Dott. Domenico DI MARIA Specialista in ORL. Domenico DI MARIA M.D. Direttore del Corso di ORL...

Domenico DI MARIA M.D. www.domenicodimaria.it 27/02/16

ORL VI PIANO

Dott. Domenico DI MARIASpecialista in ORL

Dirigente Medico I Livello U.O.C di ORL A.O. “G: Rummo” - Benevento

Direttore: Dott. E. D’Avenia

PROGRAMMA PRELIMINARE

SEGRETERIA ORGANIZZATIVA

CapriMed srlVia Sella Orta, 3 - 80073 Capri (NA)

Tel. +39 081 8375841 - Fax +39 081 [email protected] - www.caprimed.com

COORDINAMENTO SCIENTIFICO

OSSERVATORIO NAZIONALE SULLA SALUTEDELL’INFANZIA E DELL’ADOLESCENZA

CAMPUS IN

SAPER FARE

OSSERVATORIO NAZIONALE SULLA SALUTEE DELL’ADOLESCENZA

14-17 APRILE 2016

CON IL PATROCINIO DI

•USA IL CERVELLO! •PASSO DOPO PASSO!







CAMPUS IN

SAPER FARE


14-17 APRILE 2016


ll Reflusso Gastro Esofageo: quanto di competenza otorino?

NIENTE!!!







CAMPUS IN

SAPER FARE


14-17 APRILE 2016


Un Otorino competente ed un Pediatra consapevole del

Reflusso Laringo-Faringeo!

COMPETENZA La letteratura sul tema concorda sulla definizione delle competenze come una combinazione di conoscenze, abilità ed attitudini appropriate ad un contesto.

Dott. Domenico DI MARIA M.D.Direttore del Corso di ORL Pediatrica 7-8-9 settembre 2016

Il reflusso• Il refusso gastroesofageo (RGE) consiste nel passaggio di

materiale gastrico nel lume esofageo e rappresenta un evento fisiologico comune sia nel bambino che nell’adulto. Senza sintomi, segni e complicanze non necessita di trattamento!

• Si configura invece un quadro di malattia da reflusso gastroesofageo (MRGE) quando il RGE è causa di segni, sintomi e complicanze esofagei (MRGE tipica) o extra-esofagei (MRGE atipica).

• Sintomi extraesofagei o atipici sono presenti in circa il 35% dei soggetti adulti con MRGE tipica, ma è importante ricordare che questi possono essere anche l’unica manifestazione della MRGE.


Considerazioni• Il percorso anatomico dei feti nati a termine, dei neonati e degli

infanti, ripercorre la scala evoluzionistica descritta

• Studi hanno ben documentato la posizione alta del laringe nella regione intranarinale/retro- palatale (Magripes U e Laitman JT 1987), ciò rende possibile la doppia via deglutitoria e respiratoria anche nel periodo post-natale e nella prima infanzia.

• La laringe rimane in posizione cervicale alta sino ad 1,5-2 anni di età (Sasaki et al. 1977), gli studi sono concordi con l’affermare che già a tre anni la laringe si trova in una posizione decisamente più bassa (C3-C6).

• Una via oro ed ipofaringea comune alle vie aeree e digestive predispone al reflusso!


LE BARRIERE CONTRO IL REFLUSSO

LES

PERISTALSI ESOFAGEA

UES

AUMENTO carboanidrasi

La carboanidrasi NON AUMENTA!

•Alcuni Autori ci dimostrano che la mucosa esofagea è in grado di resistere senza danno ai circa 50 episodi di reflusso fisiologici giornalieri, mentre quella faringo-laringea può subire un danno già dopo un singolo episodio (Posma et al. 2001).

