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Rao YF, Wang J, Cheng DN, Xu Y, Ren X, Yang W, Liu G, Xu W, Yan XH, Song Y, Zheng YB, An P, Zhong DL, He ZP, Ren JJ, Zhao Y. The Controversy of Pepsinogen A/Pepsin A in Detecting Extra-Gastroesophageal Reflux. J Voice 2023; 37:748-756. [PMID: 34090740 DOI: 10.1016/j.jvoice.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/31/2021] [Accepted: 04/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pepsinogen A (PGA)/pepsin A is often used as a diagnostic marker of extra-gastroesophageal reflux. We aimed to explore whether its positivity in upper aerodigestive tract (UADT) was specific enough to diagnose reflux. METHODS PGA/pepsin A protein levels were examined in 10 types of tissues and 10 types of body fluid by immunological staining, western blot or Elisa, using three different commercially available brands simultaneously. Liquid chromatography-tandem mass spectrometry parallel reaction monitoring (LC-MS/MS PRM) served as a gold reference for the detection of PGA/pepsin A proteins. PGA gene expression was analyzed by reverse transcriptase sequencing methods for tissue samples. Specifically, 24 hour pH monitoring technique was conducted for patients who donated saliva samples. RESULTS Eight out of ten types of human tissue samples (stomach, esophagus, lung, kidney, colon, parotid gland, nasal turbinate and nasal polyps) were confirmed positive for PGA/pepsin A gene and protein by genetic and PRM technique, respectively. Two out of ten types of body fluid samples (gastric fluid, urine) were confirmed positive for PGA/pepsin A protein by PRM technique. The consistence rates of PGA/pepsin A positivity among three commercial antibody brands and Elisa kit were poor, and Elisa results of salivary did not match with 24-hour pH monitoring. CONCLUSIONS Multiple tissues and body fluid could be detected baseline expression levels of PGA/pepsin A gene and protein. However, those commercially available PGA/pepsin A antibodies achieved poor sensitivity and specificity, therefore, relying on the detection of PGA/pepsin A in UADT by single antibodies to diagnose extra-gastroesophageal reflux without a specific positive cut-off value is unreliable.
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Affiliation(s)
- Yu-Fang Rao
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Dan-Ni Cheng
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xue Ren
- Institute of statistics and management, Shanghai University of Finance and Economics, Shanghai, China
| | - Wen Yang
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Geoffrey Liu
- Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON, Canada.; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wei Xu
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Xiao-Hong Yan
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yao Song
- Institute of statistics and management, Shanghai University of Finance and Economics, Shanghai, China
| | - Yong-Bo Zheng
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Ping An
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Da-Lin Zhong
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhao-Ping He
- Department of Biomedical Research, Nemours/Alfred I.duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jian-Jun Ren
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.; Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON, Canada..
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, and West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China..
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Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review. CHILDREN 2023; 10:children10030583. [PMID: 36980141 PMCID: PMC10047907 DOI: 10.3390/children10030583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023]
Abstract
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.
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Restuti RD, Tamin S, Nugroho DA, Hutauruk SM, Mansyur M. Factors affecting the occurrence of otitis media with effusion in preschool and elementary school children: a comparative cross-sectional study. BMJ Open 2022; 12:e065291. [PMID: 36171035 PMCID: PMC9528613 DOI: 10.1136/bmjopen-2022-065291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Identify the risk factors for otitis media with effusion (OME), especially laryngopharyngeal reflux (LPR), adenoid hypertrophy and allergic rhinitis, that could be used to develop prevention strategies in children. DESIGN A comparative cross-sectional study was conducted to make sure the adequacy of proportions of OME and non-OME cases in finding the related factors. SETTING History taking, ear/nose/throat (ENT) examination, and tympanometry were performed in preschool and elementary schools. Flexible fibreoptic nasopharyngolaryngoscopy was performed in a bronchoesophagology outpatient clinic in a tertiary referral hospital in Jakarta, Indonesia. PARTICIPANTS Preschool and elementary children in East Jakarta, Indonesia were recruited for this study. A total of 2016 participants underwent history taking, ENT examination and tympanometry. The case group was 46 children with OME, and the control group was 46 children without OME. The number of subjects fulfilled the minimum sample size for two proportions comparison. MAIN OUTCOME MEASURES A type B tympanogram indicated OME. A Reflux Finding Score of more than 7 indicated LPR. Adenoid hypertrophy was diagnosed using flexible fibreoptic nasopharyngolaryngoscopy. Allergic rhinitis was diagnosed using a questionnaire based on the International Study of Asthma and Allergies in Childhood phase III that has been validated for Indonesians. RESULTS The proportion of LPR in the OME group was significantly higher than in the non-OME group, at 78.3% and 52.2%. The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR (OR 3.3; 95% CI 1.33 to 8.189; p=0.01). There was no significant relationship between adenoid hypertrophy and OME (p=0.211; 95% CI 0.71 to 3.97), and also between allergic rhinitis and OME (p=0.463; 95% CI 0.61 to 4.28). CONCLUSION The probability of OME occurrence in patients with LPR was 3.3 times higher than in patients without LPR. LPR should be considered in patients with OME and vice versa.
