Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux

OBJECTIVES/HYPOTHESIS: To determine whether measurement of pepsin in throat sputum by immunoassay could be used as a sensitive and reliable method for detecting laryngopharyngeal reflux (LPR) compared with 24-hour double-probe (esophageal and pharyngeal) pH monitoring. STUDY DESIGN: Patients with clinical LPR undergoing pH monitoring provided throat sputum samples during the reflux-testing period for pepsin measurement using enzyme-linked immunoadsorbent assay. RESULTS: Pepsin assay results from 63 throat sputum samples obtained from 23 study subjects were compared with their pH monitoring data. Twenty-two percent (14/63) of the sputum samples correlated the presence of pepsin with LPR (pH < or = 4 at the pharyngeal probe), of which the median concentration of pepsin was 0.18 microg/mL (range 0.003-22 microg/mL). Seventy-eight percent (49/63) of the samples unassociated with (pharyngeal) reflux contained no detectible pepsin. Mean pH values for pepsin-positive samples were significantly lower than negative samples at both esophageal probe (pH 2.2 vs. pH 5.0) (P < .01) and the pharyngeal probe (pH 4.4 vs. pH 5.8) (P < .01). When the pepsin assay results were compared with the pharyngeal pH data for detecting reflux (events pH < or = 4), the pepsin immunoassay was 100% sensitive and 89% specific for LPR. CONCLUSIONS: Detection of pepsin in throat sputum by immunoassay appears to provide a sensitive, noninvasive method to detect LPR.     

Role of immunoglobulin E and gastro-esophageal reflux disease in the development of otitis media with effusion

Introduction

The role of allergy in chronic otitis media with effusion (OME) is controversial. Aim of the work: To study the role of allergy and gastroesphogeal reflux diseases in the etiology of OME. Materials and methods: It is a prospective study that was done on 43 cases; 30 patients suffer from OME with mean age 6.8 years and 13 control child with mean age 8.3 years. Blood sample were taken from patients and control children for assay of total Immunoglobulin E (IgE) and serum pepsinogen 1 (PG1). Effusion fluid samples were taken from middle ear of the patients during myringotomy and ventilation tube insertion; IgE and PG1 were assayed in the effusion samples. Total IgE and PG1 were assayed by enzyme-linked immunosorbent assay.

Results

Our results showed that, there is a correlation between serum IgE and Effusion IgE in the patients group, there is a significant negative correlation between PG1 in the effusion and serum of the studied patients.

Conclusion

Allergy is a possible risk factor for the development of OME. The level of PG1in the effusion is one tenth of its level in the serum of the patients.     

Dilated intercellular space in the larynx and esophagus of a rabbit reflux model

Objective

In this study, we investigated histological and electron microscopic changes of the laryngeal and esophageal epithelium in an animal model of reflux to demonstrate: (1) the association between laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD) and (2) the value of dilated intercellular space (DIS) as a marker of LPR.

Methods

Eight New Zealand albino rabbits were utilized. Four rabbits underwent total cardiomyectomy to induce reflux. The remains underwent a sham operation as controls. The animals were sacrificed 12 weeks after surgery to obtain histological and electron microscopic results.

Results

There were significant differences in the histological results between the study group and the control group in both the esophagus and the larynx (P = 0.041 and 0.014). Significant changes in the intercellular space (IS) were observed between the study group and the control group in the esophageal and laryngeal samples (P < 0.001).

Conclusion

The results of this study suggest that LPR and GERD have a common mechanism and DIS is a morphologic marker of LPR in rabbits.     

Expression of claudin-3 in the esophagus and larynx of rat reflux model

Objective

The aim of this study was to investigate the association between laryngeal expression of claudin-3 and laryngopharyngeal reflux (LPR) in a rat reflux model.

Methods

Eight Wistar rats were divided into two groups. Four rats underwent total esophageal myectomy to induce reflux, and the remainder underwent a sham operation as a control. All animals were sacrificed 12 weeks after surgery to perform tissue histology and Western blot analysis.

Results

Lymphocyte infiltration increased significantly in the study group in both esophageal and laryngeal samples (P = 0.001, 0.002, respectively). Both esophageal and laryngeal expressions of claudin-3 were significantly lower in the study group when compared with that in the control group (P = 0.045, 0.037, respectively).

Conclusion

The results of this study suggest that a decrease in claudin-3 could be a sensitive indicator of reflux laryngitis in rats.     

Is Gastric Reflux a Cause of Otitis Media With Effusion in Children?

