Gastroesophageal reflux causing stridor

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

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.

Subglottic Stenosis

The subglottis is a narrow region of the pediatric airway that is exquisitely susceptible to the development of airway stenosis. The incidence of acquired subglottic stenosis in the setting of prolonged intubation has significantly decreased because of improved endotracheal tube management protocols. Advances in otolaryngology interventions, such as balloon dilation and endoscopic cricoid split techniques, may allow the avoidance of tracheostomy in patients with mild to moderate subglottic stenosis. However, patients with severe subglottic stenosis are often tracheostomy dependent. Open surgical techniques to treat severe disease, such as laryngotracheal reconstruction and cricotracheal resection, offer high rates of tracheostomy decannulation.

Pepsin as a biomarker for laryngopharyngeal reflux in children with laryngomalacia

OBJECTIVES/HYPOTHESIS

Laryngomalacia is a common cause of newborn stridor. Laryngopharyngeal reflux (LPR) has been associated with laryngomalacia. Although pepsin, a component of LPR, has been associated with inflammatory diseases of the aerodigestive tract, its presence in the airways of laryngomalacia patients is unknown.

STUDY DESIGN

Prospective case-control study comparing patients under age 3 years with laryngomalacia to children without laryngomalacia.

METHODS

Children less than 3 years old undergoing supraglottoplasty for laryngomalacia or surgery unrelated to the airway, without a history of laryngomalacia, reflux, or respiratory disease, were offered enrollment. Supraglottic lavage samples (3 mL) were obtained from all subjects. Two-millimeter arytenoid biopsies were collected from laryngomalacia patients. Pepsin Western blot and enzyme-linked immunosorbent assay were performed.

RESULTS

Ten laryngomalacia and five control subjects were enrolled. Pepsin was detected in lavages of laryngomalacia patients (8/10) but absent in controls (0/5; P = .007). Pepsin was observed more frequently in lavages (8/10) than biopsies (4/10; P = .046) of laryngomalacia subjects. Higher median pepsin concentration was observed in laryngomalacia than control lavages (P = .025).

CONCLUSIONS

Pepsin in supraglottic specimens demonstrated an association with laryngomalacia, supporting a role for refluxed pepsin in laryngomalacia. These data corroborate previous work implicating pepsin in inflammatory diseases of the upper airways. Further studies are warranted to investigate the contribution of pepsin to the pathophysiology of laryngomalacia.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:2413-2417, 2017.

A systematic review of laryngomalacia and acid reflux

OBJECTIVE

To identify and appraise the evidence for an association between laryngomalacia (LM) and acid reflux through a systematic review of the existing literature.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Library, Google Scholar, and collected additional publications cited in bibliographies.

REVIEW METHODS

Literature search by both authors with structured criteria to select studies evaluated for systematic review. The Oxford Centre for Evidence-Based Medicine (CEBM) guidelines were applied to assess study quality of evidence.

RESULTS

Twenty-seven studies, representing 1295 neonates with LM, were included. Levels of evidence varied from CEBM level 2a (n = 1) to 4 (n = 23). Although reflux definitions were diverse, overall reflux prevalence in this group was 59% (pooled odds ratio [OR] of 4 controlled studies = 1.15, P = .67). Further evidence supporting an association between reflux and LM included the ubiquity of acid reflux using dual-probe pH monitoring in children with LM (2 studies; n = 84), the increased prevalence of reflux in severe as compared with mild LM (3 studies; n = 237; pooled OR = 9.86, P < .0001), case series and reports of LM improvement with antireflux therapy (6 studies; n = 275), and histological evidence of reflux-related laryngeal inflammation in children with LM (2 studies; n = 18).

CONCLUSION

The literature shows a coexistence between acid reflux and LM, but the evidence for a causal association is limited. In view of the widespread use of antireflux treatment in LM, a randomized controlled trial of antireflux medication vs placebo appears justified.

