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.     

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.     

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.     

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.     

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.     

Design and implementation of an ambulatory pH monitoring protocol in patients with suspected laryngopharyngeal reflux

OBJECTIVE/HYPOTHESIS: Adding a hypopharyngeal sensor to esophageal pH monitoring has been advocated for laryngopharyngeal reflux (LPR). However, selecting the proper pH catheter is problematic because esophageal lengths are variable among individuals. OBJECTIVE: To design and implement a new pH monitoring protocol for LPR. STUDY DESIGN/METHODS: Design parameters were defined prospectively: single-probe, triple-sensor pH catheter with sensors located in the hypopharynx (1-3 cm above upper esophageal sphincter) and in proximal and distal esophagus (20 cm and 5 cm above lower esophageal sphincter, respectively). Esophageal lengths were determined in a study population undergoing esophageal manometry. Optimal pH sensor spacings were determined using the least number of catheters to satisfy the design parameters. The protocol was implemented in consecutive subjects with suspected LPR. RESULTS: Distribution of esophageal lengths was determined in 1,043 subjects. In 92% of the study population, three pH catheters (3-15, 6-15, and 9-15 sensor-spacings) would satisfy the design criteria. Forty-one subjects with suspected LPR underwent the pH protocol. An abnormal pH test was found in 40 subjects (98%) with triple-sensor combination compared with 29 subjects (71%) if only dual esophageal sensors were used. CONCLUSIONS: Single-probe pH monitoring of the hypopharynx and esophagus was feasible. Adding a hypopharyngeal pH sensor increased the detection of abnormal acid reflux more often than traditional dual-sensor esophageal pH monitoring.     

Radiotherapy in N0 head and neck cancer patients

Summary The efficacy of elective radiotherapy in N0 cancer of the oropharynx, hypopharynx and supraglottic larynx was assessed retrospectively in a large series of head and neck cancer patients treated at the Institut Curie between 1958 and 1976. Despite a significant incidence of false-negative cases accompanied by extracapsular tumor spread, radiation tissue doses of 4500–5500 cGy were highly successful in preventing nodal disease in clinically negative necks. Isolated node failure occurred in only 2% of 611 cases of oropharyngeal and pharyngolaryngeal cancer from a total group of 1646 patients and 2% of 237 N0 cases of supraglottic vestibular cancer taken from a series of 340 patients. The impact of neck status on survival and disease-free survival is discussed. Present findings show that elective irradiation of the neck is easily integrated into the radiation management of primary pharyngeal and supraglottic laryngeal cancers and results in no additional morbidity to patients so treated.Presented at the International Symposium: Diagnosis and treatment of the N0 neck of carcinomas of the upper aero-digestive tract, 18 September 1992, Göttingen, Germany     

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.     

双探头24小时pH监测对咽喉反流的诊断价值及特点

目的对咽喉反流患者用食道测压定位法行双探头24小时pH监测,探讨其诊断价值及特点。方法对53例疑咽喉反流患者用食道测压定位法行双探头24小时pH监测同时用反流症状指数量表(reflux symptom index,RSI)、反流检查计分量表(reflux finding score,RFS)2个量表评估。结果 53例患者中31例咽喉反流阳性,与吸烟有相关性。RSI中以声嘶、咽异物感、持续清嗓为主要症状,RFS中以后连合增生、假声带沟、喉内黏液附着为主要体征。咽喉部酸反流主要发生在直立位,其中9例患者只有咽喉反流性疾病,10例只有胃食管反流性疾病;酸反流次数、酸暴露时间(即pH<4.0的总时间)与2个量表的评估有显著性差异。咽喉部pH监测结果与2个量表评估结果程度一致。结论咽喉反流性疾病可不伴发胃食管反流性疾病,减少酸反流次数及减少酸在咽喉部停留时间在治疗疾病中较为重要,RSI和RFS 2个量表可作为咽喉反流性疾病诊断的初筛。     

