Otologic findings in children with gastroesophageal reflux

The effects of treating GERD on the outcomes of otitis media with effusion: A systematic review and meta-analysis

OBJECTIVE

Gastroesophageal reflux disease (GERD) may cause otitis media with effusion (OME). However, whether treating GERD can benefit patients with OME has not been well studied.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, and Wanfang databases. The search period was from the establishment of the databases until December 31, 2022. Clinical studies related to GERD treatment on the outcomes of OME were included. Two reviewers independently conducted literature screening and data extraction according to the inclusion and exclusion criteria. To evaluate the quality of the included studies, we used the NOS assessment tool and the RevMan 5.4. Subgroup analysis was conducted to reduce the risk of heterogeneity, and Egger and Begg funnel plots were used to evaluate publication bias. Meta-analysis was performed using Stata14.0 and Review Manager 5.4 software.

RESULTS

Finally, 21,744 patients from 16 studies were included. The results showed that the rate of GERD in OME patients was 0.56 (95 % confidence interval (CI): 0.33, 0.79), while it was 0.04 (95 % CI: 0.03, 0.05) in the adult GERD population. The combined risk ratio (RR) of OME in patients with versus without GERD was 1.58 (95 % CI: 1.35, 1.85; p < 0.01). The efficacy rate of GERD treatment in OME patients was 0.59 (95 % CI: 0.44, 0.74), especially for those with chronic OME (0.64, 95 % CI: 0.36, 0.92). Compared to the control group, treatment with GERD improved the symptoms and efficacy of OME (OR = 1.65; 95 % CI: 0.95, 2.85; p > 0.05). The hearing loss cure rate was 0.70 (95 % CI: 0.57, 0.82).

CONCLUSION

GERD has been suggested to be a high-risk factor for OME. Treatment of GERD can improve the symptoms of OME. However, further studies are required to verify these findings.

Continuous versus bolus intermittent intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition among preterm and low birth weight infants. These infants are more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus method or by the continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

• To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants • To perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast versus bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication was prescribed and was given similarly to both intervention groups) SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 7), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 8 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

Association Between Laryngopharyngeal Reflux and Media Otitis: A Systematic Review

OBJECTIVES

To investigate the relationship between laryngopharyngeal reflux (LPR) and recurrent (ROM) or chronic otitis media with effusion (COME).

DATABASES

PubMed, Scopus, and Cochrane Library.

METHODS

Three authors searched articles published between January 1980 and September 2020 about the association between LPR and the development of recurrent or chronic otitis media. Inclusion, exclusion, diagnostic criteria, and clinical outcome evaluation of included studies were analyzed using PRISMA criteria. The bias analysis of included studies was evaluated with the Tool to assess Risk of Bias of the CLARITY group.

RESULTS

Twenty-six clinical and three experimental articles met our inclusion criteria, accounting for 1,624 children and 144 adults with COME or ROM. According to the pH study type, the prevalence of LPR and gastroesophageal reflux disease (GERD) in OM patients were 28.7% (range, 8-100%) and 40.7 (range, 18-64%), respectively. The majority of studies identified pepsin or pepsinogen in middle ear effusion, with a range of mean concentrations depending on the technique used to measure pepsin. There was an important heterogeneity between studies regarding definition of COME, ROM, and LPR, exclusion criteria, methods used to measure pepsin/pepsinogen in middle ear secretions and outcome assessments.

CONCLUSION

The association between LPR and OM is still unclear. Future clinical and experimental studies are needed to investigate the association between LPR and OM in both children and adults through extensive gastric content analysis in middle ear suppurations and impedance-pH monitoring considering acid, weakly acid, and alkaline reflux events.

The Relationship Between Otitis Media With Effusion and Gastroesophageal Reflux Disease: A Meta-analysis

OBJECTIVE

Recent studies have investigated the mechanism by which refluxed gastric materials reach the middle ear, to establish otitis media with effusion (OME) causal relation between them in both children and adults. Therefore, the relationship between OME and gastro-esophageal reflux disease (GERD) should be further studied extensively.

