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.     

儿童咽喉反流性疾病研究进展

咽喉反流性疾病（1aryngopharyngeal reflux disease,LPRD）是指胃内容物反流至食管上括约肌以上部位,流至咽喉部,与呼吸道和消化道上部组织接触,引起一系列症状和体征的总称。据国外研究表明到耳鼻咽喉科就诊的门诊患者约10%患有LPRD。虽然最近几年,耳鼻咽喉科医师逐渐在重视LPRD的诊疗,但LPRD目前仍是一个不明确的疾病,我们对其真实的发病率及重要性知之甚少,尤其在儿童中LPRD的评估仍存在争议。目前仍有许多工作亟待开展。     

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.     

咽喉反流性疾病在儿童的诊断与治疗

儿童咽喉反流性疾病(laryngopharyngeal reflux disease,LPRD)是儿科人群中一个复杂而又常见的问题,近些年来儿童LPRD与喂养困难、睡眠障碍、发声障碍、顽固性鼻炎鼻窦炎、中耳炎、慢性咳嗽等疾病的相关性已经引起多专业儿科医师的关注,但其诊断和临床表现仍存在争议.为提高对儿童LPRD的认识,...     

Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux

OBJECTIVE: To report the prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. STUDY DESIGN: Prospective study of 58 consecutive patients with documented laryngopharyngeal reflux, all of whom underwent transnasal esophagoscopy as part of their reflux evaluations. METHODS: All patients with a diagnosis of laryngopharyngeal reflux confirmed by abnormal pharyngeal pH monitoring over a 5-month period were included, and all subjects completed a self-administered reflux symptom index and underwent transnasal esophagoscopy with directed biopsy. RESULTS: Of the 58 study patients with pH-documented laryngopharyngeal reflux, the mean age was 49 years (+/- 13 y), and 53% (31 of 58) were women. Of the study group, 40% (23 of 58) had heartburn and 48% (28 of 58) had abnormal esophageal reflux (by pH monitoring criteria); by transnasal esophagoscopy with biopsy, 12% (7 of 58) had esophagitis and another 7% (4 of 58) had Barrett's metaplasia. Thus, 60% of the study cohort had heartburn, and 81% (47 of 58) had normal esophageal epithelium (i.e., esophagitis or Barrett's metaplasia). CONCLUSIONS: In the present series of patients with documented laryngopharyngeal reflux the prevalence of esophagitis and Barrett's metaplasia was only 19%. These data confirm the clinical impression that the patterns, mechanisms, and manifestations of laryngopharyngeal reflux differ from those of classic gastroesophageal reflux disease. Unlike gastroesophageal reflux disease, patients with laryngopharyngeal reflux uncommonly have esophagitis. Thus, although esophagoscopy may be an excellent method for screening the esophagus, it is not the method of choice for diagnosing laryngopharyngeal reflux.     

胃蛋白酶在咽喉反流疾病诊断中的应用

咽喉反流性疾病是近年来被临床医师逐渐认识并引起重视的一种疾病。美国耳鼻咽喉头颈外科学会将其定义为胃内H+和胃蛋白酶原经食管到达咽、喉、鼻、中耳、气管和支气管等部位所引起的临床症候群。随着逐渐深入的研究,学者对胃蛋白酶在咽喉反流病中的作用的认识逐渐提高,认为胃蛋白酶可以作为一种检测方法诊断咽喉反流病。     

