反流性喉炎与声带白斑关系的初步探讨

目的 探讨反流性喉炎与声带白斑的关系.方法 2009年3月～2009年11月在厦门大学附属中山医院耳鼻咽喉科经临床和病理诊断为声带白斑同时合并反流性喉炎的8例患者,予以6～8周的质子泵抑制剂(PPI)抗反流治疗,治疗前后分别进行频闪喉镜检查、嗓音主客观声学评估、嗓音障碍指数以及反流性喉炎症状评分量表和体征发现量表的评估.结果 8例患者反流性喉炎均治愈,频闪喉镜、主客观声学分析结果显示治疗后较治疗前均有所改善;8例患者声带白斑完全消失,随诊3～5个月未见声带白斑复发.结论 反流性喉炎与声带白斑可能存在某种关联,其在声带白斑的发生发展中起一定的作用,临床中应注意对声带白斑患者进行反流性喉炎的评估,PPI治疗可使部分患者避免手术.     

反应性声带肿胀与声带囊肿

一位１６岁女高音职业演员,高中学生,令人羡慕的演唱者有声嘶２个月．音调不稳,漏气过多,音量减低的病史。从９岁授课．约在过度用噪一个月后逐渐出现发音障碍。她发现很难控制过门（音区间的间歇）且嗓音疲劳有返流性喉炎症状。 动态喉镜窥查见右声带一个大的囊肿占据５０％以上声带肌膜。近囊后部有一异常曲张静脉垂直行向振动缘,也因返流导致杓状软骨区水肿,通过质子泵抑制剂和调整生活方式进行治疗。外展位时左声带接触面可见血管扩张性肿胀,通过嗓音休息疗法虽可治愈此等反应性肿胀病例,但如此大的症状性囊肿常需行手术切除。 …     

CO2激光联合质子泵抑制剂治疗复发性声带突肉芽肿的疗效观察

目的 探讨CO₂激光联合质子泵抑制剂治疗复发性声带突肉芽肿的疗效。 方法 对复发性声带突肉芽肿患者28例,采用全麻支撑喉镜下CO₂激光手术,其中有胃食管反流症状16例,胃食管反流症状不明确12例,术后应用质子泵抑制剂抗胃酸反流治疗8~12周,术后随访1年观察疗效。 结果 28例术后声嘶、咽异物感等症状均有明显改善,病理证实均为肉芽组织。术后随访1年复查电子喉镜复发2例,给予埃索美拉唑40 mg/d口服1个月,肉芽肿明显缩小1例,肉芽肿未见进一步增大1例,无声嘶及异物感等喉部症状,未予再次手术治疗。 结论 胃食管反流是声带突肉芽肿术后复发的一个重要因素;CO₂激光手术联合质子泵抑制剂是治疗复发性声带突肉芽肿的一个有效方法,创伤小、复发率低。     

窄带成像高清电子鼻咽喉镜对咽喉反流病的诊疗价值

目的:探讨窄带成像高清电子鼻咽喉镜对咽喉反流病的诊疗价值。方法:对46例有咽喉反流症状,反流症状指数量表、反流检查计分量表均为阳性,质子泵抑制剂诊断性治疗有效而确诊的咽喉反流病患者的窄带成像高清电子鼻咽喉镜检查的咽喉部特征性表现进行分析。结果:46例咽喉反流病患者的咽喉部表现为:杓状软骨间区红斑(水肿)(71.7%)、会厌充血(67.4%)、咽部孤立(融合)性红斑(65.2%)、咽后壁鹅卵石样改变(65.2%)、后连合肥厚(52.2%)、声带红斑及水肿(47.8%)、声带小结或声带息肉伴声带红斑、水肿(39.1%)、杓状软骨红斑水肿(21.7%)、室带红肿喉室消失(17.4%)、接触性肉芽肿(6.5%)、接触性溃疡(4.3%)、假声带沟(4.3%)。结论:咽喉反流病有特征性的咽喉部表现,窄带成像高清电子鼻咽喉镜操作简便,在咽喉反流病的诊断、治疗中有较高的应用价值。     

