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Tan-Geller M. Zebras in Adult Dysphagia Workup: Where to Look When You Think You Have Looked Everywhere. Otolaryngol Clin North Am 2024:S0030-6665(24)00042-2. [PMID: 38575489 DOI: 10.1016/j.otc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.
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Affiliation(s)
- Melin Tan-Geller
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.
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2
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Sadiku E, Hasani E, Këlliçi I, Mone I, Kraja F, Kraja B, Burazeri G. Extra-esophageal symptoms in individuals with and without erosive esophagitis: a case-control study in Albania. BMC Gastroenterol 2021; 21:76. [PMID: 33593300 PMCID: PMC7885502 DOI: 10.1186/s12876-021-01658-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/22/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Erosive reflux esophagitis caused a large clinical spectrum of symptoms. Our aim was to assess the prevalence of extra-esophageal symptoms in individuals with and those without erosive esophagitis in Albania. METHODS A case-control study was conducted at the Regional Hospital of Durres, the second main district in Albania, a transitional country in South Eastern Europe, including 248 patients with erosive esophagitis (aged 46.5 ± 16.3 years) and 273 controls (aged 46.4 ± 16.0 years; response rate: 70%) enrolled during the period January 2013-June 2014. Both cases and controls underwent upper endoscopy. Information on socio-demographic characteristics and lifestyle factors was also collected. Binary logistic regression was used to assess the association of erosive esophagitis and extra-esophageal symptoms. RESULTS Patients with erosive esophagitis had a higher prevalence of excessive alcohol consumption, smoking, sedentarity, non-Mediterranean diet and obesity compared to their control counterparts (9% vs. 5%, 70% vs. 49%, 31% vs. 17%, 61% vs. 49% and 22% vs. 9%, respectively). Upon adjustment for all socio-demographic characteristics and lifestyle/behavioral factors, there was evidence of a strong association of erosive esophagitis with chronic cough (OR = 3.2, 95% CI = 1.7-5.8), and even more so with laryngeal disorders (OR = 4.4, 95% CI = 2.6-7.5). In all models, the association of erosive esophagitis with any extra-esophageal symptoms was strong and mainly consistent with each of the symptoms separately (fully-adjusted model: OR = 4.6, 95% CI = 2.9-7.3). CONCLUSION Our findings indicate that the prevalence of extra-esophageal symptoms is higher among patients with erosive esophagitis in a transitional country characterized conventionally by employment of a Mediterranean diet.
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Affiliation(s)
- Edite Sadiku
- University Clinic of Gastrohepatology and Hepatology Service, University Hospital Center "Mother Teresa", Dibra Street 371, 1001, Tirana, Albania
| | - Eqerem Hasani
- Emergency Departments, University Hospital Center Mother Teresa, Dibra Street 371, Tirana, Albania.,Division of Physiology, Department of Biomedical and Experimental Sciences, Faculty of Medicine, University of Medicine, Dibra Street 371, Tirana, Albania
| | - Indrit Këlliçi
- Division of Physiology, Department of Biomedical and Experimental Sciences, Faculty of Medicine, University of Medicine, Dibra Street 371, Tirana, Albania.,Endoscopy Unit, Service of Surgery, Regional Hospital Durrës, Telat Noga Street, Durrës, Albania
| | - Iris Mone
- Division of Physiology, Department of Biomedical and Experimental Sciences, Faculty of Medicine, University of Medicine, Dibra Street 371, Tirana, Albania.,Department of Laboratory, University Hospital Center Mother Teresa, Dibra Street 371, Tirana, Albania
| | - Fatjona Kraja
- Division of Physiology, Department of Biomedical and Experimental Sciences, Faculty of Medicine, University of Medicine, Dibra Street 371, Tirana, Albania.,University Clinic of Oncology, University Hospital Center Mother Teresa, Dibra Street 371, Tirana, Albania
| | - Bledar Kraja
- University Clinic of Gastrohepatology and Hepatology Service, University Hospital Center "Mother Teresa", Dibra Street 371, 1001, Tirana, Albania. .,Division of Physiology, Department of Biomedical and Experimental Sciences, Faculty of Medicine, University of Medicine, Dibra Street 371, Tirana, Albania.
| | - Genc Burazeri
- Department of International Health, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD, Maastricht, The Netherlands
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Swain S, Choudhury J. Experience with the management of pediatric laryngopharyngeal reflux in an Indian teaching hospital. JOURNAL OF CLINICAL SCIENCES 2020. [DOI: 10.4103/jcls.jcls_38_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Van Daele DJ. Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation. Laryngoscope 2019; 130:2120-2125. [DOI: 10.1002/lary.28289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Douglas J. Van Daele
- Department of Otolaryngology–Head and Neck SurgeryRoy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa U.S.A
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Hamdan A, Khalifee E, Ghanem A, Mansour H, Yammine E. Predictive value of globus pharyngeus in patients with functional dysphonia versus organic dysphonia. Laryngoscope 2018; 129:930-934. [DOI: 10.1002/lary.27493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Abdul‐Latif Hamdan
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical Center Beirut Lebanon
| | - Elie Khalifee
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical Center Beirut Lebanon
| | - Anthony Ghanem
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical Center Beirut Lebanon
| | - Hisham Mansour
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical Center Beirut Lebanon
| | - Edmond Yammine
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical Center Beirut Lebanon
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Wise SK, Wise JC, DelGaudio JM. Association of Nasopharyngeal and Laryngopharyngeal Reflux with Postnasal Drip Symptomatology in Patients with and without Rhinosinusitis. ACTA ACUST UNITED AC 2018; 20:283-9. [PMID: 16871930 DOI: 10.2500/ajr.2006.20.2849] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux. Methods Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3). Results Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055). Conclusion Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.
