Nasolaryngoscopic Findings.docx

Nasolaryngoscopic Findings.docx

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NasolaryngoscopicFindings

RelationshipbetweenNasolaryngoscopicFindingsandpHProbeEsophagealMonitoringinChildrenwithClinicalManifestationsofExtra-esophagealReflux

Abstract:

Introduction:

Thegastroesophagealrefluxdiagnosis,mainlyinpatientswithatypicalmanifestations,hasbeenreceivingincreasingimportance.Objective:

TorelatethenasolaryngoscopicfindingswithprolongedpHprobeesophagealmonitoringinchildrenwithclinicalmanifestationsofextra-esophagealreflux.Method:

Transversalprospectiveclinicalstudy,inwhichweevaluated44childrenfromoneto12yearsold,ofbothgenders,bymeansofnasolaryngoscopy.AllweresubmittedtopHprobemonitoringforresearchofhiddenrefluxduetocasesofotitis,sinusitis,asthma,laryngitisand/ordysphoniainthelast12months.Results:

Outof44children,15（34%）presentedwithnormalpHmonitoringand29（66%）withalteredmonitoring.Outof29withalteredpHmonitoring,19（65.5%）wereboysand10（34.5%）weregirls.TherewasnostatisticallysignificantdifferencebetweengenderandthepositiveresultsofpHmonitoring,inspiteofadiscreetpredominanceofoccurrenceinthemalepopulation.Allchildrenhadsmalleradenoidsthan75%ofthecavityofconchaaerialcolumn.Sixpresentedwithpurulentsecretioninnasalcavity.Eight（18%）hadnodesinvocalcordsandfive（11%）ofwhomhadanalteredpHmonitoringandthree（7%）ofwhomwerenormal.Wefoundatleastonealterationuponnasolaryngoscopyin80%ofthe15childrenwithnormalpHmonitoringandin89.7%ofthe29whohadanalteredpHmonitoring.Conclusion:

Theprevalenceofgastroesophagealrefluxinchildrenwithrecurrentrespiratoryandotorhinolaryngologicalaffectionswashigh.However,thedataobtaineddidn'tshowanystatisticallysignificantdifference（p<0.05）amongthenasolaryngoscopicfindings,associatedornotwithgastroesophagealreflux,confirmedbypHmonitoring.Therefore,norelationshipwasfoundbetweenthepathologicalgastricacidrefluxandnasolaryngoscopicalterations.

INTRODUCTION

Evidencesareincreasinglymoreconsistentintheliterature（1,2,3）thatthegastroesophagealreflux（GER）contributesfortheairwaysaffections（mainlyinchildren）,althoughthereisn'tanydirectconfirmationofthecauseandeffectrelationyet（4,5）.ThefirstdifficultyintheGERdiseasediagnosisistosetuptheindividuallimitstobeconsideredbetweenphysiologicalandpathologicalGER.Anotheraspecttotakeintoaccountisthemeaningofanumberoffindingsintheposteriorregionofthelarynx,calledposteriorlaryngitis（1-5）.

Webelievethegastroesophagealrefluxisassociatedtoavarietyoflaryngealdisorders,amongwhichthelaryngitisforrefluxisthemostfrequent.Theestimateisthat4.0%to10.0%oftheadultswholookforotorhinolaryngologicalassistancehaveGERandabout60%to80%ofwhompresentsignsandsymptomsoflaryngitis（2,6）.However,thisestimatedoesn'tapplyforchildren（7,8）.

Thealterationsfoundthataremostlysuggestiveoflaryngitisforrefluxareedemaandhyperemiaofvocalcords（PPVV）,ofinterarytenoidand/orretrocricoidregion,granulomasinthelarynxposteriorregionand,inextremecases,subglotticstenosisandlaryngealcarcinoma（9,10,11）.

TheincreaseofGERprevalenceandtheseveralquestionsstillwithoutdefinitiveanswersregardingphysiopathology,diagnosis,evolutionandtreatmentoftheextra-esophagealmanifestations,composeanexhaustibleresearchfield（12,13）.

It'simportanttoemphasizethattherespiratoryatypicalmanifestationsmaybethefirstsignalsofthehiddengastroesophagealaffection（14,15）,andnasolaryngoscopyisoneoftheinitialpropaedeuticresourcesforevaluationofthenasal,pharyngealandlaryngealcavities（16,17）.

Thescarcityofpublicationsonthethemeinchildrenconstitutedmotivationforthestudythatcontemplatestheaccomplishmentofnaso-laryngoscopyofchildrensubmittedtoesophagealpHmonitoringforextra-esophagealrefluxclinicalmanifestations.

TheobjectiveofthestudyistorelatethenasolaryngoscopicfindingswithprolongedpHesophagealmonitoringinchildrenwithclinicalmanifestationsofextra-esophagealreflux.

METHOD

Inthistransversalprospectiveclinicalstudy,weevaluated44childrenfromfourto12yearsold,ofbothgenders,bymeansofnasolaryngoscopy.

ThisstudywasapprovedbytheEthicsCommitteeinResearchofUFMGandtheauthorizationinformedwasobtainedfromalltheparticipants'relatives.

