Pachydermia is not diagnostic of active laryngopharyngeal reflux disease

OBJECTIVE: To determine the change in pachydermia/posterior commissure hypertrophy in patients with laryngopharyngeal reflux disease (LPR) on long-term acid-suppressive therapy. STUDY DESIGN: Retrospective chart review. METHODS: Seventeen patients with LPR who were compliant with long-term acid-suppressive treatment and had good control of their symptoms for at least 20 months were examined. Pre- and posttreatment still laryngeal images from these patients were analyzed by five otolaryngologists blinded to patient information and were scored for pachydermia/posterior commissure hypertrophy according to the Reflux Finding Score (RFS) subset. Test-retest intraobserver reliability, intergrader correlations, as well as a paired t test for means of the data sets were then calculated. RESULTS: There was no significant difference in the grading scores between the pre- and posttreatment group for degree of pachydermia/posterior commissure hypertrophy despite a prolonged treatment interval (mean = 32 months) (P = .25). CONCLUSIONS: There is no statistically significant difference in the degree of pachydermia/posterior commissure hypertrophy found at diagnosis and after long-term acid suppressive therapy in patients with LPR. Therefore, it appears that pachydermia, as an isolated finding, is unreliable in determining the presence of active LPR.     

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。     

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,...     

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。     

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.     

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、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。     

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.     

喉咽反流性疾病的临床治疗研究

目的 探讨喉咽反流性疾病(LPRD)的诊疗方法,同时观察LPRD患者幽门螺杆菌检出率。 方法 156例反流症状指数(RSI)>13分和/或反流体征指数(RFS)>7分临床确诊为LPRD的患者,进行¹³C-尿素呼气试验(¹³C-UBT)^［4］检测,检出Hp阳性患者(I组)进行2周的幽门螺杆菌四联疗法^［5］(奥美拉唑+枸橼酸铋钾+阿莫西林+克林霉素)+甘桔冰梅片治疗后停药4周,观察Hp转阴率及LPRD转阴率;将Hp阴性患者随机分为2组,II组30例单纯给予甘桔冰梅片治疗4周后观察LPRD转阴率,III组30例给予奥美拉唑+莫沙必利+甘桔冰梅片治疗4周后观察LPRD转阴率。 结果 Hp阳性检出率为61.54%(96/156),经治疗2周后停药,4周复查Hp转阴率为78.12%(75/96),I组治疗后LPRD转阴率为67.71%(65/96),II组转阴率为53.33%(16/30),III组转阴率为96.67%(29/30)。经治疗后,三组RSI和RFS评分均较治疗前降低,差异有统计学意义(t=6.73,P<0.001)。治疗后III组与II组比较,III组的RSI和RFS评分更低。 结论 喉咽反流是导致咽喉炎的重要病因,使用抑酸剂及消化道促动力剂可明显改善喉咽反流的症状及体征。     

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.     

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.     

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.     

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.     

Incidence and treatment results of laryngopharyngeal reflux in chronic obstructive pulmonary disease

Laryngopharyngeal reflux (LPR) is defined as the movement of gastric content towards the larynx and the pharynx and it may cause respiratory symptoms or difficulty in their control. We aimed to find the frequency of LPR in chronic obstructive pulmonary disease (COPD) patients and to investigate its effect on COPD symptoms and the results of its treatment. At baseline 30 (20 male, 10 female, mean age: 65 ± 10 years) COPD patients completed LPR and COPD symptom questionnaires and 13 (44%) were diagnosed with LPR based on laryngeal examination. Patients with LPR were given 2 months of PPI treatment, after which LPR and COPD symptom questionnaires, laryngeal examinations and pulmonary function tests were repeated. Following the treatment, significant improvements in COPD symptom index, LPR symptom index and laryngeal examination findings were observed in patients with LPR (P < 0.01, P < 0.01, P < 0.0001, respectively). Treatment of LPR resulted in a significant improvement in the symptoms of COPD.     

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。     

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.