口咽pH监测技术在咽喉反流性疾病诊断中的应用

咽喉反流性疾病越来越普遍和受到重视,但是咽喉反流的诊断和机制存在很多争议,目前即使作为诊断金标准的24小时多通道腔内阻抗联合pH监测也存在很多问题,本文就一种新型的口咽监测技术做一综述.     

Utility of 24-hour pharyngeal pH monitoring and clinical feature in laryngopharyngeal reflux disease

Background: pH monitoring can reflect the changes in H⁺ in the airway.

Objectives: To explore the utility of pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux disease (LPRD).

Material and methods: Clinical data from 956 suspected LPRD patients from February 2016 to March 2018 were analyzed retrospectively.

Results: One hundred forty-one patients had positive Ryan score. The positive rates of reflux symptom index (RSI), reflux finding score (RFS), RSI and RFS and RSI or RFS were 14.7%, 32.5%, 21.9%, 7.8% and 46.5%, respectively. The RFS in the positive Ryan score group was higher than that in the negative Ryan score group [(6?±?3.5) vs. (4.8?±?2.9)], while the RSI was not significantly different from that in the negative Ryan score group [(10.9?±?8) vs. (11.3?±?7.1)]. Regarding Ryan score as the gold standard in the diagnosis of LPRD, the sensitivity, specificity, positive and negative predictive value of identifying LPRD by RSI/RFS were 15.9%, 86.3%, 50.4% and 54%, respectively.

Conclusions: Ryan score, RSI and RFS have poor correlation in detecting LPRD. Some patients may be missed with the Ryan score as a diagnostic criterion.

Significance: Pharyngeal pH monitoring is useful and more appropriate index is expected.     

Laryngeal pseudosulcus as a predictor of laryngopharyngeal reflux.

OBJECTIVES/HYPOTHESIS: Laryngeal pseudosulcus is an accurate prognostic indicator of laryngopharyngeal reflux (LPR) disease. STUDY DESIGN: Prospective study of 20 consecutive patients with laryngeal pseudosulcus. Pseudosulcus is infraglottic laryngeal edema that is thought to be secondary to LPR. All patients were evaluated with dual-channel pH probe 24-hour monitoring to evaluate for the presence of laryngopharyngeal reflux. METHODS: Twenty patients identified with laryngeal pseudosulcus on routine physical examination were included in the study. Each patient underwent a 24-hour dual-channel pH probe. The data were analyzed and compared with previously published normative data. The data included the total number of reflux episodes and the percentage of time the pH dropped below 4 at the proximal probe. RESULTS: Eighteen of the 20 patients with laryngeal pseudosulcus were found to have LPR. The mean number of reflux episodes at the proximal probe was 29.4 (range, 3-82). The mean percentage of time the pH dropped below 4 was 1.15%. In the upright position the mean value was 1.59% and in the supine position it was 0.19%. This gives pseudosulcus a positive predictive value for LPR of 90%. CONCLUSION: This study shows laryngeal pseudosulcus to be an accurate predictor of laryngopharyngeal reflux disease.     

管腔内pH监测在反流性疾病中的应用

反流性疾病包括为食管反流病(GERD)和咽喉反流性疾病(LPRD),两者虽在发病机制及表现上有所不同,但均指胃内容物向上反流导致的疾病。GERD尤其是LPRD/胃食管气道反流性疾病其临床症状缺乏特异性,且体征往往不完全与疾病严重程度相符,临床实践中做出正确诊断并不容易。pH监测可以客观直接监测食管或咽喉部酸碱度变化,克服了通过主观症状诊断的非特异性,其在反流性疾病诊断中的意义不言而喻,论文对管腔内pH监测的发展历程和其特点进行综述。     