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Affiliation(s)
- Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, The Emory Clinic, 1365A Clifton Road NE, Suite 2100, Atlanta, GA 30322, USA
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Fukui A, Nakayama M, Sakamoto N, Arima S, Sato S, Suzuki M, Murakami S. Relation between globus pharyngeus and OSA in patients examined simultaneously by PSG and pH monitor: A cross sectional study. Auris Nasus Larynx 2018; 45:1033-1040. [PMID: 29544872 DOI: 10.1016/j.anl.2018.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This was a first cross-sectional single-center study to research the relation between globus pharyngeus, OSA and GERD. Since previous clinical studies have demonstrated a relationship between globus phayrngeus and GERD, however, no reported study on the relation between globus pharyngeus, sleep disorders including OSA, and GERD. METHODS Seventeen patients underwent general and otorhinolaryngological examinations and responded to several questionnaires (ESS, PSQI, HADS, and Globus pharyngeus VAS score) at their first visit, and underwent a gastroesophageal test for 24-h pH monitoring and in-laboratory PSG one to two months later. RESULTS No significant differences were seen in ESS, PSQI, or HADS scores between the groups. The acid exposure time was not significantly different among the groups. The percentage of esophageal reflux time was higher than the percentage of laryngopharyngeal reflux time through the total time as well as the supine period. This indicated that GERD occurred more frequently than laryngopharyngeal reflux. The entire results showed concurrent OSA in 10 cases (59%) and concurrent GERD in 7 cases (41%). The cases with OSA were treated by CPAP or oral appliance, and those treatments were effective for globus pharyngeus. CONCLUSION Although the relation between OSA and globus phayngeus is still controversial, these findings suggest that OSA may be a previously undetected cause of globus pharyngeus. By improving OSA, it may offer an additional option of treatment for those globus pharyngeus cases combined with OSA.
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Affiliation(s)
- Ayako Fukui
- Good Sleep Center & Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Meiho Nakayama
- Good Sleep Center & Department of Otolaryngology, Nagoya City University, Nagoya, Japan.
| | - Naoko Sakamoto
- Department of Epidemiologic Research, Toho University, Tokyo, Japan
| | - Sachie Arima
- Good Sleep Center & Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Shintaro Sato
- Good Sleep Center & Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Motohiko Suzuki
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Shingo Murakami
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
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Soni S, Chouksey S. A Study of Clinicopathological Profile of Patients of Hoarseness of Voice Presenting to Tertiary Care hospital. Indian J Otolaryngol Head Neck Surg 2017; 69:244-247. [PMID: 28607898 PMCID: PMC5446350 DOI: 10.1007/s12070-017-1112-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022] Open
Abstract
Hoarseness is subjective term used to describe abnormal voice quality which may occur due to many causes because it is just a symptom. Proper knowledge and clinicopathological profile is important to treat the underlying pathology. This prospective study was carried out in 100 patients presented in Department of ENT, Gandhi Medical College, Bhopal from April 2013 to September 2014 with complaint of hoarseness of voice for more than 15 days. Objective of this study is to study incidence, duration and sex predilection for hoarseness of voice. Also to study different etiological and predisposing factors for hoarseness of voice. After taking detailed history of the patient, complete examination of ear, nose and throat has been carried out. Indirect laryngoscopy, direct laryngoscopy, FOFE is done. Any suspicious tissue is sent for histopathological evaluation. X-ray soft tissue neck and if required CT SCAN larynx is done. Out of 100 patients maximum were from 50 to 70 years age group. 89% were males while only 11% were females. Labourers (37%) and farmers (32%) were the major groups affected. Smoking habit found in 60% of patients and tobacco chewing in 33% of patients and both, also having. Most common cause for hoarseness was found out to be laryngeal neoplasms of which supraglottic growth being commonest (37%) in our study. Hoarseness of voice may be present due to various underlying pathologies. So proper diagnosis, through detailed history, clinical examination and investigations is warranted to find out the cause and starting treatment.
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Affiliation(s)
- Smita Soni
- Department of E.N.T., Gandhi Medical College (G.M.C.), Bhopal, MP 462001 India
| | - Sanchay Chouksey
- Department of E.N.T., Gandhi Medical College (G.M.C.), Bhopal, MP 462001 India
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Ciorba A, Bianchini C, Zuolo M, Feo CV. Upper aerodigestive tract disorders and gastro-oesophageal reflux disease. World J Clin Cases 2015; 3:102-11. [PMID: 25685756 PMCID: PMC4317603 DOI: 10.12998/wjcc.v3.i2.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 09/20/2014] [Accepted: 10/28/2014] [Indexed: 02/05/2023] Open
Abstract
A wide variety of symptoms and diseases of the upper aerodigestive tract are associated to gastro-oesophageal reflux disease (GORD). These disorders comprise a large variety of conditions such as asthma, chronic otitis media and sinusitis, chronic cough, and laryngeal disorders including paroxysmal laryngospasm. Laryngo-pharyngeal reflux disease is an extraoesophageal variant of GORD that can affect the larynx and pharynx. Despite numerous research efforts, the diagnosis of laryngopharyngeal reflux often remains elusive, unproven and controversial, and its treatment is then still empiric. Aim of this paper is to review the current literature on upper aerodigestive tract disorders in relation to pathologic gastro-oesophageal reflux, focusing in particular on the pathophysiology base and results of the surgical treatment of GORD.
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11
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Abstract
Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.
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12
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Abstract
Objective: This study aimed to identify voice disorders commonly misidentified as reflux and sources of such misattribution. Study Design: Retrospective chart review. Methods: Twenty-six patients carrying a diagnosis of reflux alone presenting for second-opinion evaluation were identified from among 381 new patients presenting with a chief complaint of hoarseness over an 8-month period. Patients specifically referred for further workup were excluded. Results: Average duration of reflux treatment was 10.6 ± 9.0 weeks. In no case was reflux alone the cause of hoarseness. Eleven (42%) had phonotraumatic lesions, 9 (34%) had neurologic disorders, 5 (19%) had age-related changes, and 1 (4%) was infectious. Twenty-two (85%) abnormalities were diagnosed by dynamic laryngeal examination with improved optics, including stroboscopy. Only 4 (15%) represented disorders routinely diagnosed with flexible fiberoptic laryngoscopy. Conclusion: Hoarse patients with no apparent cause for dysphonia other than reflux after flexible laryngoscopy, or who fail to improve with appropriate treatment, may benefit from further laryngeal investigation rather than continued empiric treatment or further reflux evaluation.
