Impact of laryngopharyngeal and gastroesophageal reflux on asthma control in children

doi:10.1016/j.ijporl.2012.11.021

International Journal of Pediatric Otorhinolaryngology

Volume 77, Issue 3, March 2013, Pages 341-345

https://doi.org/10.1016/j.ijporl.2012.11.021 Get rights and content

Abstract

Objective

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

Methods

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

Results

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

Conclusions

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

Introduction

Pediatric laryngopharyngeal reflux (LPR) has gained better recognition over the past few years. Even though the relationship between gastro-esophageal reflux disease (GERD) and asthma has been investigated, there was a little data about the association between asthma and laryngopharyngeal reflux (LPR) in children [1].

The relationship between reflux and respiratory distress resembles chicken or egg dilemma. There is no doubt that reflux of gastric contents is an important cause of chronic cough [2]. It was speculated that refluxate may enter the airway and stimulate tracheo-bronchial cough receptors and it is possible that microaspirations occur directly stimulating cough and/or resulting in airway inflammation and cough reflex sensitization [3]. Lung hyperinflation in asthma lowers the diaphragm and can interfere with the flap valve mechanism produced by the angulated entry of the esophagus into the stomach. These fluctuations in intrathoracic and intraabdominal pressures increase the risk of reflux [4].

Laryngopharyngeal reflux is different from classic gastroesophageal reflux. It is believed that the primary defect in LPR might be upper esophageal sphincter dysfunction, whereas GER is lower esophageal dysfunction [5]. Patients with LPR usually deny symptoms of heartburn and regurgitation. Instead of gastrointestinal symptoms, most LPR patients have throat symptoms like dysphonia, chronic cough, globus pharyngeus, and chronic throat clearing [6].

A diagnosis of LPR may be established by questioning of the symptoms, videolaryngoscopic evaluation of larynx or double probe pH monitoring [7], [8], [9]. Ambulatory 24 h double probe (pharyngeal and esophageal) pH monitoring is both highly sensitive and specific for diagnosis of LPR [10], [11].

The aim of this study was to determine the predictive value of reflux symptom score and LPR disease index to diagnose LPR and GER in children with asthma by comparing the results of double probe pH monitoring study. Secondly we aimed to determine the difference between controlled and uncontrolled asthma in terms of GER and LPR coexistence.

Section snippets

Subjects and methods

A total of 50 patients aged 7–17 years (23 girls, 27 boys) with mild to moderate persistent asthma, between December 2009 and December 2010 were randomly included in this study according to controlled and uncontrolled status at asthma outpatient clinic. Randomization was performed using a computer generated randomization list and 50 patients were selected out of 150 patients with asthma. However, 4 patients did not enter the study because the procedure was invasive. Three of these 4 patients

Results

Fifty laryngoscopic and pH monitoring studies were completed without any complications. Demographic and baseline characteristics of the patients according to the asthma control status are summarized in Table 1.

Eighty percent (40/50) of the study population had significant acid reflux documented by either the esophageal or the pharyngeal probe. Of those, seventy percent (35/50) of the patients had abnormal reflux documented by the pharyngeal probe, and forty-six percent (23/50) of the patients

Discussion

The study was designed especially with the aim of evaluating the impact of LPR-GER on asthma control status and determining the predictive value of symptoms and laryngeal findings to diagnose LPR. Currently, the gold standard to diagnose LPR is the 24-h dual probe pH meter study but it can be done only by a specialist without anesthesia and young children might need to be hospitalized for 24 h to prevent them from pulling the tube out. In addition after the replacement of probes, X-ray is

Acknowledgments

This study was supported by the Commission of Scientific Research Projects of Ondokuz Mayis University (Project No: PYO.TIP.1904.09.043) and it was presented in 30th Congress of the European Academy of Allergy and Clinical Immunology, 2011.

References (32)

G.H. Zalzal et al.
Pediatric gastroesophageal reflux and laryngopharyngeal reflux
Otolaryngol. Clin. North Am.
(2000)
P.C. Belafsky et al.
Validity and reliability of the reflux symptom index (RSI)
J. Voice
(2002)
M.E. Beaver et al.
Diagnosis of laryngopharyngeal reflux disease with digital imaging
Otolaryngol. Head Neck Surg.
(2003)
J.J. Herbst et al.
Gasroesophageal reflux causing respiratory distress and apnea in newborn infants
J. Pediatr.
(1979)
D.A. Vincent et al.
The proximal probe in esophageal pH monitoring: development of a normative database
J. Voice
(2000)
S.G. Johansson et al.
Revised nomenclature for allergy for global use: report of the Nomenclature Review Committee of the World Allergy Organization, October 2003
J. Allergy Clin. Immunol.
(2004)
P. Stavroulaki
Diagnostic and management problems of laryngopharyngeal reflux disease in children
Int. J. Pediatr. Otorhinolaryngol.
(2006)
D.M. Hicks et al.
The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers
J. Voice
(2002)
K. Thakkar et al.
Gastroesophageal reflux and asthma in children: a systematic review
Pediatrics
(2010)
J. Smith et al.
New developments in the objective assessment of cough
Lung
(2008)

S. Ayazi et al.

Thoraco-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease

Dig. Dis. Sci.

