© Borgis - New Medicine 4/2004, s. 90-93
Mieczysław Chmielik, Małgorzata Dębska, Eliza Brożek, Anna Bielicka
Subglottic laryngitis and gastroesophageal reflux in children
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik, MD, PhD
Objective. To estimate the occurrence of the gastroesophageal reflux in children hospitalised for subglottic laryngits and to compare the clinical course of laryngitis in children with respect to the presence of the reflux.
Methods. Children hospitalised for subglottic laryngitis at the Department of Otolaryngology, Warsaw were divided into two subgroups: Group 1 included children with gastroesophageal reflux, Group 2 included children without reflux. Group classification depended on the results of investigations to recognise gastroesophageal reflux, i.e. oesophageal X-ray with a contrast medium and subphrenic oesophageal ultrasonography. In both patient groups either directoscopy or directobronchoscopy was performed. Assessment included the clinical course of the disease i.e. recurrent dyspnoea, frequency of occurrence in every patient, required treatment etc., and a directoscopic view of the larynx. Both groups were interviewed for the history of gastroesophageal reflux.
Results. Children with subglottic laryngitis and concomitant gastroesophageal reflux constituted a smaller group in comparison with the other group. The directoscopic view of the larynx in the first group was typical of subglottic laryngitis (subglottic roll-shaped oedema) with a more frequent congestion in the laryngeal vestibule. In a few cases mucosal lesions in the trachea were noted. Children with gastroesophageal reflux presented a more severe course of subglottic laryngitis (more frequent episodes of inspiratory dyspnoea during hospital stay) and a higher recurrence rate.
Conclusions. GERD is manifested by numerous gastrointestinal and respiratory symptoms. Recurrent episodes of inspiratory dyspnoea in infants and young children without other symptoms typical of gastroesophageal reflux may be suggestive of the condition.
Subglottic laryngitis frequently causes respiratory airway obstruction in children. The mucous membrane, a natural barrier, plays a major role in the pathogenesis of the infection. Recurrent infections, drying of the mucous membrane, exposure to cigarette fumes and environment pollution favour increased permeability of the epithelium, which allows penetration of the antigen. Generally, laryngitis is more frequent in winter, probably due to living in heated accommodation with low air humidity. In children with a history of allergy, the response of the respiratory epithelium may be enhanced through IgE activation and pro-inflammatory cytokine production. Children with gastro-oesophageal reflux constitute a separate group of patients predisposed to laryngitis; the reflux results in aspiration of the gastric acid contents and irritation of the respiratory airway and laryngeal mucous membrane, which, consequently, may lead to laryngitis. The aim of this paper is to evaluate the frequency of reflux in children hospitalised for subglottic laryngitis, and compare the clinical course of laryngitis in children with and without gastro-oesophageal reflux. The patients´ histories, clinical observations, and diagnostic and therapeutic proce-dures were evaluated. Both nosological entities are described in the introduction to provide better under-standing of the subject discussed.
In terms of different symptoms, laryngitis in children can be divided into acute subglottic laryngitis, acute diffuse laryngitis, acute epiglottitis, acute laryngo-tracheobronchitis, and acute malignant laryngotracheo-bronchitis.
Acute subglottic laryngitis is the most frequent type of laryngitis in children. The peak incidence is usually between the 6th month and 3rd year of age. The main pathogenic organisms isolated are parainfluenza viruses: Paramyxovirus parainfluenzae types 1 and 3, more rarely RSV, parainfluenza viruses types 2 and 4, or influenza viruses types A and B. The symptoms are evoked by oedema in the subglottic portion of the larynx. The mucous membrane covering the cricoid cartilage is formed mostly by a loose connective tissue and it also contains elements of lymphatic tissue. The histological structure encourages the occurrence of oedema at this site. Anatomical conditions also predispose to a pathological condition in this area. The diameter of the cricoid cartilage in a one-year-old child is approximately 5.5 mm; a 1-mm thick subglottic oedema would decrease the cross-sectional area by about 60%. In a ten-year-old child (mean width approx. 9.0 mm) the same-thickness oedema would narrow the lumen of the respiratory airway by about 40%. The inspiratory dyspnoea may be accompanied by a subfebrile body temperature, occasional fever, watery nasal discharge, hoarseness, a characteristic barking cough, and stridor. The endoscopic view of subglottic laryngitis shows a roll-shaped oedema and inflammatory lesions in the mucous membrane. Endoscopic examination may exclude chronic malformations, which may be recognised for the first time.