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Affiliation(s)
- Ratna Dwi Restuti
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Susyana Tamin
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dwi Agustawan Nugroho
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Syahrial Marsinta Hutauruk
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Muchtaruddin Mansyur
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Martin CN, Barnawi Z, Chorvinsky E, Pillai D, Gatti M, Collins ME, Krakovsky GM, Bauman NM, Sehgal S, Pillai DK. Positive bronchoalveolar lavage pepsin assay associated with viral and fungal respiratory infections in children with chronic cough. Pediatr Pulmonol 2021; 56:2686-2694. [PMID: 33930245 PMCID: PMC8327477 DOI: 10.1002/ppul.25450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To assess the association between commonly obtained endoscopic and serologic data and bronchoalveolar lavage pepsin assay (BAL) results in children with chronic cough. STUDY DESIGN We performed a retrospective chart review of 72 children with a BAL pepsin obtained through our Aerodigestive Center over an 18-month period. BAL outcomes include evidence of viral, bacterial, or fungal infection, presence of lipid-laden macrophages, and cytology (eosinophils, neutrophils, and lymphocytes). Gastrointestinal outcomes include esophagogastroduodenoscopy (EGD) and pH impedance probe findings. Other characteristics include serum eosinophils, neutrophils, and lymphocytes; spirometry; FeNO; and IgE. RESULTS Seventy-two patients underwent BAL pepsin testing. Median age was 4.9 years, 30.6% had severe persistent asthma, and 59.2% were on reflux medication. There was an association between positive BAL pepsin assay and positive viral panel (p = .002) or fungal culture (p = .027). No significant association found between positive BAL bacterial culture; BAL cytology; the presence of BAL lipid-laden macrophages; IgE; spirometry; FeNO; CBC neutrophil, eosinophil, or lymphocytes; pH impedance testing parameters; or EGD pathology. CONCLUSIONS BAL pepsin is associated with a positive BAL viral PCR or fungal culture. Lack of correlation between pepsin-positivity and pH-impedance parameters or EGD pathology suggests microaspiration may be due to an acute event (such as a respiratory infection) rather than chronic gastroesophageal reflux disease. This may be especially true in the presence of a positive viral panel or fungal culture when a BAL pepsin is obtained.
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Affiliation(s)
- Corey N Martin
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Zhour Barnawi
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Elizabeth Chorvinsky
- Department of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Dhruv Pillai
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Meagan Gatti
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Maura E Collins
- Department of Hearing and Speech, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Gina M Krakovsky
- Department of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Nancy M Bauman
- Department of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sona Sehgal
- Division of Pediatric Gastroenterology, Children's National Hospital, Washington, DC, USA
| | - Dinesh K Pillai
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA.,Department of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Lechien JR, Hans S, Simon F, Horoi M, Calvo-Henriquez C, Chiesa-Estomba CM, Mayo-Yáñez M, Bartel R, Piersiala K, Nguyen Y, Saussez S. Association Between Laryngopharyngeal Reflux and Media Otitis: A Systematic Review. Otol Neurotol 2021; 42:e801-e814. [PMID: 33710157 DOI: 10.1097/mao.0000000000003123] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jerome R Lechien
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head and Neck Surgery, Ambroise Paré Hospital (APHP), Paris Saclay University, Paris, France
- Department of Otolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, Paris Saclay University
| | - Stéphane Hans
- Department of Otolaryngology-Head and Neck Surgery, Ambroise Paré Hospital (APHP), Paris Saclay University, Paris, France
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, Paris Saclay University
| | - Francois Simon
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Pediatric Otolaryngology - Head and Neck Surgery Department, Necker-Enfants Malades Hospital, Paris, France
| | - Mihaela Horoi
- Department of Otolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Christian Calvo-Henriquez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Complex of Santiago de Compostela, Santiago de Compostela
| | - Carlos M Chiesa-Estomba
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Donostia, San Sebastian
| | - Miguel Mayo-Yáñez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Otorhinolaryngology - Head and Neck Surgery, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006, A Coruña, Galicia
- Clinical Research in Medicine, International Center for Doctorate and Advanced Studies (CIEDUS), Universidade de Santiago de Compostela (USC), 15782, Santiago de Compostela, Galicia
| | - Ricardo Bartel
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universitario Mutua Terrasa, Barcelona, Spain
| | - Krzysztof Piersiala
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Yann Nguyen
- Groupe Hospitalo-Universitaire Pitié Salpêtrière, Otorhinolaryngology Department, Unit of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université, Paris, France
| | - Sven Saussez
- Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
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Michel F, Dannesberger R, Stroh T, Fritsche R, Ahrens P. [Pharyngeal acid load and different functional endoscopy findings]. HNO 2019; 67:940-947. [PMID: 31407018 DOI: 10.1007/s00106-019-0723-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The findings of functional endoscopy (upper esophageal sphincter insufficiency, cardia insufficiency, esophagitis, gastric heterotopia, axial sliding hernia, and visible aerosols) can be traced back to pharyngeal acid exposure by oropharyngeal pH measurement. Significantly increased pharyngeal acid loads are seen in gastric heterotopy and axial sliding hernia. For all measured statistics, the pharyngeal acid load is in the pathological or even very pathological range. The value of functional endoscopy in the context of laryngopharyngeal reflux diagnosis is clearly documented. The findings "heterotopic gastric mucosa" and "axial sliding hernia" may cause marked airway symptoms and a pathogenetic relationship with otorhinolaryngologic reflux-associated symptoms must be postulated for these entities.
