GASTROESOPHAGEAL REFLUX AND ITS ROLE IN PEDIATRIC OTOLARYNGOLOGY

1
GASTROESOPHAGEAL REFLUX AND ITS ROLE
INPEDIATRIC OTOLARYNGOLOGY

• Wendy Mackey, APRN, CORLN
• Pediatric Otolaryngology Symposium
• November 2, 2006

2
Definitions

• Gastroesophageal Reflux
• Involuntary return of gastric contents into the
  esophagus as a result of a dysfunctional lower
  esophageal sphincter
• Physiologic vs Pathologic
• Extraesophageal Reflux

3
Epidemiology

• First described as a clinical entity in
  pediatrics in the 1950s
• incidence 1/4000 live births
• Cherry and Margulies (1968) - contact ulcers of
  the larynx
• Three-fold predominance in boys over girls
• Increased incidence in certain clinical
  conditions
• neurologic impairment
• prematurity (70 preemies lt1700 grams)
• diaphragmatic hernia
• esophageal atresia
• feeding tubes
• gastric/intestinal mobility disorders
• various syndromes

4
Pathophysiology

• The primary barrier against GE reflux is the
  lower esophageal sphincter
• sphincter lacks appropriate tone or other
  incompetency
• gastric volume or pressure
• poor gastric emptying
• altered neuromuscular development
• abnormal esophageal motility
• acuity of the angle of His
• other anatomic defects

5
Clinical Presentation

• Classic symptoms
• vomiting, pain / irritability, failure to thrive
• Hiccuping, yawning, and sneezing
• Severe symptoms
• Pulmonary compromise
• apnea, pneumonia, wheezing, asthma, stridor
• Epigastric bleeding, anemia, hematemesis
• esophagitis
• Sandifer syndrome
• Silent reflux

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Otolaryngologic Diseases Attributed to GERD

• Hoarseness
• Laryngitis
• Chronic rhinitis
• Sinusitis
• Recurrent croup
• Subglottic stenosis

• Otalgia
• Vocal cord granulomas
• Oropharyngeal dysphagia
• Laryngomalacia
• Stridor

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GASTROESOPHAGEAL REFLUX AND THE PEDIATRIC AIRWAY
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Laryngeal symptoms in Children Bouchard et al
pH study

• Evaluate the pertinence of pH studies for
  persistent ENT symptoms and their eventual
  relationship to GER
• 3,000 pH studies/ 16 years
• 105 children referred for ENT symptoms
• 88 children referred for laryngeal symptoms
• stridor, laryngomalacia, laryngitis, dysphonia,
  laryngeal papillomatosis
• Bouchard, S., Lallier, M., Yazbeck, S.
  Bensoussan, A. (1999). The otolaryngologic
  manifestations of gastresophageal reflux When
  is a pH study indicated? Journal of Pediatric
  Surgery, 34(7), 1053-1056.

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Laryngeal symptoms in Children Bouchard et al
pH study

• Reasons for referral (n/mean age)- positive pH
  probe
• stridor (n31/8m) - 58
• laryngomalacia (n18/13m) - 61
• laryngitis (n16/50m) - 56
• dysphonia (n14/59m) - 14
• laryngeal papillomatosis (n8/62m) - 25
• dysphagia (n1)
• Authors recommend pH study be performed on
  children with stridor, laryngomalacia and
  laryngitis when conventional tx fails
• pH probe not as beneficial in children with
  laryngeal papillomatosis and dysphonia
• Bouchard, S., Lallier, M., Yazbeck, S.
  Bensoussan, A. (1999). The otolaryngologic
  manifestations of gastresophageal reflux When
  is a pH study indicated? Journal of Pediatric
  Surgery, 34(7), 1053-1056.

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Laryngeal symptoms in Children Bouchard et al
pH study

• Follow-up of 3 largest groups following
  initiation of medical treatment of the GER
• Resolution of symptoms
• Stridor and GER- 83
• Laryngomalacia and GER- 80
• Laryngitis and GER-86
• Bouchard, S., Lallier, M., Yazbeck, S.
  Bensoussan, A. (1999). The otolaryngologic
  manifestations of gastresophageal reflux When
  is a pH study indicated? Journal of Pediatric
  Surgery, 34(7), 1053-1056.

