Diagnostic and management problems of laryngopharyngeal reflux disease in children

Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis

OBJECTIVES

To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI).

RESULTS

100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment.

CONCLUSIONS

Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.

Analysis of clinical characteristics in proximal and distal reflux monitoring among patients with gastroesophageal reflux disease

The purpose of this study was to examine the characteristics of proximal and distal gastroesophageal reflux in patients with gastroesophageal reflux disorder and analyze their clinical symptoms. A total of 67 patients with typical esophageal symptoms were selected for this study. All participants completed the reflux disease questionnaire and a questionnaire survey of extraesophageal symptoms. Diagnosis was made using a 24-h impedance-pH detection and proton pump inhibitor. The results showed that the proximal reflux group had a higher number of acid reflux episodes compared to the distal reflux group (P < 0.05). Similarly, the proximal reflux group also had a higher number of gas reflux episodes compared to the distal reflux group (P < 0.05). On the other hand, the distal reflux group had a higher number of mixed reflux episodes compared to the proximal reflux group (P < 0.05). These differences were statistically significant. This study revealed that acid reflux and gas reflux were more predominant in the proximal reflux group, while mixed reflux was more predominant in the distal reflux group.

Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review

Purpose: Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. Methods: A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. Findings: The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Conclusions: Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.

Pediatric Laryngopharyngeal Reflux in the Last Decade: What Is New and Where to Next?

BACKGROUND

Laryngopharyngeal reflux may affect people of any age; still, most of the accumulated knowledge concerns adults, and evidence regarding pediatric populations remains relatively restricted. This study aims to review the most recent and emerging aspects of pediatric laryngopharyngeal reflux from the last ten years. It also attempts to identify gaps in knowledge and highlight discrepancies that future research should urgently address.

METHODS

An electronic search of the MEDLINE database was conducted, limited to January 2012 through December 2021. Non-English language articles, case reports, and studies that concerned a purely or predominantly adult population were excluded. The information from the articles with the most relevant contribution was initially categorized by theme and subsequently synthesized into a narrative form.

RESULTS

86 articles were included, of which 27 were review articles, eight were surveys, and 51 were original articles. Our review systematically maps the research done in the last decade and provides an updated overview and the current state-of-the-art in this subject.

CONCLUSIONS

Despite discrepancies and heterogeneity in accumulating research, evidence gathered so far endorses a need for refining an escalating multiparameter diagnostic approach. A step-wise therapeutic plan appears to be the most reasonable management approach, starting with behavioral changes for mild to moderate, uncomplicated cases and escalating to personalized pharmacotherapy options for severe or nonresponsive cases. Surgical options could be considered in the most severe cases when potentially life-threatening symptoms persist despite maximal medical therapy. Over the past decade, the amount of available evidence has been gradually increasing; however, its strength remains low. Several aspects remain markedly under-addressed, and further adequately powered, multicenter, controlled studies with uniformity in diagnostic procedures and criteria are urgently needed.

Frequency of gastroesophageal reflux disease in children with adenoid hypertrophy

OBJECTIVES

Recent studies have suggested that the reflux of gastric contents can cause adenoid hypertrophy (AH). The frequency of gastro-oesophageal reflux disease (GERD) in this AH population is unknown, but according to studies using pH-metry it may be as high as 65%. The aim of this study was to estimate the frequency of GERD among children with AH.

METHODS

This was a cross-sectional, multicentre, prospective study of children with AH selected for adenoidectomy. The diagnosis of AH was made by a single laryngologist using a flexible fiberscope. All children had 24-hr multichannel intraluminal pH-impedance (MII/pH) assessment. A GERD diagnosis was made using BioVIEW software analysis after manual review by a single investigator.

RESULTS

38 consecutive patients (21 males, mean age 6.58 years) were enrolled in the study. GERD was diagnosed in 5 (13.2%) patients. A total of 1462 gastro-oesophageal reflux events (GERs) were detected by MII/pH and the majority (60.9%) were acidic. The only significant differences between the GERD-positive and GERD-negative groups were the total number of GERs, and the number of acid GERs.

