Antibiotics for Pediatric Patients With Laryngotracheobronchitis in Korea: A Nationwide Study Based on Administrative Data.

BACKGROUND: Antimicrobial resistance (AMR) is an important global public health concern in adults and children. Laryngotracheobronchitis (croup) is a common acute respiratory infection (ARI) among children, most often caused by a virus, and should not be treated with antibiotics. Reducing the usage of unnecessary antibiotics in ARI using an antimicrobial stewardship program (ASP) is an effective measure against AMR in children. This study investigates the antibiotic prescription pattern in pediatric patients with laryngotracheobronchitis in Korea. Our results will be useful to improve the ASP. METHODS: The data were obtained from the government agency Health Insurance Review and Assessment Service. We analyzed outpatient prescriptions issued to children ≤ 5 years of age with a first-listed diagnosis code for laryngotracheobronchitis, i.e., International Classification of Disease, 10th Revision, code J050 (croup), J040 (laryngitis), or J041 (tracheitis), during 2017-2020. For each prescription, demographic information and information about medical facilities visited (type of hospital, specialty of physician, location of hospital) were extracted. The overall antibiotic prescription rate was subsequently estimated, and multivariable analysis was conducted to determine the associated factors of antibiotic prescription. Prescribed antibiotics were described and classified into extended-spectrum penicillins, cephalosporin, and macrolides. RESULTS: Of 2,358,194 prescriptions reviewed, 829,172 (35.2%) contained antibiotics. In the multivariable analysis, management in a hospital was the strongest factor associated with antibiotic prescription (adjusted odds ratio [aOR], 22.33; 95% confidence interval [CI], 20.87-23.89; P < 0.001), followed by management in a clinic (aOR, 12.66; 95% CI, 11.83-13.54; P < 0.001) and management in a general hospital (aOR, 8.96; 95% CI, 8.37-9.59; P < 0.001). Antibiotic prescription was also significantly associated with patients who were ≤ 2 years of age, managed by a pediatric specialist, and treated at a hospital located in a non-metropolitan region. Overall, extended-spectrum penicillins were the most frequently prescribed (18.6%) antibiotics, followed by cephalosporins (9.4%) and macrolides (8.5%). CONCLUSION: The results of our study suggest that ASPs need to focus on physicians in hospitals, clinics, general hospitals, and pediatric specialties. Providing education programs to these groups to increase awareness of AMR and appropriate antibiotics use could be effective ASP policy and may help to reduce unnecessary prescriptions of antibiotics for laryngotracheobronchitis among pediatric patients and therefore potentially AMR in children in Korea.

Position paper of diagnosis and treatment of post-extubation laryngitis in children: a multidisciplinary expert-based opinion.

OBJECTIVES: To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities. METHODS: A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%. RESULTS: Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy. CONCLUSIONS: Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

Practical Application of Culture-Directed Treatment for Chronic Bacterial Laryngitis.

BACKGROUND/OBJECTIVES: Situated at the center of the upper aerodigestive tract, the larynx often is susceptible to a variety of insults including infection. Manifestations of laryngitis include hoarseness, cough, and sore throat, among others. The purpose of this research is to better understand the clinical presentation and patient characteristics of chronic infectious laryngitis. We aim to better understand when culture-directed therapy should be initiated in patients presenting to the otolaryngologist with suspected chronic infectious laryngitis and how this may influence treatment outcomes. METHODS: A single center, retrospective chart review was performed for patients with laryngitis of >3 weeks duration and who had positive laryngeal cultures obtained at a tertiary referral laryngology office from January 2016 through January 2023. RESULTS: Twenty-four patients (ages 36-84 years) with 29 positive cultures of the larynx met inclusion criteria. Ninety percent of patients were already on acid suppression therapy prior to culture acquisition. Fifty-five percent were immunocompromised. The most common species of bacterial growth included Klebsiella sp. (27.5%), Staphylococcus sp. (27.5%), and methicillin-resistant staphylococcus sp. (13.7%). Twelve cultures (41.4%) revealed multiple bacterial species, and 10 cultures (34.5%) had concomitant fungal isolates. The average treatment duration was 10 days. Twenty-one patients (72%) experienced improvement or resolution in symptoms after completion of culture-directed therapy. CONCLUSIONS: The use of culture-directed therapy for chronic bacterial laryngitis was helpful in the determination of appropriate treatment in these cases. More studies are needed to determine the optimal timing of cultures, duration of treatment, and implications of concomitant fungal laryngitis. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:335-339, 2024.