咽喉反流对CO2激光喉显微手术后喉功能及创面愈合影响及对策初探

目的探讨咽喉反流对CO_2激光喉显微手术后喉功能康复与创面愈合的影响及其对策。方法回顾性分析2010年1月至2014年7月我院支撑喉镜下CO_2激光喉显微手术患者63例,根据RSI、RFS量表得分确定患者是否存在咽喉反流;术后对部分咽喉反流患者进行质子泵抑制剂治疗。患者随访3月,应用嗓音障碍指数量表对患者进行嗓音评估。结果咽喉反流组的术后声带肉芽肿发生率高于无咽喉反流组(P<0.05)。无咽喉反流且未行质子泵抑制剂干预患者术后肉芽肿发生率为57.1%,咽喉反流阴性但行PPI干预治疗患者术后肉芽肿发生率为16.7%,组间差异具有统计学意义(P<0.05);咽喉反流阳性而未行质子泵抑制剂干预患者术后肉芽肿发生率为61.1%,咽喉反流阳性并行PPI干预患者术后肉芽肿发生率为27.8%,组间差异具有统计学意义(P<0.05)。无论咽喉反流阴性或阳性,给予或不给予PPI干预治疗,其术后嗓音障碍指数评分指数分布差异均有统计学意义(P<0.05)。结论咽喉反流对CO_2激光喉显微手术后的喉功能康复及创面愈合有一定影响,应用PPI干预治疗能有效减少术后声带肉芽肿等并发症的发生,促进喉功能及创面恢复。     

两种方法诊断咽喉反流患者的嗓音特征及治疗前后变化

目的　用pH监测和反流症状指数量表（reflux symptom index,RSI）联合反流体征评分量表（ref lux finding score,RFS）分别诊断咽喉反流,了解质子泵抑制剂治疗前后两种不同方法诊断咽喉反流患者嗓音学参数的变化,以期将嗓音改变作为咽喉反流疾病诊断和疗效判断的辅助指标之一。方法　2012年8月～2013年8月在北京大学 第三医院耳鼻咽喉科就诊,应用24小时多通道腔内阻抗及pH监测诊断为咽喉反流的患者26例,作为pH组;通过RSI、RFS诊断为咽喉反流的患者26例为量表组,无任何咽喉部不适的志愿者52名为对照组,对所有研究对象应用MDVP软件进行嗓音学参数检查;对实验组患者进行埃索美拉唑20 mg,2次/d,口服治疗,治疗1个月后复查嗓音学参数,分析治疗前、后患者嗓音学参数的差异。结果　咽喉反流患者与正常对照组之间比较,质子泵抑制剂治疗前频率微扰、振幅微扰、噪谐比均有显著性差异（P 均<0.05）;基频、最长发音时间无显著性差异;治疗后上述各嗓音声学参数与对照组之间比较均无显著性差异（P 均>0.05）;结论　咽喉反流患者存在嗓音声学参数的异常,质子泵抑制剂治疗后明显好转,某些嗓音学参数有可能作为咽喉反流疗效评估的客观指标之一。     

胃食管反流问题

近年,胃食管反流对某些难以理解的症状和疾病的作用,已越来越引起注意。耳鼻咽喉科-头颈外科所涉及的范围包括喉(特别是其后部)、吞咽和癔球,以及某些肺部情况。最近研究指出,顽固性咳嗽、气哽发作(choking spells)、“拽液”、清嗓、不明原因的嘶哑等喉部症状常可由酸性胃内容物反流所引起。有上述症状的患者,检查时可发现杓区有红斑,杓间粘膜增厚、堆起,以及声带后1/3处有炎症。这种情况称“后部”喉炎或“酸性”喉炎。喉接触性溃疡产生的主要原因传统地认为是滥用嗓音。自1968年以来,一些作者根据动物实验和用抗酸疗法能治愈的事实,认为喉接触性溃疡很可能是由胃食管反流所引起的一种消化性溃疡。Delahunty在一个胃食管反流病人的喉后部取活检,发现有角化不全上皮的增生     