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Affiliation(s)
- F Michel
- HNO-Praxis im Kreiskrankenhaus, Hauptstraße 30, 64342, Seeheim-Jugenheim, Deutschland.
| | | | - T Stroh
- Refluxzentrum Darmstadt, Darmstadt, Deutschland
| | - R Fritsche
- Refluxzentrum Darmstadt, Darmstadt, Deutschland
| | - P Ahrens
- Refluxzentrum Darmstadt, Darmstadt, Deutschland
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Diagnosis of laryngopharyngeal reflux in children with voice disorders using 24-hour pharyngeal pH monitoring. Int J Pediatr Otorhinolaryngol 2019; 121:188-196. [PMID: 30925396 DOI: 10.1016/j.ijporl.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/07/2019] [Accepted: 03/10/2019] [Indexed: 11/21/2022]
Abstract
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.
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Kubba H. The Role of Reflux in Childhood Otorhinolaryngological Disorders. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Boers SA, de Zeeuw M, Jansen R, van der Schroeff MP, van Rossum AMC, Hays JP, Verhaegh SJC. Characterization of the nasopharyngeal and middle ear microbiota in gastroesophageal reflux-prone versus gastroesophageal reflux non-prone children. Eur J Clin Microbiol Infect Dis 2018; 37:851-857. [PMID: 29404836 PMCID: PMC5916997 DOI: 10.1007/s10096-017-3178-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/25/2017] [Indexed: 12/21/2022]
Abstract
Otitis media (OM) is one of the most common pediatric infections worldwide, but the complex microbiology associated with OM is poorly understood. Previous studies have shown an association between OM and gastroesophageal reflux (GER) in children. Therefore, in order to bridge the gap in our current understanding of the interaction between GER and OM, we investigated the nasopharyngeal and middle ear microbiota of children suffering from GER-associated OM and OM only, using culture-independent 16S rRNA gene sequencing. Middle ear fluid, nasopharyngeal swabs, and clinical data were collected as part of a prospective pilot study conducted at the Department of Otorhinolaryngology of the Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands. A total of 30 children up to 12 years of age who suffered from recurrent acute otitis media (AOM) (5), chronic otitis media with effusion (OME) (23), or both (2), and who were listed for tympanostomy tube placement, were included in the study. Nine children were included in the GER-associated OM cohort and 21 in the OM-only cohort. We found no obvious effect of GER on the nasopharyngeal and middle ear microbiota between the two groups of children. However, our results highlight the need to assess the true role of Alloiococcus spp. and Turicella spp. in children presenting with a high prevalence of recurrent AOM and chronic OME.
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Affiliation(s)
- Stefan A Boers
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marjolein de Zeeuw
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ruud Jansen
- Department of Molecular Biology, Regional Laboratory of Public Health, Haarlem, The Netherlands
| | - Marc P van der Schroeff
- Department of Otorhinolaryngology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Annemarie M C van Rossum
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Suzanne J C Verhaegh
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Abstract
Diagnosis of extraesophageal reflux (EER) currently relies on tools designed for diagnosis of gastroesophageal reflux. Such tools lack the sensitivity and reproducibility to detect the less frequent and mildly acidic reflux associated with upper airway disease. Pepsin has been posited to be a reliable biological marker of EER. Our aim was to present a comprehensive literature review of the use of pepsin as a diagnostic marker of EER. Two methods are typically used for detection of pepsin in the airways: enzymatic and immunologic. The limitations, advantages, and examples of use of each are discussed. Pepsin assay has been used to identify refluxate in trachea, lung, sinus, middle ear, combined sputum and saliva, and breath condensate. An immunologic pepsin assay of combined sputum and saliva was determined to be 100% sensitive and 89% specific for detection of EER (based on pH-metry), and an enzymatic test of nasal lavage fluid (100% sensitivity and 92.5% specificity) demonstrated an increased incidence of EER in patients with chronic rhinosinusitis. Pepsin assay identified tracheal pepsin to be an indicator of bronchopulmonary dysplasia and related mortality risk in ventilated preterm infants. Pepsin assay is a useful tool for correlation of reflux with airway disease and is a reliable diagnostic marker of EER.
