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Diagnosis of pediatric laryngopharyngeal reflux
International Journal of Pediatric Otorhinolaryngology (2006) 70, 757—758
www.elsevier.com/locate/ijporl
LETTER TO THE EDITOR Diagnosis of pediatric laryngopharyngeal reflux
KEYWORDS Reflux; Larynx; Papillomas; Children; Acid; Extraoesophageal; Diagnosis
We read with great interest the well-written cases series by McKenna and Brodsky [1]. Indeed, laryngopharyngeal reflux (LPR) is the hottest topic in laryngology and over the last few years, multidisciplinary courses on reflux and pepsin have been organised by laryngologists, gastroenterologists, chest physicians, pediatricians and speech therapists. It is possible that many ear, nose and throat ‘‘mysteries’’ including perhaps recurrent respiratory papillomas (RRPs) may find an answer through correctly diagnosing and managing synchronous reflux-related problems, both in adults and children. A few reservations about this specific paper are the way LPR was diagnosed in patients 2—4. Patient 1 was, in our opinion, correctly diagnosed with a combination of history, flexible laryngoscopy, scintiscan, esophagoscopy and dual probe pH-monitoring and responded well to Nissen fundoplication. In patients 2—4 though, ‘‘diagnosis’’ was based on flexible and rigid laryngoscopy and symptomatic response on empiric treatment with proton pump inhibitors. We agree that a suspicion of reflux can be made based on history and laryngoscopy and a response to proton pump inhibitors but a definitive
diagnosis-based on history and examination–—will be very difficult even for an experienced laryngologist. Also, the fact that a remission of RRPs was noted after antireflux treatment may well be a complete coincidence and part of the natural disease progress of papillomas. Diagnosis of LPR is a very grey area in laryngology and if we give a picture of an ‘‘angry-looking’’ larynx to 10 experienced laryngologists to comment, it is quite possible they will come up with different terminology in an attempt to ‘‘grade’’ a reflux related laryngeal injury. It is easily understood that, for example, a nodule in a patient who does not use his voice a lot is of different diagnostic gravity than in an opera singer on a night before a performance. Evaluation of any medical or surgical outcome depends on accurate diagnostic methods and until today there are no validated tools that can accurately document symptoms or signs of reflux laryngitis; there are of course the widely used reflux finding score and symptom index but these cannot easily be applied to kids [2,3]. Various methods for diagnosing reflux including pH monitoring, multi-channel intraluminal impedance (MII), scintigraphy, fluoroscopy and esophageal biopsy have been used in children. Dual probe pH-monitoring, despite its low sensitivity and inability to detect gaseous or non-acidic reflux remains the most commonly used test. MII can measure conductivity during passage of a bolus of liquid, food or gas and in that respect is superior to pHmetry, although further studies are required to validate its use. Scintigraphy is useful for estimating gastric emptying and demonstrating reflux, but correlation with pH metry is poor [4].
DOI of original article: 10.1016/j.ijporl.2005.09.015. 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.016
758
References [1] M. McKenna, L. Brodsky, Extraesophageal acid reflux and recurrent respiratory papilloma in children, Int. J. Pediatr. Otorhinolaryngol. 69 (5) (2005) 597—605. [2] P.C. Belafsky, G.N. Postma, J.A. Koufman, Validity and reliability of the reflux symptom index (RSI), J. Voice 16 (2) (2002) 274—277. [3] P.C. Belafsky, G.N. Postma, J.A. Koufman, The validity and reliability of the reflux finding score (RFS), Laryngoscope 111 (8) (2001) 1313—1317. [4] C.D. Rudolph, L.J. Mazur, G.S. Liptak, R.D. Baker, J.T. Boyle, R.B. Colletti, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition, J. Pediatr. Gastroenterol. Nutr. 32 (Suppl. 2) (2001) S1—S31.
