Pepsin and bile acids in saliva in patients with laryngopharyngeal reflux - a prospective comparative study.

OBJECTIVES: Laryngopharyngeal reflux (LPR) and biliary duodenogastric reflux can cause damage to the laryngeal mucosa and voice disorders. The aim of this study was to find out whether levels of pepsin and bile acids in the saliva can serve as diagnostic markers of LPR. SETTING: A prospective comparative study. PARTICIPANTS: Twenty-eight patients with LPR proven via high-resolution manometry and combined multichannel intraluminal impedance and 24-h pH monitoring and 48 healthy controls without symptoms of LPR were included in the study. MAIN OUTCOME MEASURES: In the patients with LPR symptoms, oesophagogastroscopy with oesophageal biopsy was performed. The levels of total pepsin, active pepsin, bile acids and the pH of the saliva were determined in all participants and compared between the groups. Reflux symptom index (RSI) and reflux finding score (RFS) were also obtained and compared. The groups differed significantly in RSI (P = 0.00), RFS (P = 0.00), the levels of bile acids (P = 0.005) and total pepsin in saliva (P = 0.023). The levels of total pepsin and bile acids were about three times higher in the patients with LPR than in the healthy controls. There was a significant correlation between the RSI and RFS score and the level of total pepsin and bile acids in the saliva. Histopathological examination of the oesophageal biopsy taken 5 cm above the lower oesophageal sphincter confirmed reflux in almost 93% of patients with symptoms. CONCLUSIONS: The study results show that the levels of total pepsin and bile acids in saliva are significantly higher in patients with LPR than in the controls, thus suggesting this as a useful tool in the diagnosis of LPR and particularly biliary LPR.

Is an occupation with vocal load a risk factor for laryngopharyngeal reflux: a prospective, multicentre, multivariate comparative study.

OBJECTIVES: To compare the prevalence of laryngopharyngeal reflux in choristers, teachers and control subjects without vocal load at work and to determine the risk factors for laryngopharyngeal reflux. DESIGN: A prospective, multicentre, multivariate comparative study. PARTICIPANTS: One hundred and nineteen singers from four professional choirs, seventy teachers from four schools and 111 control subjects with an occupation without vocal load. MAIN OUTCOME MEASURES: All participants completed a questionnaire about their dietary habits, height and weight, presence of stress, smoking and allergies, including the nine-item Reflux Symptom Index. The groups of choristers, teachers and the controls were compared with each other with regard to their sex, age, dietary habits, body-mass index, Reflux Symptom Index score and other factors affecting voice quality. The subjects from all three groups with suspected laryngopharyngeal reflux were compared with the subjects without it. The relationship between the Reflux Symptom Index score and the possible risk factors for reflux was estimated. RESULTS: The results showed significantly higher Reflux Symptom Index scores in the choristers than in the teachers and the controls (mean scores, 7.86 versus 6.33, P = 0.044; 7.86 versus 4.80, P = 0.000, respectively), but the number of subjects with suspected laryngopharyngeal reflux (Reflux Symptom Index score >13) did not differ significantly between the groups. The choristers were significantly more often treated for laryngopharyngeal reflux than the teachers and the controls (41%, 17% and 28%, respectively). The occupation chorister and frequently experiencing stress were the only factors that influenced the total Reflux Symptom Index score. CONCLUSIONS: Laryngopharyngeal reflux affects the choristers more often than the teachers or the control subjects without vocal load at work. These results suggest that singing as the main professional activity can notably contribute to the development of the reflux. Vocal load without singing is probably not an important aetiological factor for laryngopharyngeal reflux. The extraoesophageal symptoms affecting voice require treatment for laryngopharyngeal reflux and proper dietary habits especially in the group with high voice quality demands.

Isolated bulbar paralysis in a patient with medullar tau pathology: a case report.

Increased morbidity and mortality rates as well as some other manifestations in Alzheimer's disease can be explained by subcortical degeneration. Pathological evidence is scarce but confirmative. We report a 77-year-old patient who presented with a 6-year history of dyspnoea, stridor and dysphagia. Unexpectedly, histopathological examination disclosed extensive degeneration of the medulla by tau pathology. The majority of symptoms and signs could be explained by the medullary tau pathology. Whether the medullary tau pathology in this case was a rare aberrant progression of Alzheimer's disease or a new presentation of tauopathy concomitant with subclinical Alzheimer's disease should be elucidated by additional studies.

Ear, nose and voice problems in children with orofacial clefts.