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Affiliation(s)
- Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ren JJ, Zhao Y, Wang J, Ren X, Xu Y, Tang W, He Z. PepsinA as a Marker of Laryngopharyngeal Reflux Detected in Chronic Rhinosinusitis Patients. Otolaryngol Head Neck Surg 2017; 156:893-900. [PMID: 28457223 DOI: 10.1177/0194599817697055] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives We aimed to confirm the presence of pepsinA in the nasal secretions and tissues of chronic rhinosinusitis (CRS) patients and reveal the relationship between CRS and laryngopharyngeal reflux (LPR). Study Design Cross-sectional study. Setting The study was conducted at the Department of Oto-Rhino-Laryngology, West China Hospital, Sichuan University. Subjects and Methods A total of 32 CRS patients with or without nasal polyps (CRSwNP and CRSsNP, respectively) and 10 normal controls were enrolled in our study. We investigated the expression of pepsinA in the nasal tissues, secretions, and blood plasma from the subjects by immunohistochemical staining, Western blot, or ELISA. Additionally, the expressions of MUC4, MUC5AC, MUC5B, MUC8, and pepsinogenA in nasal tissue were evaluated by quantitative real-time polymerase chain reaction. Results Immunohistochemistry and Western blot revealed that the pepsinA expression levels in the turbinate mucosa in CRSwNP/CRSsNP patients, which were largely restricted to the epithelial layer or glandular mucous cells in nasal tissues, were significantly higher than those in controls and in the polyp tissues of CRSwNP patients ( P < .05). In addition, the concentration of pepsinA in nasal secretions was significantly increased in the CRSwNP (147.85 ± 53.69 ng/mL, P < .001) and CRSsNP (134.12 ± 36.23 ng/mL, P < .001) groups as compared with the controls (68.69 ± 19.28 ng/mL). Although MUC5AC, MUC5B, and MUC8 expression differed among the groups, no correlation between pepsinA and mucin genes was found. Conclusion The results of this study provided evidence of an association between LPR and CRS, although no correlation was found to exist between LPR and mucin genes in CRS patients.
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Affiliation(s)
- Jian-jun Ren
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Xue Ren
- School of Mathematics and Statistics, Chongqing Technology and Business University, Chongqing, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Wenlong Tang
- Shenzhen Key Laboratory of ENT, Institute of ENT & Longgang ENT Hospital, Shenzhen, China
| | - Zhaoping He
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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Iannella G, Di Nardo G, Plateroti R, Rossi P, Plateroti AM, Mariani P, Magliulo G. Investigation of pepsin in tears of children with laryngopharyngeal reflux disease. Int J Pediatr Otorhinolaryngol 2015; 79:2312-5. [PMID: 26586244 DOI: 10.1016/j.ijporl.2015.10.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/23/2015] [Accepted: 10/26/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Numerous investigations postulated that laryngopharyngeal reflux (LPR) is implicated in the pathogenesis of various upper airway inflammatory diseases as sinusitis or dacryostenosis. The presence of pepsin in tears might be confirmed the presuntive hypothesis of the arrival in the nasolacrimal ducts and precorneal tears film through the laryngopharyngeal reflux of either gastric acid or stomach secretions (pepsin) with inflammatory potentialities. The aim of this preliminary study was to identify the presence or absence of pepsin in the tears collected from children with a high suspicion of LPR who underwent 24-h pH (MII-pH) monitoring to confirm the disease. METHODS This study enrolled 20 patients suffering from symptoms of laryngopharyngeal reflux that underwent 24-h multichannel intraluminal impedance (MII)-pH monitoring to confirm the disease. The findings of the study group were compared with those of a control group of patients with negative pH monitoring. The quantitative analysis of human pepsin concentration in the tear samples was performed by ELISA method in both groups. RESULTS Four children (20%) of the study group showed pepsin in the tears. All of the subjects belonging to the control group were negative for its presence. No difference differences in the total number of reflux episodes and the number of weakly basic reflux in the pepsin positive patients vs. pepsin negative children were present. CONCLUSIONS 20% of the children with diagnosed LPR showed pepsin in the tears. Our specific investigation might provide information regarding sinusitis or dacryostenosis.
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Affiliation(s)
- Giannicola Iannella
- Organi di Senso Department, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giovanni Di Nardo
- Department of Pediatrics, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Rocco Plateroti
- Organi di Senso Department, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Paolo Rossi
- Department of Pediatrics, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Andrea Maria Plateroti
- Organi di Senso Department, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Paola Mariani
- Department of General and specialized surgery Paride Stefanini, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giuseppe Magliulo
- Organi di Senso Department, University "La Sapienza", Viale del Policlinico, 151, 00161 Rome, Italy.
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Brunworth JD, Mahboubi H, Garg R, Johnson B, Brandon B, Djalilian HR. Nasopharyngeal acid reflux and Eustachian tube dysfunction in adults. Ann Otol Rhinol Laryngol 2014; 123:415-9. [PMID: 24671547 DOI: 10.1177/0003489414526689] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aimed to evaluate the relationship between nasopharyngeal pH and Eustachian tube dysfunction (ETD) in adults. STUDY DESIGN Unmatched case-control study. METHODS Forty-one subjects, 20 adults with a diagnosis of ETD and 21 healthy adults as controls, were enrolled from an outpatient clinic. All subjects had a Dx-pH probe placed near the torus tubarius in the posterior nasopharynx for 24 hours. The pH values were recorded every 0.5 second. Decreases in pH were considered as reflux events if the pH dropped below 5.5. RESULTS The average nasopharyngeal pH value was 6.90 (range, 5.33-7.73) in the subjects with ETD and 7.07 (range, 5.99-7.94) in the controls. The difference between the 2 groups was not statistically significant (P = .30). The ETD group, on average, had a higher number of nasopharyngeal reflux events (2.3 +/- 1.6 vs 0.8 +/- 1.2, respectively; P = .002) and higher reflux finding score (3.6 +/- 2.7 vs 0.4 +/- 1.4, respectively; P < .00 I) than the control group. CONCLUSION By using a novel pH probe that allows detection of acidity in a nonliquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score. Nasopharyngeal reflux may have a role in the pathogenesis of ETD.
