[en] [en] OBJECTIVES/HYPOTHESIS: To assess the impact of diet on the saliva pepsin concentration of patients with laryngopharyngeal reflux (LPR).
STUDY DESIGN: Non-controlled Prospective Study.
METHODS: Patients with positive LPR regarding hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were enrolled from three European Hospitals. Patients collected three saliva samples, respectively, in the morning (fasting), and 1 to 2 hour after lunch and dinner. Patients carefully detailed foods and beverages consumed during meals and before the pepsin samples. The 3-month treatment was based on the association of diet, proton pump inhibitors, alginate, or magaldrate regarding the HEMII-pH characteristics. Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were used for assessing the pre- to posttreatment clinical evolution. The Refluxogenic Diet Score and the Refluxogenic Score of a Dish (RESDI) were used to assess the refluxogenic potential of foods and beverages. The relationship between saliva pepsin concentration, HEMII-pH, RESDI, RSS, and RSA was investigated through multiple linear regression.
RESULTS: Forty-two patients were included. The saliva pepsin concentration of the 24-hour period of testing was significantly associated with foods and beverages consumed during the testing period and the evening dinner (rs = 0.973, P < .001). RSS and RSA significantly improved throughout treatment. The level of saliva pepsin in the morning was a negative predictive factor of the therapeutic response regarding RSA and RSS (P < .036).
CONCLUSIONS: Foods and beverages may significantly impact the saliva pepsin concentration of patients with LPR. Patients with high-level saliva pepsin in the morning had lower therapeutic response compared with those with low-level saliva pepsin.
LEVEL OF EVIDENCE: 4 Laryngoscope, 131:350-359, 2021.
Disciplines :
Otolaryngology
Author, co-author :
Lechien, Jerome R ; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium ; Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France ; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Bobin, Francois; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Otolaryngology, Polyclinique Elsan de Poitiers, Poitiers, France
Muls, Vinciane; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Gastroenterology, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
Horoi, Mihaela; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Thill, Marie-Paule; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Dequanter, Didier; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Finck, Camille ; Université de Liège - ULiège > Département des sciences cliniques > Phoniatrie ; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France
Rodriguez, Alexandra; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Saussez, Sven; Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the, International Federation of Oto-Rhino-Laryngological Societies, Paris, France ; Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium ; Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
Language :
English
Title :
Saliva Pepsin Concentration of Laryngopharyngeal Reflux Patients Is Influenced by Meals Consumed Before the Samples.
This work was supported by an IRIS research grant (King Baudouin Foundation) and a Vesale grant.Patients with LPR symptoms and signs were enrolled from three European hospitals (University Hospital Center Saint-Pierre, Cesar De Paepe Hospital, Brussels, Belgium; Elsan Private Hospital of Poitiers, Poitiers, France) from January 2018 to June 2019. The LPR diagnostic was based on the occurrence of one or more acid or nonacid hypopharyngeal reflux episodes at the HEMII-pH.8 Elderly patients (≥60 years old) and those with gastrointestinal (GI) symptoms benefited from GI endoscopy for excluding esophagitis. Patients with the following conditions were excluded: smoker, alcohol dependence, pregnancy, neurological or psychiatric illness, upper respiratory tract infection within the last month, current use of antireflux treatment, previous history of neck surgery or trauma, benign vocal fold lesions, malignancy, history of ear, nose, and throat radiotherapy, and active seasonal allergies or asthma. The local ethics committee approved the study protocol (CHU Saint-Pierre, Université Libre de Bruxelles (ULB), No. BE076201837630). Patients were invited to participate, and informed consent was obtained. Patients with LPR symptoms and signs were enrolled from three European hospitals (University Hospital Center Saint-Pierre, Cesar De Paepe Hospital, Brussels, Belgium; Elsan Private Hospital of Poitiers, Poitiers, France) from January 2018 to June 2019. The LPR diagnostic was based on the occurrence of one or more acid or nonacid hypopharyngeal reflux episodes at the HEMII-pH.8 Elderly patients (≥60 years old) and those with gastrointestinal (GI) symptoms benefited from GI endoscopy for excluding esophagitis. Patients with the following conditions were excluded: smoker, alcohol dependence, pregnancy, neurological or psychiatric illness, upper respiratory tract infection within the last month, current use of antireflux treatment, previous history of neck surgery or trauma, benign vocal fold lesions, malignancy, history of ear, nose, and throat radiotherapy, and active seasonal allergies or asthma. The characteristics of the HEMII-pH device, placement, and analyses have been described in previous publications.9,10 In summary, eight impedance segments and two pH electrodes composed the HEMII-pH (Versaflex Z, Digitrapper pH-Z Testing System; Medtronic, Minneapolis, MN). The impedance segments were placed along the esophagus zones (Z1 to Z6; centered at 19, 17, 11, 9, 7, and 5 cm above the lower esophagus sphincter (LES)). Two additional impedance segments were placed 1 and 2 cm above the upper esophagus sphincter (UES) in the hypopharynx. The pH electrodes were placed 2 cm above LES and 1–2 cm below the UES, respectively. A proximal/hypopharyngeal reflux event consisted of an episode reaching two impedance sensors in the hypopharynx. An acid reflux episode consisted of an episode with pH ≤ 4.0. A nonacid reflux episode consisted of an episode with