Letter to the Editor P.D. Karkos* Department of Pediatric Otolaryngology, Alder Hey Childrens Hospital, Liverpool, United Kingdom M.T. Apostolidou T. Apostolidis Department of Otolaryngology-Head&Neck Surgery, University of Thessalia, Larissa, Greece *Corresponding author. Tel.: +44 790 958 1962 E-mail address: [email protected]. (P.D. Karkos) 18 May 2005
www.elsevier.com/locate/ijporl
LETTER TO THE EDITOR Diagnosis of pediatric laryngopharyngeal reflux
KEYWORDS Reflux; Larynx; Papillomas; Children; Acid; Extraoesophageal; Diagnosis
We read with great interest the well-written cases series by McKenna and Brodsky [1]. Indeed, laryngopharyngeal reflux (LPR) is the hottest topic in laryngology and over the last few years, multidisciplinary courses on reflux and pepsin have been organised by laryngologists, gastroenterologists, chest physicians, pediatricians and speech therapists. It is possible that many ear, nose and throat ‘‘mysteries’’ including perhaps recurrent respiratory papillomas (RRPs) may find an answer through correctly diagnosing and managing synchronous reflux-related problems, both in adults and children. A few reservations about this specific paper are the way LPR was diagnosed in patients 2—4. Patient 1 was, in our opinion, correctly diagnosed with a combination of history, flexible laryngoscopy, scintiscan, esophagoscopy and dual probe pH-monitoring and responded well to Nissen fundoplication. In patients 2—4 though, ‘‘diagnosis’’ was based on flexible and rigid laryngoscopy and symptomatic response on empiric treatment with proton pump inhibitors. We agree that a suspicion of reflux can be made based on history and laryngoscopy and a response to proton pump inhibitors but a definitive
diagnosis-based on history and examination–—will be very difficult even for an experienced laryngologist. Also, the fact that a remission of RRPs was noted after antireflux treatment may well be a complete coincidence and part of the natural disease progress of papillomas. Diagnosis of LPR is a very grey area in laryngology and if we give a picture of an ‘‘angry-looking’’ larynx to 10 experienced laryngologists to comment, it is quite possible they will come up with different terminology in an attempt to ‘‘grade’’ a reflux related laryngeal injury. It is easily understood that, for example, a nodule in a patient who does not use his voice a lot is of different diagnostic gravity than in an opera singer on a night before a performance. Evaluation of any medical or surgical outcome depends on accurate diagnostic methods and until today there are no validated tools that can accurately document symptoms or signs of reflux laryngitis; there are of course the widely used reflux finding score and symptom index but these cannot easily be applied to kids [2,3]. Various methods for diagnosing reflux including pH monitoring, multi-channel intraluminal impedance (MII), scintigraphy, fluoroscopy and esophageal biopsy have been used in children. Dual probe pH-monitoring, despite its low sensitivity and inability to detect gaseous or non-acidic reflux remains the most commonly used test. MII can measure conductivity during passage of a bolus of liquid, food or gas and in that respect is superior to pHmetry, although further studies are required to validate its use. Scintigraphy is useful for estimating gastric emptying and demonstrating reflux, but correlation with pH metry is poor [4].
DOI of original article: 10.1016/j.ijporl.2005.09.015. 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.016
758
References [1] M. McKenna, L. Brodsky, Extraesophageal acid reflux and recurrent respiratory papilloma in children, Int. J. Pediatr. Otorhinolaryngol. 69 (5) (2005) 597—605. [2] P.C. Belafsky, G.N. Postma, J.A. Koufman, Validity and reliability of the reflux symptom index (RSI), J. Voice 16 (2) (2002) 274—277. [3] P.C. Belafsky, G.N. Postma, J.A. Koufman, The validity and reliability of the reflux finding score (RFS), Laryngoscope 111 (8) (2001) 1313—1317. [4] C.D. Rudolph, L.J. Mazur, G.S. Liptak, R.D. Baker, J.T. Boyle, R.B. Colletti, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition, J. Pediatr. Gastroenterol. Nutr. 32 (Suppl. 2) (2001) S1—S31.
Letter to the Editor P.D. Karkos* Department of Pediatric Otolaryngology, Alder Hey Childrens Hospital, Liverpool, United Kingdom M.T. Apostolidou T. Apostolidis Department of Otolaryngology-Head&Neck Surgery, University of Thessalia, Larissa, Greece *Corresponding author. Tel.: +44 790 958 1962 E-mail address: [email protected]. (P.D. Karkos) 18 May 2005