(2011)

J.A. Koufman

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury

Laryngoscope

(1991)

J.A. Koufman

Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease

Ear Nose Throat J.

(2002)

P.C. Belafsky et al.

The validity and reliability of the reflux finding score (RFS)

Laryngoscope

(2001)

G.N. Postma et al.

Laryngopharyngeal reflux testing

Ear Nose Throat J.

(2002)

J.P. Little et al.

Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children

Ann. Otol. Rhinol. Laryngol. Suppl.

(1997)

Cited by (21)

Combined multi-channel intraluminal impedance measurement and pHmetry in the detection of gastroesophageal reflux disease in children with cystic fibrosis
2023, Jornal de Pediatria
To assess the prevalence of GERD exclusively by means of multichannel intraluminal impedanciometry associated with pH monitoring (MIIpH) and compare it with respiratory symptoms in children with CF. To compare MIIpH with pHmetry alone to perform GERD diagnosis.
An analytical cross-sectional study was conducted with children diagnosed with CF who underwent MIIpH. Clinical and laboratory markers, including respiratory and digestive symptoms, were used for comparative analyses. High-resolution chest computed tomography was performed on patients with symptoms of chronic lung disease. Severity was classified according to the Bhalla score.
A total of 29 children < 10 yo (18 girls) were evaluated; 19 of whom with physiological GER and 10 with GERD. Of the children with GERD, seven had predominantly acid GER, two acid+non-acid GER, and one non-acid GER. Three patients had GERD diagnosed only by MIIpH. Bhalla scores ranged from seven to 17.75 with no significant relationship with GERD. The number of pulmonary exacerbations was associated with a decrease in esophageal clearance regardless of the position in pHmetry and MIIpH.
The prevalence of GERD was 34% in children with CF. There was no association between respiratory disease severity and GER types. MIIpH detected 30% more patients with GERD than pHmetry.
Proton pump inhibitors are still overprescribed for hospitalized children
2022, Archives de Pediatrie
Citation Excerpt :
This indication was found for only four patients in our study but remains frequently encountered in general pediatric practice. In children with extra-digestive manifestations, the role of GERD in the occurrence of symptoms is still debated [6,13]. Although erythema of the posterior margella has not been proven to be a specific sign of GERD, PPIs are often prescribed by otolaryngologists [14] without confirmed efficacy [15].
The use of proton pump inhibitors has increased exponentially over the past 20 years. Several side effects have been reported and concerns exist about the consequences of long-term proton pump inhibitors on health, leading to limitation of their use. The present study analyzed prescriptions of proton pump inhibitors at inpatient units and assessed their compliance with current recommendations.
This single-center, observational, retrospective study reviewed medical file of patients hospitalized at the pediatric medical departments of the Bordeaux University Hospital between April 1 and September 30, 2019. Patients younger than 18 years, hospitalized in the pediatric hospital units and treated with proton pump inhibitors were included. Prescriptions of proton pump inhibitors were compared with French and international guidelines.
Proton pump inhibitors were prescribed for 251 of 2237 children (11%), mainly for gastroesophageal reflux disease (47%) and prevention of peptic ulcer disease (32.7%). Proton pump inhibitor prescription complied to recommendations in 34.5% of cases, less often in children aged younger than 1 year (13.5%) than in older children. Compliance to recommendations was lower when proton pump inhibitors were indicated for the prevention of peptic disease (5%) than for gastroesophageal reflux disease (48%).
Proton pump inhibitors are frequently prescribed for hospitalized children, and indications comply with recommendations in only 35% of the cases. Efforts in spreading awareness of the recommendations on the use of proton pump inhibitors in children are mandatory among hospital pediatricians.
Gastroesophageal Reflux
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Esophageal reflux is a common finding in infants and children. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition have developed guidelines for the management of infants and children with this condition. In children with prolonged or severe symptoms, determination of the underlying etiology enables appropriate therapeutic intervention.
Use OF NBI for the assessment of clinical signs of rhino-pharyngo-laryngeal reflux in pediatric age: Preliminary results
2020, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
The low specificity and the variability of symptoms make diagnosis of pediatric LPR still challenging. Moreover in children LPRD in addition to the laryngeal manifestation has been associated typically with other conditions that involve rhino-pharingo-tubaric and tracheobronchial districts (rhinosinusitis [16], laryngomalacia [17,18], subglottic stenosis [19,20], pneumonia, asthma [21–23], otitis media [24,25] and dacriocistostenosis [26]). Therefore the clinical-diagnostic assessment and therapeutic classification of LPRD is still not well established.
Laryngopharyngeal reflux (LPR) is a complex problem in pediatric population: diagnosis and clinical presentation are still controversial.
Classic white light endoscopy shows some pathognomonic signs of LPR in children, such as thickening of pharyngo-laryngeal mucus, the cobblestoning aspect of pharyngeal mucosa, arytenoid edema/hyperemia, nodular thickening/true vocal cord edema, hypertrophy of the posterior commissure, subglottic edema.