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Determine correlation between findings at DLB
and presence of EERD

• 155 children - DLB for airway symptoms due to
  suspicion of EERD
• 0.3-11.7y, retrospective chart review
• 1 test GER -- UGI, pH probe, gastric
  scintiscan or esophogeal bx
• 130/155 (84) has GERD diagnosed
• GER - 90 had at least 1 larygnotracheal
  abnormality
• GER - -27 patients had an abnormal larynx or
  trachea, and 11 had both
• Carr, M., Nguyen, A., Poje, C., Pizzuto, M.,
  Nagy, M. Brodsky, L. (2000). Correlation of
  findings on direct laryngoscopy and bronchoscopy
  with presence of extraesophageal reflux disease.
  Laryngoscope, 110(9), 1560-1562.

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DLB and Extraesophageal Reflux
DiseaseAbnormalities in GER Patients

• Laryngeal anomalies (83)
• Postglottic edema (69)
• Arytenoid edema (30)
• Large lingual tonsils (16)
• Vocal fold edema (12)
• Vocal fold nodule (12)
• Hypopharyngeal cobblestoning (3)

• Tracheal anomalies (66)
• (104 patients with tracheal descriptions)
• Tracheal cobblestoning (33)
• Blunting of carina (12.5)
• Subglottic stenosis (11)
• Increased secretions (11)
• General edema or erythema (5)

Carr, M., Nguyen, A., Poje, C., Pizzuto, M.,
Nagy, M. Brodsky, L. (2000). Correlation of
findings on direct laryngoscopy and bronchoscopy
with presence of extraesophageal reflux disease.
Laryngoscope, 110(9), 1560-1562.
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Correlation of Findings at DL B with GERD in
Children

• 77 consecutive pts who underwent DLB
  (prospective)
• Age 0.1-15.1 yrs -- 51 male26 female24
  tracheostomy present
• MR revealed history of positive GERD test
• Group Results
• GERD group 50/77 (65) 1 positive diagnostic
  test
• GERD - group 21/77 (27) negative dx test,
  symptom free
• Indeterminant grp 6/77 (8) neg test, positive
  symptoms

Carr, M., Nagy, M., Pizzuto, M., Poje, C.
Brodsky, L. (2001). Archives of Otolaryngology-
Head and Neck Surgery. 127 (4), 369-374.
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DLB Findings GERD Group

• Laryngeal findings
• Large lingual tonsil (Plt.001)
• Postglottic edema (Plt.001)
• Artyenoid edema (Plt.001)
• True vocal cord edema (P.003)

• Cricotracheal findings
• General edema and erythema (P0.003)
• Blunting of carina (Plt.001)

• Severe arytenoid edema, postglottic edema or
  lingual tonsils pathognomonic of GERD (98)
• However only half of GER displayed one of these
  findings
• 17 GERD -ve had one of these findings present,
  all minor score
• Carr, M., Nagy, M., Pizzuto, M., Poje, C.
  Brodsky, L. (2001). Correlation of findings at
  DL B with GERD in Children.
• Archives of Otolaryngology- Head and Neck
  Surgery. 127 (4), 369-374.

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Hoarseness

• 21 children with chronic hoarseness for 3 months
  
• all had a fibroptic laryngoscopy suggestive of
  GER
• No complaints of GER symptoms
• All underwent 24 hour pH probe
• 13/21 tested positive for GER (62)
• 7/13 with GER 3X normal
• pH graphs also recorded frequent refluxes with
  short duration
• 0.4-37.4 x / hour- median 7.3refluxes/hour
• most occurred while awake versus while asleep
• median 14.8 r/hr vs 0.9r/hr (p0.0009)
• Suggestive that GERD plays a direct role in
  pathogenesis of chronic laryngitis and hoarseness
  in children
• Gumpert, L., Kalach, N., Dupont, C. Contensin,
  P. (1998). Hoarseness and gastroesophageal
  reflux in children. Laryngology Otol, 112(1),
  49-54.