Visual Gaze Patterns in the Analysis of Glottic Lesions: Does Experience Increase Diagnostic Accuracy?

OBJECTIVES: The purpose of this study was to evaluate visual gaze patterns and the ability to correctly identify cancer among participants of different experience levels when viewing benign and malignant vocal cord lesions. METHODS: Thirty-one participants were divided into groups based on level of experience. These included novice (medical students, PGY1-2 otolaryngology residents), intermediate (PGY3-5 otolaryngology residents, gastroenterology fellow), advanced practice providers (physician assistants, nurse practitioners, and speech language pathologists), and experts (board-certified otolaryngologists). Each participant was shown 7 images of vocal cord pathology including glottic cancer, infectious laryngitis, and granuloma and asked to determine the likelihood of cancer on a scale of certain, probable, possible, and unlikely. Eye tracking data were collected and used to identify the area of interest (AOI) that each participant fixated on first, fixated on the longest, and had the greatest number of fixations. RESULTS: No significant differences were seen among groups when comparing AOI with first fixation, AOI with longest fixation, or AOI with most fixations. Novices were significantly more likely to rate a low likelihood of cancer when viewing infectious laryngitis compared to more experienced groups (P < .001). There was no difference in likelihood of cancer rating among groups for the remaining images. CONCLUSIONS: There was no significant difference in gaze targets among participants of different experience levels evaluating vocal cord pathology. Symmetric appearance of vocal cord lesions may explain differences seen in likelihood of cancer rating among groups. Future studies with larger sample sizes will better elucidate gaze targets that lead to accurate diagnosis of vocal cord pathology.

Efficacy, safety, and tissue penetration of solithromycin in Japanese patients with otorhinolaryngological infections.

OBJECTIVE: To assess the efficacy, safety, and tissue penetration of solithromycin for the treatment of otorhinolaryngological infections, we conducted three studies: a tissue penetration study with patients scheduled to undergo otorhinolaryngological tissue removal, an open-label study comprising patients with otitis media, pharyngitis, laryngitis, and tonsillitis, and a non-inferiority study compared with high-dose cefcapene-pivoxil (CFPN-PI). METHODS: Tissue penetration study; 17 patients with chronic rhinosinusitis, chronic otitis media, chronic tonsillitis, or palatine tonsillar hypertrophy, who required resection or removal of their tissue, were enrolled. Solithromycin was administered orally, and otorhinolaryngological tissues were collected 3.5-6 h after drug administration; blood was collected within 15 min before and after drug administration. The collected tissues and blood concentrations were measured at a central laboratory. Open-label study; 55 patients who were diagnosed with acute otitis media, laryngopharyngitis, or tonsillitis were enrolled. Solithromycin was administered orally 800 mg on Day 1, while on days 2-7, 400 mg of the drug was administered once daily. The primary endpoint is the clinical response at Test-of-Cure (TOC: 5-10 days after completion) Non-inferiority study; 283 patients with acute rhinosinusitis or acute exacerbation of chronic rhinosinusitis were randomized into either the solithromycin group or CFPN-PI group. Solithromycin was administered 800 mg once daily on Day 1 and 400 mg once daily while on Days 2-7 in solithromycin group, and CFPN-PI was administered 150 mg three times a day while on Days 1-7 in CFPN-PI group. The primary endpoint is the clinical response at TOC. RESULTS: In the tissue penetration study, the tissue concentration ratios (tissue concentration/plasma concentration) of solithromycin were 4.19 in the sinonasal mucosa, 1.33 in the middle ear mucosa, and 6.12 in the palatine tonsil tissue. In the open-label study, the efficacy rates at the TOC were 97.0 % for acute otitis media, 100 % for laryngopharyngitis, and 81.8 % for tonsillitis. In the non-inferiority study comprising patients with rhinosinusitis, the efficacy rate at the TOC was 87.7 % for solithromycin and 89.7 % for CFPN-PI. The difference in the efficacy rate (95 % confidence interval) was -2.0 % (-9.4 % to 5.4 %), verifying the non-inferiority of solithromycin to CFPN-PI. The most common adverse events in patients administered solithromycin were diarrhea (20.7 %), nausea and nasopharyngitis (3.6 %,), pharyngitis and elevated hepatic function test results (3.1 %), and abnormal hepatic function (2.1 %). CONCLUSION: Based on the findings, it is suggested that solithromycin is useful for the treatment of otorhinolaryngological infections.