•Pare oramai certo che per una restituito ad integrum del danno della mucosa laringo-faringea possa essere necessario un periodo di tempo fino a sei mesi (Belafsky et al. 2001)

MECCANISMO PROSSIMALE E DISTALE O DEL “RIFLESSO”• meccanismo prossimale: danno diretto da HCl e da pepsina in laringe • meccanismo distale: esposizione acida dell’esofago distale con rilascio di tachinine

(sostanza P e neurochinina A) - riflessi vago mediati - sintomi


Reflusso negli infanti

• difficoltà nell’alimentazione

• wheezing

• stridore laringeo

• tosse persistente

• apnea

• rigurgito

• episodi di crup


reflusso nei bambini(>3 anni i sintomi sono simili a quelli dell’adulto)

• tosse persistente

• disfonia

• stridore

• bolo orofaringeo

• asma

• apnea

• rigurgito

• infezioni bronco-polmonari ricorrenti


DIAGNOSI DI RLFIn quel 65% dei pazienti con sintomi tipici siamo fortunati!!!

In quel 35% dei pazienti SENZA sintomi tipici siamo SFIGATI?

The aim of this study was to determine the predictive value ofreflux symptom score and LPR disease index to diagnose LPR andGER in children with asthma by comparing the results of doubleprobe pH monitoring study. Secondly we aimed to determine thedifference between controlled and uncontrolled asthma in terms ofGER and LPR coexistence.

2. Subjects and methods

A total of 50 patients aged 7–17 years (23 girls, 27 boys) withmild to moderate persistent asthma, between December 2009 andDecember 2010 were randomly included in this study according tocontrolled and uncontrolled status at asthma outpatient clinic.Randomization was performed using a computer generatedrandomization list and 50 patients were selected out of 150patients with asthma. However, 4 patients did not enter the studybecause the procedure was invasive. Three of these 4 patients hadcontrolled asthma. Four other patients were selected by therandomization programme to replace the missing ones. The age,sex, height, weight, active and passive smoking, skin prick tests,pulmonary function test, treatments and asthma control status ofthe subjects were recorded. Asthma severity was used only as acriterion for patient selection and the patients with intermittentasthma were not included the study. However, the patients weredivided into two groups: those with controlled asthma or thosewith uncontrolled asthma. The diagnosis, severity and controlstatus of asthma were assessed according to the Global Initiativefor Asthma (GINA) guidelines. The assessment of asthma controlincluded the control of the clinical manifestations (symptoms,night waking, reliever use, activity limitation and lung function)over 4 weeks [12].

All patients completed the reflux symptom questionnaire [7]and were examined by the same allergist (MK). Pulmonaryfunction tests were performed. After these procedures werecompleted, flexible fiberoptic laryngoscopy was performed bysame ENT specialist (SA) and according to the images LPR diseaseindex was calculated [9]. Finally, 24 h double probe (pharyngealand distal esophageal) pH monitoring study (MMS, Ohmega,software 8.11 version, Holland) was performed. The ENT specialistand the gastroenterologists were blinded to the asthma controlstatus of the patients. Dual channel probe had two sensors formeasuring pH, separated on the two different probes (MMS,Holland). The probes are connected with common entry (Fig. 1).Calibration was performed before and after each examination atpH 7 and pH 1. The electrodes were introduced transnasally. Thepharyngeal probe was located above UES (within 1 cm of glottis)

and the esophageal probe was located above LES (3rd vertebralbody above diaphragm). After initial placement of the probe, alateral chest X-ray was obtained to document accurate positioning(Fig. 2).

During the 24 h examination the children were encouraged tolive a normal everyday life and eat normally. Parents wereinstructed to press a button on the monitor to indicate the after-feeding and sleeping periods. Abnormal symptoms and signs suchas coughing episodes, respiratory distress, and emesis were alsorecorded by the parents.

Subjects were studied for approximately 24 h. The GastrosoftProgramme was used to review the events recorded on theesophageal and pharyngeal probes.