The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease

OBJECTIVE: To determine the reliability of the assessment of laryngoscopic findings potentially associated with laryngopharyngeal reflux disease (LPRD). STUDY DESIGN: Prospective randomized blinded study. METHODS: One hundred twenty video segments of rigid fiberoptic laryngeal examinations were prospectively analyzed by five otolaryngologists blinded to patient information and were scored according to several variables potentially associated with LPRD. Separate assessments of the degree of erythema and degree of edema were scored on a five-point scale for the anterior commissure, membranous vocal fold, and interarytenoid region. Similarly, interarytenoid pachydermia, likelihood of LPRD involvement, and severity of LPRD findings were assessed. For each of these scored physical findings, inter-rater and intrarater reliabilities were determined. RESULTS: The inter-rater reliabilities of the laryngoscopic findings associated with LPRD were poor. Intraclass correlation coefficients were 0.161 and 0.461 for edema of the arytenoids and membranous vocal folds, respectively (P <.001). Intraclass correlation coefficients were 0.181 and 0.369 for erythema of the arytenoids and membranous vocal folds, respectively (P <.001). Raters demonstrated poor agreement as to the severity of LPRD findings (intraclass correlation coefficient, 0.265) and the likelihood of an LPRD component for dysphonia (intraclass correlation coefficient, 0.248). Similarly, intrarater reliability was extremely variable for the various physical findings, with Kendall correlation coefficients ranging from -0.121 to 0.837. CONCLUSIONS: Accurate clinical assessment of laryngeal involvement with LPRD is likely to be difficult because laryngeal physical findings cannot be reliably determined from clinician to clinician. Such variability makes the precise laryngoscopic diagnosis of LPRD highly subjective.     

咽喉反流性疾病的发病机制及诊疗进展

近年来,随着社会生活节奏的加快,人们饮食习惯的改变,出现越来越多的消化道及咽喉疾病.咽喉反流性疾病(laryngopharyngeal reflux disease,LPRD)作为耳鼻咽喉科的一类疾病,其发病率也呈现不断上升的趋势.长期以来,LPRD并未受到耳鼻咽喉科医师的重视,诊断也是建立在胃食管反流疾病(gastroesophageal reflux disease,GERD)的认识之上,常常漏诊和误诊.因此,明确LPRD的发病机制及诊疗方法并与GERD相区别有着重要的意义.     

High incidence of laryngopharyngeal reflux in patients with head and neck cancer

OBJECTIVES: Laryngopharyngeal reflux may play a role in the etiology of squamous cell cancer of the head and neck and contribute to complications in head and neck cancer patients after surgery or during radiotherapy. STUDY DESIGN: Prospective study. METHODS: To investigate the incidence of laryngopharyngeal and gastroesophageal reflux in patients with head and neck cancer, ambulatory 24-hour double-probe pH monitoring was performed in 24 untreated patients with laryngeal or pharyngeal squamous cell carcinoma. In addition, 10 patients who had been irradiated in the head and neck area were analyzed for reflux to study the effect of radiotherapy on reflux. RESULTS: Only 4 of the 24 head and neck cancer patients (17%) had neither pathological laryngopharyngeal nor gastroesophageal reflux. Esophageal acid exposure was abnormal in five patients and acid exposure at the level of the upper esophageal sphincter was abnormal in four patients. Eleven patients had pathological reflux in both areas. Irradiated patients did not differ from the untreated patients considering the incidence of pathological laryngopharyngeal or gastroesophageal reflux. CONCLUSIONS: The data obtained in this study indicate that reflux is a common event in head and neck cancer patients.     

Prevalence of laryngopharyngeal reflux in a population with gastroesophageal reflux