The purpose of this study was to compare the prevalence of ear, nose and particularly voice problems in groups of children with cleft palate (CP) and with unilateral cleft lip, alveolus and palate (UCLP). On the basis of history, regular otorhinolaryngological examinations and hearing tests, the prevalence of different pathologies was assessed in 80 CP children (35 boys and 45 girls) and 73 UCLP children (47 boys and 26 girls). Ear pathology was reported in 53.8 per cent of CP children and in 58.9 per cent of UCLP children. Nasal breathing was impaired in 14 CP (17.5 per cent) and 36 UCLP (49.3 per cent) children. Dysphonia was detected in 12.5 per cent of CP and 12.3 per cent of UCLP children. In 9.2 per cent of all cleft children, functional voice disorder caused a hoarse voice. Two-thirds of cleft children with functional dysphonia had protracted hearing loss. Therefore, ENT specialists must take an active role early in the treatment of children with clefts.

Amyloidosis of the larynx.

Amyloidosis of the larynx is an uncommon disease and mainly a local occurrence. Hoarseness is the prevalent symptom. Surgical excision of the amyloid masses is the treatment of choice. In the present paper, the authors describe seven cases treated in the last twenty years.

Voice quality after radiation therapy for early glottic cancer.

OBJECTIVE: To evaluate the voices of irradiated patients with early glottic carcinoma and to compare these with the voices of healthy volunteers. DESIGN: Case-control study. SETTING: University Department of Otorhinolaryngology and Cervicofacial Surgery, University of Ljubljana, Ljubljana, Slovenia. SUBJECTS AND METHODS: The voice samples (sustained vowel) of 50 patients (44 men and 6 women) who had been irradiated for T1 (43 subjects) or T2 (7 subjects) glottic squamous carcinoma at least 1 year prior to the study were analyzed with the Multi-Dimensional Voice Program (Kay Elemetrics Corp, Lincoln Park, NJ) and compared with those of a normal group of 50 age- and sex-matched volunteers. Average fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and degree of voiceless elements were determined. In the irradiated group, videostroboscopy was performed. The patients assessed their voice fatigue. RESULTS: The irradiated subjects demonstrated significantly higher values for jitter, shimmer, and degree of voiceless elements than did the healthy volunteers. The values for noise-to-harmonic ratio were higher in the irradiated group, but the difference was not significant (P =.08). The values for fundamental frequency were almost equal in both groups. In most of the irradiated subjects, some irregularities of the vocal fold vibration were noticed. Many of these patients also reported voice fatigue. CONCLUSIONS: Radiation therapy for early glottic cancer results in poorer voice quality compared with normal age- and sex-matched speakers. In most of the irradiated patients, greater than normal effort in voice production was found based on patient assessment. This may result from stiffness of the vibratory source and inadequate compensatory maneuvers in phonation. We suggest that voice therapy during and after radiation therapy may result in better voice quality.

Role of surface EMG in diagnostics and treatment of muscle tension dysphonia.

In muscle tension dysphonia (MTD) excessive tension of both the internal and external laryngeal muscles is observed. In the present pilot study, 9 pairs of surface electrodes were used to determine the electromyographic (EMG) characteristics of different muscles in the perioral area and anterior neck before and during phonation. Eleven patients with MTD and 5 normal speakers were included within the study. The results show a 6-8-fold increase of EMG activity and/or an alternation of the EMG activity level in the perioral and supralaryngeal muscles before and during phonation in most of the patients with MTD. It is not clear whether these muscles are activated as compensation for excessive tension of internal laryngeal muscles, or whether they are responsible for some of the voice disorders.

The role of allergy in the etiopathogenesis of laryngeal mucosal lesions.

The results of this study showed that allergy is an important factor in the etiopathogenesis of laryngeal mucosal lesions. Despite adequate treatment, no other unfavourable factors appeared to have significant influence on the results of the treatment. It seems that hypersensitivity to different inhalatory and nutritional allergens make laryngeal mucosa more susceptible for adverse action of other factors: vocal misuse, gastroesophageal reflux (GER), smoking, irritants in the surrounding microclimate, endocrinologic disorders, etc. Acting together, all these factors cause the development of laryngeal mucosal lesions. In the treatment of noninfectious laryngitis, vocal cord nodules, polyps or Reinke's edema, all the stated adverse factors should be identified and suitably diminished or eliminated. Allergy (Ig-E-mediated and non-IgE-mediated) should be considered as only one of the etiopathogenetic factors.