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1.
Artigo em Chinês | MEDLINE | ID: mdl-33472303

RESUMO

Objective: To compare the clinical characteristics of patients with different type of laryngopharyngeal reflux disease in order to study the effect of non-acid reflux on laryngopharyngeal reflux disease. Methods: From January 2015 to January 2020, 349 inpatients or outpatients suspected of having laryngopharyngeal reflux underwent 24-hour multichannel intraluminal impedance pH monitoring (MII-pH). There were 303 male and 46 female patients, with an average age of 56.03 years old ranged from 25 to 81 years old. The reflux symptom index (RSI)and reflux findings score(RFS)were recorded before MII-pH monitoring. The number of acid reflux events and non-acid reflux events in hypopharynx were counted. It was defined mainly acid reflux type when the ratio of acid reflux to all reflux events was greater than 50%, mainly non-acid reflux type when the ratio of non-acid reflux to all reflux events was greater than 50%. The clinical characteristics of patients with different type of reflux were compared. SPSS 19.0 software was used for statistical analysis, and multiple independent samples were compared between groups. The quantitative data were analyzed by multivariate analysis of variance, and the counting data were analyzed by chi-square test, the difference was statistically significant when P<0.05. Results: The 24-hour MII-pH showed that there were 90 patients with no reflux events, 51 patients with mainly acid reflux type, 198 patients with mainly non-acid reflux type and 10 patients with equal acid reflux events and non-acid reflux events. Statistics showed that the RSI(10.72±4.40), RFS(7.70±2.73) and the average number of reflux events(0) in the group without reflux events were significantly lower than those in patients with mainly acid reflux type (RSI 13.16±6.62,RFS 10.08±3.03,average number of reflux events 5.33±3.15,P<0.05) and mainly non-acid reflux type(RSI 13.25±5.54,RFS 8.81±2.54,average number of reflux events 7.93±5.26, P<0.05). There was no significant difference in RSI between the mainly non-acid reflux type group and the mainly acid reflux type group, but the RFS of the mainly non-acid reflux type group was significantly lower than that of the mainly acid reflux type group. The average number of reflux events in the mainly non-acid reflux group was significantly higher than that in the mainly acid reflux type group (P<0.05). Conclusion: The results show that non-acid reflux plays a certain role in laryngopharyngeal reflux disease, but the effect of acid reflux is greater.


Assuntos
Refluxo Laringofaríngeo , Adulto , Idoso , Idoso de 80 Anos ou mais , Monitoramento do pH Esofágico , Feminino , Humanos , Hipofaringe , Refluxo Laringofaríngeo/diagnóstico , Refluxo Laringofaríngeo/epidemiologia , Masculino , Pessoa de Meia-Idade , Sistema Respiratório
4.
J Vis Exp ; (166)2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33369600

RESUMO

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, hoarseness or asthma, which can be caused by laryngopharyngeal reflux (LPR). Due to their multifactorial origin, those symptoms can be a great diagnostic and therapeutic challenge. Esophageal pH-monitoring is commonly used to determine abnormal esophageal acid exposure and confirm the diagnosis of GERD. However, for better evaluation of acid exposure above the upper esophageal sphincter, a new laryngopharyngeal pH measurement system is now available and may lead to more reliable results in patients with predominantly extraesophageal symptoms. This article aims to present a standardized protocol for simultaneous pH measurement using esophageal and laryngopharyngeal pH probes in order to obtain acid exposure scores from both measurements.


Assuntos
Monitoramento do pH Esofágico , Hipofaringe/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateteres , Monitoramento do pH Esofágico/efeitos adversos , Feminino , Humanos , Refluxo Laringofaríngeo/diagnóstico , Refluxo Laringofaríngeo/etiologia , Refluxo Laringofaríngeo/terapia , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Adulto Jovem
5.
Codas ; 32(5): e20180052, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-33174981