METHODS

To identify eligible original articles, we searched a range of computerized databases, including Medline via PubMed, EMBASE, CNKI, and Web of Science with a systematic searching strategy. Subgroup analysis was performed to analyze heterogeneity and Egger and Begg funnel plot to assess the publication bias of the included articles.

RESULTS

The meta-analysis had an overall sample size of 1961. We identified a significant relationship between OME and GERD, with a pooled odds ratio (OR) of 4.52 (95% confidence interval [CI]: 2.42-8.44; p < 0.001). The pooled data were calculated with the random-effects model as a high significant heterogeneity was found among the studies and there was no significant publication bias observed.

CONCLUSIONS

The meta-analysis suggested that there was a significant association between otitis media with effusion and gastroesophageal reflux disease.

Risk of otitis media with effusion (OME) in children by Pseudomonas aeruginosa

OBJECTIVE

Two third of children in the world experience otitis media with effusion (OME) at least once in their life. According to the importance of knowing OME reason in pediatrics, beside introduced probable bacterial and viral causal agents, Pseudomonas aeruginosa was evaluated either.

METHODS

In this study, 42 middle ear fluid (MEF) samples were collected from pediatrics who confirmed OME by an ears, nose and throat (ENT) specialist. Samples were cultured on bacteriological media for bacterial growth and were either extracted for total DNA and RNA to be tested for introduced bacterial and viral agents with simple and Reverse Transcriptase PCR method within specific primers.

RESULTS

Total results from culture and molecular methods showed that the most prevalent infections were Pseudomonas aeruginosa and streptococcus pneumonia with 33.33% and 14.29% respectively. In total, 66.67% of patients were infected with bacteria, 11.9% with test viruses while in 21.42% of patients no infectious agents were detected. Influenza type A was the only virus was detected.

CONCLUSION

Pseudomonas aeruginosa was the most prevalent agent while mostly detected in patients who were referred from the tropical and humid region. According to these results, it is highly recommended to know the pattern of OME infection in each area separately for more successful treatment.

Matrix association region/scaffold attachment region: the crucial player in defining the positions of chromosome breaks mediated by bile acid-induced apoptosis in nasopharyngeal epithelial cells

Background

It has been found that chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC). CRS can be caused by gastro-oesophageal reflux (GOR) that may reach nasopharynx. The major component of refluxate, bile acid (BA) has been found to be carcinogenic and genotoxic. BA-induced apoptosis has been associated with various cancers. We have previously demonstrated that BA induced apoptosis and gene cleavages in nasopharyngeal epithelial cells. Chromosomal cleavage occurs at the early stage of both apoptosis and chromosome rearrangement. It was suggested that chromosome breaks tend to cluster in the region containing matrix association region/scaffold attachment region (MAR/SAR). This study hypothesised that BA may cause chromosome breaks at MAR/SAR leading to chromosome aberrations in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is a deletion hotspot in NPC.

Methods

Potential MAR/SAR sites were predicted in the AF9 gene by using MAR/SAR prediction tools. Normal nasopharyngeal epithelial cells (NP69) and NPC cells (TWO4) were treated with BA at neutral and acidic pH. Inverse-PCR (IPCR) was used to identify chromosome breaks in SAR region (contains MAR/SAR) and non-SAR region (does not contain MAR/SAR). To map the chromosomal breakpoints within the AF9 SAR and non-SAR regions, DNA sequencing was performed.

Results

In the AF9 SAR region, the gene cleavage frequencies of BA-treated NP69 and TWO4 cells were significantly higher than those of untreated control. As for the AF9 non-SAR region, no significant difference in cleavage frequency was detected between untreated and BA-treated cells. A few breakpoints detected in the SAR region were mapped within the AF9 region that was previously reported to translocate with the mixed lineage leukaemia (MLL) gene in an acute lymphoblastic leukaemia (ALL) patient.

Conclusions

Our findings suggest that MAR/SAR may be involved in defining the positions of chromosomal breakages induced by BA. Our report here, for the first time, unravelled the relation of these BA-induced chromosomal breakages to the AF9 chromatin structure.