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Affiliation(s)
- Lucian Sulica
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College, New York, New York, USA
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13
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Schindler A, Mozzanica F, Alfonsi E, Ginocchio D, Rieder E, Lenglinger J, Schoppmann SF, Scharitzer M, Pokieser P, Kuribayashi S, Kawamura O, Kusano M, Zelenik K. Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus. Ann N Y Acad Sci 2013; 1300:250-260. [PMID: 24117647 DOI: 10.1111/nyas.12251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.
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Affiliation(s)
- Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco,", University of Milan, Milan, Italy
| | - Francesco Mozzanica
- Department of Biomedical and Clinical Sciences "L. Sacco,", University of Milan, Milan, Italy
| | - Enrico Alfonsi
- Spinal and Cranial Reflexes Laboratory, Fondazione Istituto Neurologico C Mondino IRCCS, Pavia, Italy
| | - Daniela Ginocchio
- Department of Audiology, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Peter Pokieser
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Shiko Kuribayashi
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Osamu Kawamura
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Motoyasu Kusano
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Karol Zelenik
- Department of Otorhinolaryngology, University Hospital Ostrava, Ostrava, Czech Republic
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SØRENSEN MK, RASMUSSEN N, KRISTENSEN MS, BØTTGER M, FREDENSBORG BB, HANSEN CM, RASMUSSEN LS. Laryngeal morbidity after tracheal intubation: the Endoflex(®) tube compared to conventional endotracheal intubation with stylet. Acta Anaesthesiol Scand 2013; 57:737-44. [PMID: 23379725 DOI: 10.1111/aas.12079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tracheal intubation may cause vocal fold damage. The trial was designed to assess laryngeal morbidity comparing the Endoflex(®) tube with a conventional endotracheal tube with stylet. We hypothesised that laryngeal morbidity within the first 24 h after extubation would be lower with the Endoflex tube than with the conventional endotracheal tube with stylet because of less rigidity. METHODS This randomised trial included 130 elective surgical patients scheduled for general anaesthesia with endotracheal intubation. Pre- and post-operative assessment of hoarseness, vocal fold pathology, and voice analysis using the Multidimensional Voice Program was performed. Induction of anaesthesia was standardised. After complete neuromuscular paralysis, intubation was done with an Endoflex tube or a conventional endotracheal tube with stylet. RESULTS Post-operative hoarseness was found in 45% with the Endoflex tube and 55% with the endotracheal tube with stylet at 24 h after extubation (P = 0.44). Post-operative vocal fold injury was present in 23% in the Endoflex tube group and in 36% in the endotracheal tube with stylet group (P = 0.13). The increase in shimmer, the voice analysis variable reflecting vocal fold oedema, was 0.5% in the Endoflex tube group and 2.5% in the endotracheal tube with stylet group (P = 0.02). CONCLUSION No significant difference was found in the incidence of hoarseness or vocal fold injury using the Endoflex tube. However, the statistically significant lower increase in the shimmer values in that group implies that the Endoflex may be associated with less laryngeal morbidity.
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Affiliation(s)
- M. K. SØRENSEN
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - N. RASMUSSEN
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - M. S. KRISTENSEN
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - M. BØTTGER
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - B. B. FREDENSBORG
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - C. M. HANSEN
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
| | - L. S. RASMUSSEN
- Department of Anaesthesia, Centre of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
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Reflux and aerodigestive tract diseases. Eur Arch Otorhinolaryngol 2012; 270:417-23. [PMID: 22773190 DOI: 10.1007/s00405-012-2085-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 06/05/2012] [Indexed: 02/08/2023]
Abstract
Gastroesophageal reflux disease can present with a wide variety of extraesophageal symptoms. In particular, the type of disease characterized predominately by laryngopharyngeal reflux may be difficult to diagnose because of the absence of regurgitation or heartburn. The available battery of diagnostic tools is often insufficient to confirm a diagnosis of reflux, so the diagnosis is often made by elimination. In many cases, treatment with proton pump inhibitors will relieve symptoms and respiratory complications, despite the persistence of non-acidic reflux. Such treatment is often employed to "confirm" the diagnosis, as measured by patient response. Many diseases have been related to this condition in the literature. The authors review knowledge about these manifestations and their relationship with refluxed gastric content. Physiopathology, symptoms and treatment are reviewed in order to clarify our understanding of laryngopharyngeal reflux diseases and related manifestations.
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Lee BE, Kim GH. Globus pharyngeus: A review of its etiology, diagnosis and treatment. World J Gastroenterol 2012; 18:2462-71. [PMID: 22654443 PMCID: PMC3360444 DOI: 10.3748/wjg.v18.i20.2462] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 01/30/2012] [Accepted: 03/09/2012] [Indexed: 02/06/2023] Open
Abstract
Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.
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Wang AJ, Liang MJ, Jiang AY, Lin JK, Xiao YL, Peng S, Chen J, Wen WP, Chen MH. Predictors of acid suppression success in patients with chronic laryngitis. Neurogastroenterol Motil 2012; 24:432-7, e210. [PMID: 22276941 DOI: 10.1111/j.1365-2982.2011.01873.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Up to 50% of the patients suspected of reflux laryngitis syndrome failed to respond to acid suppression therapy. However, predictors of acid suppression success have not been determined. METHODS Consecutive patients with chronic laryngitis were enrolled prospectively. All the patients underwent laryngoscopy, esophagogastroduodenoscopy and 24-h multichannel intraluminal impedance and pH (MII-pH) monitoring before receiving rabeprazole 10 mg b.i.d. for 3 months. Patient was considered as a responder to acid suppression if the chief laryngeal complaint score during the last week since last interview had decreased by at least 50% after the start of therapy compared with baseline. Cox regression analysis was used to determine the independent predictors of acid suppression success. KEY RESULTS Of 92 patients (age 42.4 ± 14.3 years, 50 women), 42 (45.7%) responded to acid suppression after 3 months. Gastroesophageal reflux disease was defined in 22 patients, of whom 19 patients had pathological distal esophageal acid exposure and 5 were defined as erosive esophagitis. The time to response showed a significant hazard ratio for patients with increased distal esophageal acid exposure time (β: 0.93; HR: 2.55; 95% CI: 1.24-5.24; P = 0.011) and increased laryngopharyngeal bolus exposure time (BET; β: 0.96; HR: 2.61; 95% CI: 1.36-5.00; P = 0.004). The latter had the best Youden Index (0.34) and accuracy (68.5%). CONCLUSIONS & INFERENCES The success of acid suppression on chronic laryngitis could be predicted using reflux parameters detected by MII-pH, among which increased laryngopharyngeal BET is the best.