咽喉反流及胃食管反流在喉癌前病变及喉癌发生中的作用

目的探讨咽喉反流及胃食管反流在喉癌前病变及喉癌发生中的作用。方法2004年4月-2009年5月北京大学人民医院耳鼻咽喉科就诊并手术切除经病理确诊为声带黏膜不典型增生,经患者同意行24小时双探头pH监测（简称监测）的患者12例,1例喉鳞状细胞癌（T1N0M0）患者。结果13例患者监测,咽喉部pH阳性7例（53．85％）,食管部pH阳性8例（61．53％）,两者均阳性6例（46．15％）,其中7例咽喉部阳性和8例食管部阳性的患者反流症状指数量表阳性均为5例,反流检查计分阳性均为6例。结论咽喉反流及胃食管反流可能是喉癌前病变和喉癌发生的危险因素之一。     

The potential uses of high-dose-rate brachytherapy in patients with head and neck cancer

Brachytherapy has proven to be an extremely valuable method of treatment for head and neck cancer. The data supporting its application, however, is based on continuous low-dose-rate brachytherapy. To benefit from improved radiation protection, outpatient treatments, and increased patient tolerance of treatment set-up over that encountered in conventional low-dose-rate manually afterloaded brachytherapy, we implemented a high-dose-rate remote afterloading approach in selected patients with head and neck cancers. This treatment was utilized in two different roles in managing 29 patients. In its first role, it was used as the sole treatment in 13 patients with T1–2 NO malignancies. A total of ten treatments of 450–500 cGy each were delivered twice a day with a minimum of 5–6 h between treatments. With a median follow-up of 9 months, only 1 patient failed locally. In a second role, brachytherapy was applied in a post-operative adjuvant setting following wide local excision of tumors in patients who presented with recurrent disease (12 cases) or a second primary in the head and neck (4 cases). All patients had previously received external irradiation to the head and neck. Due to this previous course of irradiation, only eight treatments of 300 cGy each were delivered, for a total of 2400 cGy over a period of 4 days. However, with a follow-up of 2–16 months, only 3 patients remain disease-free.Presented at the combined meeting of the Society of Head and Neck Surgeons and the European Organization for Research and Treatment of Cancer, Paris, France, 25–28 May 1994     

Paraneoplastic syndromes in patients with primary head and neck cancer

Paraneoplastic syndromes represent the clinical manifestations of the indirect and remote effects produced by tumor metabolites or other products. The clinical spectrum of the various paraneoplastic syndromes related to primary malignancies of the head and neck region is presented. A review of the literature on paraneoplastic syndromes in patients with primary head and neck cancer was carried out. Paraneoplastic syndromes related to primary malignancies of the head and neck region can be categorized as: endocrine, cutaneous or dermatologic, hematologic, neurologic, osteoarticular or rheumatologic, ocular syndromes. Sometimes, paraneoplastic syndromes can be more serious than the consequences of the primary tumor itself and can precede, follow or be concurrent to the diagnosis of a malignancy; moreover, they can dominate the clinical picture and thus lead to errors with respect to the origin and type of the primary tumor. Physicians who deal with cancer-associated syndromes should be able to differentiate the paraneoplastic syndromes from the benign disorders that mimic them. Patients with a suspected paraneoplastic disorder should undergo a complete panel of laboratory studies, in addition to imaging studies and endoscopy. Identification of paraneoplastic syndromes allow the clinician to make an early diagnosis and to provide adequate treatment of tumors, with a favorable oncologic outcome and improved life expectancy for the patient. These syndromes can follow the clinical course of the tumor and thus be useful for monitoring its evolution.     

Immunosuppressive retroviral-related factors in sera of patients with head and neck cancer

Summary The chemotactic responsiveness of mononuclear phagocytes has often been found defective in patients with various malignancies. We have previously reported a defective chemotactic responsiveness in patients with head and neck cancer. Low-molecular-weight factors (LMWFs) have been isolated from tumors and can be held responsible for the inhibitory effect on monocyte chemotactic responsiveness. It is an intriguing new finding that these LMWFs can be neutralized by antibodies reactive to P15E, a structural envelope protein of murine leukemia retroviruses. In this report we describe a relatively easy and rapid method for the detection of immunosuppressive P15E-like factors in the sera of patients with head and neck cancer. The test is based on the monocyte polarization assay. Although only nine head and neck cancer patients were included in this study, the findings indicate that the test might be of value for clinical application. An early detection of a recurrence after treatment might be possible by the finding of a reappearance of the P15E-like factors in patients' sera during follow-up.     

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。