AllchildrenwerepreviouslysubmittedtopHprobemonitoringforresearchofhiddenrefluxduetocasesofotitis,sinusitis,asthma,laryngitisand/ordysphoniainthelast12months.ThepHmonitoringwasperformedinthePediatricGastroenterologyServiceofUFMG,byusingsemi-disposablepediatricprobeswithantimonysensoranddistalesophagealpHmonitoring,accordingtothestandardprocedure.Therecordsweremadeforaminimumof18hours,whilethepatientsexertednormalactivities（18,19）.Thedefinitivediagnosisofrefluxwasbasedonapositivestudyofthe24-houresophagealpHmonitoring（DeMesster'sScore>14.72）.

Weexcludedfromthestudypatientswithaerodigestivecongenitalmalformationsorwhoweresubmittedtodigestivesystemsurgery,withairwaysacuteinfection,proteinallergyfromcowmilk,whowereusingoralorinhaledcorticosteroid,acidgastricsecretionblockers,procineticandanti-acidswithin14daysbeforetheotorhinolaryngologicalevaluation.

ThenasolaryngoscopywerecarriedoutfromJanuary2005toApril2006atClínicaOtomedBH.Thechildrenwereplacedsittingontheirparents'lapintheexaminationchair.Thevasoconstrictionandnasalanesthesiaweremademinutesbeforetheprocedure（topicallidocaineat2%andpediatricnasalneosinefrinespray）.TheendoscopieswerecarriedoutbyusingMachidaopticfiber（3.2mmofdiameter）andtheimagesrecordedinvideocassettetapes（VHS）forfurtheranalysis.

Todaythereisnosingleinstrumentthathasbeenvalidatedorthatiswidelyusedinacademicorprivatecontexts（36）andtheposteriorlaryngitisfindingsarecurrentlyacceptedasthemostcommonlaryngoscopicsignalsofreflux,basedoninternationalresearchamongotorhinolaryngologists（37）.

Theparametersconsideredinthenasolaryngoscopicevaluationwere:

a）presenceorabsenceofpurulentsecretioninnasalcavity;

b）adenoidsvolume;

c）presenceorabsenceofinterarytenoidmucosaedema;

d）presenceorabsenceofretrocricoidregionedema;

e）presenceorabsenceofnodesinPPVV.

ThedatacollectedformindividualevaluationprotocolswereperformedusingSPSS11.0.1.FortheanalysesweconsideredthepatientswhohadnormalpHmonitoring（negative）andaltered（positive）.Thehypothesestestedconsideredp<0.05tobestatisticallysignificant.

TocomparethenasolaryngoscopicfindingsbetweenthechildrengroupswhohadnormalandalteredpHmonitoringweemployedthechi-squaretest（evaluationoftheassociationsbetweenvariables）orFisher'sexacttestforanalysisofthecategoricalvariables（age,sexetc.）.

RESULTS

The44patients'meanagewasoffouryearsand16（36.0%）weregirlsand28（64.0%）boys.Twentynine（66%）hadanalteredpHmonitoringand15（34.0%）anormalone.Outof29withalteredpHmonitoring,19（65.5%）wereboysand10（34.5%）weregirls.DespitetherewasadiscreetpredominanceofGERoccurrenceinthemalepopulationtherewasnostatisticallysignificantdifferencebetweenthesamplesgenders（p>0.05）.Outofthe44childrensixpresentedwithpurulentsecretioninnasalcavity.

InTable1wemaynotethedistributionoftheadenoidvolumes.

Thefrequencydistributionsofpresenceorabsenceofedemaoftheinterarytenoid,retrocricoidregionsandnodesinPPVVinviewofthepHmonitoringproceduresareshowninTables2,3and4.+'

Therewasnostatisticallysignificantdifference（p>0.05）asfortheparametersevaluatedinthenasolaryngoscopyproceduresbetweengroupsofchildrenwithnormalandalteredpHmonitoringresults.Intheanalysiswefoundatleastonesignofposteriorlaryngitisuponnasolaryngoscopyin15（80.0%）childrenwhohadnormalpHmonitoringresultandin29（89.7%）withalteredresult.

DISCUSSION

IsspiteGERisafrequentandgenerallybenignantconditioninthechildhood,itmayrelatetoseveralrespiratoryaffections;therefore,theawarenessoftheseveralformsofpresentationoftheextra-esophagealmanifestations,associatedwithagoodclinicalhistoryisveryimportantforaGERdiagnosis.

Intheliterature,themostfrequentlysymptomsandaffectionspresentedbythechildrenwithhiddenGERare:

crisesofasthma,apnea,laryngealstridor,chroniccough,sinusitis,otitisandrecurrentpneumoniasetc.（3,5,21）.Whichdiffersfromthemostfrequentlypresentedbytheadultsthatare:

sensationofglobuspharyngeus,chroniccough,hoarseness,persistentraucousness,thoracicpainetc.（22,23）.

TheGERprevalenceof66.0%inthepopulationstudiedwasverysignificant,despitethelackofdefinitivelaryngoscopicfindings.Infact,otherstudiesintheliterature（24,25,26）foundsimilardata.Inaddition,nomatterthedirectionoftherelationshipbetweenGERandrespiratoryaffections,non-treatedGERhasmanypotentialcomplications（24,25,26）.

ABrazilianstudy（27）involvingadultsfoundaprevalenceof12.0%ofGERamongthosewhopresentedwithtypicalsymptomsofheartburntwiceaweek.However,thisstudydidn'ttakeintoaccounttheatypicalmanifestations,which,wouldprobablyraisesuchfigures.

ThepHmonitoringofthestudiedpatientswascarriedoutbyusingonlyadistalsensor.Someauthorsconsideredtheuse