老年人胃食管反流性咽喉炎30例临床分析

目的 探讨老年人胃食管反流性咽喉炎的诊治方法.方法 采用喉镜、胃镜和24h食管pH值监测明确诊断,并分析30例老年人胃食管反流性咽喉炎患者经抑酸药和胃肠动力药治疗前后的症状、喉镜和胃镜检查结果的改变情况.结果 30例老年人胃食管反流性咽喉炎患者经抑酸药和胃肠动力药治疗后有效率为93.33%.结论 喉镜、胃镜和24h食管pH值监测有助于明确老年人胃食管反流性咽喉炎的诊断,采用抑酸药和胃肠动力药治疗本病有效.     

反流性咽喉病患者嗓音声学特征分析

目的观察反流性咽喉病(laryngopharyngeal reflux disease,LPRD)患者的嗓音声学特征。方法对耳鼻咽喉科门诊就诊的反流症状指数(reflux symptom index,RSI)量表评分总分≥13分的45例LPRD患者和36例正常成人进行硬管喉镜检查,并用德国XION DIVAS嗓音测试分析系统对两组受试者的持续元音信号进行检测分析,计算嗓音障碍指数(dysphonia severity index,DSI),比较两组结果,并分析LPRD患者RSI量表评分及声嘶症状评分与DSI值的相关性。结果 45例LPRD患者RSI评分均值为17.7±5.15分,喉镜检查表现为杓状软骨区红斑、充血、水肿、糜烂、溃疡,声门后区增生肥厚、肉芽肿和声带水肿、肥厚;LPRD组的基频微扰(jitter)及振幅微扰(shimmer)均值比正常对照组增高,最长发声时间(MPT)和DSI的均值LPRD组较正常对照组降低,差异均有统计学意义(P<0.01)。LPRD患者DSI值与RSI量表评分和声嘶症状评分呈负相关,相关系数分别为-0.344和-0.447(P<0.05)。结论 LPRD患者可出现嗓音异常,提示反流性咽喉病可能导致声带病理改变而造成嗓音损害。     

影响声带任克水肿程度的常见因素分析

目的：探讨影响声带任克水肿（Reinke’s edema）严重程度的常见因素。方法对85例声带任克水肿患者按病变程度分为 I 度19例,II 度49例,III 度17例,分别对不同程度组患者的吸烟、嗓音滥用、喉咽反流的关系进行分析。结果85例中,喉咽反流阴性67例,阳性18例;43例有嗓音滥用,42例无嗓音滥用;66例有吸烟史,19例无吸烟史,烟龄≤25年25人,＞25年41人。单项有序分类变量秩和检验及有序多分类 logistic 回归模型分析显示,烟龄超过25年（P＜0．001）、喉咽反流（P＜0．01）、嗓音滥用（P＜0．01）与声带任克水肿分度有关。所有患者均经全麻支撑喉镜显微镜下行声带外侧微瓣术,术后随访一年以上,7例复发。结论吸烟、喉咽反流、嗓音滥用与声带任克水肿分度及复发有关,其中烟龄影响较大,烟龄越长,水肿程度越重。     

Silent reflux: ex juvantibus criteria for diagnosis and treatment of laryngeal disorders