OBJECTIVE: Laryngopharyngeal reflux (LPR) is a syndrome associated with a constellation of symptoms usually treated by ENT surgeons. It is believed to be caused by the retrograde flow of stomach contents into the laryngopharynx, this being a supra-esophageal manifestation of gastroesophageal reflux disease (GERD). It has been cited that LPR and GERD can be considered separate entities. Our hypothesis was that LPR is a supra-esophageal manifestation of GERD and therefore that patients with GERD should have a degree of symptoms suggestive of LPR because of the reflux of the gastric contents. We examined a population of patients with both upper gastrointestinal endoscopy and symptom-proven GERD and, using a questionnaire, looked at their existing symptoms to help assess the prevalence of LPR. We also looked at whether, with more severe GERD (suggestive of increased gastric content reflux), the degree of symptoms suggestive of LPR would be increased, as would be expected. METHODS: A population of patients with endoscopically proven GERD were recruited and divided into groups depending on the severity of their reflux disease. A questionnaire was then administered that examined both LPR and GERD scoring criteria. The relationship between GERD and LPR was then analyzed. RESULTS: We recruited 1,383 subjects with GERD; those with severe GERD had significantly higher LPR scores compared with those with mild (P < .01), moderate (P < .05), or inactive disease (P < .001). CONCLUSIONS: The condition of LPR is likely to represent a supra-esophageal manifestation of GERD. This study examined a large number of patients with endoscopically proven GERD and has demonstrated a correlation between the severity of GERD and the prevalence of LPR. LPR and GERD are common and interlinked conditions. The subsequent prevalence of LPR in the population with GERD is therefore likely to be dramatically underestimated.     

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.     

Association of laryngopharyngeal symptoms with gastroesophageal reflux disease

OBJECTIVES: The prevalence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal disorders is probably greater than realized. STUDY DESIGN: Prospective study. METHODS: To investigate the incidence of gastroenterological diseases including GERD in patients complaining of nonspecific laryngopharyngeal symptoms, laryngological examinations and gastroenterological evaluation with esophagogastroduodenoscopy were performed in 30 patients who refused to undergo 24-hour pH monitoring. Therapeutic intervention by behavioural and dietary modifications, antireflux medication, and eradication of Helicobacter pylori were assessed for changes in laryngeal findings and relief of symptoms. RESULTS: Posterior laryngitis was present in 26 patients and in 19 of them was accompanied by erythema and edema of the interarytenoid region. Gastroenterological diseases such as GERD (43%), hiatal hernia (43%), and Helicobacter pylori-positive antrum gastritis (23%) were confirmed in 22 (73%) cases by esophagogastroduodenoscopy and histological examination of biopsy specimens. Medical antireflux treatment and eradication of Helicobacter pylori resulted in a remarkably therapeutic success rate of 90% because there was resolution of laryngopharyngeal symptoms and laryngeal findings in 20 of 22 patients with gastroenterological diseases for the mean follow-up period of 8 months. CONCLUSIONS: Laryngopharyngeal symptoms can be predictors of gastroesophageal diseases and GERD because the most frequent underlying cause is supposed to be associated with posterior laryngitis. Medical antireflux treatment is effective for relief of symptoms and mucosal healing of posterior laryngitis.     

咽喉反流与发声障碍的相关性研究

目的:探讨咽喉反流的嗓音学特征及其对患者生活质量的影响,分析主客观评估方法的相关性。方法:对196例可疑有咽喉反流的患者行一般情况调查、电子鼻咽喉镜检查、反流症状指数量表(RSI)和反流检查计分量表(RFS)评估,将其中RSI评分>13分、RFS评分>7分定为阳性。将2个量表评分均为阳性的100例患者作为研究对象,进一步进行嗓音障碍指数量表(VHI)评估、嗓音声学分析及电声门图检查,并与健康对照组比较。结果:男女基频均比健康对照组降低,基频微扰、振幅微扰及标准化噪声能量增高,接触率降低,最大发声时间缩短,与健康对照组比较,差异均有统计学意义(均P<0.01)。VHI量表评估生理P评分最高,其次为功能F评分,情感E评分最低。咽喉反流患者的RSI与VHI有一定相关性(P<0.05),而RFS与RSI、VHI无明显相关性(P>0.05)。咽喉反流患者的嗓音障碍指数评估示生理、功能和情感之间明显相关。结论:嗓音声学分析及电声门图检测从客观上提示咽喉反流相关的嗓音障碍疾病严重影响了喉的发声功能,使基频下降、声带振动不稳定、声门闭合不良及声门接触时间缩短。主客观评估方法的相关性结果提示具有明显咽喉反流症状的患者并不一定具有明显的咽喉反流体征。