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Sensitivity of pH Probe as Diagnostic ToolFor
GER in Pediatric ENT

• 72 pts with chronic/recurrent ENT pathology
  (2m-17y)
• no identifiable cause, refractory to medical
  treatment
• pH probe- 56 GER (pHlt4 gt4.2 time)
• Discovered multiple short reflux episodes during
  the day
• Included all patients gt40 reflux episodes/day
• 75 GER
• 80 clinically improved with pharmacologic
  intervention
• van Den Abbeele, T., Gouloigner, V., Faure, C
  Narcy, P. (2003). The role of 24 h pH-recording
  in pediatric otolaryngologic gastro-esophageal
  reflux disease. International Journal of
  Pediatric Otorhinolaryngology, 67(1), S95-S100.

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Laryngotracheal Diseasevan Den Abbeele et al
Study

• 28 patients with laryngotracheal disease
• Cough, dyspnea, dysphonia, laryngotracheal
  stenosis
• pH probe-
• 46 GER (normal criteria)
• 68 GER ( episode criteria)
• Overall 71 GER
• 79 responded to pharmacologic intervention
• van Den Abbeele, T., Gouloigner, V., Faure, C
  Narcy, P. (2003). The role of 24 h pH-recording
  in pediatric otolaryngologic gastro-esophageal
  reflux disease. International Journal of
  Pediatric Otorhinolaryngology, 67(1), S95-S100.

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Recurrent Croup

• Evaluate the incidence of GER in recurrent croup
• 66 patients requiring hospitalization for
  recurrent croup (5 year retrospective study)
• 47 had established diagnosis of GER
• Patients with 3 admissions- 63 had GER
• Kids with GER were younger and had shorter
  intervals between admissions
• Waki, E., Madgy, D., Belenky, W. Gower, V.
  (1995). The incidence of gastroesophageal reflux
  in recurrent croup. International Journal of
  Pediatric Otorhinolaryngology, 32(3),223-232.

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Laryngomalacia

• Identify the incidence and clinical role of GER
  in patients with laryngomalacia
• 33 consecutive infants with laryngmalacia
  (graded)
• mean-95 days, 27 evaluated for GER
• GER observed in 18/27 (66) (ve pH probe/Ba)
• 17/27 with severe laryngomalacia
• 11/17(65) had high grade GER (p0.0163)
• 3/17(18) had borderline GER
• 4/10 mild laryngomalacia had GER
• The incidence of complications (severe
  laryngomalacia) was found to be significantly
  associated with the degree of GER (p 0.0163)

Giannoni, C., Sulek, M., Friedman, E. Duncan,
N. (1998). Gastroesophageal reflux association
with laryngomalaciaa prospective study.
International Journal of Pediatric
Otorhinolaryngology, 43(1), 11-20.
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GASTROESOPHAGEAL REFLUX AND PEDIATRIC RHINOLOGY
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Rhinitis and Nasopharyngitis

• 31 children - 24 hour pH probe
• 13 known GER
• suffered chronic or recurrent rhinitis or
  nasopharyngitis
• 18 controls
• ( GER), no upper airway inflammation
• GER/rhinitis group
• increased incidence of time pHlt6 than controls
  (plt0.00005)
• more dramatic drops in pH
• Contencin, P. Narcy, P. (1991). Nasopharyngeal
  pH monitoring in infants and children with
  chronic rhinopharyngitis. International Journal
  of Pediatric Otorhinolaryngology, 22(3), 249-256.

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Chronic Sinus Disease

• What is prevalence of GER NPR in children with
  CSD?
• 30 patients (2-18 yrs) referred for CSD
• 24 hour dual pH probe monitoring
• 19/30 (63) GER
• 6/19 (32) NPR
• What is their response to GER treatment?
• 15/19 (79) improved with GER treatment
• Recommend children with CSD refractory to
  aggressive medical management be evaluated for
  GER and treatment
• Distal pH probes sufficient
• Phipps,C., Wood, E., Gibson, W. Cochran.
  (2000). Gastroesophageal reflux contributing to
  chronic sinus disease in children. Archive
  Otolaryngology and Head and Neck Surgery, 126(7),
  831-836.