Hoarseness in children: the role of laryngopharyngeal reflux

OBJECTIVE: The role of laryngopharyngeal reflux (LPR) in hoarseness in children is not well studied. The purpose of this study was to determine the prevalence of LPR in hoarse children. METHODS: Retrospective chart review identified 337 children with hoarseness over a 3-year period. Data collected: mode of presentation, associated symptoms, endoscopic findings, laboratory testing, and therapeutic interventions and their outcomes. RESULTS: Mean age at presentation was 7.2+/-4.3 years with a male:female ratio of 1.7:1. Of the 295/337 (88%) children who underwent endoscopy, 107/295 (36%) had LPR changes alone, 86/295 (29%) had vocal fold nodules, 63/295 (20%) had both LPR and vocal fold nodules; and 22/295 (7%) had a finding other than LPR or nodules. Of the children diagnosed with LPR by endoscopy (with or without nodules), 93/170 (55%) underwent at least one additional test for reflux with 69/93 (74%) having a positive test. Of the children diagnosed with LPR by endoscopy, neither cough nor throat clearing was identified in 82/170 (48%) of children. At the first follow-up visit, an average of 3 months from initial presentation, 50% of 169 children who were treated for reflux had improved or resolved. By the second follow-up visit, 4.5 months later, 68% of those children had improved or resolved. CONCLUSIONS: LPR appears to be a very common cause of hoarseness in children, and is an increasingly important symptom in identifying children with LPR. Treatment of LPR often results in improvement of hoarseness.     

Empiric esomeprazole in the treatment of laryngopharyngeal reflux

OBJECTIVE: Objectives were to determine the efficacy of empiric treatment with esomeprazole for patients diagnosed with laryngopharyngeal reflux and to determine a treatment paradigm for this patient population. STUDY DESIGN: Prospective study. METHODS: Patients were treated with a once-daily dose of 40 mg esomeprazole for 8 weeks. All patients completed a subjective symptom scale (rating laryngeal symptoms and esophageal symptoms) and scoring of flexible fiberoptic examination before treatment and at 4 and 8 weeks of treatment. Nonresponders (<50% reduction in symptom score) were recommended to undergo 24-hour dual-probe pH study while on a regimen of 40 mg esomeprazole once a day, to evaluate for the adequacy of acid suppression. RESULTS: Thirty patients completed the course of therapy. After 4 weeks of treatment, only 8 of 30 patients had significant improvement of their overall symptoms (8 of 30 improved on laryngeal score, and 11 of 18 improved on esophageal score). At 8 weeks of treatment, 19 of 30 patients had significant improvement on their overall symptoms (18 of 30 on laryngeal score, and 13 of 18 on their esophageal score). Five of seven nonresponders who agreed to be tested had positive findings on pH studies (on medication regimen) at 1 cm above the upper esophageal sphincter. Four of 10 nonresponders improved further after increasing their dosage to 40 mg twice a day. Laryngeal examination scores were statistically improved in responders after 8 weeks of treatment. CONCLUSIONS: Laryngopharyngeal reflux symptoms require at least 8 weeks of treatment for significant improvement in the majority of patients. Esophageal symptoms improve sooner. Nonresponders at a daily dose of 40 mg should be treated with a dosage of 40 mg twice daily, and pH study on medication reserved for nonresponders at this higher dose. Laryngeal examination scores showed mild but statistically significant improvement at 8 weeks of therapy in responders.     

An assessment of olfactory function in patients with laryngopharyngeal reflux disease

Conclusions: The results reported here indicate that there was a statistically significant difference in the olfactory functions of laryngopharyngeal reflux patients vs the healthy group. To the best of the authors’ knowledge, this study is the first to evaluate the olfactory function of patients diagnosed with laryngopharyngeal reflux using an objective method, 24-h pH monitoring.

Objectives/Hypothesis: The aim of this study was to investigate olfactory functions in laryngopharyngeal reflux (LPR) patients and compare the results with healthy controls.

Methods: A total of 60 participants; 30 men and women with a diagnosis of laryngopharyngeal reflux and 30 healthy controls, were included in the study. Patients in the laryngopharyngeal reflux group were evaluated by the Reflux Symptom Index (RSI), Reflux Finding Scores (RFS), and finally 24-h pH monitoring to confirm the diagnosis of laryngopharyngeal reflux. The Sniffin’ Sticks olfactory test results of the laryngopharyngeal reflux and control groups were compared, and the relationship between the study findings and the olfactory parameters were evaluated.

Results: The odor threshold, odor discrimination, odor identification, and TDI scores of the laryngopharyngeal reflux group were significantly lower than those of the control group. Also there was a statistically significant negative correlation detected between the olfactory test and some symptom and finding scores.     

Is laryngopharyngeal reflux an important risk factor in the development of laryngeal carcinoma?