The NBI (Narrow Band Imaging) technology, generally used in oncology, allows to study neoangiogenesis and hypervascularization of the mucosa, common aspects in both chronic inflammation and neoplastic transformation. The aim of our study was to evaluate the added value of this technology in identifying the main laryngopharyngeal reflux sign in a pediatric population.
We evaluated at the Otolaryngology Unit of the “Fondazione Policlinico A. Gemelli” hospital and the Airway Surgery Unit of the “Bambino Gesù” Children's Hospital 35 patients aged from 2 months to 16 years divided into two groups in the period between November 2017 and May 2018. Group A included patients with clinical suspicion of LPR after gastroenterologist evaluation and Group B included patients who underwent an endoscopic evaluation for the assessment of recurrent respiratory symptoms such as stridor, recurrent croup, wheezing and persistent cough. We performed an endoscopic evaluation by white light and NBI for each patient, comparing the results of both methods to evaluate signs of pharyngo-laryngeal reflux and to calculate the value of reflux finding score (RFS).
The analysis of the data showed: for Group A an average value of RFS with white light of 11,84 (range 8–17, standard deviation 2,52 ± 0,57) and with NBI of 13,63 (range 10–17, standard deviation 2,13 ± 0,49); for Group B the analysis of the data showed an average value of RFS with white light of 10,06 (range 8–14, standard deviation 2,32 ± 0,58) and with NBI of 12,50 (range 9–18, standard deviation 2,63 ± 0,65). The comparison between the two methods resulted significant.
Furthermore evaluation by NBI allowed to highlight other signs of pharyngo-laryngeal reflux, characteristic of pediatric age and not included in RFS, in particular cobblestone aspect of the hypopharingeal mucosa, phlogosis of the tonsillar crypts and adenoid surface, hyperemia and hypervascularization of subglottic and tracheal mucosa.
Although still preliminary our results represent an interesting starting point for further studies, because they underline the potentiality of NBI endoscopy in LPR evaluation and how this technology could improve the identification of reflux signs.
Management of a rare case of arytenoid mucosa oedema inducing stridor and cough
2013, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
We previously placed proximal recording probe trans-nasally immediately above the upper oesophageal sphincter, under the guidance of flexible or rigid laryngoscopy, whereas the distally one was placed 5 cm above the lower esophageal sphincter (identified by manometry). In our department the percentage of time below pH 4 exceeding 4% is chosen as the definition of pathologic acid gastroesophageal reflux, whereas gastro-pharyngeal reflux was defined abnormal by an index are reflux (RAI) > 6.3 [5–8]. Trans-nasal fibreoptic laryngoscopy, 2-week after admittance, shown persistence of arytenoids and intra-arytenoid mucosa swelling and the same mechanism of cough described at the emergency department, sustaining a vicious circle of cough.
Objective: Current guidelines recommend a multidisciplinary systematic integrated approach to patient with chronic cough in which nowadays otolaryngologists play an increasingly valuable role as new procedures are used for evaluation and treatment. Surgery has been never taken into consideration to treat refractory chronic cough. Method: We present a rare case of arytenoid mucosa oedema inducing stridor and cough, lasting 8 months, that critically affected the quality of life of a 15-year-old adolescent arrived to our emergency department with prominent arytenoid oedema causing paroxysmal cough and laryngeal stridor and that was successfully treated by laryngeal debridement. Results: In this case report we observed that prominent swelling of arytenoid mucosa might sustain a vicious cycle of cough persistence and that laryngeal surgical debridement might interrupt it resolving the particular clinical condition. Conclusion: The description of this case could be of some help for clinicians to draw new insight about diagnosis and therapy of rare selected cases of chronic refractory cough.
Laryngopharyngeal reflux disease in children
2013, Pediatric Clinics of North America
Citation Excerpt :
The use of β-agonists has also been studied as a possible trigger for reflux by reducing the tone of the lower esophageal sphincter.39 However, a recent study seems to prove that no such correlation exists.37 Another belief was that uncontrolled asthma may worsen LPRD, but it seems that children with asthma, whether controlled or uncontrolled, have similar rates of LPRD.16

View all citing articles on Scopus

View full text

Impact of laryngopharyngeal and gastroesophageal reflux on asthma control in children

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Subjects and methods

Results

Discussion

Acknowledgments

Otolaryngol. Clin. North Am.

J. Voice

Otolaryngol. Head Neck Surg.

J. Pediatr.

J. Voice

J. Allergy Clin. Immunol.

Int. J. Pediatr. Otorhinolaryngol.

J. Voice

Gastroesophageal reflux and asthma in children: a systematic review

Pediatrics

New developments in the objective assessment of cough

Lung

Thoraco-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease

Dig. Dis. Sci.

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury

Laryngoscope

Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease

Ear Nose Throat J.

The validity and reliability of the reflux finding score (RFS)

Laryngoscope

Laryngopharyngeal reflux testing

Ear Nose Throat J.

Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children

Ann. Otol. Rhinol. Laryngol. Suppl.