El pediatra de Atención Primaria y la laringitis aguda / Primary care pediatrician and acute laryngitis

La laringitis aguda (crup) es una enfermedad común de origen viral, que constituye la causa más frecuente de obstrucción de la vía aérea superior en la infancia. Se caracteriza por la presencia de un grado variable de tos perruna o metálica, afonía, estridor y dificultad respiratoria. La incidencia estimada es del 3-6% de niños entre 3-6 meses y 6 años, con un pico máximo en el segundo año de vida y durante el otoño y el invierno. La principal causa es el virus parainfluenza tipo 1. El diagnóstico se realiza por la clínica, tos perruna, afonía y estridor inspiratorio. No son necesarias otras exploraciones. En función de la gravedad, que estableceremos con un score clínico, pautaremos el tratamiento. El tratamiento farmacológico será a base de corticoides y adrenalina en las laringitis moderadas y graves. La dexametasona oral es el corticoide de elección en todos los casos. (AU)

Acute laryngitis/croup is a common disease of viral origin, which is the most frequent cause of upper airway obstruction in childhood. It is characterized by the presence of a variable degree of dog or metal cough, aphonia, stridor and respiratory distress. The estimated incidence is 3-6% of children between 3-6 months and 6 years, with a peak in the second year of life and during the autumn and winter. The main cause is the parainfluenza virus type 1. The diagnosis is made based on the symptoms, barking cough, hoarseness and inspiratory stridor. No other examinations are necessary. Depending on the severity, which will be objectively established with a clinical score, will the treatment be prescribed. Oral corticosteroids are the treatment of choice in all diagnosed children. Pharmacological treatment is corticosteroids and adrenaline in moderate and severe laryngitis. Oral dexamethasone is the corticosteroid of choice in all cases. (AU)

Older Adult Woman in a Coma After Acute Laryngitis.

CASE PRESENTATION: A 72-year-old woman with a history of adenocarcinoma of the lung, for which she was receiving tyrosine kinase inhibitor therapy with osimertinib, was admitted to the ED because of clinical deterioration with extreme fatigue and fever. She was already receiving antibiotic therapy initiated by her general practitioner because of symptoms of an upper respiratory tract infection. She was febrile (38.5 °C) with normal laboratory values except for leukocytosis and elevated C-reactive protein. She was hospitalized because of profound general malaise. On the basis of the physician's working hypothesis of severe viral laryngitis, the antibiotic therapy was stopped, and only supportive measures were taken. Over the next 3 days, her condition deteriorated, and she developed respiratory symptoms with a right-sided pleural effusion demonstrated by ultrasound examination. Over time, the patient became increasingly confused and drowsy. There was preserved urinary output and a stable glomerular filtration rate of 57 mL/min. Further on, bilirubin levels as well as coagulation were normal, indicating the absence of any relevant underlying chronic liver condition. Clinically, there were no signs of meningitis. No sedative medications that would explain her confusion were given except for low-dose opioid analgesics. On day 4 after hospitalization, she was transferred to the shock room for immediate stabilization and diagnostics because of profound encephalopathy and increasing oxygen requirements.

Obesity and risk for respiratory diseases: a Mendelian randomization study.

