Pepsin-mediated inflammation in laryngopharyngeal reflux via the ROS/NLRP3/IL-1β signaling pathway

BACKGROUND

Laryngopharyngeal reflux (LPR) is one of the most common disorders in otorhinolaryngology, affecting up to 10% of outpatients visiting otolaryngology departments. In addition, 50% of hoarseness cases are related to LPR. Pepsin reflux-induced aseptic inflammation is a major trigger of LPR; however, the underlying mechanisms are unclear. The nucleotide-binding domain and leucine-rich repeat protein 3 (NLRP3) inflammasome has become an important bridge between stimulation and sterile inflammation and is activated by intracellular reactive oxygen species (ROS) in response to danger signals, leading to an inflammatory cascade. In this study, we aimed to determine whether pepsin causes LPR-associated inflammatory injury via mediating inflammasome activation and explore the potential mechanism.

METHODS

We evaluated NLRP3 inflammasome expression and ROS in the laryngeal mucosa using immunofluorescence and immunohistochemistry. Laryngeal epithelial cells were exposed to pepsin and analyzed using flow cytometry, western blotting, and real-time quantitative PCR to determine ROS, NLRP3, and pro-inflammatorycytokine levels.

RESULTS

Pepsin expression was positively correlated with ROS as well as caspase-1 and IL-1β levels in laryngeal tissues. Intracellular ROS levels were elevated by increased pepsin concentrations, which were attenuated by apocynin (APO)-a ROS inhibitor-in vitro. Furthermore, pepsin significantly induced the mRNA and protein expression of thioredoxin-interacting protein, NLRP3, caspase-1, and IL-1β in a dose-dependent manner. APO and the NLRP3 inhibitor, MCC950, inhibited NLRP3 inflammasome formation and suppressed laryngeal epithelial cell damage.

CONCLUSION

Our findings verified that pepsin could regulate the NLRP3/IL-1β signaling pathway through ROS activation and further induce inflammatory injury in LPR. Targeting the ROS/NLRP3 inflammasome signaling pathway may help treat patients with LPR disease.

Voice Outcomes Following Colon Interposition

SIGNIFICANCE STATEMENT

This case highlights the consequences of colon interposition on phonation and swallowing. Findings in this patient included laryngopharyngeal reflux, vocal fold paralysis, poor esophageal peristalsis, failed bolus transfers, and others. The mechanical and functional differences between the colon and the esophagus can impact bolus transfer, reflux, and phonation. Further research is required to identify the mechanisms by which colon interposition can impact voice and swallowing.

Incidence of adverse respiratory events after adjustment of clear fluid fasting recommendations to 1 h: a prospective, observational, multi-institutional cohort study

BACKGROUND

Preoperative fasting reduces the risk of pulmonary aspiration during anaesthesia, and 2-h fasting for clear fluids has commonly been recommended. Based on recent evidence of shorter fasting times being safe, the Swiss Society of Paediatric Anaesthesia began recommending 1-h fasting for clear fluids in 2018. This prospective, observational, multi-institutional cohort study aimed to investigate the incidence of adverse respiratory events after implementing the new national recommendation.

METHODS

Eleven Swiss anaesthesia institutions joined this cohort study and included patients aged 0-15 yr undergoing anaesthesia for elective procedures after implementation of the 1-h fasting instruction. The primary outcome was the perioperative (defined as the time from anaesthesia induction to emergence) incidence of pulmonary aspiration, gastric regurgitation, and vomiting. Data are presented as median (inter-quartile range; minimum-maximum) or count (percentage).

RESULTS

From June 2019 to July 2021, 22 766 anaesthetics were recorded with pulmonary aspiration occurring in 25 (0.11%), gastric regurgitation in 34 (0.15%), and vomiting in 85 (0.37%) cases. No major morbidity or mortality was associated with pulmonary aspiration. Subgroup analysis by effective fasting times (<2 h [n=7306] vs ≥2 h [n=14 660]) showed no significant difference for pulmonary aspiration between these two groups (9 [0.12%] vs 16 [0.11%], P=0.678). Median effective fasting time for clear fluids was 157 [104-314; 2-2385] min.

CONCLUSIONS

Implementing a national recommendation of 1-h clear fluid fasting was not associated with a higher incidence of pulmonary aspiration compared with previously reported data.

The Controversy of Pepsinogen A/Pepsin A in Detecting Extra-Gastroesophageal Reflux

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.

