Extraoesophageal manifestations of gastro-oesophageal reflux.

A variety of pulmonary and ear, nose, and throat (ENT) symptoms and disorders are considered to be extraoesophageal manifestations of gastro-oesophageal reflux disease (GORD). These extraoesophageal manifestations include asthma, chronic cough, laryngeal disorders, and various ENT symptoms. Recent studies have established that GORD underlies or contributes to chronic sinusitis, chronic otitis media, paroxysmal laryngospasm, excessive throat phlegm, and postnasal drip. Traditionally, management of extraoesophageal GORD manifestations relies on prolonged empiric therapy with high doses of proton pump inhibitors (PPI), followed by pH monitoring under PPI in refractory cases. Recent studies found no benefit of empiric long term high dose PPI therapy. The diagnostic yield of endoscopy in extraoesophageal GORD manifestations seems higher than previously appreciated while pH monitoring under PPI therapy has a low yield. Based on these new findings, a new management algorithm can be proposed that uses short term empiric PPI therapy and GORD investigations off PPI. Well designed controlled studies evaluating the proposed management algorithms and treatment approaches in this area are urgently needed.

The role of (duodeno)gastroesophagopharyngeal reflux in unexplained excessive throat phlegm.

Gastroesophageal reflux (GER), through the occurrence of gastroesophagopharyngeal reflux (GEPR), is an established cause of several otorhinolaryngological (ORL) manifestations. It has been suggested that unexplained excessive throat phlegm might also be a manifestation of GER, but formal evidence is lacking. The aim of the present study was to investigate the prevalence of GER as well as duodenogastroesophageal reflux (DGER) in consecutive patients with chronic complaints of excessive throat phlegm. Fifty-nine consecutive patients with chronic unexplained excessive throat phlegm, transparent in 33 patients (TTP) and yellow in 26 patients (YTP), underwent gastrointestinal endoscopy, 24-hr dual esophageal pH monitoring, and fiberoptic DGER monitoring. Proximal esophageal DGER monitoring was performed in seven YTP patients and analysis of bile acids in throat phlegm was performed on 16 samples. The effect of high-dose acid suppressive therapy was evaluated at 2-week intervals. Endoscopy and pH monitoring established a diagnosis of pathological GER in 75% of the patients. Pathological DGER was present in 56% of the patients and this was associated with YTP. Proximal DGER exposure was high in all investigated subjects and chemical analysis revealed a median bile acid concentration of 0.184 microM in nine YTP samples and no detectable bile acids in seven TTP samples. After a median of 4 weeks of acid suppressive therapy, most patients improved and 61% became asymptomatic. YTP patients were more likely to require maintenance acid suppressive therapy than TTP patients. Unexplained excessive throat phlegm is a sign suggestive of GER and GEPR, and unexplained yellow throat phlegm a sign suggestive of duodenogastroesophagopharyngeal reflux (DGEPR).

Perception of aggression among psychiatric nurses in Switzerland.

OBJECTIVE: To identify principal components and patterns in the perception of aggression by psychiatric nurses and to explore relationships between the perception of aggression and personal and workplace characteristics. METHOD: Seven hundred and twenty-nine nurses working in psychiatric inpatient departments of German-speaking Switzerland completed the perception of aggression scale (POAS). Data analysis included factor analysis, group comparisons and multivariate analysis of covariance. RESULTS: Two plausible factors were identified, representing different dimensions in the perception of aggression and accounting for 35% of the variance. Firstly, aggression is perceived as dysfunctional/ undesirable and, secondly, aggression is perceived as a functional/ comprehensible phenomenon. Only minor differences were found in the perception of aggression with regard to personal characteristics or work environment of the nurses. CONCLUSION: Nurses perceive aggression not just as a negative phenomenon. The perception of aggression as measured by POAS is independent of many characteristics expected to be related to the perception of violence, such as grade of education, work experience, etc.

Chronic middle ear disease and gastroesophageal reflux disease: a causal relation?

OBJECTIVE: To describe one patient with a puzzling therapy-resistant unilateral chronic otitis media, analyze his diagnosis, and describe three similar patients with the same symptoms and signs, i.e., a chronic ear problem together with gastroesophageal reflux disease (GERD). STUDY DESIGN: Thorough analysis of one patient with a chronic ear problem and GERD, both of which responded favorably after antireflux therapy consisting of omeprazole and conservative antireflux measures (raising the head of the bed by 20 to 25 cm, avoiding meals and drinks 3 hours before retiring, and other dietary and lifestyle modifications), and a search for more patients with similar coexisting conditions. SETTING: Tertiary referral center. METHODS: Patients with chronic ear problems and GERD were thoroughly analyzed by the otorhinolaryngologist and the gastroenterologist. The latter used endoscopy and Savary-Miller's classification of esophagitis, a 24-hour ambulatory dual esophageal pH monitoring, and esophageal manometry. RESULTS: Four patients were identified who had a chronic ear problem and simultaneous GERD. It is reasoned that the GERD leads to nasopharyngitis and this to a chronic ear problem. All the patients responded favorably to anti-GERD therapy. CONCLUSIONS: GERD may manifest itself as an extraesophageal manifestation, such as nasopharyngitis, leading to ear disease. Therapy-resistant chronic middle ear disease may be caused by GERD.

Otorrhea during transtympanal ventilation.

The authors followed 1685 transtympanal ventilation tubes during at least 6 months. In 10.4% of the cases, otorrhea was noticed; it formed a serious problem in 3.1% of the ears. It was more frequent in younger children: 20.8% under 2 years vs 7% above 6 years. It was more frequent (25%) in patients with a history of recurrent acute otitis media, especially if they had associated otorrhea.

[Follow-up of trans-tympanum tubes]. / Follow-up van transtympanale drains.

During a follow-up period varying from 6 months to 6 years, the authors followed 1685 transtympanal ventilating tubes (VT). The mean age of the patients was 4 years 11 months. The mean duration of the VT in the tympanic membrane is 14 months. In 10.4% of the cases otorrhea was noticed. The otorrhea forms a serious problem in 30% of the VT that show drainage; it is more frequent in younger children and in those with a history of recurrent otitis media, especially if they were associated with otorrhea. Perforations persisted in 1.3% of the ears.

Absolute versus relative evaluation of the caloric test results.

A comparative study of clinical cases elucidates the value of "relative" and "absolute" evaluation of the caloric test results, using both parameters slow phase velocity (SPV) and frequency. It is shown that combining both techniques of evaluation, using both parameters, contributes to obtain more nuanced dysfunction patterns. Unilateral peripheral vestibular hypofunction can only be evaluated by using SPV in a relative way according to the formula of Jongkees. Absolute evaluation by both parameters provides indications for central components.