CONCLUSION

It is first study using MII/pH to assess the frequency of GERD in children with AH. The data suggest that GERD in children with AH seems to be not as common as it was previously raised. Further studies are needed to confirm these results.

Proton pump inhibitor administration in neonates and infants. Lack of consensus - An ASPO survey

OBJECTIVE

Laryngopharyngeal and Gastroesophageal reflux (LPR and GER) are distinct clinical entities that present with a range of non-specific symptoms. The exact prevalence in the pediatric population is unknown. While there has been an increase in the use of PPIs, lack of clear guidelines, conflicting evidence regarding efficacy and safety concerns with long-term use require physicians to use their own anecdotal experience and clinical judgement when treating patients. The goal of this study was to evaluate practice patterns among pediatric otolaryngologists regarding the use of proton-pump inhibitors for reflux-related conditions.

METHODS

A survey was submitted to American Society of Pediatric Otolaryngology (ASPO) members to determine practice patterns regarding use of PPIs for reflux-related conditions in the newborn and infant population. Statistical analysis using Fisher's exact test was performed.

RESULTS

37% of respondents would not prescribe PO PPIs in neonates, with 50% not prescribing IV PPIs. 60% would prescribe a PPI as second or third-line treatment for infants (10 weeks to 1-year). Only 10% would prescribe as first-line in this age group. 48% would prescribe PPIs once daily and 19% as BID. No significant practice differences exist based on years of experience, number of relevant patients seen, and setting of practice.

CONCLUSION

There was no agreement regarding dosage, frequency and duration of PPI treatment for reflux disease in neonates and infants. There was also no correlation with experience or practice setting. This emphasizes the need for a multidisciplinary approach and consensus statement to guide management of GER and LPR in this population.

Laryngeal signs and pH-multichannel intraluminal impedance in infants and children: The missing ring: LPR and MII-pH in children

OBJECTIVE

to investigate the reliability of laryngeal reflux finding score (RFS) and symptom index (RSI) in assessing gastroesophageal reflux (GER) in children and infants.

METHODS

patients with laryngeal or respiratory symptoms, who underwent laryngoscopy and esophageal pH-impedance (MII-pH) were recruited. RSI and RFS were correlated to MII-pH results. A RSI>13, RFS>7, acid exposure index>7%, total reflux episodes>100/24 h in infants or>70/24 h in children, or a positive symptom index or association probability, were considered pathological. Analysis considering age (</>12 months) was performed. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the laryngeal scores were calculated.

RESULTS

197 children (median 53 months, 61 infants) were enrolled. MII-pH was pathological in 5/10 patients with RFS>7, and in 17/31 with RSI>13. RFS>7 had 3.9% sensitivity, 93% specificity, a PPV of 50 and a NPV of 34 in predicting GER disease. RFS was inversely associated to weakly acidic and proximal GER. RSI>13 had 13% sensitivity, 83% specificity, and a PPV and NPV similar to RFS. RSI was significantly associated with the number of acid reflux episodes, and, in infants, with bolus exposure index.

CONCLUSIONS

RSI and RFS aren't accurate in predicting GER in infants and children. Acid reflux relates to laryngeal symptoms, but neither acid, nor proximal and weakly acidic GER relate to laryngeal alterations.

Significance of Extra-Esophageal Symptoms in Pediatric Gastroesophageal Reflux Disease

Introduction  Current practice guidelines in gastroesophageal reflux disease (GERD) often require invasive diagnostic testing.

Objective  The aim of the present study was to evaluate the significance of extra-esophageal symptoms and reliability of a screening risk score that is simple to use.

Methods  A longitudinal retrospective single-institution cohort study. Setting: A university clinical hospital tertiary referral center. The present study enrolled pediatric patients with symptoms suggestive of GERD: epigastric pain, occasional nausea, regurgitation, tasting acid in the oral cavity, chronic cough, hoarseness of voice, frequent throat clearing. The patients underwent 24-hour esophageal pH monitoring and fiber-optic laryngoscopy. The correlations between the local findings, anamnestic and objective measurement data were analyzed.