Laryngopharyngeal Reflux Patient Changes during the COVID-19 Quarantine

Background and Objective: To examine the effects of the lockdown on diet adherence and stress levels in patients with laryngopharyngeal reflux (LPR). Materials and Methods: Patients with a positive LPR diagnosis at the hypopharyngeal-esophageal impedance-pH monitoring were treated from a pre- to lockdown period with a 3-month high-protein, low-fat, alkaline, plant-based diet, with behavioral changes, and an association of pantoprazole (20 MG/d) and alginate (Gaviscon 3/d). The following patient-reported outcomes questionnaire and findings instrument were used: Reflux Symptom Score-12 (RSS-12) and Reflux Sign Assessment (RSA). At the posttreatment time, patients were invited to evaluate the impact of lockdown on diet adherence and stress management with a predefined grid of foods and beverages and the perceived stress scale (PSS), respectively. Results: Thirty-two patients completed the evaluations. RSS-12 and RSA significantly improved from baseline to 3-month posttreatment. Most patients experienced mild-to-severe stress levels at the end of the lockdown. The level of stress substantially increased in 11 patients (34%) due to the lockdown, while it did not change in 11 patients (44%). In 11 cases (34%), patients reported that the adherence to the anti-reflux diet was better than initially presumed thanks to the lockdown period, while 44% (N = 14) reported that the lockdown did not impact the adherence to a diet. PSS and RSS-12 were significantly correlated at the end of the pandemic (rs = 0.681; p < 0.001). The increase in stress level was positively associated with the lack of adherence to diet (rs = 0.367; p = 0.039). Conclusions: During the lockdown, the diet habits of LPR patients were improved in one-third and unchanged in 44% of cases. The stress level was increased in one-third of patients, which was associated with an increase in symptom scores.

Tolerability and Feasibility of the Upper Esophageal Sphincter Assist Device in Preventing Acute and Chronic Allograft Rejection Among Lung Transplant Recipients

GOALS

We aimed to evaluate a novel upper esophageal sphincter (UES) assist device loaner program for the prevention of acute cellular rejection and chronic lung allograft dysfunction among lung transplant (LTx) recipients.

BACKGROUND

Laryngopharyngeal reflux can lead to chronic microaspiration and LTx rejection. The UES assist device applies external pressure at the level of UES to decrease reflux.

STUDY

We prospectively enrolled and issued UES assist devices to consecutive transplant patients referred for gastrointestinal motility testing from 2016 to 2020. Device tolerability was defined by successful utilization as a bridge to ambulatory pH monitoring and/or antireflux procedure, or as permanent therapy. Incidence of rejection was analyzed before, during, and after device implementation.

RESULTS

Twenty-six participants were issued devices (15 pathologic, 5 physiological, 6 unknown reflux status), none of whom developed acute rejection episodes or chronic lung allograft dysfunction while using the device. Thirteen adopted the device promptly after transplantation (mean 1.7 mo) and remained free of rejection episodes over a mean 24.7 months of follow-up. Among those with pathologic reflux, lag time to device adoption strongly correlated with the development of rejection ( r =0.8, P =0.0006). There was no such correlation among those with physiological reflux. Five developed acute rejection after device return.

CONCLUSIONS

The device was tolerated by a majority of LTx patients and appears feasible as a barrier measure in the prevention of rejection. Delayed treatment of laryngopharyngeal reflux may lead to early allograft failure; therefore, the UES assist device should be given important consideration in transplant protection.

Investigation of the potential relationship between gastroesophageal reflux disease and laryngopharyngeal reflux disease in symptomatology - a prospective study based on a multidisciplinary outpatient

OBJECTIVE

To investigate the relationship between laryngopharyngeal reflux disease (LPRD) and gastroesophageal reflux disease (GERD).

METHODS

Gastroesophageal Reflux Disease Questionnaire (GERD-Q) and Reflux Symptom Index (RSI) scale were administered to patients attending the gastroenterology outpatient clinic at the Sixth Medical Center of the PLA General Hospital from 7 April 2021 to 10 June 2021. Patients with GERD-Q score >7 were indicated GERD, and patients with RSI >13 were indicated LPRD. The analysis of patients with pure GERD (independent GERD, iG), patients with LPRD and GERD (LPRD & GERD, L&G), patients with simple LPRD (independent LPRD, iL) and the percentage of normal group (GERDQ-negative and RSI-negative, N).

RESULTS

3060 GERD-Q and RSI questionnaires were distributed, and 2974 complete questionnaires were returned. Among them, 274 (9.20%) iL, 334 (11.23%) iG and 151 (5.10%) L&G patients and 2215 (74.48%) N patients. The positive rate of GERD in this sample was 16.31%, of which 31.13% had coexisting LPRD, and the positive rate of LPRD was 14.29%, of which 35.53% had coexisting GERD. Among patients with LPRD, the positive rate of concomitant GERD (χ2 = 4.157, p = 0.041) and RSI score (Z = -6.823, p = 0.000) was significantly higher in patients with the presence of respiratory symptoms than in those without respiratory symptoms.

CONCLUSION

LPRD can exist alone or in conjunction with GERD. Patients with both LPRD and GERD had the most severe reflux symptoms. The need to focus on the risk of those initially screened only with GERD developing LPRD. Respiratory symptoms play an important role in reflux disease.