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Shewel Y, Bassiouny M, Rizk MM. Detection of gastric pepsin in middle ear fluid of children with chronic otitis media with effusion. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2014. [DOI: 10.4103/1012-5574.133176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Role of immunoglobulin E and gastro-esophageal reflux disease in the development of otitis media with effusion. Otolaryngol Pol 2014; 68:119-23. [DOI: 10.1016/j.otpol.2013.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 08/14/2013] [Accepted: 08/26/2013] [Indexed: 11/20/2022]
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Luo HN, Yang QM, Sheng Y, Wang ZH, Zhang Q, Yan J, Hou J, Zhu K, Cheng Y, Wang BT, Xu YL, Zhang XH, Ren XY, Xu M. Role of pepsin and pepsinogen: Linking laryngopharyngeal reflux with otitis media with effusion in children. Laryngoscope 2014; 124:E294-300. [DOI: 10.1002/lary.24538] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Hua-Nan Luo
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Qi-Mei Yang
- Department of Otolaryngology-Head and Neck Surgery; Shan'Xi Provincial People's Hospital; Xi'an China
| | - Ying Sheng
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Zheng-Hui Wang
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Qing Zhang
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Jing Yan
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Jin Hou
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Kang Zhu
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Ying Cheng
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Bo-Tao Wang
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Ying-Long Xu
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Xiang-Hong Zhang
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Xiao-Yong Ren
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
| | - Min Xu
- Department of Otolaryngology-Head and Neck Surgery; The Second Hospital, Xi'an Jiao Tong University, Xi'an
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Abdel-aziz MM, El-Fattah AMA, Abdalla AF. Clinical evaluation of pepsin for laryngopharyngeal reflux in children with otitis media with effusion. Int J Pediatr Otorhinolaryngol 2013; 77:1765-70. [PMID: 24011938 DOI: 10.1016/j.ijporl.2013.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/10/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We sought to evaluate the clinical role of pepsin for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME). METHODS Pepsin/pepsinogen and fibrinogen were analyzed in fifty effusion and blood samples of children with OME using enzyme linked immunosorbent assay (ELISA). Ambulatory 24-h dual-probe pH monitoring was additionally performed in 31 children divided into two groups according to response of medical treatment. RESULTS The effusion levels of pepsin/pepsinogen ranged from 8.5 to 1512 μg/dl and were up to 4-540 times higher than the concentrations found in plasma samples. The effusion levels of fibrinogen ranged from 0.05 to 4.1g/dl. Some effusion samples showed fibrinogen concentrations did not exceed 10 times higher than the concentrations found in plasma samples and others showed lower concentrations. The pH of effusion samples was 7.13 to 8.72. Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant acid reflux documented by either the esophageal probe or the pharyngeal probe and all of them had LPR. There is a significant positive correlation between the level of pepsin assayed in the effusions and the number of pharyngeal reflux episodes measured by pH monitoring. CONCLUSIONS Analysis of pepsin/pepsinogen in effusion samples of children with OME, using ELISA, can be considered as a reliable biochemical marker for assessment of laryngopharyngeal reflux.
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Affiliation(s)
- Mohamed Mohamed Abdel-aziz
- Biotechnology Research Laboratories Division, Gastroenterology Surgical Center, Faculty of Medicine, Mansoura University, Egypt.
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Bohman JK, Kor DJ, Kashyap R, Gajic O, Festic E, He Z, Lee AS. Airway pepsin levels in otherwise healthy surgical patients receiving general anesthesia with endotracheal intubation. Chest 2013; 143:1407-1413. [PMID: 23117366 DOI: 10.1378/chest.12-1860] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Airway pepsin has been increasingly used as a potentially sensitive and quantifiable biomarker for gastric-to-pulmonary aspiration, despite lack of validation in normal control subjects. This study attempts to define normal levels of airway pepsin in adults and distinguish between pepsin A (exclusive to stomach) and pepsin C (which can be expressed by pneumocytes). METHODS We performed a prospective study of 51 otherwise healthy adult patients undergoing elective extremity orthopedic surgery at a single tertiary-care academic medical center. Lower airway samples were obtained immediately following endotracheal intubation and just prior to extubation. Total pepsin and pepsin A concentrations were directly measured by an enzymatic activity assay, and pepsin C was subsequently derived. Pepsinogen/pepsin C was confirmed by Western blot analyses. Baseline characteristics were secondarily compared. RESULTS In all, 11 (22%; 95% CI = 9.9%-33%) had detectable airway pepsin concentrations. All 11 positive specimens had pepsin C, without any detectable pepsin A. Pepsinogen/pepsin C was confirmed by Western blot analyses. In a multivariate logistic regression, men were more likely to have airway pepsin (OR, 12.71, P = .029). CONCLUSIONS Enzymatically active pepsin C, but not the gastric-specific pepsin A, is frequently detected in the lower airways of patients who otherwise have no risk for aspiration. This suggests that nonspecific pepsin assays should be used and interpreted with caution as a biomarker of gastropulmonary aspiration, as pepsinogen C potentially expressed from pneumocytes may be detected in airway samples.