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Affiliation(s)
- A J Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Shimizu Y, Dobashi K, Kusano M, Mori M. Different gastoroesophageal reflux symptoms of middle-aged to elderly asthma and chronic obstructive pulmonary disease (COPD) patients. J Clin Biochem Nutr 2012; 50:169-75. [PMID: 22448100 PMCID: PMC3303481 DOI: 10.3164/jcbn.11-75] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 07/06/2011] [Indexed: 12/21/2022] Open
Abstract
Symptomatic differences and the impact of gastroesophageal reflux disease (GERD) have not been clarified in patients with asthma and chronic obstructive pulmonary disease (COPD). The purpose of this study is to assess the differences of GERD symptoms among asthma, COPD, and disease control patients, and determine the impact of GERD symptoms on exacerbation of asthma or COPD by using a new questionnaire for GERD. A total of 120 subjects underwent assessment with the frequency scale for the symptoms of GERD (FSSG) questionnaire, including 40 age-matched patients in each of the asthma, COPD, and disease control groups. Asthma and control patients had more regurgitation-related symptoms than COPD patients (p<0.05), while COPD patients had more dysmotility-related symptoms than asthma patients (p<0.01) or disease control patients (p<0.01). The most distinctive symptom of asthma patients with GERD was an unusual sensation in the throat, while bloated stomach was the chief symptom of COPD patients with GERD, and these symptoms were associated with disease exacerbations. The presence of GERD diagnosed by the total score of FSSG influences the exacerbation of COPD. GERD symptoms differed between asthma and COPD patients, and the presence of GERD diagnosed by the FSSG influences the exacerbation of COPD.
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Affiliation(s)
- Yasuo Shimizu
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan
- Jobu Hospital for Respiratory Disease, 586-1 Taguchi-machi, Maebashi, Gunma 371-0048, Japan
- Department of Pulmonary Medicine, Maebashi Red Cross Hospital, 3-21-36 Asahi-cho Maebashi, Gunma 371-0014, Japan
| | - Kunio Dobashi
- Gunma University School of Health Sciences, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Motoyasu Kusano
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Masatomo Mori
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Lundkvist K, Friberg D. Pharyngeal disturbances in OSAS patients before and 1 year after UPPP. Acta Otolaryngol 2010; 130:1399-405. [PMID: 20629584 DOI: 10.3109/00016489.2010.496465] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONCLUSIONS The results indicate that conservative uvulopalatopharyngoplasty with tonsillectomy (UPPP) did not change the degree of pharyngeal disturbances in patients with obstructive sleep apnea syndrome (OSAS). OBJECTIVES To investigate if the symptom scores of pharyngeal disturbances in OSAS patients were changed 1 year after UPPP, by using a questionnaire pre- and postoperatively, and to compare with healthy non-snoring controls. METHODS Fifty men and eight women, median age 46 years (range 25-75), median body mass index (BMI) 28 kg/m2 (20-38), and median preoperative oxygen desaturation index 16 (7-100) were included as they had all failed non-surgical treatment and wanted pharyngeal surgery. The questionnaire consisted of 10 questions with 4 degrees of disturbances; the maximum score was 30 and was evaluated before and 1 year after surgery. Fifteen age-, gender- and BMI-matched controls responded to the same questionnaire. RESULTS Responses to the questionnaire were provided pre- and postoperatively by 47 of 58 patients (81%). Their median score was unchanged from 5 (range 0-17) to 5 (0-19), compared with controls 1 (0-3). Analyses of separate questions showed a significant decrease in the score for 'globus sensation' and 'swelling' postoperatively.
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Affiliation(s)
- Karin Lundkvist
- Department of Otorhinolaryngology, Karolinska University Hospital, Huddinge, Stockholm and Clintec, Karolinska Institute, Sweden.
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Lam PKY, Ng ML, Cheung TK, Wong BYH, Tan VPY, Fong DYT, Wei WI, Wong BCY. Rabeprazole is effective in treating laryngopharyngeal reflux in a randomized placebo-controlled trial. Clin Gastroenterol Hepatol 2010; 8:770-6. [PMID: 20303417 DOI: 10.1016/j.cgh.2010.03.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/18/2010] [Accepted: 03/07/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy about the efficacy of treating patients with laryngopharyngeal reflux (LPR) using proton pump inhibitors (PPIs). We assessed the effects of high doses of the PPI rabeprazole in patients with LPR. METHODS Patients with LPR symptoms were assigned randomly to receive rabeprazole (20 mg, twice daily, n = 42) or placebo (n = 40) for 12 weeks. All patients completed symptom questionnaires; these provided demographic information and the reflux symptom index before, during, and 6 weeks after cessation of treatment. Videolaryngostroboscopy was used to document the laryngeal findings and determine the reflux finding score. RESULTS Twenty-four patients (57.1%) in the rabeprazole group and 27 patients (67.5%) in the placebo group had pH-documented LPR. The total reflux symptom index score decreased significantly in the group given rabeprazole, compared with patients given placebo, at weeks 6 and 12, but not at week 18. However, there were no significant differences in reflux finding scores between the rabeprazole and placebo groups at any of the time points. CONCLUSIONS Twelve weeks of treatment with rabeprazole (20 mg, twice daily) significantly improved reflux symptoms, compared with placebo, in patients with LPR. Relapse of symptoms was observed 6 weeks after stopping PPI therapy, indicating the requirement for longer treatment duration in patients with LPR.