Results  The present study evaluated 89 pediatric patients. Patients with asthma presented significantly more often with adjoining gastrointestinal symptoms ( p  = 0.0472). Patients that were obese were linked to a higher rate of reports of gastrointestinal symptoms ( p  = 0.0495). After the patients had been assigned to newly developed risk groups, obesity showed to be significantly more frequent in patients placed in higher risk groups ( p  < 0.0001) for a positive GERD diagnosis.

Conclusion  Patients with leading symptoms of asthma presented significantly more often with adjoining gastrointestinal symptoms. Obesity showed to be significantly more frequent in patients placed in higher risk groups for a positive GERD diagnosis.

Use OF NBI for the assessment of clinical signs of rhino-pharyngo-laryngeal reflux in pediatric age: Preliminary results

OBJECTIVES

Laryngopharyngeal reflux (LPR) is a complex problem in pediatric population: diagnosis and clinical presentation are still controversial. Classic white light endoscopy shows some pathognomonic signs of LPR in children, such as thickening of pharyngo-laryngeal mucus, the cobblestoning aspect of pharyngeal mucosa, arytenoid edema/hyperemia, nodular thickening/true vocal cord edema, hypertrophy of the posterior commissure, subglottic edema. The NBI (Narrow Band Imaging) technology, generally used in oncology, allows to study neoangiogenesis and hypervascularization of the mucosa, common aspects in both chronic inflammation and neoplastic transformation. The aim of our study was to evaluate the added value of this technology in identifying the main laryngopharyngeal reflux sign in a pediatric population.

METHODS

We evaluated at the Otolaryngology Unit of the "Fondazione Policlinico A. Gemelli" hospital and the Airway Surgery Unit of the "Bambino Gesù" Children's Hospital 35 patients aged from 2 months to 16 years divided into two groups in the period between November 2017 and May 2018. Group A included patients with clinical suspicion of LPR after gastroenterologist evaluation and Group B included patients who underwent an endoscopic evaluation for the assessment of recurrent respiratory symptoms such as stridor, recurrent croup, wheezing and persistent cough. We performed an endoscopic evaluation by white light and NBI for each patient, comparing the results of both methods to evaluate signs of pharyngo-laryngeal reflux and to calculate the value of reflux finding score (RFS).

RESULTS

The analysis of the data showed: for Group A an average value of RFS with white light of 11,84 (range 8-17, standard deviation 2,52 ± 0,57) and with NBI of 13,63 (range 10-17, standard deviation 2,13 ± 0,49); for Group B the analysis of the data showed an average value of RFS with white light of 10,06 (range 8-14, standard deviation 2,32 ± 0,58) and with NBI of 12,50 (range 9-18, standard deviation 2,63 ± 0,65). The comparison between the two methods resulted significant. Furthermore evaluation by NBI allowed to highlight other signs of pharyngo-laryngeal reflux, characteristic of pediatric age and not included in RFS, in particular cobblestone aspect of the hypopharingeal mucosa, phlogosis of the tonsillar crypts and adenoid surface, hyperemia and hypervascularization of subglottic and tracheal mucosa.

CONCLUSION

Although still preliminary our results represent an interesting starting point for further studies, because they underline the potentiality of NBI endoscopy in LPR evaluation and how this technology could improve the identification of reflux signs.

Diagnosis of laryngopharyngeal reflux in children with voice disorders using 24-hour pharyngeal pH monitoring

OBJECTIVES

The aim of this study was to assess the usefulness of 24-h pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux (LPR) in children with voice disorders.

METHODS

The study was conducted on 68 children aged 3-18 years old. In all cases, pH monitoring was successful; no child removed the probe from the nasal cavity or reported discomfort or other complaints. The following definitions were adopted: LPR in the upright position if Ryan Score upright >9.41; LPR in the supine position if there was at least one supine episode below pH 5.0 (equal to a Ryan Score supine >2.91).

RESULTS

In 43 children (63%), vocal fold edema was strongly related to recorded reflux episodes, especially in the upright position. In 18 children (26%), vocal nodules were observed, but their occurrence did not significantly affect the Ryan Score, either upright or supine. The selected potential LPR markers were significantly correlated to all the pH monitoring variables and individual elements on the Reflux Symptoms Index and the Reflux Finding Score questionnaire.