Gastroesophageal reflux scintigraphy: interpretation methods and inter-reader agreement

BACKGROUND

Scintigraphic imaging is a useful screening tool for patients with suspected gastroesophageal reflux. New scintigraphic interpretation methods have recently been introduced. This study was undertaken to evaluate the efficiency of various scintigraphic interpretation methods in the detection of gastroesophageal reflux and to measure their influence on inter-reader agreement.

METHODS

Scintigraphic images of 49 children with suspected gastroesophageal reflux were interpreted by three different methods: visual interpretation, time activity curves, and condensed images. The readings were performed by three specialists and a resident. The discordant results were resolved by a consensus reading done together by all interpreters based on the three different methods. The gastroesophageal refluxes were grouped according to their number, location and intensity.

RESULTS

Gastroesophageal reflux scintigraphy revealed 22 patients with negative results and 27 with positive results. The sensitivity, positive predictive value and specificity for each of the three specialists vs. the resident were 96%, 96% and 81% vs. 96%; 93%, 90% and 96% vs. 81%; and 90%, 86%, and 95% vs. 73%, respectively. The mean inter-observer reproducibility (κ value) was 0.910 for visual interpretation, 0.652 for time activity curves and 0.789 for condensed images. Twenty-seven percent of the results were discordant and most of these refluxes were of low grade (92%), low intensity (77%) and localization in the distal esophagus (54%).

CONCLUSION

Gastroesophageal scintigraphy is a useful tool for detecting patients with suspected reflux, and visual interpretation is better than the other two methods in terms of accuracy and inter-observer reproducibility.

An approach to the management of paroxysmal laryngospasm

OBJECTIVE

To review the presentation, risk factors and management of paroxysmal laryngospasm.

STUDY DESIGN

Retrospective review of cases.

SETTING

A teaching hospital otolaryngology department with a subspecialty interest in airway disorders.

PATIENTS

All patients diagnosed with laryngospasm over a two-year period were reviewed. Information was obtained about disease presentation, risk factors, management and symptom resolution.

RESULTS

Laryngospasm was diagnosed in nine women and six men. The average age at presentation was 56+/-6.5 years, and there was an 80 per cent association with gastroesophageal reflux disease. Proton pump inhibitors led to complete symptom resolution in six patients and to partial symptomatic relief, requiring no further treatment, in a further four patients. Of the remaining five patients unresponsive to proton pump inhibitor therapy, two continued to experience syncopal episodes due to laryngospasm. Both these patients achieved complete remission after laryngeal botulinum toxin injection. Symptoms recurred after three to four months and were successfully treated with a repeat injection.

CONCLUSIONS

The primary risk factor for spontaneous laryngospasm is laryngopharyngeal reflux. Symptoms are distressing and may be relieved in most cases by treatment aimed at suppressing gastric acid secretion. Laryngeal botulinum toxin injection appears to be a viable treatment modality in selected patients with refractory symptoms.

Non-rapid eye movement sleep parasomnias

Parasomnias are unpleasant or undesirable behavioral or experiential phenomena that occur during sleep. Once believed unitary phenomena related to psychiatric disorders, it is now clear that parasomnias result from several different phenomena and usually are not related to psychiatric conditions. Parasomnias are categorized as primary (disorders of the sleep states) and secondary (disorders of other organ systems that manifest themselves during sleep). Primary sleep parasomnias can be classified according to the sleep state of origin: rapid eye movement sleep, non-rapid eye movement sleep, and miscellaneous (those not respecting sleep state). Secondary sleep parasomnias are classified by the organ system involved.