Subglottic laryngitis, a primarily viral infection, should be treated symptomatically. Administration of cortico-steroids is the most effective treatment, which reduces mucosal oedema by affecting the permeability of capillary vessels in the endothelium. Recent reports have shown no significant difference as regards the route of drug administration. When the patient does not respond to the treatment, intubation should be done, which requires hospitalisation. Further therapeutic management should include the need for an increased fluid intake. Over the last few years it has also been suggested that antireflux therapy should be considered.
Since the 1999´s, many reports have been published on association between respiratory diseases and gastro-oesophageal reflux disease (GERD). It is worth mentioning that the reflux phenomenon may occur at any age, and the disease should only be diagnosed when the characteristic symptoms and complications appear. The definition of GERD includes the fact that there is a range of consequences, i.e. injury to the oesophagus and/or adjacent organs, depending on the influence of the gastric contents on the oesophagus and upper portions of the alimentary and respiratory tracts. The medical vocabulary has been increased by concepts such as laryngopharyngeal reflux (LPR) and extraoesophageal reflux disease (EERD).
The symptoms of GERD in children, depending on their age, include vomiting, a decreased food intake followed by failure to thrive, sucking disorders and dysphagia, abdominal pains, retrosternal pains, oeso-phagitis, and many others associated with the respi-ratory airway. The last group of symptoms includes snoring (commonly described by parents of the newborn and infants as husky breathing), stridor, cough, recurrent laryngeal dyspnoea, wheezing, nasal patency disorders, apnoea, hoarseness and sputum expect-oration. Considering the range of symptoms, the significance of reflux becomes increasingly important in paediatric conditions such as subglottic stenosis, laryngomalacia, sleep apnoea, laryngospasm, chronic cough, recurrent laryngotracheitis, chronic rhinosinusitis, and nodules on the vocal folds.
The pathological background associating reflux with the respiratory airway may be indirect – neurogenic, where inflammatory process mediators transfer stimuli via the autonomic nervous system and vagus nerve, or direct, associated with microaspiration of gastric contents in the pharynx, larynx and tracheobronchial tree, or a combination of those conditions. The first mechanism may refer to gastro-oesophageal reflux disease (GERD), while the other seems to be related to laryngopharyngeal reflux (LPR). Reflux, being a physiological phenomenon, does not have to produce any symptoms in the alimentary tract, due to the defence mechanisms in the system, i.e. the anatomical antireflux barrier (lower oesophageal sphincter, diaphragmatic pinchcock, angle of His), oesophageal clearance (gravity and peristalsis) and oesophageal mucosal resistance. Whilst the first of these protect the respiratory system against micro-aspiration, the remaining two do not have such significance. The mucous membrane in the respiratory tract, containing the respiratory epithelium, is not a sufficient protection against gastric acid as compared to the oesophageal mucosal barrier and its pre-epithelial, epithelial and post-epithelial defence mechanisms.
The diagnosis of gastro-oesophageal reflux involves several techniques including a 24-hour oesophageal pH study, oesophageal X-ray with a contrast medium, endoscopic examination with obtaining a biopsy specimen, and scintigraphy. Nevertheless, many authors underline a lack of studies enabling an unequivocal diagnosis. Regarding the lack of objective methods for the diagnosis of GERD, Carr et al. made an attempt at laryngobronchoscopic evaluation of patients who had at least one of the available diagnostic tests positive. The patient with reflux in this study developed subglottic oedema, arytenoid oedema, enlarged lingual tonsils, oedema of the vocal folds, nodules on the vocal folds, ventricular obliteration, and hypopharyngeal cobbles-toning. The trachea revealed tracheal cobblestoning, blunting of the carina, subglottic stenosis, increased secretions, generalized erythema, and oedema. A relatively high sensitivity and specificity associated with gastro-oesophageal reflux was found to be coexistent with lingual tonsil enlargement, postglottic and arythenoid oedema.
The aim of our study was to assess the frequency of gastro-oesophageal reflux in children admitted for subglottic laryngitis, and to compare the clinical course of laryngitis in children with the reflux.
