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Gastroesophageal Reflux in Patients with Subglottic Stenosis

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Gastroesophageal Reflux in Patients with Subglottic Stenosis ORIGINAL ARTICLE Gastroesophageal Reflux in Patients With Subglottic Stenosis David L. Walner, MD; Yoram Stern, MD; Mark E. Gerber, MD; Colin Rudolph, MD; Constance Y. Baldwin, BS; Robin T. Cotton, MD Objectives: To determine the incidence of gastroesopha- for reflux-associated symptoms have not been estab- geal reflux in patients with subglottic stenosis (SGS) and lished. Therefore, patients were grouped as having a pH to determine if upper esophageal reflux occurs in addi- of less than 4.0 in the upper esophagus for 0%, 0.1% to tion to lower esophageal reflux in these patients. 0.9%, 1.0% to 1.9%, 2.0% to 3.0%, or more than 3% of the study time. Design: Esophageal pH probe studies were reviewed in patients diagnosed as having SGS. Results: Thirty-seven of the 74 patients who under- went lower probe testing had a pH of less than 4.0 more Setting: A tertiary care pediatric medical center. than 5% of the study time, and 24 had a pH of less than 4.0 more than 10% of the study time. Twelve of the 55 Patients: All patients diagnosed as having SGS be- patients who underwent upper probe testing had no mea- tween January 1990 and July 1996 who had undergone surable reflux; 27 of the 55 had a pH of less than 4.0 more monitoring with an overnight esophageal pH probe. Sev- than 1% of the study time; 14 had a pH of less than 4.0 enty-four patients qualified for the study. All 74 pa- more than 2% of the study time, and 11 had a pH of less tients underwent lower probe testing, and 55 of the 74 than 4.0 more than 3% of the study time. underwent dual (upper and lower) probe testing. Conclusions: Gastroesophageal reflux is frequently Main Outcome Measures: The percent of time a pH present in patients with SGS. Gastric contents fre- measurement of less than 4.0 was recorded in the upper quently reach the upper and lower esophagus in these and lower esophagus. A lower probe pH measurement patients. In addition, the high incidence of gastroesopha- of less than 4.0 more than 10% of the study time was geal reflux in these patients suggests that it may play a considered high risk for developing reflux-associated role in the development of SGS. The possible effect of pathologic symptoms. A lower probe pH measurement gastroesophageal reflux on the surgical repair of SGS re- of less than 4.0 for 5% to 10% of the study time was quires further study. considered a marginal risk for developing reflux- associated pathologic symptoms. Upper probe criteria Arch Otolaryngol Head Neck Surg. 1998;124:551-555 HE INCIDENCE of subglottic rection into the esophagus. Brief epi- stenosis (SGS) in neonates sodes of GER occur in almost 50% of 4 From the Department of requiring endotracheal in- healthy infants less than 2 months of age. Pediatric Otolaryngology and tubation ranges from 1% to By the age of 12 months and thereafter, Maxillofacial Surgery 8%.1,2 The cause of acquired only 8% of children are thought to have (Drs Walner, Stern, Gerber, TSGS is not well understood.3 Several syner- GER.5 In most infants and children, GER Baldwin, and Cotton, and gistic factors likely play a role in the devel- has no consequences, but airway symp- Ms Baldwin) and the Division opmentofthedisorder.Thesefactorsinclude toms have been shown to be related to GER of Pediatric Gastroenterology but are not limited to the size of the endo- in some patients. These symptoms in- and Nutrition (Dr Rudolph), tracheal tube, movement of the endotracheal clude aspiration pneumonia, exacerba- Children’s Hospital Medical tube, duration of intubation, traumatic in- tion of asthma, apnea, stridor, croup, and Center, Cincinnati, Ohio. tubation, presence of an infection while in- laryngitis or hoarseness.6-8 More specifi- Dr Walner is now with the 9 Department of Otolaryngology/ tubated, and possibly gastroesophageal re- cally, Jindal et al suggest that GER Bronchoesophagology, flux (GER) with or without intubation. may cause certain cases of SGS. Contencin Rush-Presbyterian-St Luke’s Gastroesophageal reflux occurs when et al6 comment on the close relationship Medical Center, Chicago, Ill. gastric contents move in a retrograde di- between SGS and GER. This relationship ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 124, MAY 1998 551 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 PATIENTS AND METHODS from birth to 1 year of age, the proximal sensor of the probe was placed 5 cm above the distal sensor. For patients 1 to 3 years of age, the proximal sensor was A list was reviewed of all patients evaluated for SGS at placed 10 cm above the distal sensor. For