CONCLUSION

Our findings indicate that, together with vocal fold edema, laryngeal edema and posterior commissure mucosal hypertrophy are important determinants of paediatric LPR. In fact, if LPR is suspected in a child, 24-h pharyngeal pH monitoring appears to be a valuable and welltolerated diagnostic tool. Vocal fold edema observed in laryngeal endoscopy can be considered a probable sign of LPR. The Reflux Finding Score appears to be helpful in diagnosing LPR in children, especially if a cut-off value of 4/5 is adopted.

Gastroesophageal reflux and respiratory diseases: does a real link exist?

INTRODUCTION

Gastro-esophageal reflux disease (GERD) indicates a gastroesophageal reflux that causes symptoms such as pain, and needs medical therapy, and may result in complications such as erosive esophagitis, aspiration pneumonia. Here, we review if it exists a real link between clinical presentation of some respiratory diseases such as asthma, chronic cough, cystic fibrosis and laryngopharyngitis and GERD.

EVIDENCE ACQUISITION

This review was conducted employing 2 databases: PubMed and Science Direct.

EVIDENCE SYNTHESIS

Asthma may lead to reflux, and reflux could exacerbate asthma or cause asthma-like symptoms. Prevalence of GERD in children with asthma ranged from as low 32% to as high 80%. There are several studies where the use of proton pump inhibitors (PPIs) and histamine H2 receptor antagonists lead to inconclusive results. The relation of chronic unexplained cough to GERD remains controversial in children and pediatric guidelines do not currently recommend empirical GERD treatment trials for pediatric chronic cough. Gastroesophageal reflux is more frequent in patients with cystic fibrosis (CF) than general population. Although PPIs are regularly prescribed in approximately half of the patients with CF, there are no specific guidelines for treatment of reflux in CF and it was shown that chronic treatment with PPIs was correlated to possible increased risk of exacerbations.

CONCLUSIONS

The pathogenesis of GER-related respiratory symptoms is multifactorial. The causal relationship between these two conditions may be difficult to prove also with the aid of supporting tests. Multichannel intraluminal impedance associated with pH-metry (pH/MII) detect all gastroesophageal reflux episodes accompanied with a bolus movement and classify GER episodes according to their content (liquid, gas and mixed), pH value and proximal extension. There are no consistent evidences confirming the validity of medical therapy in reflux with respiratory symptoms.

The importance of combined 24-hour multichannel intraluminal impedance-pH monitoring in the evaluation of children with suspected laryngopharyngeal reflux

OBJECTIVE

The aim of this study was to investigate the diagnostic usefulness of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in children with suspected laryngopharyngeal reflux (LPR).

DESIGN, SETTING AND PARTICIPANTS

A prospective study including children in whom, due to LPR suggestive symptoms, MII-pH monitoring was performed at tertiary medical centre from February 2012 to July 2015.

INTERVENTIONS

All included children underwent same diagnostic protocol which included examination by single pulmonologist and ENT specialist and underwent 24-hour MII-pH monitoring.

MAIN OUTCOMES

Primary outcome was to determine MII-pH characteristics of the children in whom LPR was suspected based on symptoms and ENT examination.

RESULTS

One hundred and four patients (mean age 8.9 years; range 0.4-17.9 years; male/female 57/47) participated in the study. In children with signs and symptoms suggestive of LPR, MII-pH monitoring found the median incidence of proximal gastro-oesophageal reflux (GER) of 15 (range 0-129), proximal acidic GER of 6.5 (range 0-66) and weakly acidic GER of 5 (range 0-102). There were significant positive correlations between the number of GER (proximal total, acidic and weakly acid) with Reflux Finding Score, Reflux Symptom Index and presence of eosinophils in nasal swabs. The only endoscopy ENT finding which significantly correlated with total proximal GER, acid proximal GER and weakly acidic proximal GER was arytenoid hyperaemia.

CONCLUSION

Both acid and non-acid reflux seem to have a significant role in the pathogenesis of LPR.