Electronic supplementary material

The online version of this article (10.1186/s12920-018-0465-4) contains supplementary material, which is available to authorized users.

Characteristics of laryngopharyngeal reflux in patients with chronic otitis media

OBJECTIVE

To summarize the characteristics of laryngopharyngeal reflux (LPR) in patients with chronic otitis media.

METHODS

This was a prospective study in which 31 patients with chronic otitis media were enrolled. General patient information, reflux symptom index (RSI), reflux finding scores (RFSs), and Ryan scores were summarized.

RESULTS

Most (29/31, 93.5%) patients had a negative RSI (RSI ≤ 13). The most common symptoms of these patients were throat clearing (22/31, 71.0%), symptoms of the stomach and esophagus (19/31, 61.3%), and excess throat mucus or postnasal drip (14/31, 45.2%). In contrast to the RSI, most patients (22/31, 71.0%) had a positive RFS (RFS > 7). Among all of the signs found under the transnasal fiber-optic laryngoscope, erythema was the most frequent symptom (31/31, 100.0%), followed by vocal cord edema (27/31, 87.1%), and posterior commissure hypertrophy (27/31, 87.1%). Most cases (24/31, 77.4%) had a positive Ryan score, and most positive scores were upright scores.

CONCLUSIONS

Most patients with chronic otitis media had LPR simultaneously. The LPR in these patients manifested mainly by a positive RFS under a laryngoscope and not by symptoms of the larynx and pharynx. This suggests that LPR may be an important factor in the pathogenesis of COM and anti-reflux treatment may play a significant role in the management of chronic otitis media.

The relationship between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease: a meta-analysis

BACKGROUND

Obstructive sleep apnea hypopnea syndrome (OSAHS) means apnea and hypopnea caused by partial or complete obstruction of upper airway collapse during sleep. Gastroesophageal reflux disease (GERD) is believed to be associated with various manifestations in the otorhinolaryngology and has been found to be an additional risk factor for OSAHS.

AIM

A meta-analysis was performed to identify the association between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

METHODS

To identify eligible original articles, we searched a series of computerized databases, including Medline via PubMed, EMBASE, Web of Science, and CNKI with a systematic searching strategy. The characteristics of each article and pooled odds ratios (ORs) with corresponding confidence intervals (CIs) were calculated and subgroup analysis was performed to analyze the source of heterogeneity.

RESULTS

A total of 2699 patients from seven articles were included in the meta-analysis. We identified a significant relationship between obstructive sleep apnea syndrome and gastroesophageal reflux disease, with a pooled OR of 1.75 (95% CI 1.18-2.59, P < 0.05). The pooled data was calculated under the random-effects model as a significant moderate heterogeneity was found among the meta-analysis.

CONCLUSIONS

The meta-analysis showed that there was a significant correlation between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

Bile acids at neutral and acidic pH induce apoptosis and gene cleavages in nasopharyngeal epithelial cells: implications in chromosome rearrangement

BACKGROUND

Chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC) while nasopharyngeal reflux is known to be one of the major aetiological factors of CRS. Bile acid (BA), the component of gastric duodenal contents, has been recognised as a carcinogen. BA-induced apoptosis was suggested to be involved in human malignancies. Cells have the potential and tendency to survive apoptosis. However, cells that evade apoptosis upon erroneous DNA repair may carry chromosome rearrangements. Apoptotic nuclease, caspase-activated deoxyribonuclease (CAD) has been implicated in mediating translocation in leukaemia. We hypothesised that BA-induced apoptosis may cause chromosome breaks mediated by CAD leading to chromosome rearrangement in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is one of the most common deletion sites in NPC.

METHODS

We tested the ability of BA at neutral and acidic pH in inducing phosphatidylserine (PS) externalisation, reactive oxygen species (ROS) production, mitochondrial membrane potential (MMP) disruption, and caspase 3/7 activity in normal nasopharyngeal epithelial (NP69) and NPC (TWO4) cells. Inverse-PCR (IPCR) was employed to detect AF9 gene cleavages. To investigate the role of CAD in mediating these cleavages, caspase inhibition was performed. IPCR bands representing AF9 cleaved fragments were sequenced.