[Effect of gastroesophageal reflux disease on the clinical characteristics of patients with laryngopharyngeal reflux disease]

Objective: To investigate the effect of gastroesophageal reflux disease (GERD) on the clinical characteristics of patients with laryngopharyngeal reflux disease(LPRD). Methods: The data of 141 patients with symptoms of LPRD, who were admitted to the Department of Pharyngology, Laryngology& Phonosurgery at the Sixth Medical Center of the PLA General Hospital from November 2020 to October 2021, were retrospectively analyzed.There were 118 males and 23 females, aged 28-75 (56.72±10.04) years old. The included patients underwent simultaneous 24-hour hypopharyngeal and esophageal multichannel intraluminal impedance pH monitoring (24h-HEMII-pH), salivary pepsin test at multiple times, Reflux Symptom Index (RSI), and Reflux Finding Score (RFS). One laryngopharyngeal reflux event on 24 h-HEMII-pH monitoring results was used as a diagnostic criterion for LPRD. And the duration of lower esophageal pH<4.0>4.0% at 24 h or DeMeester score>14.7 were used as diagnostic criteria for GERD. Among them, patients with both positive LPRD and GERD were classified as L&G group, patients with positive LPRD and negative GERD were classified as IL group, patients with negative LPRD and positive GERD were classified as IG group, and patients with both negative LPRD and GERD were classified as N group. The differences in the clinical characteristics of reflux and salivary pepsin assay in each group were statistically analyzed. SPSS 23.0 software was applied for statistical analysis. Results: According to the 24 h-HEMII-pH results, 116 (82.3%) patients were diagnosed with LPRD and 45 (31.9%) with GERD, including 82 (58.2%) in the IL group, 34 (24.1%) in the L&G group, 11 (7.8%) in the IG group, and 14 (9.9%) in the N group. Based on the salivary pepsin test, a total of 106 patients had positive results, and the L&G group had a significantly higher rate of positive total salivary pepsin test (94.1%) and positive morning test (70.6%) than the IL group (75.6%, 26.8%), IG group (63.6%, 27.3%) and N group (35.7%, 28.6%), with chi-square values of 19.01 and 20.81, both with P<0.001. The patients in the L&G group had a significantly higher RSI score (14.0) than the IL group (7.0), IG group (1.0) and N group (0), H=52.26,P<0.001. The difference in RFS between the L&G and IL groups was not statistically significant (Z=-0.92,P>0.05). Conclusion: Combined with GERD, LPRD patients have more obvious clinical symptoms and higher positive rate of pepsin test in saliva.

[Mechanism of pepsin promoting lingual tonsil hypertrophy by stimulating macrophage]

Objective: To investigate the possible pathophysiological mechanism of laryngopharyngeal reflux (LPR) in the development of lingual tonsil hypertrophy (LTH). Methods: The lingual tonsil tissues were collected from 73 patients [48 males and 25 females, aged from 24 to 76 (52.86±12.04) years] who underwent surgery for laryngopharyngeal diseases at the Department of Otolaryngology and Head and Neck Surgery, Southern Hospital of Southern Medical University from October 2019 to December 2020, and the lingual tonsil grade (LTG), reflux symptom index (RSI) and reflux finding score (RFS) were assessed. The expression of pepsin in LTH was detected by immunohistochemistry. The coexpression of pepsin and macrophages were detected by immunohistofluorescence. In vitro, cytological experiments and pathway assays were performed on macrophages stimulated by pepsin. Pathway alterations of macrophages in pepsin-positive high-grade LTH were detected by double-fluorescence immunohistochemistry. Data were analyzed by SPSS 20.0 software. Results: There were 44 clinically significant LPRD patients with LTG 3 and 4, and the pepsin positive rate was 88.6% (39/44). While, the pepsin positive rate of LTG 1 and 2 was 48.3% (14/29). LTG was significantly positively correlated with RFS/RSI positive rate(χ²=23.01/19.62, P<0.001/0.001; r=0.54/0.51, P<0.001/0.001) and pepsin tissue staining intensity (H=21.58, P<0.001; r=0.53, P<0.001), respectively. Pepsin and macrophages were clearly colocalized in high grade LTH. In vitro, pepsin promoted macrophage proliferation (P<0.05) and production of IL-6/IL-8 (P<0.05). Pepsin significantly up-regulated the p38/JNK MAPK pathway in macrophages (P<0.05). Pepsin up-regulated the expression of IL-6 and IL-8 of macrophages by activating the p38 MAPK pathway (P<0.05), and up-regulated the expression of IL-8 by activating the JNK pathway (P<0.05). The p38/JNK MAPK pathways were highly expressed in macrophages of pepsin-positive LTH (P<0.05). Conclusions: LPR is an important pathogenic factor in LTH. Macrophages may mediate pepsin-induced inflammation and the pathogenesis of LTH.

Factors affecting the occurrence of otitis media with effusion in preschool and elementary school children: a comparative cross-sectional study

OBJECTIVE

Identify the risk factors for otitis media with effusion (OME), especially laryngopharyngeal reflux (LPR), adenoid hypertrophy and allergic rhinitis, that could be used to develop prevention strategies in children.