Severe obstructive airway disorders and diseases: vocal fold dysfunction

Vocal Fold Dysfunction is a syndrome characterized by abnormal adduction of the focal folds during inspiration and is the cause of a wide spectrum of clinical manifestations ranging from mild inspiratory stridor to an inability to move any air. Patients present with varying degrees of intermittent respiratory difficulty, the most severe caused by intense laryngospasm. Distinguishing Vocal Fold Dysfunction from Refractory Asthma is important to avoid unnecessary pharmacotherapy and intubation. The diagnosis of Vocal Fold Dysfunction can only be made with certainty by flexible fiberoptic laryngoscopy while the patient is symptomatic. Pulmonary function studies and a lack of response to bronchodilators may provide clues to the diagnosis. Most patients with the condition can be managed by speech therapy and the use of breathing strategies that eliminate the abnormal vocal fold movement. Chronic laryngeal irritation may be a trigger for Vocal Fold Dysfunction and conditions such as laryngopharyngeal reflux disease should be aggressively managed in this patient population.

Fundoplication for laryngopharyngeal reflux disease

BACKGROUND

Laryngopharyngeal reflux (LPR) disease arises from the effects of refluxed gastric contents on the proximal aerodigestive tract. LPR patients are often lumped into the category of "atypical" reflux. LPR symptoms are hoarseness, globus, cough, and pharyngitis. Severe disease is associated with subglottic stenosis and laryngeal cancer. Treatment includes lifestyle modifications and medications. The role of fundoplication for LPR has yet to be defined.

STUDY DESIGN

Forty-one patients underwent fundoplication for LPR. They were prospectively followed with three outcomes measures: The Reflux Symptom Index, a laryngoscopic grading scale (Reflux Finding Score), and a reflux-based specific quality-of-life scale.

RESULTS

Average early followup was at 4 months and late followup was at 14 months. The Reflux Symptom Index improved by 5.4 early (p < 0.05) and 6.5 late (p < 0.05). Improvement between early and late periods approached significance (p < 0.09). Reflux Finding Score improved 3.8 (p < 0.05) early and 4.4 (p < 0.05) late. The Quality of Life Index improved 0.6 early and 2.3 (p < 0.05) late. By Reflux Symptom Index criteria, 26 patients were improved early versus 35 late (p < 0.05). Factors associated with poor outcomes were structural laryngeal changes in five patients (p < 0.05) and no response to proton pump inhibitors in six patients (p < 0.05).

CONCLUSIONS

Fundoplication augments treatment of LPR. Improvement of symptoms continues past the first 4 months. Laryngoscopy is critical in patient selection because selected findings are associated with outcomes, diagnosis, and management.

Reflux esophagitis: sequelae and differential diagnosis in infants and children including eosinophilic esophagitis

Gastroesophageal reflux disease (GERD) is a common condition in infants and children and has many clinical mimics. Most pediatric pathology departments process many mucosal biopsies from the proximal gastrointestinal tract to evaluate the presence or absence of reflux esophagitis. Since this subject was last reviewed in the 1997 edition of Perspectives in Pediatric Pathology devoted to gastrointestinal diseases in children (Dahms BB. Reflux esophagitis and sequelae in infants and children. In: Dahms BB, Qualman SJ, eds. Gastrointestinal Disease. Perspectives in Pediatric Pathology, vol. 20. Basel: Karger, 1997;14-34), progress in the field has allowed recognition of additional presenting symptoms and treatments of GERD. Histologic criteria for diagnosing reflux esophagitis have not changed. However, the entity of eosinophilic esophagitis has emerged since 1997 and has been defined well enough to allow it to be distinguished from reflux esophagitis, with which it was probably previously confused. Refinements (though not simplification!) in the definition of Barrett esophagus are still in evolution. This review will summarize these newer concepts and briefly review the standards of diagnosis of reflux esophagitis.

Gastroesophageal reflux and the upper airway

EER is a disorder commonly seen in otolaryngologic practice and differs from GERD in its clinical manifestations, pathophysiology, and response to treatment. Its association with numerous disorders in children should lead otolaryngologists to consider this diagnosis in all patients with voice, airway, and swallowing complaints.