RESULTS

BA-treated cells showed higher levels of PS externalisation, ROS production, MMP loss and caspase 3/7 activity than untreated control cells. The effect of BA in the induction of these intracellular events was enhanced by acid. BA at neutral and acidic pH also induced significant cleavage of the AF9 gene. These BA-induced gene cleavages were inhibited by Z-DEVD-FMK, a caspase-3 inhibitor. Intriguingly, a few chromosome breaks were identified within the AF9 region that was previously reported to participate in reciprocal translocation between the mixed lineage leukaemia (MLL) and AF9 genes in an acute lymphoblastic leukaemia (ALL) patient.

CONCLUSIONS

These findings suggest a role for BA-induced apoptosis in mediating chromosome rearrangements in NPC. In addition, CAD may be a key player in chromosome cleavages mediated by BA-induced apoptosis. Persistent exposure of sinonasal tract to gastric duodenal refluxate may increase genomic instability in surviving cells.

Sleep quality and communication aspects in children

OBJECTIVES

To correlate quality of life of children in terms of sleep, with their oral language skills, auditory processing and orofacial myofunctional aspects.

METHODS

Nineteen children (12 males and seven females, in the mean age 9.26) undergoing otorhinolaryngological and speech evaluations participated in this study. The OSA-18 questionnaire was applied, followed by verbal and nonverbal sequential memory tests, dichotic digit test, nonverbal dichotic test and Sustained Auditory Attention Ability Test, related to auditory processing. The Phonological Awareness Profile test, Rapid Automatized Naming and Phonological Working Memory were used for assessment of the phonological processing. Language was assessed by the ABFW Child Language Test, analyzing the phonological and lexical levels. Orofacial myofunctional aspects were evaluated through the MBGR Protocol. Statistical tests used: the Mann-Whitney Test, Fisher's exact test and Spearman Correlation.

RESULTS

Relating the performance of children in all evaluations to the results obtained in the OSA-18, there was a statistically significant correlation in the phonological working memory for backward digits (p = 0.04); as well as in the breathing item (p = 0.03), posture of the mandible (p = 0.03) and mobility of lips (p = 0.04).

CONCLUSION

A correlation was seen between the sleep quality of life and the skills related to the phonological processing, specifically in the phonological working memory in backward digits, and related to orofacial myofunctional aspects.

Variations in Definitions and Outcome Measures in Gastroesophageal Reflux Disease: A Systematic Review

CONTEXT

Gastroesophageal reflux (GER) is defined as GER disease (GERD) when it leads to troublesome symptoms and/or complications. We hypothesized that definitions and outcome measures in randomized controlled trials (RCTs) on pediatric GERD would be heterogeneous.

OBJECTIVES

Systematically assess definitions and outcome measures in RCTs in this population.

DATA SOURCES

Data were obtained through Cochrane, Embase, Medline, and Pubmed databases.

STUDY SELECTION

We selected English-written therapeutic RCTs concerning GERD in children 0 to 18 years old.

DATA EXTRACTION

Data were tabulated and presented descriptively. Each individual parameter or set of parameters with unique criteria for interpretation was considered a single definition for GER(D). Quality was assessed by using the Delphi score.

RESULTS

A total of 2410 unique articles were found; 46 articles were included. Twenty-six (57%) studies defined GER by using 25 different definitions and investigated 25 different interventions. GERD was defined in 21 (46%) studies, all using a unique definition and investigating a total of 23 interventions. Respectively 87 and 61 different primary outcome measures were reported by the studies in GER and GERD. Eight (17%) studies did not report on side effects. Of the remaining 38 (83%) studies that did report on side effects, 18 (47%) included this as predefined outcome measure of which 4 (22%) as a primary outcome measure. Sixteen studies (35%) were of good methodological quality.

LIMITATIONS

Only English-written studies were included.