OBJECTIVES/HYPOTHESIS: Otitis media with effusion is the most common cause of childhood deafness. Gastroesophageal reflux has been implicated in the disease pathogenesis; therefore, it is necessary to identify the presence or absence of gastric juice in the middle ear. STUDY DESIGN: Middle ear effusions were collected from children undergoing myringotomy. If gastric reflux has occurred, effusions should contain pepsin protein. METHODS: Total pepsin/pepsinogen protein, fibrinogen, and albumin content of effusions were measured in enzyme-linked immunosorbent assays using antibodies to porcine pepsin, human albumin, and human fibrinogen. Proteolytic activity of each effusion was measured at pH 2. The pH of effusions was measured. RESULTS: Fifty-nine of 65 effusion samples gave a positive result with the antipepsin antibody, which also recognized pepsinogen. Pepsin/pepsinogen levels ranged from 0.8 to 213.9 microg/mL (serum reference levels, 49.8-86.6 ng/mL). All effusions contained albumin and fibrinogen with respective ranges of 1.77 to 95.75 and 0.30 to 2.30 mg/mL (serum reference levels, 35-45 and 2.2 to 4.6 mg/mL, respectively). Acidic protease activity occurred in 19 of 65 effusion samples. The pH of effusion samples was 7 to 9. CONCLUSIONS: The majority of effusion samples contained pepsin/pepsinogen protein; only 29% were active. The pepsin level in effusion samples based on activity is substantially lower than levels based on antibody detection; however, the pH present would irreversibly inhibit pepsin, which would explain the low levels of active enzyme. Pepsin/pepsinogen levels in the effusion samples were up to 1000 times higher than serum levels, whereas albumin and fibrinogen levels were of the same magnitude. The pepsin in middle ear effusions is almost certainly due to reflux of gastric contents, and there may be a role for antireflux therapy in the treatment of otitis media with effusion.     

The role of laryngopharyngeal reflux as a risk factor in laryngeal cancer: a preliminary report

Objectives

To evaluate the significance of laryngopharyngeal reflux (LPR) as a risk factor in laryngeal cancer.

Methods

We performed a case-control study with 29 consecutive laryngeal cancer patients who had undergone 24-hour ambulatory double pH monitoring from 2003 to 2006. The control group included 300 patients who had undergone 24-hour ambulatory double pH monitoring due to LPR-related symptoms. We analyzed the prevalence of LPR and numerous parameters from the 24-hour ambulatory double pH monitoring in the laryngeal cancer patient and control groups. Pathologic LPR is defined when more than three episodes of LPR occur in 24 hours.

Results

The prevalence of pathologic LPR was significantly higher in the laryngeal cancer group than the control group (P=0.049). The reflux number of the upper probe was significantly higher in the laryngeal cancer group (P<0.001). However the effects of pathologic LPR on laryngeal cancer risk were diluted after adjusting for smoking and alcohol consumption in the multivariable logistic regression.

Conclusion

The pathologic LPR might be a possible risk factor in the development of laryngeal cancer. A further study should be necessary to verify the exact role of LPR in laryngeal cancer.     

Association of reflux symptom index scores with gastroesophageal flap valve status

Objective

Gastroesophageal reflux disease is a chronic symptom of mucosal damage caused by gastric acid reflux. Impaired gastroesophageal flap valve (GEFV) is one of the common etiologic factors of gastroesophageal reflux. The aim of this study was to investigate the association between GEFV, RSI, and GER in patients who underwent gastroesophageal endoscopy.

Methods

Two hundred and fifty seven consecutive patients with reflux symptoms (151 men and 106 women, mean age was 50.22 years) who underwent routine upper gastrointestinal endoscopy were enrolled to our study. GEFV was graded as I through IV according to the Hill's classification. Symptoms of laryngopharyngeal and upper gastrointestinal disease and endoscopic severity of esophageal injury were correlated with GEFV status. The GEFV was classified into two groups: normal GEFV group (grade I) and the abnormal GEFV group (grades II–III and IV). The reflux symptom index (RSI) was used as a diagnostic tool for LPR.

Results

Age, male gender, and body mass index were significantly related to an abnormal GEFV. The rate of abnormal grades of GEFV (Grade II + III + IV) was 31%. Age of normal and abnormal grades of GEFV (49.0/50.8 vs 52.9) and values of BMI (26.2/26.7 vs 26.5) were similar. RSI scores were correlated with gastroesophageal flap valve grades but RSI scores were not correlated with Los Angeles gastroesophageal reflux (GER) Classification. Moreover, gastroesophageal reflux grade of Los Angeles Classification was positively correlated with gastroesophageal flap valve grades.