Laryngeal manifestations of gastroesophageal reflux disease in children

Although the association between gastroesophageal reflux disease (GERD) and laryngeal disorders in adults is well established there is still a lack of information concerning the true extent of the laryngeal complications of GERD in children. The aim of this study was to determine the laryngeal status of children with diagnosed GERD. We sought to identify the initial appearance of their larynges and then to determine the clinical response to antireflux therapy. GERD was recognized in 90/100 children examined. Using 24-h pH monitoring we found that most of the patients experienced episodes of gastroesophageal reflux during the daytime when they were in an upright position. The hallmark of GERD affecting the larynx in our group was posterior laryngitis, which is characterized by erythema of the mucous membrane overlying the arytenoid cartilages and the posterior mucosal wall of the glottis. The findings regarding the effectiveness of therapy were that, in children with severe laryngeal alterations, voice quality improved significantly after 12 weeks of antireflux treatment (p < 0.001) and laryngeal status was significantly better after 6 weeks of treatment (p < 0.001). This study provides evidence that gastroesophageal reflux in children is the underlying cause of inflammatory and morphological lesions, and that antireflux treatment is effective in reducing or eliminating these lesions.

Update on gastroesophageal reflux disease in pediatric airway disorders

In this article, the literature regarding the effects of gastroesophageal reflux disease (GERD) on otolaryngologic disorders in infants and children is reviewed. We specifically focus on studies that suggest how GERD may be associated with sinusitis, cough, laryngitis, airway obstruction, apnea, recurrent croup, laryngomalacia, stridor, and subglottic stenosis in children.

Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease (GERD)

OBJECTIVES

To present a potentially life-threatening manifestation of gastroesophageal reflux disease (GERD), laryngospasm. This review covers the diagnosis and management of eight patients treated by the authors.

STUDY DESIGN

A retrospective analysis of 8 consecutive patients who were referred for the evaluation of unexplained laryngospasm. The medical therapy and lifestyle modifications of treatment are discussed.

METHODS

The patient records were reviewed and tabulated for age, onset of symptoms, and history of GERD; the presence of an associated upper respiratory infection with persistent cough; and the development of syncope in the presence of laryngospasm.

RESULTS

All 8 patients had initial control of laryngospasm. Three had complete control without relapse, 3 had initial control with rare relapse of mild laryngospasm, and 2 patients had initial control with frequent relapses. Six of the 8 had syncopal episodes as a consequence of the laryngospasm. All patients were initially treated with a proton pump inhibitor. Five of the 8 required the addition of an esophageal prokinetic agent to control the reflux and subsequent laryngospasm. Two patients are off all medications at the time of this writing and 4 of the 8 have had rare relapses after initial control of symptoms. Once control of the laryngospasm had been achieved, there were no subsequent episodes of syncope.

CONCLUSIONS

Based on the data collected in these 8 individuals, patients with reflux disease (known or unknown) can develop severe laryngospasm and possible syncope. The key factor seems to be the association of a recent or concurrent upper respiratory infection that results in a protracted cough that is more severe when supine and at times violent. The cough increases the amount of the refluxate, which is the noxious insult to the larynx.

Esophageal biopsy for the diagnosis of gastroesophageal reflux-associated otolaryngologic problems in children

Recently, gastroesophageal reflux (GER) has been found to contribute to many types of otolaryngologic pathology in infants and children. The complaints may be intermittent and unresponsive to usual therapies, such as antimicrobial treatments. A high index of suspicion for GER and for the concept of "silent" GER (GER without overt symptoms) is necessary for accurate diagnosis and treatment of otolaryngologic manifestations of GER in these patients. In this prospective historical cohort study, the records were reviewed from 101 children who underwent esophagoscopy and biopsy as a diagnostic test for GER at the time of other otolaryngologic procedures. Significant associations were found between the presence of histologic esophagitis and asthma, recurrent croup, cough, apnea, sinusitis, stridor, laryngomalacia, subglottic stenosis, posterior glottic erythema, and posterior glottic edema. There were no complications. Esophageal biopsy is a rapid, safe and effective diagnostic test for GER that should be considered at the time of other procedures in children with selected GER-associated problems.