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Affiliation(s)
- Paul K Y Lam
- Department of Surgery, University of Hong Kong, Hong Kong, China
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21
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Abstract
Postnasal drip (PND) is a common clinical complaint, yet its physiologic basis and appropriate treatment have been inadequately addressed in the medical literature. PND may be caused by a variety of conditions involving the nose and throat. Often, the symptom is not caused by actual secretions draining from the nose into the pharynx. In many instances, no definitive cause can be identified. Empiric treatment for PND symptoms should be guided by associated symptoms that suggest either a sinonasal cause or gastroesophageal reflux. Rarely, PND may be a symptom of a serious process such as a mass lesion in the pharynx or a malignancy and thus referral to an otolaryngologist is appropriate if symptoms are persistent, unexplainable, or associated with warning signs of malignancy.
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Affiliation(s)
- Matthew W Ryan
- Department of Otolaryngology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA.
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Baek CH, Chung MK, Choi JY, So YK, Son YI, Jeong HS. Role of salivary function in patients with globus pharyngeus. Head Neck 2010; 32:244-52. [PMID: 19572282 DOI: 10.1002/hed.21176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Our aim was to investigate the prevalence and the clinical role of salivary hypofunction in patients with globus sensation. METHODS We conducted a prospective observational study in 340 patients with globus pharyngeus. A standard questionnaire and (99m)Tc-pertechnate salivary scintigraphy were used to evaluate salivary hypofunction, with a full examination from the nasal cavity to the larynx (N = 303). We also investigated the effect of xerostomia management on globus symptoms (N = 252). RESULTS The symptom scores for xerostomia were higher in patients with severe globus (p < .05). Objective salivary hypofunction was noted in 57.4% of the patients, based on the reference values from control groups. Globus symptoms were more severe in the subgroup with salivary hypofunction (p = .0447). Conservative management of xerostomia significantly reduced the severity of globus at 1 and 3 months (p = .0002) regardless of salivary function. CONCLUSIONS Salivary hypofunction seems to be an aggravating factor in globus pharyngeus, but not a direct cause. Conservative management of xerostomia improves globus symptoms.
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Affiliation(s)
- Chung-Hwan Baek
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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Kwiatek MA, Mirza F, Kahrilas PJ, Pandolfino JE. Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation. Am J Gastroenterol 2009; 104:289-98. [PMID: 19174789 PMCID: PMC2890315 DOI: 10.1038/ajg.2008.150] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation. METHODS HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus. RESULTS UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function. CONCLUSIONS Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.
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Affiliation(s)
- Monika A. Kwiatek
- Division of Gastroenterology, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Faiz Mirza
- Division of Gastroenterology, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Mahieu HF. Review article: The laryngological manifestations of reflux disease; why the scepticism? Aliment Pharmacol Ther 2007; 26 Suppl 2:17-24. [PMID: 18081645 DOI: 10.1111/j.1365-2036.2007.03474.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment. AIM Proper understanding of laryngopharyngeal reflux disease (LPRD). METHOD Review of literature. RESULTS Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials. CONCLUSIONS LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.
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Affiliation(s)
- H F Mahieu
- Department of Otorhinolaryngology, Meander Medical Centre, Amersfoort, The Netherlands.
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Paine PA, Hamdy S, Chitnis X, Gregory LJ, Giampietro V, Brammer M, Williams S, Aziz Q. Modulation of activity in swallowing motor cortex following esophageal acidification: a functional magnetic resonance imaging study. Dysphagia 2007; 23:146-54. [PMID: 17955290 DOI: 10.1007/s00455-007-9114-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 07/03/2007] [Indexed: 12/11/2022]
Abstract
Esophageal acid exposure induces sensory and motility changes in the upper gastrointestinal tract; however, the mechanisms involved and the effects on activity in the brain regions that control swallowing are unknown. The aim of this study was to examine functional changes in the cortical swallowing network as a result of esophageal acidification using functional magnetic resonance imaging (fMRI). Seven healthy volunteers (3 female, age range=20-30 years) were randomized to receive either a 0.1 M hydrochloric acid or (control) saline infusion for 30 min into the distal esophagus. Postinfusion, subjects underwent four 8 min blocks of fMRI over 1 h. These alternated between 1 min swallowing water boluses and 1 min rest. Three-dimensional cluster analysis for group brain activation during swallowing was performed together with repeated-measures ANOVA for differences between acid and saline. After acid infusion, swallowing-induced activation was seen predominantly in postcentral gyrus (p<0.004). ANOVA comparison of acid with saline showed a significant relative reduction in activation during swallowing of the precentral gyrus (M1) BA 4 (p<0.008) in response to acid infusion. No areas of increased cortical activation were identified with acid vs. saline during swallowing. Esophageal acidification inhibits motor and association cortical areas during a swallowing task, probably via changes in vagal afferent or nociceptive input from the esophagus. This mechanism may play a protective role, facilitating acid clearance by reduced descending central motor inhibition of enteric/spinal reflexes, or by preventing further ingestion of injurious agents.
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Affiliation(s)
- Peter A Paine
- GI Sciences, University of Manchester, Manchester, UK.
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27
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Nonspecific Swallowing Complaints. TOPICS IN GERIATRIC REHABILITATION 2007. [DOI: 10.1097/01.tgr.0000299159.60116.ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Block BB, Brodsky L. Hoarseness in children: the role of laryngopharyngeal reflux. Int J Pediatr Otorhinolaryngol 2007; 71:1361-9. [PMID: 17644193 DOI: 10.1016/j.ijporl.2006.10.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 10/10/2006] [Accepted: 10/15/2006] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Bradley B Block
- Department of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, 3435 Main Street, Buffalo, New York 14214-3013, USA
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Lipan MJ, Reidenberg JS, Laitman JT. Anatomy of reflux: a growing health problem affecting structures of the head and neck. ACTA ACUST UNITED AC 2007; 289:261-70. [PMID: 17109421 DOI: 10.1002/ar.b.20120] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are sibling diseases that are a modern-day plague. Millions of Americans suffer from their sequelae, ranging from subtle annoyances to life-threatening illnesses such as asthma, sleep apnea, and cancer. Indeed, the recognized prevalence of GERD alone has increased threefold throughout the 1990s. Knowledge of the precise etiologies for GERD and LPR is becoming essential for proper treatment. This review focuses on the anatomical, physiological, neurobiological, and cellular aspects of these diseases. By definition, gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus; when excessive and damaging to the esophageal mucosa, GERD results. Reflux that advances to the laryngopharynx and, subsequently, to other regions of the head and neck such as the larynx, oral cavity, nasopharynx, nasal cavity, paranasal sinuses, and even middle ear results in LPR. While GERD has long been identified as a source of esophageal disease, LPR has only recently been implicated in causing head and neck problems. Recent research has identified four anatomical/physiological "barriers" that serve as guardians to prevent the cranial incursion of reflux: the gastroesophageal junction, esophageal motor function and acid clearance, the upper esophageal sphincter, and pharyngeal and laryngeal mucosal resistance. Sequential failure of all four barriers is necessary to produce LPR. While it has become apparent that GER must precede both GERD and LPR, the head and neck distribution of the latter clearly separates these diseases as distinct entities warranting specialized focus and treatment.