Background: No existing comprehensive Mendelian randomization studies have focused on how obesity affects respiratory diseases. Methods: BMI and waist circumference, mainly from the UK Biobank, and 35 respiratory diseases from the FinnGen Biobank were subjected to Mendelian randomization analyses. In this study, the inverse variance weighting method was used as the predominant analysis method and was complemented by MR-Egger and weighted median methods. Horizontal pleiotropy and potential outliers were detected by employing the MR-PRESSO method. Results: This study indicated that obesity rises the possibility of acute upper respiratory infections (BMI: OR=1.131, p<0.0001; WC: OR=1.097, p=0.00406), acute sinusitis (BMI: OR=1.161, p=0.000262; WC: OR=1.209, p=0.000263), acute pharyngitis (WC: OR=1.238, p=0.0258), acute laryngitis and tracheitis (BMI: OR=1.202, p=0.0288; WC: OR=1.381, p=0.00192), all influenza (BMI: OR=1.243, p=0.000235; WC: OR=1.206, p=0.0119), viral pneumonia (WC: OR=1.446, p=0.000870), all pneumoniae (BMI: OR=1.174, p <0.0001; WC: OR=1.272, p <0.0001), bacterial pneumoniae (BMI: OR=1.183, p=0.000290; WC: OR=1.274, p<0.0001), acute bronchitis (BMI: OR=1.252, p <0.0001; WC: OR=1.237, p=0.000268), acute unspecified lower respiratory infection (BMI: OR=1.303, p=0.000403), chronic tonsils and adenoids diseases (BMI: OR=1.236, p <0.0001; WC: OR=1.178, p=0.000157), chronic laryngotracheitis and laryngitis (WC: OR=1.300, p=0.00785), COPD (BMI: OR=1.429, p <0.0001; WC: OR=1.591, p <0.0001), asthma (BMI: OR=1.358, p <0.0001; WC: OR=1.515, p <0.0001), necrotic and suppurative conditions of lower respiratory tract (WC: OR=1.405, p=0.0427), pleural effusion (BMI: OR=1.277, p=0.00225; WC: OR=1.561, p<0.0001), pleural plaque (BMI: OR=1.245, p=0.0312), other diseases of the respiratory system (BMI: OR=1.448, p <0.0001; WC: OR=1.590, p <0.0001), and non-small cell lung cancer (BMI: OR=1.262, p=0.00576; WC: OR=1.398, p=0.00181). This study also indicated that obesity decreases the possibility of bronchiectasis (BMI: OR=0.705; p=0.00200). Conclusion: This study revealed that obesity increases the risk of the majority of respiratory diseases (including 20 of all 35 respiratory diseases) and that obesity decreases the risk of bronchiectasis.

Difficult glottis: Diagnostic dilemma in viewof the clinical presentation.

<br><b>Introduction:</b> The taxonomy of vocal fold lesions has been refined, and it serves as a common descriptive language for diagnosis, treatment algorithms, and reporting of outcomes. However, we observe rare cases when numerous pathologies overlap, resulting in an unclear and complicated clinical presentation of the glottis.</br> <br><b>Aim:</b> The aim of this paper is to present cases of overlapping etiopathological factors which poses a challenge when making a diagnosis and referring a patient for adequate treatment.</br> <br><b>Material and method:</b> The study presents different photographs of the glottis, including some unique and unusual images in which overlapping pathologies were captured. The photographs are accompanied by case descriptions, comments, and pathological analyses.</br> <br><b>Results:</b> Four selected photographs showed a bunch of exophytic growth lesions with foci of whitish plaques, covered by yellowish crusts, with thinned, reddened vocal folds presenting foci of leukoplakia. The study discussed possible causes of vocal folds edema, diffuse erythema, presence of crusts or exudate, whitish debris/plaques or development of leukoplakia, non-neoplastic ulceration, as well as injected and reddened mucous membrane. Chronic infectious laryngitis, idiopathic ulcerative laryngitis, and drug-induced laryngitis were also mentioned. The study also raised the issues concerning diabetics and patients treated with inhaled corticosteroids, including candidiasis and primary aspergillosis of the larynx.</br> <br><b>Conclusions:</b> To conclude, everyday clinical practice involves encountering cases of unclear onset and course, with complicated presentation of the glottis. Therefore, comprehensive history-taking and thorough investigation of systemic causes are of immense importance. Recommended management includes conducting the most meticulous differential diagnosis, implementing treatment for the most likely cause, and, whenever possible, refraining from biopsy in order to avoid permanent damage to vocal cords.</br>.

Hoarseness: When to observe and when to refer.