Laryngopharyngeal reflux (LPR) as a causative irritating factor in the development of laryngeal carcinoma has been suggested. However, the association between LPR and laryngeal carcinoma remains unclear. The aim of this study was to compare the prevalence and severity of reflux between patients with laryngeal carcinoma and clinical LPR. The intention was to find out if a correlation exists between the laryngeal findings and the level of acid reflux. The study population consisted of 29 patients with laryngeal cancer (group I), 33 LPR patients with normal laryngeal findings (group II) and 70 LPR patients with related laryngeal pathology (group III). The results of 24-h, double-channel ambulatory esophageal pH monitoring were analyzed comparing the three groups. The occurrence and severity of abnormal acid reflux at the upper and lower esophageal segments were evaluated. The incidence of LPR or gastroesophageal reflux (GER) did not vary in any of the three groups (LPR was present in 62, 42 and 56% of the patients, while GER was present in 45, 24 and 37% of the patients, respectively). Patients with LPR or GER from the three groups did not differ significantly in terms of the number of acid reflux episodes and percentage of times when the pH was <4. Our data do not support the hypothesis that LPR can be an independent risk factor in the development of larynx cancers. However, the data also do not thoroughly exclude the possibility. The reason why LPR leads to variable pathologies in the larynx may be uncovered by studies probing the differences between patients via detailed examinations of the local anti-reflux barriers such as epithelial morphology and functions.     

Laryngopharyngeal reflux identified using a new catheter design: defining normal values and excluding artifacts

OBJECTIVE: To define normal values for laryngopharyngeal reflux using an improved catheter design with adjustable electrode placement for pH monitoring. STUDY DESIGN: Cohort study of normal volunteers. METHODS: The setting was an institutional-based gastroenterology practice. Subjects included 20 healthy volunteers with no history of laryngeal, pharyngeal, or reflux symptoms. These included 10 men and 10 women (mean age, 33 y; age range, 26-49 y). Ambulatory 24-hour triple-electrode monitoring of pH in distal esophagus, proximal esophagus, and pharynx using new bifurcated probe was performed. The distal electrode was placed 5 cm above the lower esophageal sphincter, with the proximal two electrodes straddling the upper sphincter. The main outcome measure was the number of true pharyngeal reflux episodes. RESULTS: Sixteen of 20 subjects had no episodes, and 2 subjects had only one episode of pharyngeal reflux. The two subjects exceeding this value (8 and 15 episodes, respectively) had abnormal distal and proximal esophageal reflux. Artifacts for pharyngeal reflux due to acidic meals or "pseudoreflux" were excluded. Subject tolerance of this new probe was excellent. CONCLUSION: The triple-electrode bifurcated adjustable pH probe provides a well-tolerated technique to identify true hypopharyngeal acid reflux episodes. When artifacts produced by meals and pseudoreflux are excluded, 90% of normal subjects show no episodes or a single episode over a 24-hour period.     

Correlation of pH probe-measured laryngopharyngeal reflux with symptoms and signs of reflux laryngitis

OBJECTIVES/HYPOTHESIS: Laryngitis secondary to gastric acid reflux is a prevalent, yet incompletely understood, otolaryngological disorder. Further characterization of the relationship between symptoms and signs and reflux severity is needed. STUDY DESIGN: Prospective clinical trial. METHODS: Forty-two consecutive, nonsmoking patients with one or more reflux laryngitis symptoms were recruited to complete a symptom questionnaire, videostrobolaryngoscopy, and 24-hour, dual-sensor pH probe testing. Twenty-nine patients had more than four episodes of laryngopharyngeal reflux, and the remaining 13 served as control subjects. Symptom scores were produced by multiplying the severity by the frequency for the following: hoarseness, throat pain, "lump-in-throat" sensation, throat clearing, cough, excessive phlegm, dysphagia, odynophagia, and heartburn. Endoscopic laryngeal signs included erythema and edema of the vocal folds and arytenoids, and interarytenoid irregularity. RESULTS: Symptom scores varied significantly, with throat clearing being greater than the rest. None of the symptoms, except heartburn, correlated with reflux (laryngopharyngeal and esophageal) severity. Patients with worse laryngopharyngeal reflux were found to have worse esophageal reflux. Endoscopic laryngeal signs were rated as mild, on average, and did not correlate with laryngopharyngeal reflux severity. The number of laryngopharyngeal reflux episodes (per 24 h) ranged from 0 to 40 (mean number, 10.6 episodes). CONCLUSIONS: Throat clearing was the most intense symptom in the present group of patients with proven reflux laryngitis. Dual-sensor pH probe testing could not predict the severity of patient's reflux laryngitis symptoms or signs. Only the heartburn symptom correlated with laryngopharyngeal and esophageal reflux.     

