Riitta Ylitalo

Symptoms, laryngeal findings, and 24-hour pH monitoring in patients with suspected gastroesophago-pharyngeal reflux.

Objectives To investigate the laryngeal signs and symptoms associated with gastroesophago‐pharyngeal reflux (GEPR).

Extraesophageal reflux in patients with contact granuloma: a prospective controlled study.

The aim of this study was to compare the incidences of extraesophageal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per subject). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.

A retrospective study of contact granuloma

Objectives: This study evaluates the clinical features of contact granuloma and compares the results of voice therapy in operated versus unoperated cases. Study Design: Retrospective review of 123 patients with contact granuloma. Thirty‐six patients had undergone one or more surgeries before phoniatric consultation. After their final operation, 33 patients had recurrence. The three patients who were cured by operation were not studied further. The course of disease in the 33 patients with recurrence was compared with that of 87 patients who did not have surgery. Methods: The hospital records were reviewed concerning age, sex, symptoms, side of granuloma, and outcome of treatment. Results: The predominant symptoms were vocal fatigue, vocal discomfort, the need for excessive throat clearing, and hoarseness. The recurrence rate after operation was 92%. Twelve months after voice therapy, 35% of the operated group and 51% of the unoperated group were cured. The patients who had surgery had almost twice as many sessions of voice therapy as the unoperated group, and their mean recovery time was 17 months, compared with 8 months for the unoperated group. Conclusions: The recurrence rate after surgery was high. Surgery may prolong the recovery time. Subjective symptoms diminished during voice therapy, but we cannot confirm that it was beneficial for the healing process.

Voice characteristics, effects of voice therapy, and long-term follow-up of contact granuloma patients

This study evaluates the laryngoscopic findings and voice characteristics of male contact granuloma patients before and after voice therapy and at a follow-up about 9 years later. Pre- and posttherapy recordings as well as follow-up recordings were made for 19 granuloma patients. Pretherapy revealed the most salient perceptual voice characteristics were low pitch, monotony, and a high degree of vocal fry and hyperfunction. Interjudge reliability for these traits was high. Immediately following therapy the healed patients (n = 10) had a decrease in hyperfunction, vocal fry, and monotony, while the unhealed patients (n = 9) had an increase in hyperfunction and vocal fry decreased only marginally. Monotony decreased significantly in this group. As regards the acoustic analyses, no significant differences were found in mean fundamental frequency (F0) or perturbation. At the follow-up assessment 4 patients had granuloma while 15 had normal laryngeal status. Perceptually their voice characteristics resembled those pretherapy independently of the laryngeal findings. The results suggest that reduced hyperfunction and decreased vocal fry may create better circumstances for the healing process at the posterior glottis.

Laryngeal Findings in Patients with Contact Granuloma: a Long-Term Follow-Up Study

In order to evaluate the long-term outcome of contact granuloma a follow-up study of 59 patients was conducted. Primary treatment consisted mainly of voice therapy or of voice therapy in combination with surgery. A careful history was taken and the patients were examined using videolaryngoscopy. The average follow-up time was 12 years (range 5-20 years). In total, 10 out of 59 patients (17%) had a granuloma at the follow-up examination, 6 of them presenting without subjective symptoms. Another 28 patients had various signs of inflammation of the posterior glottis. The history taken at follow-up revealed that eight patients had had a previous temporary recurrence during the follow-up time. The recurrence frequency was the same for patients who received voice therapy after postoperative recurrence and patients who were treated with voice therapy only. About 80% of the patients had no symptoms at follow-up. The findings of the present study indicate that contact granuloma is one of several manifestations of chronic posterior laryngitis and that it may occur without symptoms.