Reliability of the reflux finding score for infants in flexible versus rigid laryngoscopy

OBJECTIVES

The Reflux Finding Score for Infants (RFS-I) was developed to assess signs of laryngopharyngeal reflux (LPR) in infants. With flexible laryngoscopy, moderate inter- and highly variable intraobserver reliability was found. We hypothesized that the use of rigid laryngoscopy would increase reliability and therefore evaluated the reliability of the RFS-I for flexible versus rigid laryngoscopy in infants.

METHODS

We established a set of videos of consecutively performed flexible and rigid laryngoscopies in infants. The RFS-I was scored twice by 4 otorhinolaryngologists, 2 otorhinolaryngology fellows, and 2 inexperienced observers. Cohen's and Fleiss' kappas (k) were calculated for categorical data and the intraclass correlation coefficient (ICC) was calculated for ordinal data.

RESULTS

The study set consisted of laryngoscopic videos of 30 infants (median age 7.5 (0-19.8) months). Overall interobserver reliability of the RFS-I was moderate for both flexible (ICC = 0.60, 95% CI 0.44-0.76) and rigid (ICC = 0.42, 95% CI 0.26-0.62) laryngoscopy. There were no significant differences in reliability of overall RFS-I scores and individual RFS-I items for flexible versus rigid laryngoscopy. Intraobserver reliability of the total RFS-I score ranged from fair to excellent for both flexible (ICC = 0.33-0.93) and rigid (ICC = 0.39-0.86) laryngoscopies. Comparing RFS-I results for flexible versus rigid laryngoscopy per observer, reliability ranged from no to substantial (k = -0.16-0.63, mean k = 0.22), with an observed agreement of 0.08-0.35.

CONCLUSION

Reliability of the RFS-I was moderate and did not differ between flexible and rigid laryngoscopies. The RFS-I is not suitable to detect signs or to guide treatment of LPR in infants, neither with flexible nor with rigid laryngoscopy.

Oropharyngeal 24-Hour pH Monitoring in Children With Airway-Related Problems

Objectives

Diagnosis and clinical presentation of pediatric laryngopharyngeal reflux (LPR) is still controversial. The aims of this work were to study the possibility of performing 24-hour oropharyngeal pH monitoring for children in the outpatient clinic setup and to explore the results of this test in correlation to airway-related problems.

Methods

In this descriptive qualitative study, 26 children suffering from airway-related problems were included. Oropharyngeal 24-hour pH monitoring was performed for all subjects in the outpatient clinic setting. The distribution of airway diagnoses among the study group was studied versus the results of the pH monitoring.

Results

There were 16 males and 10 females participated in the study with a mean age of 6.88 (SD, ±5.77) years. Thirty-five percent of the patients were under the age of 3 years (range, 11 months to 3 years). Eight-five percent of the patients tolerated the pH probe insertion and completed 24-hour of pH recording. Laryngomalacia and subglottic stenosis (SGS) were more frequently reported in the positive LPR patients (77%).

Conclusion

Oropharyngeal 24-hour pH monitoring can be conducted for children in the outpatient setup even in young age children below 3 years old. Among the positive LPR group, SGS and laryngomalacia were the most commonly reported airway findings.

The assessment of children with suspected laryngopharyngeal reflux: An Otorhinolaringological perspective

The assessment of pediatric laryngopharyngeal reflux (LPR) is controversial. Otorhinolaryngologists may play a role in the evaluation of children with suspected LPR detecting typical airway endoscopic findings and/or associated diseases and may help in the selection of children to be subjected to further instrumental tests. In this perspective the present review aims at examining the available evidence in the literature regarding the assessment of LPR in children. After careful literature search there are no current validated symptoms assessment questionnaires for LPR evaluation in children; flexible fiberoptic nasopharyngolaryngoscopy remains controversial as a diagnostic tool in suspect LPR cases; even though the multichannel intraluminal impedance with pH monitoring has been proposed as the instrumental gold standard, further evidence need to be found for validation in children with typical features of LPR.