RESUMO

PURPOSE: To verify the association between laryngopharyngeal reflux (LPR) with age, gender, vocal deviation and voice complaints. METHODS: The study included patients between 18 and 70 years old, referred to the Otorhinolaryngology service for complaints of voice or reflux, of both sexes. Endolaryngeal findings were classified using the Reflux Finding Score (RFS) scale. The presence or absence of vocal and reflux complaints was verified and correlated with the RFS classification. On the same date, they were submitted to sustained vowel voice recording and chained speech. The auditory-perceptual assessment was performed by a speech therapist, classifying the general degree of vocal deviation based on the GRBASI scale. RESULTS: Ninety-seven patients were evaluated, with a mean age of 42. 6 years, 62. 3% female, and mean RFS scores of 6. 26 points. Among the patients, 48 subjects had vocal complaints, 34 women with a mean age of 44. 9 years and an average RFS score of 6. 94 points. The other 49 individuals had no vocal complaints, and of these 27 were women, with a mean age of 41. 2 years and a mean RFS score of 5. 5 points. The variables "reflux complaint", "vocal complaint" and age were the ones that most correlated with the RFS scale scores. CONCLUSION: There is a relationship among reflux complaints, laryngeal findings and vocal complaint.


Assuntos
Refluxo Laringofaríngeo , Voz , Adolescente , Adulto , Idoso , Feminino , Humanos , Refluxo Laringofaríngeo/complicações , Refluxo Laringofaríngeo/diagnóstico , Masculino , Pessoa de Meia-Idade , Qualidade da Voz , Adulto Jovem
10.
J Laryngol Otol ; 134(8): 684-687, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32758307

RESUMO

BACKGROUND: The coronavirus disease 2019 pandemic has necessitated almost exclusive National Health Service focus on emergency work and cancer care. There are concerns that increased hospital and community pressures will lead to decreased referrals and worse outcomes for head and neck cancer patients. METHOD: This is a retrospective review of all cases referred for suspected head and neck cancer to our institution in January and April 2020. RESULTS: There was a 55 per cent decrease in referrals but diagnostic yield rose from 2.9 per cent in January to 8.06 per cent in April. In both months, 100 per cent of patients met the 31- and 62-day targets, with similar 14-day wait time success (97.83 per cent for January vs 98.33 per cent for April). Referrals for laryngopharyngeal reflux rose from 27.5 per cent to 41.9 per cent. Referrals for those aged over 60 years fell from 42 per cent to 26 per cent. CONCLUSION: It is suggested that further research be conducted into the reasons why fewer patients were referred, particularly elderly patients, and why laryngopharyngeal reflux is so prevalent in fast-track referrals.


Assuntos
Infecções por Coronavirus/transmissão , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Refluxo Laringofaríngeo/epidemiologia , Pneumonia Viral/transmissão , Encaminhamento e Consulta/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus/isolamento & purificação , Estudos de Casos e Controles , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Feminino , Neoplasias de Cabeça e Pescoço/epidemiologia , Humanos , Refluxo Laringofaríngeo/diagnóstico , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Prevalência , Estudos Retrospectivos , Medicina Estatal/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos , Ultrassonografia/métodos , Reino Unido/epidemiologia
12.
Ann Otol Rhinol Laryngol ; 129(10): 1020-1029, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32468832

RESUMO

OBJECTIVES: To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). METHODS: From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. RESULTS: A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. CONCLUSIONS: It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.


Assuntos
Monitoramento do pH Esofágico , Esôfago/fisiopatologia , Refluxo Laringofaríngeo/diagnóstico , Manometria , Adulto , Estudos de Casos e Controles , Tosse/etiologia , Tosse/fisiopatologia , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/fisiopatologia , Feminino , Sensação de Globus/etiologia , Sensação de Globus/fisiopatologia , Azia/etiologia , Azia/fisiopatologia , Rouquidão/etiologia , Rouquidão/fisiopatologia , Humanos , Refluxo Laringofaríngeo/complicações , Refluxo Laringofaríngeo/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise de Componente Principal , Psicometria , Reprodutibilidade dos Testes , Inquéritos e Questionários
13.
Ann Otol Rhinol Laryngol ; 129(8): 801-805, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32249595