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Rhinologic Diseasevan Den Abbeele et al Study

• 28 patients with rhinologic symptoms
• Rhinosinusitis, obstructive rhinitis, unilateral
  polyposis
• pH probe-
• 61 GER (normal criteria)
• 75 GER ( episode criteria)
• Overall 82 GER
• 19/22 (86) responded to pharmacologic
  intervention
• van Den Abbeele, T., Gouloigner, V., Faure, C
  Narcy, P. (2003). The role of 24 h pH-recording
  in pediatric otolaryngologic gastro-esophageal
  reflux disease. International Journal of
  Pediatric Otorhinolaryngology, 67(1), S95-S100.

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Adenoids vs AOME
What is the incidence of GER in children lt2yrs
with

• Symptoms of adenoid
• hypertrophy requiring
• surgery
• 95 children
• GER incidence 42
• lt1 year incidence 88
• 1-2years incidence 32

• AOME requiring tympanostomy tubes without
  adenoidectomy
• 99 children
• GER incidence 7
• lt1 year incidence 14
• 1-2years incidence 2

Children lt2years with symptomatic adenoid
enlargement requiring adenoidectomy have
significantly higher incidence of GER than
children requiring PE tubes (plt0.001) Carr, M.,
Poje, C., Ehrig, D. Brodsky, L. (2001).
Incidence of reflux in young children undergoing
adenoidectomy. Laryngoscope, 111(12), 2170-2172.
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GASTROESOPHAGEAL REFLUX AND PEDIATRIC OTOLOGY
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Chronic Otitis

• Determine frequency and ratio of pathologic GER
  in development of chronic tubotympanal disorders
• 27 children (2-13 yrs), no GER symptoms,
  prospective study
• 14 COME (4m), 13 recurrent OM (5/yr)
• 24 hr pH probe
• 15/27 patient (55.6) with pathologic GER
• 7/14 COME, 8/13 ROM
• significantly more episodes of reflux during day
• Dual pH probe in 11 patients
• 6 GER distal GER, 3 GER with proximal GER
• Rozmanic, V., Velepic, M., Ahel, V., Bonifacic,
  D. Velepic, M. (2002). Prolonged esophageal
  pH monitoring in the evaluation of
  gastroesophageal reflux in children with chronic
  tubotympanal disorders. Journal of Pediatric
  Gastroesterology and Nutrition, 34(3), 278-280.

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Chronic OM with Effusion

• Is there an association between COME and
  pharyngeal reflux in children using 24 hr dual pH
  probe (prospective study, 3-12yrs)
• 25 children with COME (3m hx effusion and
  tympanogram B or C
• GER 16/25 (64), EER 12/25 (48)
• 18/25 (72) no sx of GER- 10/25 (56) silent GER
• Control 12 healthy children (no ENT issues 1
  month, no GER sx, type A tymp)
• GER 3/12 (25), EER 1/12 (8.3)
• Risk of developing COME is 10 x greater in
  children with path EER, and 5.3 x greater in
  children with path GER
• Keles, B, Ozturk, K., Gunel, E., Arbag, H.
  Ozer, B. (2004). Pharyngeal reflux in children
  with chronic otitis media with effusion. Acta
  Otolaryngology, 124, 1178-1181.

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Otitis-Pharyngeal Diseasevan Den Abbeele Study

• 16 patients with otitis-pharyngeal disease
• Tonsillitis, pharyngitis, halitosis, recurrent
  AOM, OME
• pH probe-
• 62 GER (normal criteria)
• 68 GER ( episode criteria)
• Overall 68 GER
• 70 responded to pharmacologic intervention
• van Den Abbeele, T., Gouloigner, V., Faure, C
  Narcy, P. (2003). The role of 24 h pH-recording
  in pediatric otolaryngologic gastro-esophageal
  reflux disease. International Journal of
  Pediatric Otorhinolaryngology, 67(1), S95-S100.