Extrathoracic airway dysfunction in cough associated with gastroesophageal reflux

BACKGROUND

Cough associated with gastroesophageal reflux (GER) may originate in extrathoracic airway receptors made hypersensitive by acid-induced mucosal injury.

OBJECTIVE

We investigated the role of laryngeal disease and dysfunction in the pathogenesis of GER-associated cough in nonasthmatic patients.

METHODS

Seven patients with GER-associated cough were compared with 7 patients with GER but no cough. The patients underwent fiberoptic endoscopy for assessment of laryngitis and esophagitis (expressed by scores); esophageal manometry; 24-hour pH monitoring; lung function tests; and histamine inhalation challenge with assessment of bronchial threshold (concentration provoking 10% fall in FEV1 [PC10]), extrathoracic airway threshold (concentration provoking 25% fall in the maximal midinspiratory flow [PC25MIF50]), and cough threshold (concentration provoking 5 or more coughs PCcough). The patients were reevaluated after 3 months of medical treatment for GER.

RESULTS

Patients with cough, compared with those without cough, had significantly higher laryngitis scores (P = .002), lower esophageal sphincter pressures, longer time with pH below 4 (P = .003), greater number of episodes of reflux longer than 5 minutes (P = .016), longer esophageal clearance time (P = .048), and significantly lower PC25MIF50 (P = .005) and PCcough (P = .008) values. Laryngitis score was significantly inversely related to either PCcough (P < .001) or PC25MIF50 (P <.01) but not to PC10. Laryngitis score, PC25MIF50, and PCcough were all closely related to GER severity. After GER treatment, laryngitis, PC25MIF50, and PCcough were all significantly improved.

CONCLUSIONS

These findings suggest that GER-associated cough is strongly associated with laryngeal disease and dysfunction consequent to acid reflux injury in nonasthmatic patients.

Acid-induced laryngospasm in a canine model

A canine model was used to investigate the efferent laryngeal responses to stimulation by topically applied acid and pepsin. Five adult mongrel dogs were studied. Electromyographic recordings from the thyroarytenoid muscle were measured with hooked-wire electrodes as an acid solution (normal saline/hydrochloric acid at pH 6.0, 5.0, 4.0, 3.0, 2.5, 2.0, 1.5, and 1.0) was sequentially instilled into the larynx. Laryngospasm (tonic, sustained contraction of the thyroarytenoid muscle) occurred in all animals at pH 2.5 to 2.0 or less. Control substances such as neutral pH isotonic saline, hypotonic saline, hypertonic saline, water, and pepsin alone failed to produce laryngospasm. Next, solutions containing both acid (in the same pH range) and pepsin were tested. The laryngeal responses were similar to those of acid alone. The superior laryngeal nerves were sectioned bilaterally and the above experiments repeated. None of the test solutions produced laryngospasm; however, when capsaicin (1%) was instilled into the subglottis, laryngospasm occurred. Thus, chemoreceptors in the subglottis (supplied by the recurrent laryngeal nerves) appear to be responsive to capsaicin stimulation but not to acid stimulation. The data suggest that pH-sensitive chemoreceptors in the canine larynx cause laryngospasm (when the pH of the test solution is 2.5 or less) and that these acid receptors are supplied by the superior laryngeal nerves.