Conclusion

Endoscopic grading of GEFV is a simple and useful technique which may provide an accurate diagnosis of laryngopharyngeal and gastroesophageal reflux. Also, reflux symptom index (RSI) is a simple, economic and noninvasive diagnostic tool for gastroesophageal reflux. However, in this research, we did not find any correlation between reflux symptom index and degree of esophageal mucosal injury which was classified according to LA classification.     

Do the laryngopharyngeal symptoms and signs ameliorate by empiric treatment in patients with suspected laryngopharyngeal reflux?

Objectives

In clinical practice, antireflux medication is given almost always empirically without pH monitorization. We aimed to evaluate the improving effect of empiric antireflux treatment on layngopharyngeal symptoms and signs in patients with gastroesophageal reflux (GER) and suspected laryngopharyngeal reflux (LPR) according to reflux symptom index (RSI) and reflux finding score (RFS).

Methods

GER was determined by esophagogastroduedonoscopy and biopsy in 127 patients. RSI and RFS were calculated for each patient. The patients with a pathology other than LFR which may be responsible from laryngopharyngeal symptoms and signs were excluded from the study. Fifty patients whom were thought to have LPR according to RSI and RFS comprised the study group. After 12-weeks of antireflux treatment, RSI and RFS were calculated again. The statistical analyses were made according to the changes in the severity and frequency of each symptom and sign.

Results

There was statistically significant improvement in RSI and RFS after treatment when compared with initial scores. There was statistically significant improvement in severity of all symptoms and signs. Although there was quantitively decrease in frequency of some signs and symptoms, complete resolution of the disease was not observed generally.

Conclusion

Empiric antireflux treatment according to RSI and RFS is an effective method. Antireflux treatment has a significant improving effect on laryngopharyngeal symptoms and signs. There may be needed longer times of treatment for complete resolution of symptoms and signs.     

Histological changes of rat soft palate with exposure to experimental laryngopharyngeal reflux

Objective

The possible effects of laryngopharyngeal reflux (LPR) on laryngeal and otologic disorders have been studied in the literature. There have been no reports explaining the possible effects of LPR on the soft palate. Therefore, in this study, we investigated the histopathologic changes in the rat soft palate using an experimental model of reflux.

Subjects and methods

Eighteen healthy 200–220-g 20-week-old Sprague-Dawley rats were used. The animals were divided into three groups according to exposure time (1, 4, and 12 week exposures), and four rats were examined as controls who had undergone sham operation. An experimental model of gastroesophageal reflux was induced under general anesthesia. After exposure, the animals were sacrificed, and their soft palates were removed. The histopathological changes in the soft palates were observed under a light microscope.

Results

Submucous gland hyperplasia, inflamation, subepithelial edema, vascular engorgement, muscular atrophy and dilated glandular excretory duct were compared among the groups. Submucous gland hyperplasia, subepithelial edema, inflammation, vascular engorgement, muscular atrophy and dilated glandular excretory duct were significantly different in the exposure groups compared with the control group.

Conclusion

On the basis of histopathological evaluations, our findings suggest that reflux affects the soft palate, which suggests that these pathological changes may reflect the relationship between LPR and airway obstruction.     

Pilot study: Association between Helicobacter pylori in adenoid hyperplasia and reflux episodes detected by multiple intraluminal impedance in children

Objectives

The aim of this pilot study was to investigate an association between laryngopharyngeal reflux detected by combined multiple intraluminal impedance and pH monitoring and Helicobacter pylori in adenoid hyperplasia detected with real time polymerase chain reaction (PCR).

Methods

The study group consisted of 30 children (median age 5.34 years) with extraesophageal symptoms of gastroesophageal reflux disease with adenoid hyperplasia. All children underwent adenoidectomy with subsequent PCR detection of H. pylori DNA in the tissue and multiple intraluminal impedance and pH monitoring. The most proximal impedance sensor was located 1 cm caudal to the entrance of the oesophagus.

Results

We found significant differences in the number of reflux episodes among patients with PCR positivity (median 35) and negativity (median 0) of H. pylori (p-value of Mann–Whitney U-test 0.0056). Patients with PCR positivity of H. pylori had significantly more reflux episodes reaching the upper oesophageal sphincter (p-value of Mann–Whitney U-test 0.023). The absence of reflux episode was the only independent factor for PCR negativity of H. pylori in the multiple logistic regression model.