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Affiliation(s)
- Michael J Lipan
- Mount Sinai School of Medicine, Center for Anatomy and Functional Morphology, Box 1007, New York, NY 10029, USA.
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Ozturk O, Oz F, Karakullukcu B, Oghan F, Guclu E, Ada M. Hoarseness and laryngopharyngeal reflux: a cause and effect relationship or coincidence? Eur Arch Otorhinolaryngol 2006; 263:935-9. [PMID: 16816932 DOI: 10.1007/s00405-006-0097-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 05/20/2006] [Indexed: 11/26/2022]
Abstract
The role of laryngopharyngeal reflux (LPR) on hoarseness is widely assumed and accepted. Few articles present objective information on the subject. One of the main problems in establishing a relationship is our lack of knowledge of what is normal. We compared patients with chronic hoarseness and healthy controls to establish three goals: (1) to demonstrate the presence of additional symptoms and signs of LPR in patients with hoarseness; (2) to find the prevalence of LPR by utilizing 24 h double-probe in patients with hoarseness and compare it with that of the control group; (3) to contribute data to establish prevalence of LPR in healthy population. Forty-three patients with hoarseness and 20 healthy volunteers were enrolled in the study. All the patients in the study group had hoarseness of more than 3 months duration. The subjects recieved videolaryngoscopic evaluation and 24 h double-probe pH monitoring, and the results were compared. In the study group, 27 patients (62.8%) out of 43 had LPR episodes, compared to 6 (30%) of 20 healthy volunteers. Mean number of LPR episodes recorded by the pharyngeal probe was 7.0 [standard deviation (SD): 8.8] in 24 h, and this was significantly higher than that of the healthy controls [0.9/24 h (SD: 1.9)] (P = 0.003). Mean number of LPR episodes of the study group in upright position was 5.8 (SD: 7,0) and in supine position was 1.2 (SD: 3.3). These numbers were also significantly higher from the controls (P = 0.005 and P = 0.014 respectively). The results of this study show that: (1) most common additional symptoms were heartburn and chronic throat clearing and most common finding is pachydermia; (2) LPR incidence in patients with chronic hoarseness is significantly higher than the LPR incidence in healthy controls; (3) LPR is present in healthy people. However, the severity of LPR seems to be the causative factor rather than its presence.
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Affiliation(s)
- Ozcan Ozturk
- Department of Otolaryngology and Head Neck Surgery, Duzce Medical Faculty, Duzce University, P.K. 8, 81010, Duzce, Turkey.
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Ylitalo R, Lindestad P, Hertegård S. Pharyngeal and laryngeal symptoms and signs related to extraesophageal reflux in patients with heartburn in gastroenterology practice: a prospective study. Clin Otolaryngol 2006; 30:347-52. [PMID: 16209677 DOI: 10.1111/j.1365-2273.2005.00996.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe pharyngeal and laryngeal symptoms and findings in correlation to extraesophageal reflux (EER) in patients with heartburn. DESIGN A prospective study. SETTING Patients referred to Department of Gastroenterology, Karolinska University Hospital Huddinge. PARTICIPANTS Forty-three patients with chronic heartburn as the primary symptom, subdivided on the basis of oesophageal manometry to have gastro-oesophageal reflux disease (GORD) (n = 25) or not (n = 18). MAIN OUTCOME MEASURES Laryngeal video recordings of 43 patients were examined off-line. The occurrence of symptoms and laryngeal pathology were correlated to the results of 24-h double-probe pH monitoring. RESULTS Pharyngeal or laryngeal symptoms occurred often or quite often in 72% (18 of 25) of the GORD patients and 61% (11 of 18) of the patients without GORD. EER occurred in 73% (16 of 22) of the GORD patients with laryngeal symptoms and in 38% (6 of 16) of those without GORD but with laryngeal symptoms (P = 0.047). In the multivariate analysis the odds for hoarseness was 17 times higher if the patient had heartburn more than five times a day, compared with patients with heartburn less than once a day (OR 17.8, CI 1.7-405.9; P = 0.01). Cohen's kappa for intrarater reliability was 0.851 (P = 0.001). Laryngeal pathology was found in 56% of the GORD patients and 44% patients without GORD. There was no significant difference in the occurrence of any specific symptom or finding between the patients with and without GORD, nor with and without EER. CONCLUSIONS Although GORD together with laryngeal symptoms seem to be predictive of EER, there are no specific pharyngeal and laryngeal symptoms or findings that would help distinguishing patients with EER from those without. However, the more frequent the heartburn to the more frequent is hoarseness.
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Affiliation(s)
- R Ylitalo
- Department of Logopedics and Phoniatrics B 69, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Abstract
PURPOSE OF REVIEW Laryngopharyngeal reflux remains a controversial subject for both diagnosis as well as treatment. Nevertheless, there is increasing clinical and experimental evidence to suggest that it is associated with many nonspecific otolaryngological symptoms. RECENT FINDINGS Twenty-four hour dual probe pH tests fail to prove or exclude laryngopharyngeal reflux because of insufficient specificity and sensitivity. Therefore, the diagnosis is usually based on a combination of diagnostic signs and symptoms, which cannot be explained by pathology other than laryngopharyngeal reflux. Many signs of laryngopharyngeal reflux, however, are also found in individuals without symptoms. Treatment should consist of high-dose proton-pump inhibitor medication twice daily. SUMMARY Laryngopharyngeal reflux disease is a diagnosis by exclusion, and resolution of symptoms following a 4-month trial of high-dose proton pump inhibitor twice daily is, for all practical purposes, considered proof of the initial diagnosis. Nonresponse does not exclude the diagnosis of laryngopharyngeal reflux disease, however, since proton-pump inhibitors will only reduce the acid component of the refluxate.