RESUMO

OBJECTIVE: The objective of this study was to examine referral patterns between otolaryngology and gastroenterology in order to delineate areas of clinical overlap, as well as to identify areas that might benefit from improved inter-specialty communication and collaboration. METHODS: Montefiore's Clinical Looking Glass tool was used to define parameters for electronic medical record data extraction from 2015 to 2018. Two cohorts were generated, one representing referrals placed by gastroenterology to otolaryngology and a second representing referrals placed by otolaryngology to gastroenterology. The ICD-10 codes in both cohorts were reviewed and 13 distinct "reason for referral" categories were defined. The rates of referral for each category were then calculated for each of the referral cohorts. RESULTS: Otolaryngology referred to gastroenterology at a greater rate than gastroenterology referred to otolaryngology, despite seeing fewer total patients than gastroenterology. For referrals from gastroenterology to otolaryngology, the three most frequent referral reasons were oral cavity/oropharyngeal pathology (28.3%), dysphagia (28.3%), and gastroesophageal reflux disease/laryngopharyngeal reflux disease (GERD/LPRD) (11.3%). For referrals from otolaryngology to gastroenterology, the three most frequent referral reasons were GERD/LPRD (61.7%), dysphagia (18.6%), and esophageal pathology (5.3%). CONCLUSIONS: GERD/LPRD was more frequently referred out by otolaryngology than it was by gastroenterology, suggesting the need for further characterization of the discrepancy in management of a disease commonly treated by both specialties. The discrepant rates of referral for dysphagia also suggest a need to better understand what factors contribute to the differences in management of another clinical condition commonly assessed by both specialties. LEVEL OF EVIDENCE: 4.


Assuntos
Educação Médica/normas , Gastroenterologia/normas , Refluxo Laringofaríngeo/diagnóstico , Otolaringologia/normas , Padrões de Prática Médica , Encaminhamento e Consulta/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
14.
Am J Otolaryngol ; 41(3): 102441, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32144021

RESUMO

PURPOSE: To use the synchronous esophageal and oropharyngeal Dx-pH monitoring analysis to investigate the relationship between LPRD and GERD. MATERIALS AND METHODS: Synchronous esophageal and oropharyngeal Dx-pH monitoring, electronic gastroscopy, reflux symptom index (RSI) and gastroesophageal reflux questionnaire (Gerd-Q) were collected from 514 consecutive patients and comparative analysis was done. RESULTS: A total of 85 patients had positive Ryan score and 251 cases had positive DeMeester or acid exposure time percent (AET) ≥4.2%. Moreover, 61.2% (52/85) of all LPRD cases were pure LPRD without GERD. There was no statistical difference in the acid exposure to oropharynx between pure LPRD group and LPRD+GERD group (U test, P > 0.05). Furthermore, there were no statistical differences in the other esophageal reflux data between pure GERD without LPRD group and LPRD+GERD group (U test, P > 0.05) apart from the number of episodes, which was higher in the pure GERD group than in LPRD+GERD group (U test, P = 0.027). Additionally, 149 patients were diagnosed with reflux esophagitis by electronic gastroscopy. No significant difference in the acid exposure to oropharynx was seen between different grades of reflux esophagitis (U test, P > 0.05). Among the LPRD patients, 32 cases (37.6%) were negative for Gerd-Q, Dx-pH esophageal probe and gastroscopy. CONCLUSION: The results of synchronous esophageal and oropharyngeal Dx-pH monitoring demonstrated that LPRD and GERD could co-exist as separate medical conditions. Our data suggest that some LPRD are not accompanied by GERD, and that LPRD is not secondary to severe GERD.


Assuntos
Monitoramento do pH Esofágico/métodos , Refluxo Gastroesofágico/diagnóstico , Refluxo Laringofaríngeo/diagnóstico , Adulto , Comorbidade , Feminino , Refluxo Gastroesofágico/epidemiologia , Gastroscopia , Humanos , Refluxo Laringofaríngeo/epidemiologia , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
15.
Int J Pediatr Otorhinolaryngol ; 133: 109974, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32197186

RESUMO

OBJECTIVES: Describe acoustic and laryngeal findings in pediatric patients with subjective dysphonia attributed to laryngopharyngeal reflux (LPR). Determine the impact of LPR on perceived voice quality using the pediatric Voice Handicap Index (pVHI). Compare these findings with age-matched normative values as well as data on pediatric patients with dysphonia due to other etiologies. METHODS: Retrospective case series of pediatric patients (age 2-17 years) evaluated at a specialty pediatric voice clinic at a tertiary care children's hospital from January 1 2007 to December 31 2017 in whom LPR in whom LPR was deemed to be the most significant contributing factor for dysphonia based on physical examination and history. Patients with structural laryngeal abnormalities unrelated to LPR, such as raised lesions, stenosis, papillomatosis, or vocal fold immobility were excluded. RESULTS: 163 out of 1195 evaluable patients met inclusion criteria. Of these, 87% had pVHI and 83% had acoustic data available from their first appointment for analysis. Mean total pVHI score was 24 (range: 0-81). Perturbation measures were elevated in both females (jitter 1.38%, shimmer 4.16%) and males (jitter 2.01%, shimmer 5.62%). Laryngologic assessment revealed: vocal fold changes including erythema and/or pre-nodules in 72% of patients. Cobblestoning of any portion of the pharynx was present in 67% with hypopharyngeal cobblestoning the most common, present in 64% of patients. CONCLUSION: Pediatric patients with clinically diagnosed LPR have pVHI, jitter, and shimmer scores that are comparable to previously reported patients with raised lesions, scar and immobility, and values that are significantly higher than published normative data. Dysphonic children should be assessed for LPR and treated when indicated. LEVEL OF EVIDENCE: 4.