DESIGN

A comparative cross-sectional study was conducted to make sure the adequacy of proportions of OME and non-OME cases in finding the related factors.

SETTING

History taking, ear/nose/throat (ENT) examination, and tympanometry were performed in preschool and elementary schools. Flexible fibreoptic nasopharyngolaryngoscopy was performed in a bronchoesophagology outpatient clinic in a tertiary referral hospital in Jakarta, Indonesia.

PARTICIPANTS

Preschool and elementary children in East Jakarta, Indonesia were recruited for this study. A total of 2016 participants underwent history taking, ENT examination and tympanometry. The case group was 46 children with OME, and the control group was 46 children without OME. The number of subjects fulfilled the minimum sample size for two proportions comparison.

MAIN OUTCOME MEASURES

A type B tympanogram indicated OME. A Reflux Finding Score of more than 7 indicated LPR. Adenoid hypertrophy was diagnosed using flexible fibreoptic nasopharyngolaryngoscopy. Allergic rhinitis was diagnosed using a questionnaire based on the International Study of Asthma and Allergies in Childhood phase III that has been validated for Indonesians.

RESULTS

The proportion of LPR in the OME group was significantly higher than in the non-OME group, at 78.3% and 52.2%. The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR (OR 3.3; 95% CI 1.33 to 8.189; p=0.01). There was no significant relationship between adenoid hypertrophy and OME (p=0.211; 95% CI 0.71 to 3.97), and also between allergic rhinitis and OME (p=0.463; 95% CI 0.61 to 4.28).

CONCLUSION

The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR. LPR should be considered in patients with OME and vice versa.

Acute oxygen desaturation characterizes pulmonary aspiration in patients with gastroesophageal reflux disease and laryngopharyngeal reflux

The aim of this study was to characterise pulmonary aspiration of refluxate in patients with gastroesophageal reflux disease (GORD) and laryngopharyngeal reflux (LPR) by continuous pulse oximetry (SpO2) during the supine phase of a scintigraphic reflux study. Variables assessed for significance included age, hiatus hernia, frequency, amplitude of reflux and clearance of reflux from the oesophagus/pharynx. The patients included in this study had established GORD and LPR by clinical history. All patients underwent fused three- dimensional scintigraphic/ X-ray computed tomography (CT) and simultaneous continuous pulse oximetry when supine for 30 minutes. A total of 265 patients (40.4% M, 59.6% F) were studied. Mean age of aspirators was 57.0 years and non-aspirators was 53.5 years. Seven patients had baseline oxygen saturation <95%, with 6/7 showing aspiration by scintigraphy. The remainder had mean baseline saturation of 97.7%. Continuous SpO2 monitoring showed a significant fall in pulmonary aspirators after 20 min of supine acquisition with significant variability. Analysis revealed a cyclic event every 1.5 min in aspirators only. Panel regression analysis showed a significant effect of age, hiatus hernia, pulse rate and reflux frequency on the fall in SpO2. Pulmonary aspiration in patients with LPR and GORD is characterised by acute oxygen desaturation. Variables affecting oxygen desaturation were age, hiatus hernia, pulse rate and reflux frequency. A cyclic event was observed every 1.5 min in aspirators and may be due to reflex homeostatic mechanism attempting to correct perceived hypoxia.

[The effect of expression of pepsin in vocal polyps on postoperative curative effect]

Objective:To investigate the effect of tissue pepsin expression of vocal polyps on the postoperative curative effect. Methods:Retrospectively analyze the data of 112 patients diagnosed with vocal cord polyps and undergone surgery from June 2019 to March 2021. The cases were divided into positive group and negative group according to the immunohistochemical pepsin expression. The preoperative reflux symptom index （RSI） and the reflux finding score （RFS） were compared, and the recovery of the voice acoustic function and postoperative vocal cord morphology were analyzed. Results:Among the postoperative specimens of 112 patients,76 cases were positive for pepsin staining, accounting for 67.9%, and 36 cases were negative, accounting for 32.1%. In the pepsin-positive group, 48 cases of vocal cord morphology returned to normal, and 20 cases remained scar or edema in the operation area, 8 cases of polyps relapsed; in the pepsin-negative group, a total of 32 cases of vocal cord morphology returned to normal, 4 cases of remained scar or edema in the operation area, no relapsed cases, the difference in vocal cord morphology recovery was significant （χ²=8.689, P=0.013）. The symptoms of hoarseness improved after 12 weeks. The differences between pre and post operative of G grade, VHI, MPT, fundamental frequency perturbation and amplitude perturbation assessed by GRBAS were significant （P<0.05）; postoperative G grade, VHI, MPT, fundamental frequency perturbation and amplitude perturbation were compared between the pepsin-positive group and the pepsin-negative group, and the differences were significant （all P<0.05）. Conclusion:The expression of pepsin in vocal polyps is a significant clinical indicator that affects the acoustic effect and morphological recovery of vocal cords after surgery. For patients with positive expression, acid suppression treatment should be strengthened after surgery.