CONCLUSIONS: Some primary laryngeal pathologies with specific clinical presentation may be related to silent laryngeal reflux. An ex adjuvantibus proton pump inhibitor (PPI) treatment may be helpful for showing evidence of such a hidden laryngeal disorder. OBJECTIVE: To assess the validity of PPI as an ex adjuvantibus criterion for diagnosis and treatment of suspected reflux-associated laryngitis. PATIENTS AND METHODS: Sixty patients with clinical suspicion of laryngo-pharyngeal reflux (LPR) were identified on the grounds of laryngeal symptoms (dysphonia, cough, globus sensation, increased throat clearing, bad taste, and laryngeal spasm), laryngeal features (arytenoid edema/erythema, partial or total vocal fold erythema, and posterior glottic edema) with or without gastro-esophageal reflux disorder (GERD). They were consequently subdivided in three groups: type I, with LPR symptoms and features without GERD; type II with LPR symptoms and features with GERD; and type III with LPR features only. Types I and III were randomly treated with omeprazole (group A) or with immunostimulating vaccine (group B) for 3 months. Pre- and post-treatment laryngeal features and symptoms in all groups were evaluated by laryngo-stroboscopy and analyzed for statistical correlation. RESULTS: All omeprazole-treated patients showed improvement of laryngeal features and symptoms. With PPI treatment, a more significant improvement was noticed with respect to nonspecific immunostimulant therapy. Also, patients without LPR symptoms showed improvement of laryngeal features.     

Silent reflux: Ex juvantibus criteria for diagnosis and treatment of laryngeal disorders

Conclusions. Some primary laryngeal pathologies with specific clinical presentation may be related to silent laryngeal reflux. An ex adjuvantibus proton pump inhibitor (PPI) treatment may be helpful for showing evidence of such a hidden laryngeal disorder. Objective. To assess the validity of PPI as an ex adjuvantibus criterion for diagnosis and treatment of suspected reflux-associated laryngitis. Patients and methods. Sixty patients with clinical suspicion of laryngo-pharyngeal reflux (LPR) were identified on the grounds of laryngeal symptoms (dysphonia, cough, globus sensation, increased throat clearing, bad taste, and laryngeal spasm), laryngeal features (arytenoid edema/erythema, partial or total vocal fold erythema, and posterior glottic edema) with or without gastro-esophageal reflux disorder (GERD). They were consequently subdivided in three groups: type I, with LPR symptoms and features without GERD; type II with LPR symptoms and features with GERD; and type III with LPR features only. Types I and III were randomly treated with omeprazole (group A) or with immunostimulating vaccine (group B) for 3 months. Pre- and post-treatment laryngeal features and symptoms in all groups were evaluated by laryngo-stroboscopy and analyzed for statistical correlation. Results. All omeprazole-treated patients showed improvement of laryngeal features and symptoms. With PPI treatment, a more significant improvement was noticed with respect to nonspecific immunostimulant therapy. Also, patients without LPR symptoms showed improvement of laryngeal features.     

喉结核临床表现及喉内镜观察

目的探讨现今喉结核的临床表现及喉内镜下的病变特点。方法回顾性分析1994年以来经病理确诊的36例喉结核患者的临床资料。结果患者年龄19-78岁，中位年龄39，5岁；声嘶为主要症状（83．3％）。纤维喉镜下见病变多累及声带、室带，病变形态以肉芽样或结节样增殖性病变为主；动态喉镜下见病变声带黏膜波及振动消失或减弱；24例喉部多部位病灶者中79，2％（19／24）并发活动性肺结核，12例喉部单一病灶者中75．0％（9／12）肺部正常。全部患者均行系统抗结核治疗，除失访10例外，其余26例均治愈。结论当今喉结核的局部症状不典型，全身症状不明显；可以发生于无肺结核者，其病变可累及喉部多处，以声带、室带多见。     

Gastroesophageal reflux -- a common illness?