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Affiliation(s)
- J Kyle Bohman
- Department of Anesthesia, Mayo Clinic College of Medicine, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesia, Mayo Clinic College of Medicine, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Emir Festic
- Department of Critical Care Medicine, Division of Pulmonary Medicine, Mayo Clinic College of Medicine, Jacksonville, FL
| | - Zhaoping He
- Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Augustine S Lee
- Department of Critical Care Medicine, Division of Pulmonary Medicine, Mayo Clinic College of Medicine, Jacksonville, FL.
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Farhath S, He Z, Saslow J, Soundar S, Amendolia B, Bhat V, Pyon K, Stahl G, Mehta D, Aghai ZH. Detection of pepsin in mouth swab: correlation with clinical gastroesophageal reflux in preterm infants. J Matern Fetal Neonatal Med 2013; 26:819-24. [PMID: 23311720 DOI: 10.3109/14767058.2013.764408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To study the relationship between pepsinogen/pepsin in a mouth swab and clinical gastroesophageal reflux (GER) in preterm infants. METHODS Preterm infants (birth weight ≤ 2000 g) on full enteral feeds were enrolled. Mouth swabs from cheek and below the tongue were collected one, two and three hours after feeding. An enzymatic assay with substrate fluorescein isothiocyanate-casein was used to detect pepsin A and C activities with further confirmation by western blot. Blinded investigators reviewed the infant's medical record to clinically diagnose GER. RESULTS A total of 101 premature infants were enrolled. Pepsinogen/pepsin was detected in 45/101 (44.5%) infants in at least one sample. A clinical diagnosis of GER was made in 36/101 (35.6%) infants. Mouth swabs were positive in 26/36 (72%) infants with clinical GER and only 19/65 (29%) infants without GER (p < 0.001). Similarly, the levels of pepsinogen/pepsin A and C were higher in the mouth swabs of infants with clinical GER. CONCLUSION The detection of pepsinogen/pepsin in a mouth swab correlates with clinical GER in premature infants.
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Affiliation(s)
- Sabeena Farhath
- Department of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
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Lautermann J, Begall K, Hilger G, Wilhelm T, Mir-Salim P, Kaschke O, Zahnert T. [Guideline "Otitis media with effusion" - long version. S1 Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery]. HNO 2012; 60:540-3. [PMID: 22669440 DOI: 10.1007/s00106-012-2512-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- J Lautermann
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Krankenhaus Martha-Maria Halle-Dölau gGmbH, Röntgenstr. 1, 06120, Halle/Saale, Deutschland.
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Antibody in middle ear fluid of children originates predominantly from sera and nasopharyngeal secretions. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2012; 19:1593-6. [PMID: 22855395 DOI: 10.1128/cvi.05443-11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The human middle ear is devoid of any immunocompetent cells in normal mucosa. We sought to determine the source of antibody present in the middle ear of children. Total IgG, IgA, and secretory IgA antibodies were determined by enzyme-linked immunosorbent assay from the nasopharyngeal, middle ear, and serum samples of children with acute otitis media. The two-dimensional gel electrophoresis pattern of the entire array of IgA antibodies in the nasal wash (NW) and middle ear fluid (MEF) was compared from the MEF and NW samples using isoelectric focusing and Western blotting. The total IgG and IgA antibodies in the MEF and NW samples of 137 children were compared. The ratio of IgG to IgA in the MEF was significantly different (P < 0.008) compared to NW because IgA levels were higher and IgG levels lower in NW. The IgG/IgA ratio of MEF resembled serum consistent with transudation to the MEF. Small amounts of secretory IgA were detected in MEF but the electrophoresis patterns of the entire array of IgA antibodies in the MEF and NW were virtually identical in each child evaluated; thus, IgA in MEF derived predominantly from serum and the nasopharynx by reflux via the Eustachian tube. The IgG/IgA antibody levels in the MEF and the same composition of IgA antibody in the MEF and NW identifies the predominant source of antibody in the MEF as a transudate of serum combined with nasal secretions refluxed from the nasopharynx in children.