[Value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux in children]

OBJECTIVE

To study the value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux (LPR) in children.

METHODS

A total of 274 children with chronic cough who were treated from January 2016 to December 2019 were enrolled. The DX-pH detection system was used to conduct 24-hour airway pH monitoring. The association between chronic cough and LPR was analyzed.

RESULTS

Among the 274 children, there were 168 boys and 106 girls, with a median age of 62.8 months and a median airway pH value of 7.3. Of all the 274 children, 99 (36.1%) had LPR, and the incidence rate of LPR was 36.9% (62/168) in boys and 34.9% (37/106) in girls (P=0.737). The comparison of the incidence rate of LPR among children aged < 1 year, 1-6 years, and > 6 years showed that the younger children had a significantly higher incidence rate of LPR than the older ones (P=0.003). There was no significant difference in the incidence of LPR between the two groups with chronic cough of unknown etiology and definite etiology. The incidence of chronic cough was positively correlated with that of LPR (r_s=0.861, P < 0.01). Among the 99 children with positive RYAN index, 65 (66%) suffered from simple LPR.

CONCLUSIONS

LPR is highly associated with the development of chronic cough, and airway pH monitoring may be a safe and effective method for the diagnosis of LPR.

[An epidemiological survey of laryngopharyngeal refux disease in otorhinolaryngology head and neck surgery clinics in Chongqing area]

Objective:To investigate the prevalence and affecting factors of laryngopharyngeal reflux disease（LPRD） in otolaryngology head and neck surgery in Chongqing,and to provide a basis for the clinical diagnosis and therapy of LPRD. Methods:Multi-center cross-sectional survey method and systematic sampling method were used to select patients at fifteen hospitals in Chongqing from August to November in 2019. Then reflux symptom index（RSI） was investigated. At the same time, the information of the relevant dietary habits, including smoking and drinking, spicy diet, high-fat diet, and satiety was collected. Moreover, the factors related to LRPD（gender, age, symptoms, diet and lifestyle） were analyzed. Results:The composition ratio of LPRD was 11.90%（385/3234） in 3234 effective questionnaires and 385 positive ones. The composition ratio was 12.55%（173/1378） in men and 11.42%（212/1856） in women. The difference between the two groups was statistically significant（P<0.05）. The difference in composition ratio among different age groups was statistically significant（P<0.05）, with the highest composition ratio between 40 and 59 years old（170/1390）. Constant throat-clearing（symptom 2） and globus sensation（symptom 8） were most correlated with LPRD. Logistic regression analysis showed that spicy diet, over eating, and smoking were highly related to LPRD. Conclusion:Globus sensation and constant throat-clearing are the most common symptoms in LPRD patients. Spicy diet, over eating, and smoking are risk factors for LPRD.

[Analysis of esophageal manometry results and the inflection point of age in 41 volunteers without laryngopharyngeal symptoms]

Objective:This study aimed to explore the differences in esophageal pressure at different ages, and to analyze the possible age inflection points of the physiological degeneration of esophageal motility, and to further evaluate whether the degeneration of esophageal kinetics with age is the only risk factor for the occurrence of throat reflux disease （LPRD）. Methods:A solid-state high-resolution esophageal pressure measurement was performed on 41 volunteers without throat symptoms. The Chicago classification data were compared with the manometry results of all volunteers. In addition, the esophageal manometry results were compared among groups with pre-set age inflection point. Results:Most of the volunteers' esophageal pressure measurements were in line with Chicago standards. When the inflection point of age was 55 years, no significant difference was found between the two groups. However, when the inflection point of age was 65 years, a significant difference in the length of the upper esophageal sphincter and the contractile front velocity was found between the two groups（P=0.021 and 0.046 respectively）. Conclusion:Esophageal dynamics was weakened with increasing age in the volunteers without laryngopharyngeal symptoms, which was more obvious after the age of 65, but still within the normal range. The degeneration of esophageal motility is not the only risk factor for LPRD.

Gastric regurgitation predicts neurological outcome in out-of-hospital cardiac arrest survivors

Hypoxic-ischemic brain injury can affect and disturb the autonomous nervous system (ANS), which regulates various visceral systems including the gastro-intestinal and emetic system. The present study aimed to analyze the predictive value of gastric regurgitation (GReg) for neurological outcome in out-of-hospital cardiac arrest (OHCA) survivors. In this prospective, single-center study, 79 OHCA survivors treated at a university-affiliated tertiary care centre were included and GReg was measured at the first day after successful cardiopulmonary resuscitation. Neurological outcome was assessed by the Cerebral Performance Categories score at discharge. Seventy-six percent of the study population had a poor neurological outcome. GReg was found to be associated with poor neurological outcome with an adjusted OR of 5.37 (95% CI 1.41-20.46; p = 0.01). The area under the ROC curve for GReg was 0.69 (95% CI, 0.56-0.81) for poor neurological outcome. GReg on the first day after OHCA is an early, strong and independent predictor for poor neurological outcome in comatose OHCA survivors. These results are particularly compelling because measurement of GReg is inexpensive and routinely performed in critical care units.