For a long time heartburn was not considered a symptom for serious illness. By now, however, it is accepted that the incidence of secondary carcinoma of the esophagus caused by chronic GERD has increased dramatically since the nineteen-seventies. Mechanisms leading to GERD are complex and its incidence is not necessarily pathological. However pathological reflux in the lower esophagus (pH lower than 4 in 6 % of 24 hours), caused by decreased sphinctertonus, impaired peristalsis and clearance of the esophagus, may lead to complications. Helicobacter pylori may play a key role in GERD. There is strong evidence for a protective effect of Hp-infection in the development of GERD. In pangastritis, caused by Hp-infection, gastric acid production is inhibited resulting in a reduction of stomach-acid-concentration. This may be caused by either the chronic infection itself and the resulting atrophy of the stomach-mucosa, by the ammonia-producing HP-bacteria, or an increase in acid re-absorbtion of gastric epithelium. Laryngopharyngeal reflux (LPR) often results in atypical manifestations with oral, pharyngeal, laryngeal, and pulmonary disorders. Laryngopharyngeal reflux is known to contribute to posterior acid laryngitis and laryngeal contact ulceration or granuloma formation, laryngeal cancer, chronic hoarseness, pharyngitis, asthma, pneumonia, nocturnal choking, and dental diseases. Today, PPI are the medication of choice in both acute and long-term (prophylactic) therapy of GERD. The so called "step-up-strategy" of medication is no longer recommended. Here, patients were first treated with antacids, then prokinetics followed by H2-blockers and finally low-dose PPI. Only in the case of persisting symptoms medication was further increased to high-dose PPI therapy. In the past this increase in medication lead to a prolonged healing process and consequently to higher medication costs. Studies have shown that a "step-down"-therapy, beginning with high dose PPI, is highly preferable, since it is much more effective. Depending on the degree of the symptoms, however, medication may also be applied "on-demand". The BfArM has approved this kind of medication application only for Esomeprazol (Nexium mups 20 mg).     

Paradoxical vocal cord dysfunction in juveniles

OBJECTIVE: To evaluate demographic and videolaryngoscopic features in a large series of juveniles with paradoxical vocal cord dysfunction (PVCD). DESIGN: Case series data from videolaryngoscopic tapes retrospectively evaluated in a masked, controlled fashion, and demographic data collected via retrospective medical chart review. SETTING: A tertiary care otolaryngology and speech pathology referral center. PATIENTS: Twenty-two patients with PVCD aged 18 years and younger diagnosed as having PVCD at The Ohio State University Voice Institute, Columbus. MAIN OUTCOME MEASURES: Age, sex, social history, and medical history (demographic); epiglottic position, arytenoid and interarytenoid appearance, phase 0 stability, true vocal cord respiratory motion, degree of anteroposterior (AP) constriction, and false vocal cord adduction (videolaryngoscopic). RESULTS: Of 22 patients, 18 were girls, and 12 had significant social stressors, particularly organized sports. Nineteen patients had posterior laryngeal changes commonly found in gastroesophageal reflux disease. Twelve patients demonstrated abnormal true vocal cord adduction during quiet respiration. Seven patients demonstrated supraglottic anteroposterior constriction and false vocal cord approximation during phonation. CONCLUSIONS: Juvenile PVCD is more common in girls and is associatedwith social stresses. Anatomic laryngeal changes typically associated with gastroesophageal reflux disease are extremely common in these patients. Juveniles with PVCD frequently demonstrate abnormal true vocal cord adduction during quiet respiration. We recommend that initial evaluation of juvenile patients for possible PVCD be conducted via transnasal fiberoptic laryngoscopy while the patient is asymptomatic, and that strong consideration be given to empiric pharmacological treatment of gastroesophageal reflux disease in juveniles diagnosed as having PVCD.     

Specific features of laryngeal paresis following surgical treatment of diffuse toxic goiter (a prospective longitudinal passive study)

Specific manifestations of postoperative laryngeal paresis observed with the use of indirect laryngoscopy are described in 53 patients subjected to the surgical treatment of diffuse toxic goiter. Laryngeal paresis was shown to develop both in the early (up to 7 days) and in the late (over 14 days) postoperative periods. The delayed form of pathology accounted for 13% of the total number of the cases of postoperative laryngeal paresis. The standard treatment of transient postoperative laryngeal paresis resulted in the complete recovery of vocal cord mobility within 1-6 months after the onset of therapy, regardless of the state of the cords at the time of diagnosis of the disease. Persistent postoperative laryngeal paresis developed by the end of the 15 month observation period. Phonation was found to be preserved in 66% of the patients in whom laryngeal paresis (unilateral abduction paresis) had been diagnosed by indirect laryngoscopy. In all the remaining patients, phonation recovered 15 months or more after surgery. The authors argue that neither the recovery nor the preservation of phonation can be a criterion for the absence of complications. Also, the outcome of surgical intervention unsupported by the results of laryngoscopy performed within 1, 6, and 15 months after the treatment does not reflect the true structure of postoperative complications.     