Assuntos
Disfonia/diagnóstico , Disfonia/etiologia , Refluxo Laringofaríngeo/complicações , Refluxo Laringofaríngeo/diagnóstico , Qualidade da Voz , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Refluxo Laringofaríngeo/fisiopatologia , Masculino , Estudos Retrospectivos , Autoimagem , Prega Vocal/patologia , Prega Vocal/fisiopatologia
16.
Ann Otol Rhinol Laryngol ; 129(8): 781-787, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32186395

RESUMO

OBJECTIVES: To identify whether combination therapy with mucolytics and proton pump inhibitors (PPIs) leads to faster and more effective symptomatic relief in patients with laryngopharyngeal reflux (LPR). METHODS: Patients diagnosed as LPR with a reflux symptom index (RSI) ≥ 13 and a reflux finding score (RFS) ≥ 7 were enrolled in this prospective study. Patients were randomly allocated to control (PPI only) or experimental (PPI + mucolytics) groups and changes in RSI and RFS values were assessed at 1- and 3-month follow-up. RESULTS: One hundred sixteen patients were randomly allocated into either the control group (n = 59) or the experimental group (n = 57). The RSI and RFS scores significantly decreased in both groups (all P < .001) after 1 month of treatment; however, there was no significant difference in RSI change between groups (P = .223). After 3 months of treatment, there remained no significant difference in RSI change between groups (P = .592). CONCLUSIONS: Combination therapy with mucolytics and PPI compared to PPI alone did not lead to faster or more effective symptomatic relief in LPR patients.


Assuntos
Expectorantes/uso terapêutico , Refluxo Laringofaríngeo/tratamento farmacológico , Inibidores da Bomba de Prótons/uso terapêutico , Feminino , Seguimentos , Humanos , Refluxo Laringofaríngeo/diagnóstico , Laringoscopia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
17.
Gastrointest Endosc Clin N Am ; 30(2): 361-376, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32146951

RESUMO

Laryngopharyngeal reflux and atypical manifestations of gastroesophageal reflux disease have a high economic and social burden in the United States. There is increasing research supporting the reflex theory and hypersensitivity syndrome underlying this disease pathophysiology. Novel diagnostic biomarkers have gained more traction in the search for a more reliable diagnostic tool, but further research is needed. Current standard-of-care treatment relies on proton pump inhibitor therapy. Antireflux surgery is usually not recommended. Neuromodulators and treatments targeting specific neuronal receptors are discussed. A diagnostic algorithm is proposed for the evaluation of laryngeal symptoms suspected to be related to extraesophageal reflux disease.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Refluxo Gastroesofágico/diagnóstico , Refluxo Laringofaríngeo/diagnóstico , Algoritmos , Diagnóstico Diferencial , Refluxo Gastroesofágico/tratamento farmacológico , Humanos , Refluxo Laringofaríngeo/tratamento farmacológico , Laringe/fisiopatologia , Neurotransmissores/uso terapêutico , Inibidores da Bomba de Prótons/uso terapêutico
18.
J Gastroenterol Hepatol ; 35(9): 1509-1514, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32003045