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Middle Ear Effusions

• 54 children (2-8yrs) with OME
• Samples taken while undergoing myringotomy
• Pepsin concentration measured
• 80 samples contained pepsin/ pepsinogen at
  concentrations up to 1000x normal serum
• Tasker, A., Dettmar, P., Panetti, M., Koufman,
  J., Birchall, J. Pearson, J. (2002). Reflux
  of gastric juice and glue ear in children. The
  Lancet, 359, 493.

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Otorrhea following Tube Placement

• Does gastric reflux contribute to the development
  of otorrhea following placement of tympanostomy
  tubes?
• 26 samples/24 patients (2-16yrs)
• Samples (from barrel of PE tube) analyzed for
  presence of gastric enzymes
• 8 samples(33) for pepsinogen I
• h/e below normal serum reference range
• measurable pI in 43 COME
• measurable pI in 20 of RAOM
• No major role for GER

Antonelli, P., Lloyd, K. Lee, J. (2005).
Gastric reflux is uncommon in acute
post-tympanostomy otorrhea. Otolaryngology-
Head and Neck Surgery, 132(4), 523-526.
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Otalgia and GER

• 6 patients seen in ED with ear pain and normal
  ear exams (case report)
• pH probe, endoscopic esophageal bx
• 100 GER
• Anti-reflux regimen introduced
• otalgia eliminated
• Gibson W. Cochran, W. (1993). Otalgia in
  infants and children- a manifestation of
  gastroesophageal reflux. International Journal
  of Pediatric Otorhinolaryngology, 28 (2-3),
  213-218.

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DiagnosisDiagnostic Tests

• pH Monitoring (standard)
• Barium Swallow
• Endoscopy / Mucosal Biopsy
• Scintigraphy/Milk Scan
• DLB
• Bronchial lavage for lipen laden macrophages
• Combining tests can improve sensitivity

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Medical TreatmentConservative Measures

• Thickening feeds
• Feeding schedule
• Positioning considerations

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Medical TreatmentPharmacologic Interventions

• Antacids (Maalox, Mylanta)
• used to neutralize the gastric acid
• Histamine receptor antagonists (Ranitidine,
  Cimetidine)
• often effective in decreasing the gastric acid
  production
• Prokinetic agents (Metoclopramide, Erythromycin)
• stimulate the esophagus, gastric and intestinal
  motility
• Proton pump inhibitors (Omeprazole, Lansoprazole)
  
• decrease the production of HCl

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Operative Interventions

• Fundoplication
• Nissen fundoplication
• Thal fundoplication
• Surgical Treatment
• Approximately 15 of children with pathologic
  gastroesophageal reflux require surgery
• Surgical intervention is indicated when medical
  management fails and complications of
  gastroesophageal reflux persist

36
Role of Antireflux Surgery in Pediatric
Otolaryngology

• 14 children (age 48d-3y) who had fundo for GER
  and had GER induced ENT disease (GEROD)
• 12/14 (86) had upper airway abnormalities
  (subglottic edema, fixed subglottic stenosis,
  reflex apnea, recurrent croup)
• 2/14 (14)had severe chronic sinutsitis and OM
• Complete resolution of symptoms following
  antireflux surgery (Nissen fundoplication)
• Suskind, D., Zeringue, G., Kluka, E., Udall, J.
  Liu, D. (2001). Gastroesophageal reflux and
  pediatric otolaryngologic diesease The role of
  antireflux surgery. Archives of Otolaryngology-
  Head and Neck Surgery, 127(5), 511-514.

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Role of Antireflux Surgery in Otolaryngology

• 29 pts (adults) Nissen for EER
• Hoarseness, vocal nodules, pharyngitis, cancer,
  sinusitis, asthma, granulomas, Barrets esophagus,
  stenosis
• 25/29 (f/u 6m-108m) had excellent results, no
  medications
• Lindstrom, D., Wallace, J., Loehrl, T., Merati,
  A. Toohill, R. (2002). Nissen fundoplication
  surgery for extraesophageal manifestations of
  gastroesophageal reflux. Laryngoscope, 112(10),
  1762-1765.

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In Summary

• GER and laryngotracheal conditions
• GER and nasal/ear pathology
• Silent Reflux
• Diagnostic testing