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• W2586006767 abstract "See related article, p 127 See related article, p 127 Gastroesophageal reflux disease (GERD) is a common and well-known problem throughout medicine, and its extraesophageal manifestations have been well-documented. As the organ at the junction of the respiratory tract, the gastrointestinal tract, and the pharyngeal airway, the larynx is uniquely at risk for exposure to the effects of gastric refluxate, and is particularly susceptible to the effects of gastric contents.1Adhami T. Goldblum J.R. Richter J.E. Vaezi M.F. The role of gastric and duodenal agents in laryngeal injury: an experimental canine model.Am J Gastroenterol. 2004; 99: 2098-2106Crossref PubMed Scopus (138) Google Scholar, 2Axford S.E. Sharp N. Ross P.E. Pearson J.P. Dettmar P.W. Panetti M. et al.Cell biology of laryngeal epithelial defenses in health and disease: preliminary studies.Ann Otol Rhinol Laryngol. 2001; 110: 1099-1108Crossref PubMed Scopus (99) Google Scholar This clinical diagnosis is commonly known as laryngopharyngeal reflux disease (LPRD). A myriad of symptoms in the pediatric population have been attributed to or exacerbated by GERD and LPRD ranging from non–life-threatening symptoms that impact quality of life, such as chronic cough, globus sensation, and dysphonia, to major aerodigestive problems such as laryngomalacia, dysphagia, failure to thrive, infant apnea, and laryngotracheal stenosis. Otolaryngologists combine symptom presentation with diagnostic laryngoscopy to diagnose LPRD and may recommend empiric therapy with an endpoint of symptom and examination improvement as an alternative to more invasive testing. Most of this work has been done in adults and extrapolated to the treatment of children. In both populations, this evaluation is commonly accomplished by office-based fiberoptic laryngoscopy. A general anesthetic with diagnostic laryngoscopy in the operating room, combined with 24-hour pH-impedance (pH-MII) probe, as performed in the study by Rosen et al in this volume of The Journal,3Rosen R. Mitchell P.D. Amirault J. Amin M. Watters K. Rahbar R. The edematous and erythematous airway does not denote pathological gastroesophageal reflux.J Pediatr. 2017; 183: 127-131Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar to guide treatment decisions for non–life-threatening symptoms attributed to reflux, is not usual practice. Such an approach is more often reserved for children with life-threatening or complex aerodigestive disorders refractory to treatment or those undergoing complex airway surgery, in whom reflux is a known contributor to complications in surgical intervention of the upper airway.4Hartl T.T. Chadha N.K. A systematic review of laryngomalacia and acid reflux.Otolaryngol Head Neck Surg. 2012; 147: 619-626Crossref PubMed Scopus (59) Google Scholar, 5Ida J.B. Thompson D.M. Pediatric stridor.Otolaryngol Clin North Am. 2014; 47: 795-819Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 6Venkatesan N.N. Pine H.S. Underbrink M. Laryngopharyngeal reflux disease in children.Pediatr Clin North Am. 2013; 60: 865-878Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Empiric proton pump inhibitor therapy and its unknown long-term side effect profile, combined with the high cost of use, has led many otolaryngologists to reevaluate this practice, particularly for non–life-threatening LPRD symptoms, where causation is challenging to demonstrate. Rosen et al3Rosen R. Mitchell P.D. Amirault J. Amin M. Watters K. Rahbar R. The edematous and erythematous airway does not denote pathological gastroesophageal reflux.J Pediatr. 2017; 183: 127-131Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar elegantly demonstrate the poor correlation between visual examination of the pediatric larynx and pathologic reflux, as evaluated by 24-hour pH-MII probe testing, the gold standard for reflux testing. This scientific contribution is notable, and begins to fill the gap in the pediatric literature with regard to the diagnosis of laryngeal manifestations of reflux in the pediatric population.7Madanick R.D. Extraesophageal presentations of GERD: where is the science?.Gastroenterol Clin North Am. 2014; 43: 105-120Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 8McMurray J.S. Gerber M. Stern Y. Walner D. Rudolph C. Willging J.P. et al.Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux.Ann Otol Rhinol Laryngol. 