唾液胃蛋白酶检测在反流性咽喉炎诊断中的价值

目的 评估口腔中唾液胃蛋白酶检测对反流性咽喉炎(LPR)患者的诊断价值。 方法 选取25例LPR患者,反流症状指数量表(RSI)>13分,反流体征指数量表(RFS)>7分,治疗前采用蛋白印迹法检测患者唾液胃蛋白酶,之后口服埃索美拉唑肠溶片+2.5%碳酸氢钠雾化吸入治疗2个月,治疗完成后再次行RSI及RFS量表评分并行唾液中胃蛋白酶检测。 结果 治疗前唾液胃蛋白酶检测结果阳性12例,阴性13例。治疗后PPI实验结果阳性10例,阴性15例。唾液胃蛋白酶检测结果与PPI实验结果同为阳性9例,同为阴性12例;PPI实验结果阳性而唾液胃蛋白酶结果阴性1例,PPI实验结果阴性而唾液胃蛋白酶结果阳性3例。以PPI实验阳性作为本研究的诊断标准,胃蛋白酶检测结果诊断LPR的敏感度为90.00%,特异度为80.00%。25例患者均能完成所有检查和治疗,症状得到改善19例,症状未见明显改善6例。治疗前后RSI量表症状评分分别为(19.84±3.96)、(7.00±2.84)分,治疗前后RSI量表症状评分差异有统计学意义(P<0.001)。25例患者体征均得到明显改善,治疗前后RFS量表体征评分分别为(14.08±3.51)、(5.44±3.07)分,治疗前后的RFS量表体征评分差异有统计学意义(P<0.001)。 结论 唾液中胃蛋白酶的检测可用于辅助诊断LPR。     

咽喉反流的中医认识及辨证治疗

正咽喉痛、异物感、恶心、干呕、咽干、吭咯、咯痰,咽喉部灼烧感等都是耳鼻喉科门诊的常见主诉,目前医生和患者常在咽喉部追究其病因,然而绝大多数(约95%~98%)针对上述症状的喉内镜描述中,除了"咽部黏膜充血、淋巴滤泡增生、会厌囊肿"等外,与临床症状并不相符。从解剖上来说,颈部除了咽部外,还有喉部、颈段气管、颈段食管、甲状腺等器     

Is the pepsin immunohistochemical staining of laryngeal lesions an available way for diagnosing laryngopharyngeal reflux

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.     

Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease

OBJECTIVES/HYPOTHESIS: The objective was to investigate the potential use of pepsin and carbonic anhydrase isoenzyme III (CA-III) as diagnostic markers for laryngopharyngeal reflux disease. STUDY DESIGN: Prospective cell biological investigation was conducted of laryngeal biopsy specimens taken from 9 patients with laryngopharyngeal reflux disease and 12 normal control subjects using antibodies specific for human pepsin (produced in the authors' laboratory within the Department of Otolaryngology at Wake Forest University Health Sciences, Winston-Salem, NC) and CA-III. METHODS: Laryngeal biopsy specimens were frozen in liquid nitrogen for Western blot analysis and fixed in formalin for pepsin immunohistochemical study. Specimens between two groups (patients with laryngopharyngeal reflux disease and control subjects) were compared for the presence of pepsin. Further analyses investigated the correlation between pepsin, CA-III depletion, and pH testing data. RESULTS: Analysis revealed that the level of pepsin was significantly different between the two groups (P < .001). Secondary analyses demonstrated that presence of pepsin correlated with CA-III depletion in the laryngeal vocal fold and ventricle (P < .001) and with pH testing data in individuals with laryngopharyngeal reflux disease. CONCLUSION: Pepsin was detected in 8 of 9 patients with laryngopharyngeal reflux disease, but not in normal control subjects (0 of 12). The presence of pepsin was associated with CA-III depletion in the laryngeal vocal fold and ventricle. Given the correlation between laryngopharyngeal reflux disease and CA-III depletion, it is highly plausible that CA-III depletion, as a result of pepsin exposure during laryngopharyngeal reflux, predisposes laryngeal mucosa to reflux-related inflammatory damage.     

口咽、食管同步Dx-pH检测研究咽喉反流性疾病

采用口咽、食管同步Dx-pH检测探讨咽喉反流性疾病（LPRD）与胃食管反流病（GERD）的关系。