patients 3 the Children’s Hospital Medical Center in Cincinnati, years and older, the proximal sensor was placed 15 cm Ohio, between January 1990 and July 1996. Of the more above the distal sensor. All patients underwent fluoros- than 300 patients evaluated, only those who had under- copy or chest radiography to confirm correct placement gone pH probe testing at our institution were included of the probe. A reference electrode was placed on the in the study. Many patients had undergone GER evalua- patient’s abdomen when required. Recordings were tion at other institutions, and as a result, details of their obtained for at least 18 hours. pH studies were unavailable, and they were not included All patients were instructed to pursue their normal in the study. Seventy-four patients qualified for the activities. Patients had no meal restrictions, but the study, and a retrospective chart review was performed beginning and ending of feeding times were recorded. If for each. patients were taking acid-inhibitory or prokinetic medi- The following information was recorded for each pa- cations, those regimens were discontinued at least 24 tient: sex, age at the time of testing, the presence of a tra- hours prior to the study (except in one patient who was cheotomy tube at the time of testing, associated medical taking ranitidine hydrochloride [Zantac] during our conditions and birth history, previous reflux surgery, grade study because pH probe testing at another institution of airway stenosis identified on endoscopy, and number of had indicated severe reflux). previous airway surgeries. Airway grading was recorded from The pH probe results were recorded and distin- the endoscopy performed closest to the date of pH probe guished based on upper and lower probe location and testing and was based on the Myer/Cotton grading system the percent of time with a pH measurement less than (Figure).10 4.0. This was calculated by adding the total time within All dual-probe monitoring was performed with a 60 minutes with a pH of less than 4.0 following a meal portable pH measuring unit (model Mk3 dual-channel to the total time for more than 60 minutes with a pH of Digitrapper, Synectics Medical). Single-probe studies less then 4.0 following a meal. This sum was then were performed with a Mark II single-channel unit (Syn- divided by the total time of the study and multiplied by ectics Medical. Most dual-probe studies were performed 100 to derive the percent of time with a pH less than 4.0. in the latter half of the study (1993-1996). All electrodes This calculation was performed separately for upper and were calibrated in buffer solutions with a pH of 7.0 and lower probe measurements. then in solutions with a pH of 1.0. The pH electrodes Lower pH probe measurements of less than 4.0 were were inserted through the patient’s nose into the esopha- recorded as occurring more than 10% of the study time, gus and placed such that the tip of the electrode was 2 to 5% to 10% of the study time, or less than 5% of the study 4 cm above the gastroesophageal junction. When pres- time. Upper pH probe results of less than 4.0 were re- ent, the upper probe was positioned within 1 to 2 cm of corded as occurring 0%, 0.1% to 0.9%, 1.0% to 1.9%, 2.0% the upper margin of the esophagus. Ideally, the probe to 3.0%, or more than 3% of the study time. was placed below the upper esophageal sphincter in the Kendall t rank correlation analysis and nonparamet- esophageal inlet. One of 3 different-sized electrodes was ric analysis of variance were performed on all variables men- used, depending on the age of the child. For patients tioned. could have implications for both the origin of SGS common were prematurity and bronchopulmonary and its treatment if GER is present. The prevalence dysplasia: of GER in patients with SGS has not been clearly estab- Medical Condition No. (%) of Patients lished. Prematurity 48 (64.9) The purpose of our study was to determine the preva- Bronchopulmonary dysplasia 23 (31.1) lence of GER in pediatric patients with SGS. Gastrostomy tube 13 (17.6) Tracheomalacia 11 (14.9) History of Nissen fundoplication 11 (14.9) RESULTS Reactive airway disease 10 (13.5) Patent ductus arteriosus ligation 10 (13.5) Of the 74 patients who qualified for the study, 43 Developmental delay 7 (9.5) (58%) were male and 31 (42%) were female. The aver- Congenital SGS 6 (8.1) age age of the patients at the time of pH probe testing Brain injury 6 (8.1) was 5 years (age range, 0.3-14.3 years). Fifty-five patients (74%) underwent dual (upper and lower) Eleven patients (14.9%) had undergone Nissen probe testing, and 19 (26%) underwent only lower fundoplication prior to our study, and 13 (17.6%) were probe testing.
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