Factors influencing the development of otitis media among Sicilian children affected by upper respiratory tract infections

INTRODUCTION

Upper respiratory tract infection is a nonspecific term used to describe an acute infection involving the nose, paranasal sinuses, pharynx and larynx. Upper respiratory tract infections in children are often associated with Eustachian tube dysfunction and complicated by otitis media, an inflammatory process within the middle ear. Environmental, epidemiologic and familial risk factors for otitis media (such as sex, socioeconomic and educational factors, smoke exposure, allergy or duration of breastfeeding) have been previously reported, but actually no data about their diffusion among Sicilian children with upper respiratory tract infections are available.

OBJECTIVE

To investigate the main risk factors for otitis media and their prevalence in Sicilian children with and without upper respiratory tract infections.

METHODS

A case-control study of 204 children with upper respiratory tract infections who developed otitis media during a 3 weeks monitoring period and 204 age and sex-matched healthy controls. Seventeen epidemiologically relevant features were inventoried by means of standardized questionnaires and skin tests were performed. Univariate analysis and multivariate logistic regression analysis were used to examine the association between risk factors and occurrence of otitis media.

RESULTS

Otitis media resulted strongly associated to large families, low parental educational attainment, schooling within the third years of life (p<0.05); children were more susceptible to develop otitis media in the presence of asthma, cough, laryngopharyngeal reflux disease, snoring and apnea (p<0.05). Allergy and urban localization increased the risk of otitis media in children exposed to smoke respectively of 166% and 277% (p<0.05); the joint effect of asthma and presence of pets in allergic population increased the risk of recurrence of 11%, while allergy, cough and runny nose together increased this risk of 74%.

CONCLUSIONS

Upper respiratory tract infections and otitis media are common childhood diseases strongly associated with low parental educational attainment (p=0.0001), exposure to smoke (p=0.0001), indoor exposure to mold (p=0.0001), laryngopharyngeal reflux disease (p=0.0002) and the lack of breast-feeding (p=0.0014); an increased risk of otitis media recurrences was observed in the presence of allergy, persistent cough and runny nose (p=0.0001). The modification of the identified risk factors for otitis media should be recommended to realize a correct primary care intervention.

Clinical features and diagnostic reliability in paediatric laryngopharyngeal reflux

OBJECTIVE

The aim of this study was to assess the validity of current diagnostic approaches in pediatric laryngopharyngeal reflux (PLPR). Clinical status findings and 24h double probe oesophageal pH monitoring results in children with suspected PLPR and/or GERD were analyzed and a clinically useful probability score was developed.

METHODS

This is a retrospective longitudinal cohort study including 89 pediatric patients who underwent preliminary oropharyngoscopy, and then nasal fibre optic laryngoscopy and ambulatory 24h oesophageal pH monitoring in a tertiary pediatric and otorhinolaryngology hospital center. The patients' parents gave written informed consent for diagnostic testing. Statistical analysis was performed using standard descriptive statistics. Associations between variables were assessed using Fisher's exact test, Mann-Whitney test and Kruskal-Wallis test for non-parametric paired samples.

RESULTS

Patients' age spanned 1-18 years with a median of 11.2. Out of the 89 patients, 56 were girls, and 33 were boys. All of the patients underwent nasal fibre optic laryngoscopy and 24h double probe pH monitoring. Out of 89 examined children, 50 had PLPR. Out of the 50 positive for PLPR, 46 had a positive clinical finding, with a sensitivity of 92% (95% CI: 80.75-97.73%) and specificity of 10.26% (95% CI: 2.93-24.24%). Boys have GERD significantly more often than girls (p<0.0001), and have a worse result of pH monitoring (p<0.0001). The most common finding was an injected and granulated oropharynx accompanied by posterior laryngitis (54/89). Patients with leading symptoms of asthma had significantly worse GERD scores (p=0.0493). The patients were then reassigned to newly developed risk categories and a significant correlation with a positive PLPR diagnosis was found (p=0.0262).

CONCLUSIONS

The significance of a thorough otorhinolaryngologic and paediatric examination and patient history taking is still paramount, with additional benefit in diagnosing the disease arising from 24h oesophageal pH monitoring in select patients. This study brings to light new relationships between clinical symptoms and objective findings and presents a novel attempt to classify the likelihood of diagnosis. Patient stratification could help clinicians in defining groups at high risk and support a timely, cost-effective and precise diagnostic evaluation and proper therapy.