The terms hoarseness and dysphonia are used interchangeably, and both describe a type of altered vocal quality affecting one-third of patients. While hoarseness may be secondary to benign conditions such as reflux or viral laryngitis, it may suggest benign or malignant vocal-fold pathology. It is important for caregivers to know how to evaluate, treat, and when to refer patients for direct visualization via laryngoscopy. In this article, we review basic laryngeal anatomy and function, symptoms of vocal-fold pathology, and current guidelines from the American Academy of Otolaryngology-Head and Neck Surgery on the diagnosis and treatment of dysphonia, including patient referral.

Manifestaciones laríngeas de COVID-19 / Laryngeal manifestations of COVID-19

Introducción: la infección por COVID-19 afecta el tracto aerodigestivo superior a través de la enzima convertidora de angiotensina 2 (ECA2) y/o la proteasa transmembrana serina 2 (TMPRSS2). Sus manifestaciones agudas y secuelas han sido muy variadas y no todas están relacionadas con la intubación orotraqueal. El objetivo es describir las características sociodemográficas, clínicas y los hallazgos endoscópicos de los pacientes con síntomas laringofaríngeos posteriores a una infección por SARS-CoV-2 evaluados en el Hospital Militar Central y Hospital Universitario Clínica San Rafael entre marzo de 2020 y marzo de 2022. Materiales y métodos: estudio observacional de corte transversal con datos sociodemográficos, comorbilidades, necesidad de intubación orotraqueal, variedad de síntomas y sus hallazgos endoscópicos. Resultados: se recolectaron datos de 118 pacientes; la edad media fue de 51 años ± 14,4. El síntoma más frecuente fue la disfonía (69,5 %), seguido de la disnea (39,8 %). El 58,9 % requirió intubación orotraqueal y, de estos, la manifestación más frecuente fue disfonía por tensión muscular (DTM) y estenosis subglótica-traqueal. En el 41,1 % restante su hallazgo más frecuente fue la laringitis irritativa. Conclusiones: la COVID-19 tiene múltiples manifestaciones laringofaríngeas en relación con su mecanismo de infección e invasión en los tejidos de esta zona, de tipo inflamatorio y estructural, y no todos están relacionados con la intubación.

Introduction: COVID 19 infection affects the upper aerodigestive tract through angiotensin-converting enzyme 2 (ACE2) and/or Transmembrane serine protease 2 (TMPRSS2). Its acute manifestations and sequelae have been very varied, and not all of them are related to orotracheal intubation. The objective is to describe the sociodemographic and clinical characteristics and the endoscopic findings of patients with laryngopharyngeal symptoms after SARS-CoV-2 infection evaluated at the Hospital Militar Central and Hospital Universitario Clínica San Rafael between March 2020 and March 2022. Methods: Cross-sectional observational study, obtaining sociodemographic data, comorbidities, need for orotracheal intubation, variety of symptoms and their endoscopic findings. Results: 118 patients were collected; the mean age was 51 years ± 14.4. The most frequent symptom was dysphonia (69.5%), followed by dyspnea (39.8%). 58.9% required orotracheal intubation and of these the most frequent manifestation was muscular tension dysphonia (MTD) and subglottictracheal stenosis. In the remaining 41.1%, the most frequent finding was irritative laryngitis. Conclusions: COVID-19 has multiple laryngopharyngeal manifestations in relation to its mechanism of infection and invasion in the tissues of this area, as an inflammatory and structural type, and not all of them are related to intubation.

Using RSI and RFS scores to differentiate between reflux-related and other causes of chronic laryngitis.