Dysphonia and reflux in children: A systematic review

OBJECTIVE

Aim of this review is to evaluate the relation between reflux (either laryngopharyngeal or gastroesophageal) and dysphonia in children.

DATA SOURCES

PubMed, Scopus, Embase.

REVIEW METHODS

A literature search was conducted over a period from January 1990 to March 2020. The following search words were used either individually or in combination: voice disorders, laryngopharyngeal reflux, and gastroesophageal reflux. The search was conducted over a period of a month: April 2020.

RESULTS

Five clinical research were selected based on our objectives and selection criteria. Four studies were of level III evidence. Altogether, a total of 606 patients were pooled with male predominance of 63%. In all studies, reflux was suggested to have strong relation with dysphonia. Majority of cases used 24-h pH monitoring to confirm reflux which yielded positive results in 69%. The top three most common endoscopic findings include: interarytenoid erythema and edema (32/38), vocal cord erythema and edema (160/231) and postglottic edema (141/337). Vocal cord nodules were found in 28% of our patients. Acoustic analysis and perceptual assessment of voice was performed in only 1 study. No complication from any procedure was mentioned in any of the studies. Outcome of treatment was mentioned in 1 study, whereby after 4.5 months of follow-up, 68% of children showed improvement in symptoms.

CONCLUSION

Current evidence shows that there is strong relation between reflux and dysphonia in children. Most common laryngoscopic findings suggestive of reflux includes interarytenoid erythema and edema, vocal cord erythema and edema and postglottic edema.

Biomonitoring of Owls and Their Environment Using Pellets and Feathers

Owls are predators that perform important ecological functions. There are several threats to owl conservation such as the bioaccumulation of chemicals through environmental contamination. The high probability of bioaccumulation in these animals is related to their role as predators and high trophic positions. The objective of this study was to quantify four elements (cadmium, chromium, nickel, and lead) as the biomarkers of environmental exposure in owls. To this end, we analyzed pellets and feathers of different owl species. These matrices were contaminated with all four elements, with chromium most commonly detected. Chromium and nickel were found in the pellets in all 10 months of the study, and May was the month with the highest concentrations of all the elements. Tyto furcata appears to bioaccumulate more elements in its feathers than Megascops spp. and Athene cunicularia. Our findings showed bioaccumulation of these four elements in owls and their environment.

[Clinical efficacy of proton pump inhibitor combined with ranitidine in the treatment of throat reflux]

Objective:To investigate the clinical effect of proton pump inhibitor combined with ranitidine on patients with laryngopharyngeal reflux. Method:Seventy patients with laryngopharyngeal reflux diagnosed in our hospital were randomly divided into group A and group B according to admission time. The difference of B symptom index, reflux symptom scale, sleep breathing test, quality of life and well-being score between the two groups were detected. Result:Before treatment, the RSI index, RFS similarity and QOLS and MUNSH scores were similar （P>0.05）. After four weeks of treatment, the group B score was 3.3±1.2, the group A score was 8.2±3.5, and the group B score was significantly lower. The RFS score of group A （6.2±2.3） was higher than that of group B （2.1±1.9, P<0.05）. The scores of QOLS and MUNSH in group B were （67.57±7.26） and （23.99±3.44）, respectively. The scores of QOLS and MUNSH in group A （50.13±10.19） and （12.21±1.47）, respectively. The results of the two groups were significantly different （P<0.05）. After treatment, the RSI index, RFS score, QOLS and MUNSH scores of the two groups were lower than those before treatment. （P<0.05）. As for the sleep respiration monitoring （PSG） results, after 4-week treatment, compared with the group A, the total sleep time of the group B was significantly increased （P<0.05）, and the number of wakefulness and wakefulness was significantly decreased. The duration of Ⅲ+Ⅳ sleep was also significantly increased, and the proportion of REM sleep time and AHI was significantly reduced （P<0.05）. Conclusion:Proton pump inhibitor combined with ranitidine is more effective and safer than single drug treatment, and can significantly improve the throat reflux symptoms.

[Comparative study of three methods in the diagnosis of laryngopharyngeal reflux in children]

Objective:To compare the consistency of RSI and RFS, pepsin detection and 24 h Dx-pH monitoring in the diagnosis of laryngopharyngeal reflux （LPR） in children. Method:A retrospective analysis was made of 76 children with suspicious LPR. A total of 65 children with suspicious LPR were finally diagnosed. RSI and RFS scales, pepsin detection and Dx-pH monitoring were performed simultaneously. The diagnostic consistency of the three methods was tested, and the sensitivity and specificity were calculated. Result:The sensitivity of pepsin detection, 24 h Dx-pH monitoring, RSI and RFS in the diagnosis of LPR in 76 suspected LPR patients were 95.31%, 66.15% and 84.62%, and the specificity were 100%, 81.82% and 72.73%. The pepsin detection was well consistent with the scale（Kappa>0.75）, pepsin detection and 24 h Dx-pH monitoring were in medium consistency（Kappa=0.467）, and 24 h Dx-pH monitoring and scale were in medium consistency（Kappa=0.446）. Conclusion:Pepsin detection can be used as a reliable index for the diagnosis of LPR in children. It is objective, economical, non-invasive, comfortable and easy to spread.