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Trinick R, Johnston N, Dalzell AM, McNamara PS. Reflux aspiration in children with neurodisability--a significant problem, but can we measure it? J Pediatr Surg 2012; 47:291-8. [PMID: 22325378 DOI: 10.1016/j.jpedsurg.2011.11.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 11/10/2011] [Indexed: 02/07/2023]
Abstract
Recurrent respiratory problems are common in children with severe neurodisability, and respiratory deterioration is a leading cause of premature death in this group. Although the etiology is multifactorial, recurrent pulmonary aspiration is thought to play a significant role. Gastroesophageal reflux is known to be common, as is oral-motor discoordination. Differentiating direct aspiration of food and saliva and gastric reflux aspiration is difficult and presents a challenge in managing patients and assessing their suitability for surgical antireflux procedures. This is particularly the case when children present with predominantly respiratory symptoms, where there may be direct aspiration, reflux aspiration, neither, or both. A clinical biomarker to identify and quantify reflux aspiration would therefore be useful in surgical assessment and may also be applicable as an outcome measure for clinical trials of antireflux surgery. In this review, we discuss the evidence base behind existing and potentially novel biomarkers of aspiration in bronchoalveolar lavage fluid. We highlight the limitations of the lipid-laden macrophage index, particularly with regard to its specificity and interrater/intrarater reliability. We discuss the laboratory methods available to measure promising new biomarkers (pepsin and bile acids) and highlight their potential advantages and disadvantages. Finally, to understand how aspiration causes clinical signs and symptoms in our patients, we need to study the effect of aspirated substances on the lung, and here we review the available in vivo and in vitro literature.
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Affiliation(s)
- Ruth Trinick
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Miura MS, Mascaro M, Rosenfeld RM. Association between Otitis Media and Gastroesophageal Reflux. Otolaryngol Head Neck Surg 2011; 146:345-52. [DOI: 10.1177/0194599811430809] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Miguel Mascaro
- State University of New York Downstate Medical Center, Brooklyn, New York, USA
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Abstract
OBJECTIVE Evaluate the hypothesis that the same pepsinogen C molecule produced in the stomach is also produced by the lung. PATIENTS AND METHODS Pulmonary and gastric tissues collected postmortem were immunohistochemically stained for pepsinogen C and pepsinogen A. RESULTS Sixteen patients with diverse causes of death were evaluated. Gestational age at birth ranged between 21 and 37 weeks. Pepsinogen A was detected in 12 of the 13 stomach sections, mainly in the chief cells, but not in any lung sections. Pepsinogen C was detected in all stomach sections in chief and mucus cells and in 9 of the 16 lung sections, mainly in type II pneumocytes. Pepsinogen C was not detected in the 3 lung cases with a gestational age <23 weeks. CONCLUSIONS The same pepsinogen C molecule is produced in the stomach and in the lung. These findings potentially affect previous study results that used an enzymatic pepsin detection assay to evaluate for and associate gastroesophageal reflux disease with other morbidities.
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Sone M, Kato T, Suzuki Y, Arao H, Sugiyama K, Ishida K, Izawa K, Takasu A, Nakashima T. Relevance and characteristics of gastroesophageal reflux in adult patients with otitis media with effusion. Auris Nasus Larynx 2011; 38:203-7. [DOI: 10.1016/j.anl.2010.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 07/29/2010] [Accepted: 08/12/2010] [Indexed: 11/15/2022]
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Toros SZ, Toros AB, Ozel L, Çatal BE, Kiniş V, Zorlu A, Habeşoğlu TE, Naiboğlu B, Egeli E. Investigation of gastric pepsinogen in middle ear fluid of children with glue ear. Acta Otolaryngol 2010; 130:1220-4. [PMID: 20441533 DOI: 10.3109/00016481003753448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION The presence of pepsinogen in middle ear effusion (MEE) supports the relationship between gastroesophageal reflux (GER) and otitis media with effusion (OME). Measurement of pepsin/pepsinogen can be considered as a simple and reliable method for assesment of reflux in children. However, further research is needed to establish a definite association between GER and OME before beginning antireflux treatment in the management of MEE. OBJECTIVE The aim of this study was to investigate the relationship between GER and chronic OME, and to confirm the presence of gastric enzyme in the MEE of children with OME. METHODS This was a prospective study. MEE and blood samples were obtained from 42 children undergoing tympanostomy tube placement. Total pepsinogen concentrations of effusions and serum samples were measured with a commercial ELISA using a human pepsinogen I specific antibody. Albumin levels of effusions and serum samples were also measured with ELISA for comparison with pepsinogen levels. RESULTS Measurable pepsinogen was present in all MEEs from patients, with levels higher than the serum values. The difference between the levels of pepsinogen measured in MEE and serum was statistically significant (p < 0.01), but albumin levels were higher in serum than in MEE and the difference was statistically significant (p < 0.01).
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Affiliation(s)
- Sema Zer Toros
- Department of Otorhinolaryngology/Head and Neck Surgery, Istanbul, Turkey.
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Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547. [PMID: 19745761 DOI: 10.1097/mpg.0b013e3181b7f563] [Citation(s) in RCA: 473] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.