2001; 110: 299-304Crossref PubMed Scopus (46) Google Scholar, 9Walner D.L. Stern Y. Gerber M.E. Rudolph C. Baldwin C.Y. Cotton R.T. Gastroesophageal reflux in patients with subglottic stenosis.Arch Otolaryngol Head Neck Surg. 1998; 124: 551-555Crossref PubMed Scopus (108) Google Scholar However, limiting the study population to those with chronic cough does not factor in other etiologies of the inflamed larynx in children. Furthermore, the very use of chronic cough as the indication for study participation guaranteed a low rate of positive impedance pH results. Therefore, extrapolating a broad conclusion that visual examination of the larynx cannot predict pathologic GERD in the setting of other airway pathologies must be questioned. A study focused on children with major pediatric aerodigestive disorders with upper airway obstruction, which promotes reflux via negative intrathoracic pressures, controlled for age and other developmental considerations that affect esophageal motility, may have shown better correlation.9Walner D.L. Stern Y. Gerber M.E. Rudolph C. Baldwin C.Y. Cotton R.T. Gastroesophageal reflux in patients with subglottic stenosis.Arch Otolaryngol Head Neck Surg. 1998; 124: 551-555Crossref PubMed Scopus (108) Google Scholar, 10Aviv J.E. Liu H. Parides M. Kaplan S.T. Close L.G. Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia.Ann Otol Rhinol Laryngol. 2000; 109: 1000-1006Crossref PubMed Scopus (100) Google Scholar, 11Hart C.K. de Alarcon A. Tabangin M.E. Hamilton S. Rutter M. Pentiuk S.P. et al.Impedance probe testing prior to pediatric airway reconstruction.Ann Otol Rhinol Laryngol. 2014; 123: 641-646Crossref PubMed Scopus (12) Google Scholar Visual examination of the larynx as a diagnostic tool for extraesophageal reflux injury has not been without controversy,12Belafsky P.C. Postma G.N. Koufman J.A. The validity and reliability of the Reflux Finding Score (RFS).Laryngoscope. 2001; 111: 1313-1317Crossref PubMed Scopus (734) Google Scholar, 13Fritz M.A. Persky M.J. Fang Y. Simpson C.B. Amin M.R. Akst L.M. et al.The accuracy of the laryngopharyngeal reflux diagnosis: utility of the stroboscopic exam.Otolaryngol Head Neck Surg. 2016; 155: 629-634Crossref PubMed Scopus (19) Google Scholar, 14Tauber S. Gross M. Issing W.J. Association of laryngopharyngeal symptoms with gastroesophageal reflux disease.Laryngoscope. 2002; 112: 879-886Crossref PubMed Scopus (108) Google Scholar and there have been issues with reproducibility of the results. This is particularly true in the pediatric population, where prior attempts to correlate laryngeal findings with reflux have failed.15Singendonk M.M. Pullens B. van Heteren J.A.A. de Gier H.H.W. Hoeve H. König A.M. et al.Reliability of the reflux finding score for infants in flexible versus rigid laryngoscopy.Int J Pediatr Otorhinolaryngol. 2016; 86: 37-42Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 16van der Pol R.J. Singendonk M.M.J. König A.M. Hoeve H. Kammeijer Q. Pullens B. et al.Development of the reflux finding score for infants and its observer agreement.J Pediatr. 2014; 165: 479-484Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar We would agree that the tools of the otolaryngologist are not necessarily ideal for reflux evaluation in the pediatric population, but the decision to treat empirically is often influenced by parental concern for general anesthesia and more invasive diagnostic procedures, such as placement of a transnasal probe and esophageal biopsies. Office-based laryngoscopy is safe, brief, inexpensive, minimally invasive, well-tolerated, and readily available, making it an attractive tool for this purpose, and is viewed by many practicing pediatric otolaryngologist as adequate to guide therapeutic recommendations or further testing. Although we agree that this work by Rosen et al3Rosen R. Mitchell P.D. Amirault J. Amin M. Watters K. Rahbar R. The edematous and erythematous airway does not denote pathological gastroesophageal reflux.J Pediatr. 2017; 183: 127-131Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar presents strong evidence that laryngoscopy should not be considered a primary diagnostic tool for pediatric GERD, the demonstration that blinded evaluators' grading did not correlate with reflux scores does not refute the usefulness of laryngoscopy in the workup of GERD symptoms. Indeed, the fact that 40% of the patients in this study with Reflux Finding Scores suggesting pathologic reflux had positive impedance probe tests actually supports laryngoscopy as a useful tool in narrowing the differential toward reflux, while ruling out other potential pathologies. Yet their conclusion remains intact, that laryngoscopy “should not be used as a basis for prescribing gastroesophageal reflux therapies.” Pediatric otolaryngologists involved in the surgical management of aerodigestive disorders are presented