The number of reflux episodes (pH < 4), the percentage of timethat pH is less than 4 (reflux index), the number of reflux of at least5 min in duration, the longest reflux episode, and the total time ofrecorded pH less than 4 were recorded. The reflux index wasobtained by dividing the total registered time during whichesophageal pH persisted below 4 by the total registered period (inminutes). The result was expressed as the percentage of timeelapsed with pH below 4.

Gastroesophageal reflux was defined as abnormal reflux index(>4%) and/or total number of reflux episodes (pH < 4) > 50 within24 h [13]. There is no data about abnormal reflux index forpharyngeal probe in children. Six reflux episodes and higher onpharyngeal probe was defined as LPR with reference to the adultstudies [14,15].

Atopy was defined as reaction to allergens on skin prick test[16]. Skin prick testing was performed for common inhalerallergens Dermatophagoides farinae, Dermatophagoides pteronyssi-nus, Aspergillus fumigatus, Alternaria alternata, ragweed, trees(Ulmus, Quercus, Populus, Platanus, Salix), certain grasses (poamix, C. dactylon, P. pratensis, D. glomerata, A. sativa, Festuca), cat, dogand cockroach and food allergens (egg, milk, hazelnut, peanut,wheat, cacao) (Laboratorie des Stallergenes, Fresnes Cedex, France)with a response considered positive if the wheal was at least 3 mmgreater than the negative control.

Fig. 1. The view of the dual channel probe with two sensors, separated on the twodifferent probes. Fig. 2. X-ray imaging of the pharyngeal probe (A) and esophageal probe (B).

M. Kilic et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 341–345342

The aim of this study was to determine the predictive value ofreflux symptom score and LPR disease index to diagnose LPR andGER in children with asthma by comparing the results of doubleprobe pH monitoring study. Secondly we aimed to determine thedifference between controlled and uncontrolled asthma in terms ofGER and LPR coexistence.

2. Subjects and methods

A total of 50 patients aged 7–17 years (23 girls, 27 boys) withmild to moderate persistent asthma, between December 2009 andDecember 2010 were randomly included in this study according tocontrolled and uncontrolled status at asthma outpatient clinic.Randomization was performed using a computer generatedrandomization list and 50 patients were selected out of 150patients with asthma. However, 4 patients did not enter the studybecause the procedure was invasive. Three of these 4 patients hadcontrolled asthma. Four other patients were selected by therandomization programme to replace the missing ones. The age,sex, height, weight, active and passive smoking, skin prick tests,pulmonary function test, treatments and asthma control status ofthe subjects were recorded. Asthma severity was used only as acriterion for patient selection and the patients with intermittentasthma were not included the study. However, the patients weredivided into two groups: those with controlled asthma or thosewith uncontrolled asthma. The diagnosis, severity and controlstatus of asthma were assessed according to the Global Initiativefor Asthma (GINA) guidelines. The assessment of asthma controlincluded the control of the clinical manifestations (symptoms,night waking, reliever use, activity limitation and lung function)over 4 weeks [12].

All patients completed the reflux symptom questionnaire [7]and were examined by the same allergist (MK). Pulmonaryfunction tests were performed. After these procedures werecompleted, flexible fiberoptic laryngoscopy was performed bysame ENT specialist (SA) and according to the images LPR diseaseindex was calculated [9]. Finally, 24 h double probe (pharyngealand distal esophageal) pH monitoring study (MMS, Ohmega,software 8.11 version, Holland) was performed. The ENT specialistand the gastroenterologists were blinded to the asthma controlstatus of the patients. Dual channel probe had two sensors formeasuring pH, separated on the two different probes (MMS,Holland). The probes are connected with common entry (Fig. 1).Calibration was performed before and after each examination atpH 7 and pH 1. The electrodes were introduced transnasally. Thepharyngeal probe was located above UES (within 1 cm of glottis)

and the esophageal probe was located above LES (3rd vertebralbody above diaphragm). After initial placement of the probe, alateral chest X-ray was obtained to document accurate positioning(Fig. 2).