Paroxysmal laryngospasm secondary to gastroesophageal reflux

Over a 2-year period (1992 to 1994), 12 consecutive adult patients with paroxysmal laryngospasm were prospectively studied. All had had other symptoms of gastroesophageal reflux (GER); however, only 4 (33%) experienced symptoms of heartburn. Each patient underwent fiberoptic laryngeal examination, barium swallow/esophagography, and ambulatory, 24-hour, double-probe pH monitoring (pH-metry). Eleven (92%) of the 12 patients had evidence of GER on examination, and 10 (83%) had abnormal pH-metry, including 3 who demonstrated pharyngeal reflux while having normal total acid exposure times in the esophageal probe. All the patients responded to antireflux treatment, using dietary and lifestyle modifications and omeprazole, with complete cessation of the laryngospastic episodes. This study documents the role of GER in the etiology of paroxysmal laryngospasm, it highlights the advantages of double-probe pH-metry in diagnosing this extraesophageal manifestation of GER, and it demonstrates that antireflux therapy with omeprazole is effective in controlling GER-induced laryngospasm.

NREM sleep parasomnias

The three states of mammalian being--wakefulness, REM sleep, and NREM sleep--are not mutually exclusive and may occur simultaneously, oscillate rapidly, or appear in dissociated or incomplete form to produce primary sleep parasomnias. Dysfunctions of a wide variety of organ systems may take advantage of the sleeping state to declare themselves, resulting in the secondary sleep parasomnias. Contrary to popular opinion, most of these often bizarre and frightening experiences are not the manifestation of underlying psychological or psychiatric conditions. Formal study in an experienced sleep disorders center usually reveals a diagnosable and treatable condition. Various parasomnias may result in injurious or violent behavior. The forensic science implications are beyond the scope of this article but have been reviewed extensively elsewhere. Continued study of unusual sleep-related events undoubtedly will reveal more fascinating conditions, expanding our knowledge of sleep physiology and strengthening the bonds between clinicians and basic science sleep researchers.

Sleep-related laryngospasm

Seven patients (mean age 46.6; range 33-58; 6M,1F) presented with sleep-related choking episodes and were found to have features in common that distinguished them from other known causes of choking episodes during sleep. The characteristic features include: an awakening from sleep with an acute choking sensation, stridor, panic, tachycardia, short duration of episode (less than 60 seconds), infrequent episodes (typically less than 1 per month), and absence of any known etiology. The disorder most commonly occurs in middle-aged males who are otherwise healthy. In one patient an episode of laryngospasm was polysomnographically documented to occur during stage 3. The clinical features and the polysomnographic findings suggest spasm of the vocal cords of unknown etiology.

Behaviors associated with onset of gastroesophageal reflux episodes in infants. Prospective study using split-screen video and pH probe

To identify behaviors associated with the onset of gastroesophageal reflux episodes in infants both systematically and prospectively, each of 10 patients (aged 2 to 32 weeks) was studied during 2 hours of intraluminal esophageal pH probe monitoring, using a split-screen audiovisual recording technique. Videotape analysis of eight infants who had scoreable reflux events revealed six discrete behaviors closely associated temporally (P < .001 to < .05) with the onset of reflux events: "discomfort" (crying or frowning), "emission" (of liquid or gas, i.e., regurgitation, drooling, or burping), yawning, stridor, stretching, and mouthing. Three behaviors (hiccuping, sneezing, and thumb-sucking) were infrequent but were significantly associated with onset of reflux events in one or two patients each. A tenth behavior, coughing or gagging, was significantly associated with onset of reflux events in two patients, but not in the rest, despite relatively frequent occurrence. Exploration of temporal relations between reflux and each behavior suggested that discomfort, emission, mouthing, and cough-gag may have caused reflux episodes, and that all 10 of the behaviors may have been caused by reflux episodes. These findings and a "quiet period" immediately preceding episodes in six of the infants suggest interesting pathophysiologic mechanisms in infants which require further evaluation.

Sudden infant death syndrome prevention and an understanding of selected clinical issues

The etiology and prevention of sudden infant death syndrome (SIDS) are among the more frustrating topics in pediatrics. This article addresses several clinically relevant issues, including the relationships between apnea and SIDS, the nature of the "terminal event," effectiveness of home monitoring, the role of gastroesophageal reflux in apparent life-threatening events, and the association between the prone sleeping position and SIDS. This article is intended to provide the clinician with an awareness of the issues and the scientific basis needed to understand their contribution to SIDS.