Laryngopharyngeal reflux disease in children

Extraesophageal reflux disease, commonly called laryngopharyngeal reflux disease (LPRD), continues to be an entity with more questions than answers. Although the role of LPRD has been implicated in various pediatric diseases, it has been inadequately studied in others. LPRD is believed to contribute to failure to thrive, laryngomalacia, recurrent respiratory papillomatosis, chronic cough, hoarseness, esophagitis, and aspiration among other pathologies. Thus, LPRD should be considered as a chronic disease with a variety of presentations. High clinical suspicion along with consultation with an otolaryngologist, who can evaluate for laryngeal findings, is necessary to accurately diagnose LPRD.

Impact of laryngopharyngeal and gastroesophageal reflux on asthma control in children

OBJECTIVE

A prospective study was carried out to determine the sensitivity and specificity of reflux symptoms and laryngeal findings to diagnose laryngopharyngeal reflux (LPR) and gastro-esophageal reflux (GER) in children with asthma by comparing the results of double probe pH monitorization and to determine the difference between controlled and uncontrolled asthma in terms of GER and LPR coexistence.

METHODS

A total of 50 patients (23 girls, mean age 10.8±0.4 years) with mild to moderate persistent asthma were included in this study. The patients were divided in two groups according to the asthma control status as controlled (n=27) vs. uncontrolled asthma (n=23). All patients completed the reflux symptom questionnaire and then they underwent flexible fiberoptic laryngoscopy and 24h double probe (pharyngeal and esophageal) pH monitorization. Laryngopharyngeal and gastroesophageal reflux were defined according to the double probe pH meter results.

RESULTS

The prevalences of LPR and GER were 70% and 46% in asthmatic patients, respectively. The reflux symptom score and LPR disease index were not useful to predict LPR or GER. There was no association between asthma control status and LPR and GER. Vocal nodule seems to be a valuable sign to evaluate LPR in asthmatic children.

CONCLUSIONS

The reflux symptom score and LPR disease index do not seem reliable to diagnose LPR and GER in children with asthma. The frequency of LPR and GER are independent of asthma control, atopy and long acting beta agonist usage.

Role of laryngoscopy in children with respiratory complaints and suspected reflux

BACKGROUND

In recent years, laryngopharyngeal reflux (LPR) in children has been taken into consideration.

OBJECTIVE

The aim of this study was to assess the laryngoscopic findings in children diagnosed LPR and/or gastro-oesophageal reflux (GERD).

METHODS

The findings of 49 patients with at least one or more respiratory complaint such as chronic cough, wheezing, hoarseness, recurrent laryngitis, and throat clearing/postnasal discharge suggesting LPR were evaluated retrospectively. The diagnosis of LPR+GERD or GERD was done by the clinical history and 24 h double-probe pH monitoring and/or scintigraphy.

RESULTS

Thirty eight out of 49 patients examined by laryngoscopy underwent 24 h double-probe pH monitoring and/or scintigraphy. Thirty of them were diagnosed as LPR+GERD or GERD by any test positivity. Twelve of 30 patients diagnosed with LPR+GERD or GERD had a positive laryngeal finding on the examination of fibre optic laryngoscopy. The most common finding with eight cases was arytenoid erythema A sensitivity of 40% and specificity of 50% for the laryngoscopy in the diagnosis of LPR/GERD were found.

CONCLUSION

In children with unexplained respiratory symptoms, laryngopharyngeal reflux should be suspected. Therefore, until enough data on this issue in the literature accumulates, the history and the laboratory findings of the patients obtained from various techniques to document paediatric LPR should be evaluated together.

Evaluation of allergic sensitization and gastroesophageal reflux disease in children with recurrent croup

BACKGROUND

Croup, which is seen commonly in childhood, is a disorder that can be recurrent and progress to bronchial asthma. In the present study the prevalence of gastroesophageal reflux (GER) and atopy and the response to therapy were investigated in children with recurrent croup.