Conclusions

These results support the hypothesis that reflux episodes reaching the upper oesophageal sphincter may play an important role in the transmission of H. pylori into lymphoid tissue of the nasopharynx and thus may contribute to adenoid hyperplasia in children.     

Lack of Chlamydophila pneumoniae and predominance of Alloiococcus otitidis in middle ear fluids of children with otitis media with effusion

Objective

To investigate the presence of Chlamydophila pneumoniae and other bacterial pathogens in middle ear effusion samples obtained from children with otitis media with effusion (OME).

Materials and methods

Twenty-eight children (mean age 7.03; standard deviation 2.18) with OME unresponsive to medical therapy were included in the study. All of the children underwent ventilation tube insertion under general anesthesia. Eighteen patients were bilaterally affected whereas 10 children had unilateral disease. The middle ear fluids (46 samples in total) were collected during ventilation tube insertion, and were evaluated subsequently for the presence of C. pneumoniae and other bacterial pathogens using polymerase chain reaction (PCR).

Results

Although all samples were negative for C. pneumoniae, bacterial DNA was detected in 21 of 46 samples. Overall 40% of the patients (4/10) with unilateral involvement, and 61% of the patients (11/18) with bilateral involvement were positive for bacterial DNA. In 6 patients with bilateral OME bilateral samples were positive, whereas 5 patients with bilateral OME showed only unilateral positivity. According to the results of DNA sequencing analysis, all of the positive samples harbored only one bacterial species. In 12 of 46 samples Alloiococcus otitidis DNA (26%), in 7 Haemophilus influenzae DNA (15%), in one Streptoccoccus pneumoniae DNA (2%) and in one Moraxella catarrhalis DNA (2%) were present.

Conclusions

Our findings support that C. pneumoniae does not seem to have a role in OME in children whereas A. otitidis was found to be more frequent than the other common pathogens. Further studies are required to elucidate the exact pathogenetic role of these microorganisms in OME.     

Otitis media with effusion in children with cleft lip and palate: A narrative review

Objective

Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP.

Methods

All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles.

Results

Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference.

Conclusions

The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.     

Relevance and characteristics of gastroesophageal reflux in adult patients with otitis media with effusion

Objective

To investigate relevance and characteristics of gastroesophageal reflux (GER) in adult patients with otitis media with effusion (OME) of unknown etiology who attended private clinics.

Materials and methods

A total of 186 adults with OME of unknown etiology (OME group) and 156 adults without OME (control group) were asked to answer a questionnaire specific for the diagnosis of GER disease. Pepsinogen (PG) levels in the middle-ear effusions (MEEs) of the OME group were measured using a chemiluminescence enzyme immunoassay kit. Distributions of PG concentrations by age or body mass index (BMI) in the OME group were analyzed. Patients with high PG levels received proton pump inhibitors (PPIs) and their responses were evaluated.

Results

Symptoms of GER were reported by significantly more patients in the OME group than in the control group (43.0% vs. 12.8%). Patients with GER symptoms tended to have higher MEE PG concentrations than those without symptoms. PG levels did not show a significant difference by age. However, high PG levels were less found in patients over 60 years old with high BMI >25. This tendency was not observed in patients under 60 years old. PG levels decreased in seven out of ten patients with high PG concentrations after PPI therapy, corresponding with palliation of GER-related symptoms. Two patients had high MEE bilirubin concentration, and OME resolved in these patients after instruction about lifestyle factors related to GER, including sleeping position.

Conclusions

GER symptoms were more prevalent than expected in patients with OME of unknown etiology. BMI might affect GER-related OME, especially in elderly patients. Instruction about lifestyle factors related to GER, especially in patients who do not respond to PPI therapy, may be effective for patients with intractable OME.     

Skala Warszawska A–E oceny endoskopowych zmian w krtani związanych z refluksem gardłowo-krtaniowym. Korelacja ze skalą patologii refluksowej (RFS)

Introduction

Changes associated with laryngopharyngeal reflux (LPR) are usually related to the posterior part of the larynx and called “posterior laryngitis”. Pathologic reflux-induced mucosal changes within the larynx are easily detected with the use of videolaryngoscopy (VLS). To the multitude of described changes within the larynx that are associated with the existence of LPR Belafsky introduced assessment with 26 scale points describing changes in the larynx (RFS; reflux finding score).