During the 24 h examination the children were encouraged tolive a normal everyday life and eat normally. Parents wereinstructed to press a button on the monitor to indicate the after-feeding and sleeping periods. Abnormal symptoms and signs suchas coughing episodes, respiratory distress, and emesis were alsorecorded by the parents.

Subjects were studied for approximately 24 h. The GastrosoftProgramme was used to review the events recorded on theesophageal and pharyngeal probes.

The number of reflux episodes (pH < 4), the percentage of timethat pH is less than 4 (reflux index), the number of reflux of at least5 min in duration, the longest reflux episode, and the total time ofrecorded pH less than 4 were recorded. The reflux index wasobtained by dividing the total registered time during whichesophageal pH persisted below 4 by the total registered period (inminutes). The result was expressed as the percentage of timeelapsed with pH below 4.

Gastroesophageal reflux was defined as abnormal reflux index(>4%) and/or total number of reflux episodes (pH < 4) > 50 within24 h [13]. There is no data about abnormal reflux index forpharyngeal probe in children. Six reflux episodes and higher onpharyngeal probe was defined as LPR with reference to the adultstudies [14,15].

Atopy was defined as reaction to allergens on skin prick test[16]. Skin prick testing was performed for common inhalerallergens Dermatophagoides farinae, Dermatophagoides pteronyssi-nus, Aspergillus fumigatus, Alternaria alternata, ragweed, trees(Ulmus, Quercus, Populus, Platanus, Salix), certain grasses (poamix, C. dactylon, P. pratensis, D. glomerata, A. sativa, Festuca), cat, dogand cockroach and food allergens (egg, milk, hazelnut, peanut,wheat, cacao) (Laboratorie des Stallergenes, Fresnes Cedex, France)with a response considered positive if the wheal was at least 3 mmgreater than the negative control.

Fig. 1. The view of the dual channel probe with two sensors, separated on the twodifferent probes. Fig. 2. X-ray imaging of the pharyngeal probe (A) and esophageal probe (B).

M. Kilic et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 341–345342

PH-METRIA DUAL PROBE 24 ORE


REFLUSSO LARINGO-FARINGEO PEDIATRICO ED ORL

laringomalacia stenosi glottica

granulazioniTOSSEDISFONIA

BOLO

RINO-FARINGO-LARINGO-SCOPIA CON ENDOSCOPIO

A FIBRE OTTICHE FLESSIBILI


Laringomalacia• dispnea inspiratoria

• tosse

• soffocamento

• rigurgito

• immaturità del network cartilagineo laringeo - collasso inspiratorio

• compare nei primi mesi di vita - risoluzione tra i 15 e 20 mesi

• 65% dei pazienti affetti da laringomalacia soffrono di RFL

• l’areofagia durante l’alimentazione causa distensione gastrica tanto da stimolare un riflesso vagale seguito da reflusso e vomito postprandiale

• E’ NATO PRIMA L’UOVO O LA GALLINA???

• Il trattamento con anti-acidi riduce sensibilmente la sintomatologia


Stenosi Sottoglottica• dispnea inspiratoria sotto sforzo / a riposo

• Nel 1985 gli studi di Little e Koufman evidenziarono che la somministrazione di acido gastrico sulla mucosa sottoglottica contribuiva ad incrementare la stenosi laringea in tale sede.

• danno tissutale con successiva deposizione di collagene favorente la stenosi

• Circa i 2/3 dei pazienti con stenosi sottoglottica presentano segni e sintomi di reflusso

• Il trattamento con anti-acidi riduce sensibilmente la progressione di malattia


granulazione laringea /disfonia

• Pseudonoduli da edema del terzo POSTERIORE E GRANULAZIONI POSTERIORI delle cvv sono tipici del reflusso, rispetto al nodulo a livello della giunzione terzo anteriore/terzo medio


TOSSEDISFONIA

BOLO


ANAMNESI NEL BAMBINO CON TOSSE E SEGNI ATIPICI


DIAGNOSI NEL BAMBINO CON TOSSE E SEGNI ATIPICI


DIAGNOSI NEL BAMBINO AFFETTO DA RLFIn quel 35% dei pazienti SENZA sintomi tipici siamo SFIGATI se non utilizziamo correttamente la…….