RESUMO

BACKGROUND AND AIM: Laryngopharyngeal reflux (LPR) is caused by the reflux of gastric contents beyond the esophagus into the larynx and pharynx. However, upper esophageal sphincter (UES) motility and proximal esophagus reflux parameters are poorly studied. This study aims to explore the characteristics of UES motility and reflux parameter among LPR patients. METHODS: Patients with laryngopharyngeal symptoms only (L), patients with laryngopharyngeal symptoms and typical esophageal symptoms (L + E), patients with typical esophageal symptoms only (E), and healthy controls (H) were retrospectively included. Physiological profiles were studied and compared among groups using both high-resolution manometry and pH-impedance monitoring, including UES basal pressure, residual pressure, relaxation duration time, recovery time, the time to nadir pressure, UES length, proximal contractile integral, and proximal mean nocturnal baseline impedance (MNBI). Patients' symptom outcomes were also analyzed. RESULTS: A total of 242 patients were included. Proximal MNBI was significantly lower in patients with both laryngopharyngeal and esophageal symptoms (17 cm above low esophageal sphincter [LES]: L vs L + E vs E vs H = 3689.7 vs 2500.0 vs 3073.0 vs 3996.0; 15 cm above LES: L vs L + E vs E vs H = 3155.9 vs 2553.4 vs 3198.9 vs 2985.2; P < 0.001). Patients responded to proton pump inhibitor treatment also had lower proximal MNBI than those who did not (17 cm above LES: 1834.0 vs 3500.0; 15 cm above LES: 1946.5 vs 3432.6; P < 0.001). CONCLUSION: Decreased proximal MNBI can not only identify LPR patients but also predict patients' symptom outcomes.


Assuntos
Monitoramento do pH Esofágico/métodos , Refluxo Laringofaríngeo/diagnóstico , Manometria/métodos , Resultados Negativos , Impedância Elétrica , Junção Esofagogástrica/fisiopatologia , Motilidade Gastrointestinal , Humanos , Refluxo Laringofaríngeo/fisiopatologia , Sensibilidade e Especificidade
19.
Artigo em Chinês | MEDLINE | ID: mdl-32086894

RESUMO

Objective:To investigate the prevalence and related risk factors of laryngopharyngeal reflux in otolaryngology. Method:During January 2019 to March 2019, the inpatients in otolaryngology were investigated by the questionnaire of reflux symptom index scale and the laryngopharyngeal reflux related risk factors were analyzed. Result:Among the 227 patients, 33 patients with suspected LPR contained 19 patients(20.7%) of 92 patients in the laryngopharyngeal group, 10 patients(16.1%) of 62 patients in the nasal group, and 4 patients(5.5%) of 73 patients in the ear group. LPR prevalence in the laryngopharyngeal group was statistically different from that in the ear group(P<0.05). Univariate logistic regression analysis showed that age, gender, smoking, drinking and BMI were risk factors of LPR(P<0.01). Multivariate logistic regression analysis indicated that BMI was an independent risk factor of LPR(P<0.01). Conclusion:LPR had a high prevalence rate in otolaryngology related diseases, and appropriate synergistic anti-LPR treatment could be carried out while treating otolaryngology related diseases.


Assuntos
Refluxo Laringofaríngeo/diagnóstico , Otolaringologia , Humanos , Prevalência , Fatores de Risco , Inquéritos e Questionários
20.
Artigo em Chinês | MEDLINE | ID: mdl-32086926

RESUMO

Objective:The aim of this study is to determine the accuracy of RSI and RFS in the diagnosis of hypopharyngeal reflux (LPR), the scores of RSI and RFS were compared in different age groups. To explore the RSI and RFS scoring thresholds for diagnosis of LPR in different age groups. Method:From January 2017 to March 2019, 258 patients with suspected LPR in our hospital outpatient clinic completed the RSI and RFS scales. According to their age, 258 patients with RSI>13 and RFS>7 were selected. They were divided into group A (18-<40 years, n=86), group B (40-<60 years, n=107) and group C (≥60 years, n=65). The diagnosis was confirmed by 24 h pH-metry. The diagnostic rate, RSI and RFS scores were compared among the three groups. ROC curve was used to analyze the optimal thresholds for the diagnosis of LPR by RSI and RFS scores. Result:Among the three groups, group C had the highest diagnostic rate(93.85%). There was no significant difference in RFS score among the three groups (P>0.05), RSI score was significantly different (P<0.05), RSI score of group A and group B was higher than that of group C (P<0.05). According to ROC analysis, the best RSI cutoffs for diagnosing LPR in group C was 11, and the area under the ROC curve was 0.866. Conclusion:The RSI score is a good criterion for the diagnosis of LPR. The diagnostic threshold of RSI in elderly patients is different from that in young patients. For elderly patients, the diagnostic threshold for the recommended RSI score is 11.


Assuntos
Fatores Etários , Refluxo Laringofaríngeo/diagnóstico , Adolescente , Adulto , Idoso , Humanos , Laringe/fisiopatologia , Pessoa de Meia-Idade , Faringe/fisiopatologia , Adulto Jovem
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