Pediatric airway manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) in children may be classified as physiologic or pathologic, depending on its degree and consequences. There are many head and neck complications of GER in pediatric patients, but most numerous are the airway manifestations, including stridor, recurrent croup, exacerbation of subglottic stenosis, laryngeal irritation with or without laryngospasm, chronic cough, and obstructive apnea. Diagnosis may be difficult unless there is a high index of suspicion for GER and awareness of the concept of "silent" GER. We present the common pediatric airway manifestations of GER, illustrated by case reports, and provide a paradigm to assist in the diagnosis and management of children with airway compromise associated with GER.

Hoarseness in a child with gastroesophageal reflux

Hoarseness is not generally appreciated to be a manifestation of pediatric gastroesophageal reflux. We describe a case in which treatment of well-documented gastroesophageal reflux and esophagitis in a young girl with hoarseness and nocturnal cough led to resolution of these symptoms. Possible pathogenetic mechanisms and the difficulty in associating hoarseness with reflux by standard reflux testing are discussed.

Pseudoreflux syndrome-increased periodic breathing during the neonatal period presenting as feeding-related difficulties

Sixteen infants who presented with symptoms suggestive of gastroesophageal reflux (GER)-associated apnea were evaluated at the Breathing Disorder Center of the Children's Hospital of Philadelphia. These neonates had a history of occasional emesis and an apparent life-threatening event (ALTE) that occurred while awake which was similar to the presentation of a group of infants previously described. Evaluation of the present group of infants however, revealed increased periodic breathing (12.1 +/- 1.8 SEM% of total sleep time) as opposed to the obstructive apnea that was typically seen with GER. Pathologic gastroesophageal reflux could not be diagnosed in relationship to apneic events. Infants who present during the first month of life with symptoms suggestive of GER-associated apnea should have careful evaluation of reflux and respiratory patterns to confirm the correct diagnosis. Because of the similarities of these infants to the GER group, we have called their disorder pseudoreflux.

Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring

Gastroesophageal reflux (GER) usually presents with digestive symptoms, failure to thrive, and/or respiratory symptoms. During the 8-year period from 1981 to 1989, 1,153 children underwent 20-hour pH monitoring to assess GER. All patients were graded using the scoring system of Euler and Byrne. Patients were classified as severe (score greater than 50), moderate (score 25 to 50), and normal (score less than 25). Five hundred (43.3%) of these patients presented with respiratory symptoms including apnea, cyanosis, or "near miss" sudden infant death syndrome (36%), poorly controlled asthma (28%), recurrent bronchopneumonia (13%), bronchiolitis (9%), and miscellaneous symptoms such as intermittent dyspnea, chronic cough, and stridor (12%). Eight patients (2%) had cystic fibrosis. The ages ranged from 1 month to 20 years (mean, 19.5 months). Twelve patients had technically inadequate studies and were excluded. Severe reflux was present in 156 patients (31%) and moderate reflux in 159 patients (31%). All patients were treated initially by medical therapy for a minimum of 8 weeks. The majority of patients (81%) had resolution of their symptoms with change in position, thickened feedings, and, when indicated, additional therapy with metoclopramide, cisapride, or domperidone. Most of these patients were found to have a specific position, usually prone, which decreased reflux. The remaining 57 patients had documentation of persistent reflux by pH monitoring and underwent an antireflux procedure. Of those patients undergoing surgery 51 had severe reflux and 6 had moderate reflux. Forty-four patients had a posterior 270 degrees wrap (Toupet), 10 had a 360 degrees wrap (Nissen), and 3 had an anterior 180 degrees wrap (Boix-Ochoa).(ABSTRACT TRUNCATED AT 250 WORDS)

Gastroesophageal reflux in infants and children

Gastroesophageal reflux is a common disorder in infants and children worldwide. This paper is intended to provide updated information on various aspects of the disease. It is hoped that this review will increase awareness and stimulate research in this field.