Globus sensation caused by gastroesophageal reflux disease

Objectives: This study was designed to examine whether or not gastro esophageal reflux disease (GERD) is implicated in globus sensation. Methods: The subjects were 25 patients (16 men/9 women; mean age: 51, range 25–69 years) complaining of globus sensation with one or more of four laryngeal findings suspected of having GERD, such as pooling of saliva, erythema of posterior one-third of larynx, inter-arytenoids edema, and granuloma. All 25 patients were administrated a proton pump inhibitor (PPI) for a period of 8 weeks. All were given esophageal endoscopies, laryngoscopes, and questionnaire before and after PPI dosing. The questionnaire survey was conducted to investigate changes in globus sensation and three symptoms specific to GERD including heartburn, regurgitation, and belching. Subjective symptoms were totalled by the over all scores of the three subjective symptoms which served as an index of severity of GERD. Results: Fifty-two percent (13/25) of patients had reflux esophagitis. The esophagitis were improved after PPI administration except one case. The incidences of GERD symptoms were high (heart burn 68% (17/25), belching 49% (10/25) and regurgitation 76% (19/25)), and most of these symptoms ameliorated by PPI administration. The laryngeal findings were improved in all patients. Subjective symptoms were improved in 68% (17/25) of globus patients. The improvement rate of total score (before PPI dosing/after PPI dosing) was compared between the two groups: one with improved globus sensation (17 patients) and the other without (8 patients). The improvement rate was significantly higher in the group with improved globus sensation (P<0.05). This means that globus sensation improved because of the improvement in GERD. Conclusion: GERD is therefore concluded to be an inducing factor of globus sensation.     

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease

OBJECTIVE: To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD). STUDY DESIGN: Retrospective chart review METHODS: Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy). RESULTS: A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality. CONCLUSION: Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.     

Perspectives in Laryngopharyngeal Reflux: An International Survey

Objectives Although data exists to support the relationship between laryngopharyngeal reflux (LPR) and laryngitis, there is variability among otolaryngologists regarding the methods and criteria used to make the diagnosis. This study was undertaken to discern the current attitudes and practices of a select cohort of otolaryngologists in regards to LPR. Methods Four hundred fifteen surveys were mailed to members of the American Broncho‐Esophagological Association. Survey recipients were asked to rate patient symptomatology and physical examination findings in terms of their relationship to LPR and their preferred laryngeal visualization procedure in terms of clinical use and diagnostic accuracy. The role and validity of adjunctive diagnostic tests were also surveyed. Results Survey response rate was 38%. Symptoms felt to be most related to reflux were: throat clearing (98.3%), persistent cough (96.6%), heartburn/dyspepsia (95.7%), globus sensation (94.9%), and voice quality change (94.9%). The physical examination findings felt to be most related to reflux included: arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%). Fiberoptic laryngoscopy was the most commonly performed diagnostic visualization procedure (75.7%) and was also considered to be most sensitive and specific (45.0%). The most commonly ordered adjunctive test was a double pH probe (37.2%), which was also felt to be the most sensitive and specific adjunctive test (75.9%). Conclusion A polling of a select group of otolaryngologists demonstrated agreement in the criteria used to diagnose reflux laryngitis, although some variability exists. The development of objective guidelines for the diagnosis of LPR is a critical initial step toward evaluating the manifestations and therapeutic interventions for this disease process.