LARINGOSCOPIA A FIBRE OTTICHE FLESSIBILI

• Ipertrofia della base lingua

• Obliterazione dei ventricoli laringei

•Ipertrofia della commessura posteriore

• Pseudosulcus

• Noduli/granulazioni del terzo posteriore delle CCVVVV


4 anni 35 anni


PSEUDOSULCUS


PSEUDOSULCUSEdema sottoglottico parallelo al margine libero delle corde vocali vere


Prendi e porta a casa!!!

• Ipertrofia della base lingua

• Obliterazione dei ventricoli laringei

• Ipertrofia della commessura posteriore ed aritenoidea

• Pseudosulcus

• Noduli/granulazioni del terzo posteriore delle CCVVVV

DIAGNOSI DI RLF


TERAPIA• Modificare la dieta (per quanto possibile in un bambino)

• RIDURRE L’INDICE DI MASSA CORPOREA!

• INTENSIFICARE IL MOVIMENTO E L’ATTIVITA’ LUDICO/SPORTIVA

• Farmaci anti-reflusso

• Procinetici di derivazione biologica (estratti di zenzero, etc)

• Inibitori di pompa protonica (FDA ha approvato solo l’omeprazolo ed il lansoprazolo, ma il più efficace è l’esomeprazolo)

• H2-antagonisti (seconda linea in somministrazione serale)

• ATTENZIONE!!! LA TERAPIA SARA’ EFFICACE IN TEMPI LUNGHI!


TERAPIA/RACCOMANDAZIONI

• Evitare un uso eccessivo degli IPP per prevenirne gli effetti collaterali come aumentato rischio di infezioni intestinali e extra-intestinali anche severe!


QUANDO LA TERAPIA NON FUNZIONA?

Oppure abbiamo ragionato coi paraocchi!

• 50-75% dei pazienti affetti da reflusso laringeo soffrono anche di asma!

• Spesso coesiste anche il “post nasal drip” • Pertanto la diagnosi e la terapia devono scaturire da un approccio multidisciplinare!

Non farsi trovare in ambulatorio!


TOPICS

• Il percorso diagnostico e la terapia medica e chirurgica in rinologia pediatrica

• Tonsillite, SBEGA e dintorni

• La malattia reumatica è ancora una realtà?

• Infezioni dell'orofaringe e del collo: gestione e terapia

• Minicorso in citologia nasale ed in rinomanometria computerizzata

• Otologia, audiologia, disturbi del comportamento e del linguaggio

• La padronanza delle basi statistiche in medicina: come interpretiamo i dati

• La ricerca su pubmed: come eseguirla al meglio

• La terapia termale, la tenda del sale

• Reflusso laringeo in età pediatrica

• Corso di otoscopia pneumatica, impedenzometria e di audiologia infantile

• Lo screening audiologico infantile

• Le malattie genetiche in ORL

• Novità in antibioticoterapia delle infezioni ORL

• Esercitazioni pratiche in otoendoscopia, rinofibroscopia e laringoscopia

• Nuovi device in terapia topica delle prime vie aeree

• OMA ed OME: inquadramento diagnostico e novità terapeutiche

• I Disturbi dell’apprendimento e del linguaggio in età pediatrica

347.5338307


ADESSO DISCUTIAMONE!

“Se due persone sono d'accordo su tutto, puoi star certo che è uno solo di loro che fa andare il cervello!”

LYNDON BAINES JOHNSON

Dott. Domenico DI MARIA Specialista in ORL. Domenico DI MARIA M.D. Direttore del Corso di ORL...

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