pH > 4.0. The device was placed in the morning (8:00 a.m.), and was removed the next morning (8:00 a.m.). The patients collected three saliva samples, respectively, in the morning (fasting), and 1 to 2 hours after lunch and dinner, during 24-hour HEMII-pH testing. Patients carefully detailed foods and beverages consumed during the meals before the saliva sample collection. The saliva sample was collected into a 30-mL universal sample collection tube containing citric acid for preserving the action of any pepsin present. The saliva samples were stored in a refrigerator after the collection. The measurement of saliva pepsin level was performed through the Peptest device (RD Biomed, Hull, United Kingdom) by a trained lab technician. The steps of pepsin measurement were performed in a standardized procedure, which has been previously described.9 The saliva pepsin concentration was measured using the Cube Reader (RD Biomed, Hull, United Kingdom), which detects pepsin down to 16 ng/mL. If the results did not reach 16 ng/mL, the test was considered negative. The therapeutic algorithm was based on recent recommendations of the LPR Study Group of Young Otolaryngologists of the International Federation of Oto-Rhino-Laryngological Societies.1 Based on the HEMII-pH characteristics of LPR (daytime, nighttime, acid, nonacid, or mixed LPR), patients received a personalized therapeutic scheme associating diet, behavioral changes, and use of proton pump inhibitors (PPIs) (pantoprazole) ± alginate (Gaviscon Advance; Reckitt Benckiser, Slough, United Kingdom) ± magaldrate (Riopan; Takeda, Zaventem, Belgium) for 3 months. Medication intake was evaluated posttreatment through a visual analog scale ranging from 0 (“I did not take the medication”) to 10 (“I never forgot the medication”). Patients who did not take medication were excluded. Symptoms and findings were assessed from pre- to posttreatment with the Reflux Symptom Score (RSS)10 and Reflux Sign Assessment (RSA).11 The RSS is a 22-item, validated patient-reported outcome questionnaire assessing frequency, severity, and the impact of LPR symptoms on quality of life (Fig. 1).10 The RSA is a validated finding score rating both laryngeal and extralaryngeal signs associated with reflux (Fig. 2).11 The RSA was rated by three blinded laryngologists (j.r.l., f.b., c.f.) regarding the pre- to posttreatment status (videolaryngostroboscopy recordings and oral cavity photos). At the first consultation, patients were invited to report their diet habits through two standardized diet grids describing both foods and beverages usually consumed in Western Europe (Tables I and II).12 Western European foods and beverages were classified in five categories from “very low refluxogenic food/beverage” (category 1) to “very high refluxogenic food/beverage” (category 5). This classification of foods and beverages was based on the calculation of a score assessing the refluxogenic potential of foods and beverages (Refluxogenic Diet Score [REDS]). The REDS considers pH, fat, protein, sugar composition, and other specific factors.12 From the patient anamnesis, the authors calculated the Global Refluxonic Score (GRES), which consists of the addition of REDS of foods and beverages that have been consumed by patients over the past 2 weeks. The refluxogenic potential of foods and beverages that have been consumed during the 24-hour HEMII-pH testing (and before the saliva sample collections) was evaluated through the Refluxogenic Score of a Dish (RESDI), which consists of the weighted sum of the REDS of foods and beverages consumed during a meal.12 The RESDI may be calculated as absolute (sum of all RESDIs of the testing period) or mean (mean of all RESDIs of the testing period). At the end of the consultation, patients received a personalized diet grid identifying the foods and beverages to avoid (i.e., a diet therapeutic scheme). In practice, based on this table, laryngopharyngeal reflux patients selected the foods and beverages that they consumed once or more over the past 2 weeks, and the physician may add the categories corresponding of the consumed foods or beverages to get a score, called the Global Reflux Score. Several foods may be upgraded or downgraded according to characteristics. Raw vegetables are less digestible and may be associated with low gastric emptying time; in case of raw consumption, the food has to be upgraded 1 category. Except for green salad, the addition of vinegar or vinaigrette upgrades the category. In cases of the addition of spicy (for example, spicy ketchup), these foods have to be upgraded. For sugar, only the pH and the glycemic index have been considered regarding the lack of fat. Because spicy has no lipid and no pH, the authors based the classification of this food on the literature. If the patients only eat industrial foods (ready-made food), the foods may be upgraded regarding the acidifying potential of industrial conservative. REDS = Refluxogenic Diet Score. In practice, based on this table, laryngopharyngeal reflux patients selected the foods and beverages that they consume once or more over the past 2 weeks and the physician may add the categories corresponding of the consumed foods or beverages to get a score, called the Global Reflux Score. The classification of beverages depends on pH. For hot chocolate, the category is upgraded for additional sugar. GI high sugar-related osmolarity. The alcohol degree (>3% = upgrade). Sparkling (upgrade). Presence or lack of caffeine or theine (upgrade or downgrade). + beverage exhibits a GI>40. Cat. = category at baseline; GI = glycemic index; UCat. = upgraded category. Statistical analyses were performed using the Statistical Package for the Social Sciences for Windows (SPSS version 22.0; IBM, Armonk, NY). The relationship between GRES, RESDI of meals preceding the saliva pepsin collection, HEMII-pH findings, pre- and posttreatment RSS, and RSA was analyzed through multiple linear regression. Pre- to posttreatment changes in RSS, RSA, and GRES were evaluated using the Wilcoxon signed rank test. A level of significance of P <.05 was used.
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