[Advances of the treatments and diagnosis for sensory laryngeal neuropathy]

Sensory laryngeal neuropathy（SLN） is a kind of peripheral neuropathy presenting globus pharyngeus, chronic cough, increased mucus, dry throat, sore throat, frequent clearing of the throat, etc. When the sensory nerve of the larynx is affected by chemical, biological, mechanical or nutritional factors. Because of its nonspecific signs and symptoms, SLN is easy to be misdiagnosed as chronic pharyngitis or laryngopharyngeal reflux disease. SLN was came up to ENT physician in recent years and there are rare systematic reports currently, therefore, this review aims to summarize the etiology, clinical manifestations, diagnosis and treatment of SLN, to raise awareness of this disease among our colleagues.

[Relationship between laryngopharyngeal reflux and calcification of arytenoid cartilage in male patients with idiopathic laryngeal contact granuloma]

Objective:To investigate the relationship between laryngopharyngeal reflux and arytenoid cartilage calcification in male idiopathic laryngeal contact granuloma. Method:The clinical data of 92 male patients with idiopathic laryngeal contact granuloma who had the thin laryngeal CT scan images and laryngeal reflux symptom index（RSI） scale data before treatment were analyzed retrospectively. The effect of laryngopharyngeal reflux on the calcification of arytenoid cartilage in laryngeal contact granuloma patients was analyzed by Chi-square statistics with SPSS 16.0 software. Result:Among the 92 patients, 44 patients with RSI>13（47.83%） and 48 patients with RSI≤13（52.17%）. Unilateral granuloma was found in 87 cases（94.57%） and bilateral granuloma in 5 cases（5.43%）. A total of 97 sides of the diseased side, there were 87 sides of arytenoid cartilage with calcification（89.69%） and 10 sides without calcification（10.31%）. Among the patients with RSI>13, there were 45 sides of arytenoid cartilage with calcification（45/46, 97.83%） and one side without calcification（1/46, 2.17%）, and in the patients with RSI≤13, there were 42 sides of arytenoid cartilage with calcification（42/51, 82.35%） and 9 sides without calcification（9/51, 17.65%）. The calcification rate of arytenoid cartilage in patients with RSI>13 group was significantly higher than that in RSI≤13 group（χ²=4.701, P=0.030）. Conclusion:The calcification rate of arytenoid cartilage in male idiopathic laryngeal contact granuloma patients with laryngopharyngeal reflux is higher than that in patients without laryngopharyngeal reflux. Laryngopharyngeal reflux may aggravate or promote the inflammatory reaction of granuloma and accelerate the calcification of arytenoid cartilage.

Structural Differences in the Digestive Tract Between Females and Males Could Modulate Regurgitation Behavior in Anastrepha ludens (Diptera: Tephritidae)

With the aim of understanding the mechanisms involved in the regurgitation behavior of tephritid flies, we performed a structural study of the digestive system of the economically important fruit-fly pest, Anastrepha ludens (Loew) using optical, scanning electronic microscopy (SEM) and transmission electron microscopy (TEM), plus a feeding assay. Most structures studied are similar to those previously reported in other adult dipterans, but, importantly, we found sexual differences in some structures that apparently affect regurgitation. We report for the first time sexual differences in the crop duct nerve and large numbers of dense core vesicles within the nerve bundle. Male nerve bundles are bigger and have more secretory vesicles than female ones. The close proximity to the muscles of both the crop lobes and duct suggest that these vesicles (i.e., possibly neurosecretions) might help modulate the muscles regulating regurgitation. The salivary glands are connected to the crop via tracheae, however, SEM/TEM studies failed to find any direct structural connection. Results of the feeding assay indicate that, independently of food type (sucrose or protein) and age, males regurgitate significantly more than females. Regurgitation behavior may also play an important role in capturing bacteria in the environment, and possibly help adults eliminate ingested toxicants such as insecticides. Our findings shed light on an interesting phenomenon that has important practical implications.

CHALLENGES OF OBSTETRIC ANESTHESIA: DIFFICULT LARYNGEAL VISUALIZATION

Obstetric anesthesia is one of the high risk subspecialties of anesthesia practice. Anesthesia related complications are the sixth leading cause of maternal mortality. Difficult or failed intubation following induction of general anesthesia for CS remains the major contributory factor to anesthesia-related maternal complications. The airway management of obstetric patients is a challenging issue for several reasons. Anatomic and physiologic changes related to pregnancy may increase the difficult and failed intubation rates compared to the general surgical population. Proper evaluation of the airway anatomy and airway structures is vital to prevent airway management related catastrophes. In addition to basic airway and intubation equipment, each anesthesia department must have difficult intubation equipment cart including fiber optic laryngoscope, video laryngoscopes, and different types of laryngeal masks. It is essential that all anesthesiologists have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.