CONCLUSIONS

Inconsistency and heterogeneity exist in definitions and outcome measures used in RCTs on pediatric GER and GERD; therefore, we recommend the development of a core outcome set.

Prevalence and characteristics of gastroesophageal reflux in children with otitis media in Isfahan, Iran

BACKGROUND

Otitis media (OM) is the most common cause of childhood hearing loss and reason to visit the pediatrician. Furthermore, gastroesophageal reflux (GER) has been associated with a variety of upper aerodigestive tract symptoms or diseases, such as sinusitis, laryngitis, and otits. The objective of the present study was to determine the frequency of GER in children, aged 3 months to 7 years, with OM.

MATERIALS AND METHODS

This retrospective case-control study was conducted on 50 children with OM and 50 healthy children. Presence of GER as the main variables was diagnosed by clinical examination in all studied children using the questionnaires with 2 age-stratified versions of the pediatric GER disease symptoms for children 2 years old and younger, and children 3-7 years old.

RESULTS

The prevalence of GER in children with OM and controls was 58% and 22% respectively (P = 0.0005). The frequency of irritability, congestion, and feeding complex in children with OM were significantly more than in control groups. Among children with recurrent acute OM (AOM), and chronic serous OM (CSOM) the prevalence of GER was significantly more than controls (61.1%, vs. 22% for AOM, P = 0.004, and 72.7% vs. 22%, P= 0.003). In children with AOM, regurgitation, vomiting, irritability and congestion were significantly higher than controls included. In children with CSOM, regurgitation, vomiting, and congestion were significantly higher than controls.

CONCLUSION

Results show a significant association between GER and OM, AOM and CSOM in children with OM compares to healthy children. This shows that looking for GER in children with OM may help improving treatments outcomes.

Continuous versus bolus intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition in preterm and low birth weight infants. These infants are also more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus or continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants.We intended to perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast vs bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication prescribed and given similarly to both intervention groups).

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Group as described in The Cochrane Library (www.thecochranelibrary.com) to search for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to September 2013). We also searched previous reviews, including cross-references, abstracts and conference and symposia proceedings of the Perinatal Society of Australia and New Zealand and the Pediatric Academic Societies (American Pediatric Society/Society for Pediatric Research and European Society for Paediatric Research) from 1990 to 2012.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

Association between Otitis Media and Gastroesophageal Reflux

Objective. To systematically review the association between otitis media and gastroesophageal/laryngopharyngeal reflux in children.

Data Sources. Cochrane library, MEDLINE (1966–September 2011), EMBASE (1974–September 2011), proceedings of International Symposia on Recent Advances in Otitis Media, and reference lists of relevant selected articles.

Review Methods. Studies with planned data collection, in children with chronic otitis media with effusion/recurrent acute otitis media, assessing gastroesophageal/laryngopharyngeal reflux, pepsin/pepsinogen in middle ear, or antireflux therapy, were included.

Results. Of 242 initial studies, 15 met inclusion criteria. The authors found a mean prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion of 48.4% (range, 17.6%-64%) and in children with recurrent acute otitis media of 62.9% (range, 61.5%-64.3%). A mean prevalence of laryngopharyngeal reflux of 48.6% (range, 27.3%-70.6%) was found in children with otitis media. Mean pepsin/pepsinogen presence in otitis media was 85.3% (range, 60%-100%) and of enzymatic activity was 34.2% (range, 14.5%-73%). Two randomized trials could not find benefit after antireflux treatment for 3 months, with an absolute rate difference (95% confidence interval) of 0.23 (0.023-0.42) and 0.13 (−0.086 to 0.34), respectively. Reporting of adverse events was limited, or absent, in most studies.

Conclusion. The prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion/recurrent acute otitis media may be higher than the overall prevalence for children. Presence of pepsin/pepsinogen in the middle ear could be related to physiologic reflux. A cause-effect relationship between pepsin/pepsinogen in the middle ear and otitis media is unclear. Antireflux therapy for otitis media cannot be endorsed based on existing research.