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Affiliation(s)
- Hans F Mahieu
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Vrije Universiteit, Amsterdam, The Netherlands.
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Lam P, Wei WI, Hui Y, Ho WK. Prevalence of pH-documented laryngopharyngeal reflux in Chinese patients with clinically suspected reflux laryngitis. Am J Otolaryngol 2006; 27:186-9. [PMID: 16647983 DOI: 10.1016/j.amjoto.2005.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2005] [Indexed: 01/06/2023]
Abstract
PURPOSE Laryngopharyngeal reflux (LPR) is one of the main factors behind different laryngeal pathology according to the Western literature. Literature reported that the prevalence of gastroesophageal reflux disease (GERD) in Chinese population was considerably lower than that in Western countries. To date, however, there is no study to evaluate the prevalence of pH-documented LPR in the Chinese ethnicity. MATERIALS AND METHODS We thus recruited 28 consecutive Chinese patients with reflux symptoms including globus, throat discomfort, throat clearing, chronic cough, or burping lasting more than 1 month in the preceding 1 year, together with stroboscopic evidence suggestive of reflux laryngitis according to the reflux finding score in our study. All patients underwent thorough head and neck examination and transnasal endoscopic assessment. The prevalence of pH-documented LPR and GERD was then documented using ambulatory 24-hour pH biprobe study. RESULTS Six (21%) of the 28 patients had pH-documented LPR. Four (14%) of the 28 patients had GERD with 3 of them having concomitant LPR. Only burping was associated with pH-documented LPR (P < .05). No relationship was observed between pH-documented LPR and other factors, including age, sex, other reflux symptoms except burping, and the reflux finding score. CONCLUSION Chinese patients do have and present with symptoms of extraesophageal reflux, and we observed a lower prevalence of pH-documented LPR in Chinese patients with clinically suspected reflux laryngitis compared with white patients.
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Affiliation(s)
- Paul Lam
- Department of Surgery, Division of Otorhinolaryngology Head and Neck Surgery, The University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, Hong Kong
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DelGaudio JM. Direct Nasopharyngeal Reflux of Gastric Acid is a Contributing Factor in Refractory Chronic Rhinosinusitis. Laryngoscope 2005; 115:946-57. [PMID: 15933499 DOI: 10.1097/01.mlg.0000163751.00885.63] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether there is a difference in the prevalence of reflux in patients with refractory chronic rhinosinusitis (CRS) compared with control patients, including whether direct nasopharyngeal reflux (NPR) occurs in CRS patients. It is hypothesized that refractory CRS patients have a greater incidence of laryngopharyngeal reflux and NPR events and that NPR is a significant etiologic factor for CRS in these patients. STUDY DESIGN Prospective study. METHODS The study group consisted of 38 patients with a history of at least one endoscopic sinus surgery (ESS) with continued CRS symptoms and mucosal inflammation on endoscopy. The first control group consisted of 10 patients who had at least one ESS procedure and had no symptoms of CRS or mucosal inflammation a minimum of 1 year postoperatively. The second control group consisted of 20 subjects with no history of CRS or sinus surgery. All patients completed reflux symptom scales, a 20 item sinonasal outcome test, and a sinusitis symptom scale and underwent nasal endoscopy to grade the nasal mucosal findings. Patients underwent a 24 hour pH study with a specially designed probe with sensors located in the nasopharynx, 1 cm above the upper esophageal sphincter (UES), and the distal esophagus. The pH recordings were evaluated for NPR events less than pH 4 and 5. Reflux at the UES probe was considered pathologic if there were more than 6.9 episodes for the entire study or the reflux area index (RAI) exceeded 6.3. Esophageal reflux was defined as abnormal if greater than 4% of the study time was spent at pH less than 4. Statistical analysis was performed with Fisher's exact test to compare the reflux parameters and with analysis of variance and Tukey's post hoc analysis for the symptom and examination scores. RESULTS No statistical difference was found between the two control groups for any parameters at any sites. When a single outlier was dropped from the nonCRS control group, less NPR was found in the nonCRS group compared with the successful ESS control group (P = .03). Because these groups were statistically homogenous, they were collapsed into a single control group. Compared with the control group, the study group had significantly more patients with NPR events pH less than 4 (39% vs. 7%, P = .004) and an even greater difference in the number of patients with NPR events pH less than 5 (76% vs. 24%, P = .00003). At the UES, 74% of the study group had greater than 6.9 reflux episodes, compared with 38% of control patients (P = .006). The UES RAI was abnormal for 58% of the study group compared with 21% of the control group (P = .007). The study group also had more gastroesophageal reflux (66% vs. 31%, P = .007). For nasopharynx and UES reflux parameters, the differences between study and control groups increased when the patients with isolated frontal recess disease were removed from the dataset. The study group also had higher scores on all symptom and examination scores (P = .001 for each scale). CONCLUSIONS Patients with persistent CRS after ESS have more reflux at the nasopharynx, UES, and distal esophagus than controls. The greatest difference is in NPR, especially pH less than 5. This is the first study to document NPR in CRS patients, and it is likely to represent an important causative factor of refractory CRS in adults.
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Affiliation(s)
- John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Ylitalo R, Ramel S, Hammarlund B, Lindgren E. Prevalence of extraesophageal reflux in patients with symptoms of gastroesophageal reflux. Otolaryngol Head Neck Surg 2004; 131:29-33. [PMID: 15243554 DOI: 10.1016/j.otohns.2004.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To compare the prevalence of extraesophageal reflux (EER) in patients with heartburn, posterior laryngitis (PL), and in healthy controls. Study design and setting A retrospective and prospective study including a total of 101 subjects who underwent 24-hour dual-probe pH monitoring. RESULTS 52% of the subjects with heartburn had EER. No significant differences were found between the PL and heartburn groups for any pharyngeal reflux parameters. However, supine pharyngeal reflux was significantly more prevalent in heartburn patients with GERD than in PL patients and healthy controls (P < 0.05). Significant positive correlation (P < 0.01) was found between the percentage of time pH <4 in the pharynx and in the distal esophagus. CONCLUSION EER occurs in the majority of heartburn patients who are lacking laryngeal symptoms. Abnormal distal esophageal acid exposure makes the occurrence of EER more likely. SIGNIFICANCE EER appears to be a continuum without clear-cut differences between the groups.