MATERIALS AND METHODS
The study included children with subglottic laryngitis admitted to the Department of Paediatric Otolaryn-gology, Warsaw, between January 2003 and February 2004. The group consisted of 62 children (47 boys and 15 girls, aged 4 months to 8 years; mean age 30 months) and was divided into two subgroups: group1 consisted of children with gastro-oesophageal reflux – GER(+), and group 2 included children without the reflux – GER(-). The patient selection was based on the results of investigations i.e. oesophageal X-ray with a contrast medium, 24-hour pH study, and subphrenic oesophageal ultrasonography. In both groups either directoscopy or directobronchoscopy was performed. The clinical course of the disease was evaluated (dyspnoea recurrence, frequency of occurrence of subglottic laryngitis in each patient, hospital stay), and a directoscopic view of the larynx was assessed. The patients´ parents were interviewed for the history of their children´s gastro-oesophageal reflux or symptoms suggesting the gastro-oesophageal reflux prior to admission. Statistical analysis was performed using the Analysis of Variance test. The level of statistical significance was Ł 0.05 (p Ł 0.05).
The group of children with gastro-oesophageal reflux GER (+) consisted of 14 patients (12 boys and 2 girls) aged 6 months to 5 years (mean age 26.2 months). Before admission reflux was recognised in only 2 children from this group. The group of 48 children without GER consisted of 36 boys and 12 girls (aged 4 months to 8 years; mean age 31.5 months).
Frequency evaluation of previous episodes of subglottic laryngitis in all children, showed an incidence of 1 to 12 times (mean 1.8 times). In the GER (+) subgroup the incidence of the laryngitis was also 1 to 12 times (mean 2.71 times); in the GER (-) subgroup it was from 1 to 5 times (mean 1.52 times).
Recurrent inspiratory dyspnoea during the recent episode of subglottic laryngitis occurred in all children from 1 to 7 times (mean 2 times); in the GER(+) subgroup from 1 to 7 times (mean 2.85 times); in the GER (-) subgroup 1 to 4 times (mean 1.7 times).
Directoscopy was performed in 13 children with reflux and in 40 children without reflux. Oedema in the subglottic portion, and hyperaemia in the larynx and adjacent structures were evaluated. Directoscopy in the GER (+) group revealed roll-shaped oedema of the subglottic portion (92%), hyperaemia in the laryngeal vestibule (46%), epiglottis, interarytenoid incisure, posterior commissure and laryngeal vestibule (30.7%), laryngopharynx and laryngeal vestibule (23%). In 1 child (7.7%), disseminated micropapular lesions (cobble-stoning) were present in the trachea.
Directoscopy in the GER(-) group revealed roll-shaped oedema of the subglottic portion (82%), hyperaemia of the laryngeal vestibule (22.5%), subglottic area (15%), larynx (8%), interarytenoid incisure, posterior commis-sure and laryngeal vestibule (5%). There was no case of coexisting hyperaemia of the laryngopharynx and laryngeal vestibule in this group of children. Twenty patients (50%) had no laryngeal hyperaemia.
Historical data on the presence of respiratory diseases in the patient subgroups are shown in Table 4. One GER child had a previous history of seven pneumonia episodes.
Table 1. General characteristics of GER(+) and GER(-) patients.
|GER (+)||GER (-)||Total|
|Patients (No)||14 (22.6%)||48 (77.4%)||62 (100%)|
|Girls||3 ||11 ||14|
| 6 - 5 years|
| 4 months - 8 years|
|4 months - 8 years|
Table 2. Incidence of subglottic laryngitis and recurrence of inspiratory dyspnoea in both subgroups.
|GER (+)||GER (-)||P|
|Episodes of subglottic laryngitis (No)||1 - 12 (mean 2.71)||1 - 5 (mean 1.52)||0.018|
|Reccurent inspiratory dyspnoea in recent laryngitis (No)||1 - 7 (mean 2.85)||1 - 4 (mean 1.7)||0.0002|
Table 3. Directoscopic findings in both subgroups.
| GER (+)|| GER (-)|
|Children examined (No/%)||13 (100%)||40 (100%)|
|Roll-shaped oedema in the subglottic area||12 (92 %)||33 (82 %)|
|Laryngeal vestibule||6 (46 %)||9 (22.5 %)|
|Epiglottis, interarytenoid incisure, posterior commissure, laryngeal vestibule ||4 (30.7 %) ||2 (5 %)|
|Laryngopharynx and laryngeal vestibule ||3 (23 %)||- (0 %)|
|Subglottic portion||- (0 %)||6 (15 %)|
|Total laryngeal area ||- (0 %)||3 (8 %)|
|No hyperaemia of laryngeal mucosa||- (0 %)||20 (50 %)|
Table 4. Respiratory diseases in both patient subgroups.
|GER (+)||GER (-)|
|Recurrent bronchitis||6 (43%)||3 (6%)|
|Pneumonia ||4 (29%)||4 (8%)|
|Bronchial asthma ||1 (7%)||-|
In the present study barium swallow was selected as the main diagnostic tool to recognize gastro-oesophageal reflux, because of its accessibility and a relatively young age of children with subglottic laryngitis. The use of the examination was justified particularly when an anatomical background to this disease was suspected, most commonly in very young children. Laryngological data available in literature show that the significance of anatomical malformations, e.g., hiatus hernia, is still under-estimated. The sensitivity of the examination is evaluated at 31-86%, and its specificity at 21-83%. However, it is good to remember that some children in the subgroup without gastro-oesophageal reflux recognised on specific examinations, may be not sufficiently diagnosed (i.e. there is a likelihood of false-negative results).