Detection of gastroesophageal reflux in the head and neck: the role of scintigraphy

Patients with gastroesophageal reflux (GER) present to the head and neck specialist with a myriad of nonspecific complaints that may be manifestations of pharyngoesophageal or upper airway involvement. Numerous diagnostic tests for GER have been used in the past with varying success. In the present study, gastroesophageal scintigraphy using 99mtechnetium-sulfur colloid was used to evaluate 28 patients with head and neck manifestations of GER. The role of gastroesophageal scintigraphy as an accurate and noninvasive method of detecting GER is discussed in the context of other current diagnostic modalities.

Evaluation of technetium pertechnetate as a radionuclide marker of pulmonary aspiration of gastric contents in rabbits

At present, there is no sensitive and specific test to confirm the clinical impression that a respiratory disorder is due to aspiration of gastric contents. Since intravenous technetium pertechnetate (99mTcO4-) has been shown to be safe, actively concentrated in the gastrointestinal tract, and secreted into gastric juice, we sought to determine whether 99mTcO4-, when given intravenously, is suitable to detect pulmonary aspiration of small amounts of gastric contents in rabbits. Biodistribution studies over 24 h revealed that 99mTcO4- persistently appeared in the stomach, thyroid, and salivary glands and did not appear in the lungs. Pharmacokinetic studies showed that 99mTcO4- was rapidly picked up by the stomach wall and secreted promptly into the stomach lumen and that the stomach wall persistently secreted 99mTcO4- into stomach contents for 24 h. By injecting 99mTcO4- through an intratracheal catheter in order to simulate aspiration, the radioactive threshold for imaging intrapulmonary 99mTcO4- was determined to range between less than 0.5 microCi and 2 microCi, depending on the amount of background activity in the blood pool. By measuring the radioactivity in stomach contents (microCi/g), over 24 h after intravenous injection of 2 mCi of 99mTcO4-, we were able to calculate the amount of aspirated stomach contents that our technique should reveal at various time points. We concluded from this preliminary feasibility study that 99mTcO4-, when given intravenously, is suitable to detect pulmonary aspiration of small amounts (less than or equal to 4 ml for 8 h after an intravenous dose of 2 mCi) of gastric contents in human patients. Since our biodistribution studies show that saliva as well as stomach contents are potential sources for any aspirated 99mTcO4-, how to distinguish aspiration of oropharyngeal from stomach contents remains to be determined. It also remains to be determined how long 99mTcO4- remains in the lungs after it has been instilled; clearance that is too rapid significantly decreases the ability of this agent to reveal aspiration.

Stridor and gastroesophageal reflux: diagnostic use of intraluminal esophageal acid perfusion (Bernstein test)

Five pediatric patients with stridor were evaluated to determine whether gastroesophageal reflux (GER) contributed to their stridor. Intraluminal esophageal acid perfusion (Bernstein test), pH probe, radiographic studies, laryngobronchoscopy, and esophageal histology were utilized. Thereafter, three of the five patients responded to therapy for GER; two did not. The Bernstein test proved to have greater diagnostic reliability than any other test employed, using response to antireflux therapy as the "gold standard" for diagnosing reflux-provoked stridor.

Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children

The association of lipid-laden alveolar macrophages (LLAM) and gastroesophageal reflux (GER) was investigated prospectively in 115 patients in two groups. Group 1 included 74 children with chronic respiratory tract disorders and documented GER by prolonged esophageal pH monitoring, barium esophagram, and esophagoscopy; group 2 included 41 children with chronic respiratory tract disorders without GER. LLAM were present in 63 (85%) and eight (19%) children from groups 1 and 2, respectively (P less than 0.0001). Thus a strong association between the presence of LLAM and GER in children with chronic respiratory tract disorders was established. We suggest that LLAM from bronchial lavage may be a useful marker for tracheal aspiration in children with GER in whom chronic lung disease may subsequently develop.