Aim of the study

The aim of this study was to introduce our proposal of a new scale of endoscopic pharyngo-laryngeal findings associated with laryngopharyngeal reflux named Warsaw A–E scale. For that reason the new scale was compared to the RFS scale of Belafsky.

Material and method

A total of 249 patients were involved in this restospective study. The reflux disease was confirmed by gastroenetrologists. Larynx was evaluated with the use of videolaryngoscopy. Morphological changes within the larynx and pharynx were assessed using 1) the RFS scale according to Belafsky, 2) and using our proposed scale named Warsaw A–E scale. The results were compared.

Results

All patients received at least 7 points in RFS scale of Belafsky. Using Warsaw A–E scale, there were no patients found with the videolaryngoscopic image of the larynx classified as A type. In both the women's group, as well as the group of men prevailed type C. The comparison of the two scales showed correlation between them.

Conclusions

The study showed a statistically significant correlation of Warsaw A–E scale of laryngopharyngeal changes with a commonly used scale of RFS according to Belafsky. It was found that the Warsaw A–E scale is easier to use and less time consuming.     

Laryngeal dysfunction and oral hygiene: Any relation?

Objective

The purpose of this study is to establish a relation between poor oral hygiene and laryngeal dysfunction.

Methods

43 adult patients were divided into two groups according to caries activity and oral hygiene. 18 patients with oral hygiene index score (OHI-S) 0-1 were grouped as the control group (good oral hygiene). 25 patients with OHI-S 2-3 were grouped as the study group (poor oral hygiene). Larygostroboscopic examination, aerodynamic measures by defining maximum phonation time (MPT) and s/z ratio and the pitch level measurements were done.Patients with gastroesophageal reflux disease (GERD), laryngopharyngeal reflux (LPR), previously confirmed laryngeal diseases or pathologies, systemic other diseases, or smokers were excluded from this study.

Results

The average MPT values of the study group were found to be statistically very significantly lower than those of the control group (p < 0.01). In the stroboscopic findings, the proportion of normal closure levels were meaningfully higher in the control group than in the study group (p < 0.05). The supraglottic involvement was found statistically meaningfully higher in the study group than in the control group (p < 0.05). The proportion of normal closure phase incidences were meaningfully higher in the control group than in the study group (p < 0.05).

Conclusion

So, our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the poor oral hygiene group correlate with LPR findings such as muscle tension dysphonia. Poor oral hygiene may aggravate potential LPR in people.     

Role of extra-esophageal reflux in chronic otitis media with effusion

OBJECTIVES/HYPOTHESIS: Otitis media with effusion (OME) is the most common cause of childhood hearing loss. Despite its prevalence, the enormous health care expenditures resulting from its treatment, and the increasing therapeutic challenges imposed by antimicrobial resistance, very little is known regarding the cellular and molecular immunologic and inflammatory events in this disease process. Extra-esophageal reflux (EER) has been implicated in the pathogenesis of chronic OME. The objective of this study was to confirm that children with OME have EER into the middle ear as measured by the presence of pepsin in middle ear effusions (MEE) removed during tympanostomy tube (TT) placement. STUDY DESIGN: Prospective, translational, cell biological research study. METHODS: MEE were obtained from children undergoing TT placement for OME. The fluid was lysed in a urea buffer and the presence of pepsin quantitatively determined by Western blot analysis using a specific antipepsin antibody. The pH of the samples was recorded before lysis. RESULTS: Pepsin protein was detected in 18 of 32 (56%) samples analyzed, with 12 of 20 (60%) patients having at least one positive sample for pepsin. Pepsin levels ranged from 80 to 1,000 ng/mL. The pH of the samples ranged from 6.0 to 7.6, with a mean pH of 6.8. CONCLUSIONS: Pepsin was detected in 60% of patients with OME, confirming that EER into the middle ear occurs in these children. The pepsin present would have little or no activity at pH 6.0 to 7.6; however, pepsin is stable below pH 8.0 and thus could be reactivated after a decrease in pH.     

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.     

Laryngopharyngeal reflux in obstructive sleep apnoea patients: Literature review and meta-analysis

Purpose

Laryngopharyngeal reflux (LPR) is a frequent condition in Obstructive Sleep Apnoea (OSA) patients and different studies have been published in the last years about this topic. A review of the published literature regarding LPR in OSA patients has been reported. A meta-analysis to evaluate the incidence of LPR in OSA patients and correlate LPR positivity with OSA patients' characteristics has been performed.