The above results show that children with gastro-oesophageal reflux had laryngitis about twice as frequently as children without the reflux (2.71 vs 1.52); the GER (+) patients with laryngitis had a twice more frequent recurrent episodes of inspiratory dyspnoea (2.85 vs 1.7) than those in the GER (-)group.
Endoscopic examination in all children with gastro-oesophageal reflux showed hyperaemia of the laryngeal vestibule, whereas in children without gastro-oesophageal reflux hyperaemia in that region was found only in 36% of patients. In the GER (-) patients hyperaemia of the laryngopharynx and laryngeal vestibule did not occur simultaneously. These sites are under a direct influence of gastro-oesophageal reflux in the upper respiratory tract during microaspiration. The laryngoscopic results obtained in our study cannot be directly compared to those obtained in patients with gastro-oesophageal reflux since the picture is similar to that seen in subglottic laryngitis, subglottic oedema, or oedema of arytenoid cartilage.
The case history assessed with respect to respiratory diseases showed that recurrent bronchitis (43% vs 6%) and pneumonia (29% vs 8%) occurred more frequently in children with gastro-oesophageal reflux than in those without the reflux. The results of our study confirm the reports indicating an integration of the respiratory and alimentary tracts.
1. In children with gastro-oesophageal reflux, subglottic laryngitis had a more severe clinical course (more frequent dyspnoeic episodes in the course of subglottic laryngitis, more frequent episodes of laryngitis).
2. In subglottic laryngitis, hyperaemia of the laryngeal vestibule and laryngopharynx in children with gastro-oesophageal reflux was found more frequently than in those without the reflux.
3. In children with recurrent bronchitis, gastro-oeso-phageal reflux was more frequent.
4. In patients with subglottic laryngitis, direct laryngo-sopy is required to determine the characteristic features of gastro-oesophageal reflux, which will allow instituting early and adequate management.
1. Contencin P., Narcy P.: Gastropharyngeal reflux in infants and children. Arch. Otolaryngol. Head. Neck. Surg. 1992; 118(10): 1028-30. 2.Gumpert L., Kalach N., Dupont Ch., Contencin Ph.: Hoarseness and gastroesophageal reflux in children. J. Laryngol. Otol. 1998; 112(1): 49-54. 3.Halstead L.A.: Role of gastroesophageal reflux in pediatric upper airway disorders. Otolaryngol. Head. Neck. Surg. 1999; 120: 208-14. 4.Bouchard S., Lallier M., Yazbeck S., Bensoussen A.: The otolaryngologic manifestations of gastroesophageal reflux: when is a pH study indicated? J. Pediatr. Surg. 1999; 34(7): 1053-56. 5.Vandenplas Y., Hassall E.: Mechanisms of gastroesophageal reflux and gastroesophageal reflux disease. J. Pediatr. Gastroenterol. Nutr. 2002; 35(2): 119-136. 6.Carr M.M., Nagy M.L., Pizzuto M.P., Poje Ch.P., Brodsky L.S.: Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children. Arch. Otolaryngol. Head. Neck. Surg. 2001; 127(4): 369-74. 7.Carr M.M., Nguyen A., Nagy M., Pizzuto M., Poje C., Brodsky L.: Clinical presentation as a guide to the identification of GERD in children. Int. J. Pediatr. Otorhinolaryngol. 2000; 54: 27-32. 8.Zalesska-Krecicka M., Krecicki T., Iwanczak B., Blitek A., Horobiowska M.: Laryngeal manifestations of gastroesophageal reflux disease in children. Acta. Otolaryngol. 2002; 122: 306-10. 9.Rudolph C.D., Mazur L.J., Liptak G.S., Baker R.D., Boyle J.T., Colletti R.B., Gerson W.T., Werlin S.L.: Diagnostyka i leczenie refluksu żołądkowo-przełykowego u niemowląt i dzieci starszych - cz. I i II. Medycyna Praktyczna - Pediatria 2002 wyd.specjalne 2: 43- 88.