[Clinical observation of traumatic granuloma after CO₂ laser cordectomy and laryngopharyngeal reflux]

OBJECTIVE

Through clinical observation of granuloma after CO₂ laser cordectomy under suspensive laryngoscope to discuss the effects of laryngopharyngeal reflux(LPR) to traumatic granuloma.

METHODS

According to the classification of depth and range of CO₂ laser cordectomy, 111 cases were divided into 5 groups, and the incidence of postoperative granuloma of each group was observed. The largest number of the 5 groups was 49 cases of type III CO₂ laser cordectomy which was subdivided into 4 groups according to whether or not laryngopharyngeal reflux and whether or not proton pump inhibitor (PPI) treatment.

RESULTS

In 111 cases, 56 cases (50.5%) developed granuloma after CO₂ laser cordectomy. The incidence of traumatic granuloma after surgery was 10% (1/10), 26.1% (6/23), 53.1% (26/49), 78.6% (11/14), 80.0% (12/15) in I, II, III, IV, V type, respectively. It had statistical significance in chi-square test between 5 kinds of operative classification and the incidences of postoperative granuloma (χ² = 20.32, P < 0.01) and Spearman correlation analysis showed positive correlation between classification of operation and incidences of granuloma (r = 0.44, P < 0.01). According to LPR (-), LPR (+)and PPI (+), PPI (-), the incidence of granuloma had statistical significance in these 4 group patients of 49 type III cases (χ²= 5.83, P < 0.05). The incidence of granuloma after surgery was the lowest in LPR (-) PPI (+) group (30%) and the highest in LPR (+) PPI (-) group (80%), and it showed significant difference (χ² = 6.25, P < 0.05).

CONCLUSIONS

With the increase of removal depth and the range after CO₂ laser cordectomy, it appears rising trend in incidence of granuloma. Laryngopharyngeal reflux and PPI therapy on the incidence of traumatic granuloma has certain influence.

Identifying gastrooesophageal reflux disease in infants

This article will look at the similarities between normal baby behaviours, and normal physiological gastro-oesophageal reflux (GOR) and GORD, giving the practitioner evidence-based information to offer reassurance to parents. It will also look at conservative management of the common symptoms of GOR, and try to identify why this condition can cause confusion among health professionals and parents.

Regurgitation and remastication in the foregut-fermenting proboscis monkey (Nasalis larvatus)

Although foregut fermentation is often equated with rumination in the literature, functional ruminants (ruminants, camelids) differ fundamentally from non-ruminant foregut fermenters (e.g. macropods, hippos, peccaries). They combine foregut fermentation with a sorting mechanism that allows them to remasticate large particles and clear their foregut quickly of digested particles; thus, they do not only achieve high degrees of particle size reduction but also comparatively high food intakes. Regurgitation and remastication of stomach contents have been described sporadically in several non-ruminant, non-primate herbivores. However, this so-called 'merycism' apparently does not occur as consistently as in ruminants. Here, to our knowledge we report, for the first time, regurgitation and remastication in 23 free-ranging individuals of a primate species, the foregut-fermenting proboscis monkey (Nasalis larvatus). In one male that was observed continuously during 169 days, the behaviour was observed on 11 different days occurring mostly in the morning, and was associated with significantly higher proportions of daily feeding time than on days when it was not observed. This observation is consistent with the concept that intensified mastication allows higher food intake without compromising digestive efficiency, and represents an expansion of the known physiological primate repertoire that converges with a strategy usually associated with ruminants only.

[Symptom-based relationship between gastroesophageal reflux disease and laryngopharyngeal reflux disease]

OBJECTIVE

To explore the relationship between gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD) based on symptoms.

METHODS

A total of 1090 patients undergoing upper digestive tract motility test were invited to complete the surveys of reflux disease questionnaire and reflux symptom index from August 2007 to October 2010. And 895 responders provided valid answers. There were 474 females and 421 males.

RESULTS

Among 895 responders, 351 patients had neither, 218 suffered both conditions, 237 were diagnosed as GERD alone and 89 LPRD alone. No difference was found in age (P = 0.383)or gender ratio (P = 0.227). In 455 GERD patients, there were 218 LPRD cases (47.9%). In 307 LPRD patients, 218 (71.0%) had concurrent GERD. In GERD patients, the frequency and degree of feeling of stomach content reflux into mouth were correlated with RSI (r = 0.115, 0.141, P = 0.007, 0.001).

CONCLUSION

GERD and LPRD may coexist or occur alone. Because of a high concurrent ratio of LPRD in GERD, the treatment strategy of GERD should be modified accordingly. In GERD patients, the feeling of stomach content reflux into mouth may suggest a possibility of LPRD.