METHODS

Between October 2003 and June 2004, 57 patients with acute stridor were admitted to the emergency room. The patients who had at least three croup episodes and patients with first croup episode were compared.

RESULTS

Thirty-two children had recurrent croup history, GER was found in of 62.5%, and atopy in 17.2%. Atopy was not found in any children with first croup episode. The difference was significant. In addition it was found that atopic dermatitis, previous history of wheezing and established atopy increased the risk of croup recurrence. Alone or combined inhaled corticosteroids and GER therapy were administered, and 77.7% of the patients responded very well.

CONCLUSION

GER and atopy should be investigated in patients with recurrent spasmodic croup. Recurrent croup is a non-specific manifestation of atopy. Patients with atopy should be followed closely for developing bronchial asthma.

An overview of pediatric dysphagia

Difficulty swallowing or dysphagia can be present in children and adults alike. Pediatric dysphagias have long been recognized in the literature. Certain groups of infants with specific developmental and/or medical conditions have been identified as being at high risk for developing dysphagia. Still others may present with a swallowing or feeding problem as their primary symptom. Left untreated, these problems in infants and children can lead to failure to thrive, aspiration pneumonias, gastroesophageal reflux, and/or the inability to establish and maintain proper nutrition and hydration. Awareness of the prevalence of pediatric dysphagia in today's population and the signs and symptoms of this condition aids in its treatment. Early detection of dysphagia in infants and children is important to prevent or minimize complications. This article provides a review of symptoms, etiologies, and resources available regarding management of this condition to help the primary care physician and the families of young children and infants in its management.

Diagnosis and management of laryngopharyngeal reflux disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux should no longer be underestimated because of its negative impact on the lives of patients and its potentially dangerous long-term complications.

RECENT FINDINGS

Both laryngopharyngeal reflux and gastroesophageal reflux disease are caused by mucosal injury from acid and pepsin exposure, but the esophagus has intrinsic antireflux defenses that prevent mucosal injury (bicarbonate production, mucosal tissue resistance and esophageal motor function with acid clearance) whereas the pharynx and the larynx do not. Symptoms felt to be most related to reflux (>or= 95%) are throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in the throat) and voice-quality change, while the physical examination findings include (>or= 95%) arytenoid erythema, vocal-cord erythema and edema, posterior commissure hypertrophy, and arytenoid edema. In this regard, the reflux symptom index and the reflux finding score are very useful clinical tools. Patients are proposed an empirical therapeutic trial including behavioural and dietary recommendations and a 3-month twice-daily proton-pump inhibitor therapy. The proton-pump inhibitor should be taken 30-60 min before meals. Nonresponders undergo an assessment, ideally based on esogastroduodenoscopy and ambulatory multichannel intraluminal impedance and pH monitoring. Transnasal esophagoscopy in the outpatient setting is a safe alternative. When medical management fails, patients with demonstrable high-volume reflux and lower sphincter incompetence are often candidates for surgical intervention.

SUMMARY

The algorithm proposed by Ford has structured and confirmed our attitude on a day-to-day basis.

Rhinosinusitis: prevention strategies

Risk factors of recurrent sinusitis involve upper respiratory infections, bacterial load of the adenoids, day care attendance and exposure to tobacco smoke as well as sinonasal abnormalities, including septal deviation, choanal atresia, polyps and hypoplasia of sinuses. Furthermore, several systemic disorders can facilitate the development of chronic sinusitis, such as allergic rhinitis, gastro-esophageal reflux disease (GER), cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency diseases. A clinical practice guideline for the management of sinusitis is available only for the acute disease, but does not include for the management of the chronic form (i.e. chronic/recurrent sinusitis) and even less for the prevention strategies. As several studies indicate that the majority of children respond to sequential medical followed by surgical interventions, when needed, the best prevention of recurrence or chronicity is to properly treat acute sinusitis; in addition, children should be removed from larger and crowded day care whenever possible and should not be exposed to cigarette smoke. If allergic rhinitis co-exists, it can be managed with nasal steroids sprays and anti-histamines, although the long-term results are controversial. In case of chronic sinusitis, the strategy of prevention is to assess and to cure the associated conditions.