Effect of Acid and Pepsin on Gene Expression in Laryngeal Fibroblasts

The aim of this study was to determine changes that momentary low pH with or without pepsin causes in gene expression in laryngeal fibroblasts. Cell cultures were established from human false vocal fold (FVF) and postcricoidal (PC) mucosae. Using a real-time polymerase chain reaction, we analyzed messenger RNA gene expression of growth factors (transforming growth factor β1, vascular endothelial growth factor, fibroblast growth factor 2), matrix metalloproteinases (MMP-1, MMP-2), and decorin in normal media, pH 4 media, and pH 5 media with and without pepsin. The FVF fibroblast gene expression differed substantially from the PC fibroblast gene expression. No significant interaction effects for acid and pepsin were found in the FVF culture, but in PC cultures we found a significant overexpression interaction effect for vascular endothelial growth factor, fibroblast growth factor 2, MMP-1, MMP-2, and decorin. These results imply that PC tissue is more sensitive than FVF tissue to the noxious effects of gastric contents. Furthermore, there appears to be a synergistic effect for acid and pepsin exposure in the posterior larynx.

Prevalence of extraesophageal reflux in patients with symptoms of gastroesophageal reflux

OBJECTIVES: To compare the prevalence of extraesophageal reflux (EER) in patients with heartburn, posterior laryngitis (PL), and in healthy controls. STUDY DESIGN AND SETTING: A retrospective and prospective study including a total of 101 subjects who underwent 24-hour dual-probe pH monitoring. RESULTS: 52% of the subjects with heartburn had EER. No significant differences were found between the PL and heartburn groups for any pharyngeal reflux parameters. However, supine pharyngeal reflux was significantly more prevalent in heartburn patients with GERD than in PL patients and healthy controls (P < 0.05). Significant positive correlation (P < 0.01) was found between the percentage of time pH <4 in the pharynx and in the distal esophagus. CONCLUSION: EER occurs in the majority of heartburn patients who are lacking laryngeal symptoms. Abnormal distal esophageal acid exposure makes the occurrence of EER more likely. SIGNIFICANCE: EER appears to be a continuum without clear-cut differences between the groups.

Relationship between time of exposure of laryngopharyngeal reflux and gene expression in laryngeal fibroblasts.

Objectives: Acid reflux is damaging to the laryngeal mucosa; however, the significance of the duration of reflux episodes has not been evaluated. The purpose of this study was to determine whether varying the exposure times at low pH with or without pepsin alters gene expression in laryngeal fibroblasts. Methods: Human false vocal fold and postcricoidal cultures were exposed to pH 4 or pH 5 media with and without pepsin for 10, 30, 60, and 240 seconds. Using a real-time polymerase chain reaction, we determined the messenger RNA expression of TGFβ-1, VEGF, FGF-2, EGR-1, ATF-3, CTGF, MMP-1, MMP-2, and decorin. Results: Molecular responses were initiated at pH 5. Postcricoidal fibroblasts were more sensitive than false vocal fold fibroblasts to the presence of pepsin. Changes in transcript levels were dependent on acid exposure time, and the most significant changes were measured during the first 60 seconds after exposure. Conclusions: Time of exposure to acid and pepsin needs to be taken into consideration when determining limit of pathology in pharyngeal reflux. Genes are identified that are induced by low pH and that may be of potential importance in the pathogenesis of reflux laryngitis.

Gastroesophagopharyngeal Reflux in Patients with Contact Granuloma: A Prospective Controlled Study

The aim of this study was to compare the incidences of gastroesophagopharyngeal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory esophagopharyngeal pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per patient). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p =.009) and in the total time of pH below 4 (p =.006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p =.006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.

Effects of botulinum toxin treatment for adductor spasmodic dysphonia on voice and social function

Thirty-nine patients with adductor spasmodic dysphonia currently under treatment with botulinum toxin estimated their vocal and social function before and during treatment in percentage of normal. Subjective symptoms and side effects were registered. All patients had positive effects. Mean improvement was 45 per cent for voice function and 47 per cent for social function. Eleven patients (28 per cent) claimed they had a completely normal voice for a short period between injections. Thirty-three patients (85 per cent) reported a considerably breathy voice quality lasting several weeks after injection on one or more occasions. Sixteen patients had experienced slight deglutition problems. In spite of these side effects, the results confirm that the overall efficacy of treatment of adductor spasmodic dysphonia with botulinum toxin is very high.