OBJECTIVE: To establish if the Reflux Symptom Index (RFI) and the Reflux Finding Score (RFC) can help establish the differential diagnosis in patients with distinct causes of chronic laryngopharyngitis. METHODS: A group of 102 adult patients with chronic laryngopharyngitis (Group A - 37 patients with allergic rhinitis; Group B - 22 patients with Obstructive Sleep Apnea (OSA); Group C - 43 patients with Laryngopharyngeal Reflux (LPR)) were prospectively studied. Chronic laryngitis was diagnosed based on suggestive symptoms and videolaryngoscopic signs (RSI ≥ 13 and RFS ≥ 7). Allergies were confirmed by a positive serum RAST, OSA was diagnosed with a positive polysomnography, and LPR with a positive impedance-PH study. Discriminant function analysis was used to determine if the combination of RSI and RFS scores could differentiate between groups. RESULTS: Patients with respiratory allergies and those with LPR showed similar and significantly higher RSI scores when compared to that of patients with OSA (p < 0.001); Patients with OSA and those with LPR showed similar and significantly higher RFS scores when compared to that of patients with Respiratory Allergies (OSA vs. Allergies p < 0.001; LPR vs. Allergies p < 0.002). The combination of both scores held a higher probability of diagnosing OSA (72.73%) and Allergies (64.86%) than diagnosing LPR (51.16%). CONCLUSIONS: RSI and RFS are not specific for reflux laryngitis and are more likely to induce a false diagnosis if not used with diligence.

COVID-19 presenting as acute epiglottitis: A case report and literature review.

Coronavirus disease 2019 (COVID-19) occasionally causes acute laryngitis, requiring emergency treatment. Understanding the characteristic laryngeal findings can help diagnose COVID-19 earlier, prevent worsening infection, and properly manage airway obstruction. Herein, we report the case of a 44-year-old male with acute epiglottitis likely caused by COVID-19. On presentation, chest computed tomography (CT) showed no signs of pneumonia. However, the larynx had extensive necrotic-like erosive lesions resembling those of tuberculous laryngitis. COVID-19 was diagnosed by reverse-transcription polymerase chain reaction, and secondary bacterial superinfections were suspected after blood testing. The symptoms improved after administration of antibiotics (sulbactam sodium/ampicillin sodium), steroids (dexamethasone), and favipiravir. The patient developed a high fever on the sixth day of hospitalization, and pneumonia was identified on CT. Various culture tests, including tuberculosis, were negative. Thus, remdesivir was administered for COVID-19-induced pneumonia. The patient gradually recovered, was transferred to another hospital, and was discharged on the 35th day of hospitalization. Six previous case reports of COVID-19-induced acute epiglottitis suggested that acute epiglottitis preceded the onset of pneumonia. The laryngeal findings from this report may be useful for diagnosing COVID-19 that does not cause pneumonia and for bringing attention to pneumonia after a COVID-19 diagnosis.

Involvement of Laryngopharyngeal Reflux in Ocular Diseases: A State-of-the-Art Review.

BACKGROUND: Laryngopharyngeal reflux-associated symptoms embrace a wide variety of head and neck manifestations. Its participation in eye disorders has recently been postulated, and there is currently no consensus in this regard. The aim of this manuscript is to review the role of reflux in the development of ocular signs and symptoms, and its physio-pathological mechanisms. METHODS: A systematic approach based on the preferred reporting Items for a systematic review and meta-analysis checklist with a modified population, intervention, comparison, and outcome framework was used to structure the review process of studies that evaluated the possible association, with clear diagnostic methods, of laryngopharyngeal reflux and ocular signs and symptoms. Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through the meta-searcher Trip Database with the keywords: reflux, laryngitis, laryngopharyngeal, gastroesophageal, ocular, eye, symptoms, signs, conjunctivitis, keratitis, dacryocystitis, dry eye. RESULTS: Seven studies met the inclusion criteria, in which the primary acquired nasolacrimal duct obstruction and the ocular surface disease were evaluated. The local increase of eye pepsin concentration (>2.5 ng/mL) may affect ocular surface though its direct proteolytic activity and the local expression of proinflammatory cytokines. The H. Pylori, with a similar mechanism to reach the lacrimonasal duct, would be associated with the release of proinflammatory and vasoactive substances that would lead to a mucosa injury and chronic inflammation. Ocular Surface Disease Index seems to correlate directly with the reflux severity, with cut-off of 41.67 score as predictor for disease. DISCUSSION: The role of laryngopharyngeal reflux in the development of ocular disorders has not yet been demonstrated and data are limited and heterogeneous. It seems theoretically conceivable that pepsin may reach lachrymal duct area through hypopharyngeal-nasal gaseous reflux events. Future studies using objective testing for diagnosis and pepsin detection into the tear and nasal mucosa are needed in order to explore this potential relationship.