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Harris P, Hussey D, Watson D, Mayne G, Bradshaw A, Joniau S, Tan L, Wormald P, Carney A. Reflux changes in adenoidal hyperplasia: a controlled prospective study to investigate its aetiology. Clin Otolaryngol 2009; 34:120-6. [DOI: 10.1111/j.1749-4486.2008.01852.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Klokkenburg JJC, Hoeve HLJ, Francke J, Wieringa MH, Borgstein J, Feenstra L. Bile acids identified in middle ear effusions of children with otitis media with effusion. Laryngoscope 2009; 119:396-400. [PMID: 19172630 DOI: 10.1002/lary.20115] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Several studies have shown the presence of pepsin in the middle ear effusions of children with otitis media with effusion (OME). When gastric reflux is the cause, other noxious reflux products might be present. We therefore investigated the presence of bile acids in the middle ear effusions of children with OME. STUDY DESIGN We evaluated 38 children (63 samples of middle ear secretions (ME samples)) in a prospective study at a tertiary care children's hospital. METHODS ME samples were collected from children with OME during ventilation tube insertion. Most ME samples were diluted with albumin. The presence of bile acids was measured with the 3alpha-hydroxy steroid dehydrogenase enzymatic method. A ME sample was considered positive when it contained at least 5 mumol/l bile acids, independent of dilution. Blood samples were taken simultaneously as a reference to determine bile acids serum levels. RESULTS We found bile acids in 32 % (20/63) of all ME samples and in 42% (16/38) of all children. Bile acids concentrations of 12 well-soluble ME samples ranged from 5.9-40.9 mumol/L and were 3.1-19.7 times higher than the serum concentrations. In 4 of the corresponding serums, no bile acids were measurable at all. CONCLUSIONS Bile acids are present in a number of the ME samples of children with OME. Because of dilution, it is possible that more ears contain bile acids. Bile acids are known to be noxious to mucosal cells at a higher (pH) than pepsin and, therefore, might play a role in the pathology of OME.
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He Z, O'Reilly RC, Mehta D. Gastric pepsin in middle ear fluid of children with otitis media: clinical implications. Curr Allergy Asthma Rep 2008; 8:513-8. [PMID: 18940143 DOI: 10.1007/s11882-008-0094-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Gastroesophageal reflux and extraesophageal reflux have been postulated to be involved in the pathogenesis of otitis media. This is supported by recent studies revealing the presence of gastric pepsin in the middle ear space of children with otitis media but not in control patients without otitis media. Reflux's role in otitis media appears to be most pronounced in younger children and those with purulent effusions.
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Affiliation(s)
- Zhaoping He
- Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA
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Current world literature. Curr Opin Otolaryngol Head Neck Surg 2008; 16:569-72. [PMID: 19005328 DOI: 10.1097/moo.0b013e32831cf1a7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pathophysiological mechanisms of extraesophageal reflux in otolaryngeal disorders. Eur Arch Otorhinolaryngol 2008; 266:17-24. [DOI: 10.1007/s00405-008-0770-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 07/03/2008] [Indexed: 12/19/2022]
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Abstract
OBJECTIVES/HYPOTHESIS Gastroesophageal reflux disease (GERD) is common in children, and extraesophageal reflux disease (EORD) has been implicated in the pathophysiology of otitis media (OM). We sought to 1) determine the incidence of pepsin/pepsinogen presence in the middle ear cleft of a large sample of pediatric patients undergoing myringotomy with tube placement for OM; 2) compare this with a control population of pediatric patients undergoing middle ear surgery (cochlear implantation) with no documented history of OM; 3) analyze potential risk factors for OM in children with EORD demonstrated by the presence of pepsin in the middle ear cleft; and 4) determine if pepsin positivity at the time of myringotomy with tube placement predisposes to posttympanostomy tube otorrhea. STUDY DESIGN AND METHODS STUDY GROUP prospective samples of 509 pediatric patients (n = 893 ear samples) undergoing myringotomy with tube placement for recurrent acute OM and/or otitis media with effusion in a tertiary care pediatric hospital with longitudinal follow-up of posttympanostomy tube otorrhea. CONTROL GROUP prospective samples of 64 pediatric patients (n = 74 ears) with negative history of OM undergoing cochlear implantation at one of the three tertiary care pediatric hospitals. A previously validated, highly sensitive and specific modified enzymatic assay was used to detect the presence of pepsin in the middle ear aspirates of study and control patients. Risk factors for OM and potentially associated conditions, including GERD, allergy, and asthma were analyzed for the study group through review of the electronic medical record and correlated topresence of pepsin in the middle ear space. Study patients were followed longitudinally postoperatively to determine the incidence of posttympanostomy tube otorrhea. RESULTS The incidence of pepsin in the middle ear cleft of the study group was 20% of patients and 14% of ears, which is significantly higher than 1.4% of control patients and 1.5% of control ears (P < .05). Study patients younger than 1 year had a higher rate of purulent effusions and pepsin in the middle ear cleft (P < .05). Patients with pepsin in the middle ear cleft were more likely to have an effusion at the time of surgery than patients without pepsin in the middle ear cleft (P < .05). There was no statistical association found between the presence of pepsin and clinical history of GERD, allergy, asthma, or posttympanostomy tube otorrhea. CONCLUSIONS Pepsin is detectable in the middle ear cleft of 20% of pediatric patients with OM undergoing tympanostomy tube placement, compared with 1.4% of controls; recovery of pepsin in the middle ear space of pediatric patients with OM is an independent risk factor for OM. Patients under 1 year of age have a higher incidence of purulent effusions and pepsin-positive effusions. Clinical history of GERD, allergy, and asthma do not seem to correlate with evidence of EORD reaching the middle ear cleft. The presence of pepsin in the middle ear space at the time of tube placement does not seem to predispose to posttympanostomy tube otorrhea.
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