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Chandra A, Moazzez R, Bartlett D, Anggiansah A, Owen WJ. A review of the atypical manifestations of gastroesophageal reflux disease. Int J Clin Pract 2004; 58:41-8. [PMID: 14994970 DOI: 10.1111/j.1368-5031.2004.0081.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Manifestations of atypical gastroesophageal reflux disease (GORD) are varied, and the presentation of atypical symptoms may occur in the absence of typical symptoms. The most sensitive and specific investigation for GORD is pH monitoring, and its application in atypical disease is utilized throughout this paper as a basis for correlating disease and pathogenesis. The less well-known areas of laryngeal manifestations, particularly chronic hoarseness and globus, are discussed in addition to recent work on orodental manifestations. Well-known areas of cardiac and respiratory manifestations, which include chronic cough and asthma, are also reviewed. Evidence from clinical trials indicates that aggressive anti-reflux therapy in patients with atypical symptoms can be effective. Where appropriate, medical therapy may involve long-term proton pump inhibitor, although further research outlining the roles of other therapies such as surgery is awaited.
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Affiliation(s)
- A Chandra
- Department of General Surgery, Guy's and St Thomas' Hospital, London, UK.
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Abstract
The association between gastroesophageal reflux disease (GERD) and extraesophageal disease is often referred to as extraesophageal reflux (EER). This article reviews EER, discussing epidemiology, pathogenesis, diagnosis, and treatment with a focus on the most studied and convincing EER disorders-asthma, cough, and laryngitis. Although EER comprises a heterogeneous group of disorders, some general characterizations can be made, as follows. First, although GERD's association with extraesophageal diseases is well-established, definitive evidence of causation has been more elusive, rendering epidemiological data scarce. Secondly, regarding the pathogenesis of EER, 2 basic models have been proposed: direct injury to extraesophageal tissue by acid and pepsin exposure or injury mediated through an esophageal reflex mechanism. Third, because heartburn and regurgitation are often absent in patients with EER, GERD may not be suspected. Even when GERD is suspected, the diagnosis may be difficult to confirm. Although endoscopy and barium esophagram remain important tools for detecting esophageal complications, they may fail to establish the presence of GERD. Even when GERD is diagnosed by endoscopy or barium esophagram, causation between GERD and extraesophageal symptoms cannot be determined. Esophageal pH is the most sensitive tool for detecting GERD, and it plays an important role in EER. However, even pH testing cannot establish GERD's causative relationship to extraesophageal symptoms. In this regard, effective treatment of GERD resulting in significant improvement or remission of the extraesophageal symptoms provides the best evidence for GERD's pathogenic role. Finally, EER generally requires more prolonged and aggressive antisecretory therapy than typical GERD requires.
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Affiliation(s)
- John Napierkowski
- Department of Medicine, Uniformed University of the Health Sciences, Washington, DC, USA
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Sun J, Xu B, Yuan YZ, Xu JY. Study on the function of pharynx & upper esophageal sphincter in globus hystericus. World J Gastroenterol 2002; 8:952-5. [PMID: 12378649 PMCID: PMC4656594 DOI: 10.3748/wjg.v8.i5.952] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Globus pharyngeus is not an uncommon symptom. Presently, its unclear dated pathophysiology remains unclear and the disease can not be evaluated correctly with routine diagnostic methods. The objective of this study is to establish the normal values of pharyngeal and UES pressure, pharyngeal transit time in healthy volunteers and to compare the differences between healthy volunteers and patients with globus pharyngeus.
METHODS: Twenty-four healthy volunteers and thirty-two patients clinically diagnosed as globus pharyngeus entered the study. Pressures of pharynx and UES were measured. Pharyngeal transit time was measured by videofluoroscopic procedure.
RESULTS: Normal pressure of pharynx, and normal resting pressure of UES were 157.81 ± 63.86 mm Hg and 68.33 ± 37.56 mm Hg, respectively. The corresponding values in the patients were 175.50 ± 93.47 mm Hg and 71.38 ± 41.42 mm Hg. The pharyngeal transit time was 1.44 ± 0.30 s in normal control group, among them there were 4 cases with stasis of barium in the valleculae and one in the piriform sinus. No laryngeal penetration or aspiration was found. In the patient group, the pharyngeal transit time was 1.37 ± 0.41 s, among them there were 6 cases with stasis of barium in the valleculae and 5 in the piriform sinus. Nine cases had laryngeal penetration and 2 had aspiration. There were no statistical differences of pressures of pharynx, UES and the pharyngeal transit time between the two groups. But there was an association between laryngeal penetration and globus pharyngeus
CONCLUSION: Radiographic examination of the pharynx show specific findings of pharyngeal dysfunction in patients with globus pharyngeus. UES pressure is normal in most patients. Hence, we find no role for UES hypertonicity as an etiologic factor in globus pharyngeus.
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Affiliation(s)
- Jing Sun
- Department of Gastroenterology, Ruijin hospital, Shanghai Second Medical University, Shanghai 200025, China
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Abstract
A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.
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Affiliation(s)
- Sherry W Ray
- Chattanooga Gastroenterology, P.C., Tennessee, USA
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Eubanks TR, Omelanczuk P, Hillel A, Maronian N, Pope CE, Pellegrini CA. Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy. Am J Surg 2001; 181:466-70. [PMID: 11448445 DOI: 10.1016/s0002-9610(01)00597-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD. METHODS Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy. RESULTS Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR-). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR- patients (75%) had persistent symptoms on medical therapy. CONCLUSIONS Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.
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Affiliation(s)
- T R Eubanks
- Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA.
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