with further questions about reflux treatment and the usefulness of impedance probe testing. The pH-MII is a 24-hour snapshot in time that may not be translatable to periods surrounding interventions. For example, children undergoing major airway reconstruction for laryngotracheal stenosis are under great stress, are sedated for several days with or without paralysis, are reclined for several days, have nasogastric tubes in place, and are often receiving intermittent doses of corticosteroids, all of which place them at great risk for reflux that was not demonstrated at their baseline pH-MII. Therefore, despite normal impedance testing, patients undergoing such procedures should be treated aggressively for reflux prophylactically, because the risks of nontreatment greatly outweigh the risks of treatment. As with any good research, these results are not an endpoint, but a launching point for multiple other important questions, and many arise surrounding this article. Many pediatric otolaryngologists believe that other stigmata of upper airway inflammation may be more useful in correlating with pathologic reflux, such as lingual tonsil hypertrophy and posterior pharyngeal lymphoplasia (cobblestoning). The differences with the adult Reflux Finding Score findings are suspected to be based on upper airway anatomic differences, duration of exposure, and developmental differences between young children and adults. Further investigation of this postulate is likely to be fraught with difficulties similar to our current discussion, with inter-rater and intrarater variability, questionable reproducibility, and so on. Another important question surrounds the nature of non–reflux-related laryngeal inflammation. Based on the findings of this study, 60% of patients with laryngeal edema, erythema, mucosal hypertrophy, and other findings of airway inflammation, as determined by 3 experienced pediatric otolaryngologists, were negative for reflux based on pH-MII. This finding, therefore, leaves us with a majority of the patients with inflamed larynges without explanation. Every pediatric airway surgeon has encountered this situation. The “reactive larynx” is as of yet unexplained, and is a frequent hindrance to airway surgery. There is a belief among aerodigestive practitioners that azithromycin can be helpful in alleviating this inflammation, either by its antibiotic or anti-inflammatory effects or both, but evidence is lacking. Despite the poor positive predictive value of abnormal laryngoscopy in this study, it would be just as useful to know about the negative predictive value of a normal laryngoscopic examination. Does a normal laryngoscopic examination effectively rule out pathologic reflux? If simpler tests, like fiberoptic laryngoscopy, cannot be used to diagnose reflux, how does pH-MII fit into a health care system keen to improve efficiency and reduce costs, while promoting better outcomes? For a disease as common as GERD with medical treatments with low side effect profiles, does empiric therapy then play a role as a diagnostic tool, as it has in the past? How should children with common, nonspecific symptoms be selected for more invasive, expensive, and complex testing for GERD? Indeed, in this study, 28% of the participants with cough tested positive for reflux by pH-MII, hardly a high proportion. Clearly, there is work to be done to better understand pediatric reflux and its extraesophageal manifestations, optimal diagnosis and treatment, and epidemiologic factors that would direct practitioners to the best possible outcomes and use of resources. Until such information is available, the usefulness of laryngoscopy for definitive diagnosis of reflux is limited, but must be balanced in the context of parental goals and severity of symptoms. The poor correlation between impedance pH findings and cough as demonstrated in this study perhaps best questions the pervasive use of proton pump inhibitor therapy, and should encourage providers not to prescribe them like candy for every kid who coughs. The Edematous and Erythematous Airway Does Not Denote Pathologic Gastroesophageal RefluxThe Journal of PediatricsVol. 183PreviewTo determine if the reflux finding score (RFS), a validated score for airway inflammation, correlates with gastroesophageal reflux measured by multichannel intraluminal impedance (MII) testing, endoscopy, and quality of life scores. Full-Text PDF" @default.
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• W2586006767 title "Questioning the Utility of Laryngoscopy in the Evaluation of Pediatric Gastroesophageal Reflux" @default.
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