects (n = 22) recruited as asymptomatic control group. Twenty-six patients failed to provide demographic information; the total patient group was 985 providing 2927 salivary pepsin samples for analysis. Study participants provided 3 saliva samples, the first on rising with two samples provided post-prandial (60 min) or post-symptom (15 min). The control group provided one sample on rising and two post-prandial providing a total of 66 samples. Pepsin analysis was carried out using Peptest as previously described. High prevalence of pepsin in patient groups (75%) represents a mean pepsin concentration of 131 ng/ml. The greatest prevalence for pepsin was in the post-prandial sample (155 ng/ml) and the lowest in the morning sample (103 ng/ml). The mean pepsin concentration in the control group was 0 ng/ml. Patients across all 5 clinics showed high prevalence of salivary pepsin (ranging from 69 to 86%), and the overall sensitivity was 76.4% and specificity 100%. Pepsin was shown to be an ideal biomarker for detecting airway reflux and LPR.
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Klimara MJ, Samuels TL, Johnston N, Chun RH, McCormick ME. Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia. Ann Otol Rhinol Laryngol 2019; 129:224-229. [DOI: 10.1177/0003489419884332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objectives: Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting. Methods: Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR. Results: Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; P < .001). Four patients with laryngomalacia developed symptoms requiring supraglottoplasty. Presence and level of salivary pepsin was not significantly associated with need for surgical management, nor were the levels or presence of IL-1β or IL-8 significantly associated with presence or level of pepsin, diagnosis of laryngomalacia, or need for operative management. Conclusion: Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.
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Affiliation(s)
- Miles J. Klimara
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences and Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert H. Chun
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Otolaryngology, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Michael E. McCormick
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Otolaryngology, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
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