ARTICLE IN PRESS JID: YDLD [m5G;June 15, 2020;14:33] Digestive and Liver Disease xxx (xxxx) xxx Contents lists available at ScienceDirect Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld Alimentary Tract Laryngeal signs and pH-multichannel intraluminal impedance in infants and children: The missing ring ✩,✩✩ LPR and MII-pH in children Cecilia Mantegazza a , Saverio Mallardo b , Martina Rossano c , Fabio Meneghin a , Michela Ricci a , Paolo Rossi b , Gianluca Capra d , Patrizia Latorre e , Antonio Schindler f , Sara Isoldi b , Massimo Agosti c , Gian Vincenzo Zuccotti a , Silvia Salvatore c,* a Pediatric Department, Ospedale Buzzi, Università di Milano, Italy b Gastroenterology and Hepatology Pediatric Department, Università La Sapienza, Roma; Italy c Pediatric Department, Ospedale “F. Del Ponte”, Università dell’Insubria, Varese, Italy d Pediatric Otolaryngology, Ospedale Buzzi, Milano, Italy e Otolaryngology, Varese, Italy f Pediatric Otolaryngology, Sacco Hospital, Milano, Italy a r t i c l e i n f o Article history: Received 6 December 2019 Accepted 1 May 2020 Available online xxx Keywords: Reflux finding score Reflux symptom index Ph-impedance Gastroesophageal reflux Proton pump inhibitors a b s t r a c t Objective: to investigate the reliability of laryngeal reflux finding score (RFS) and symptom index (RSI) in assessing gastroesophageal reflux (GER) in children and infants. Methods: patients with laryngeal or respiratory symptoms, who underwent laryngoscopy and esophageal pH-impedance (MII-pH) were recruited. RSI and RFS were correlated to MII-pH results. A RSI>13, RFS>7, acid exposure index>7%, total reflux episodes>100/24 h in infants or>70/24 h in children, or a positive symptom index or association probability, were considered pathological. Analysis considering age (</>12 months) was performed. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the laryngeal scores were calculated. Results: 197 children (median 53 months, 61 infants) were enrolled. MII-pH was pathological in 5/10 patients with RFS>7, and in 17/31 with RSI>13. RFS>7 had 3.9% sensitivity, 93% specificity, a PPV of 50 and a NPV of 34 in predicting GER disease. RFS was inversely associated to weakly acidic and proximal GER. RSI>13 had 13% sensitivity, 83% specificity, and a PPV and NPV similar to RFS. RSI was significantly associated with the number of acid reflux episodes, and, in infants, with bolus exposure index. Conclusions: RSI and RFS aren’t accurate in predicting GER in infants and children. Acid reflux relates to laryngeal symptoms, but neither acid, nor proximal and weakly acidic GER relate to laryngeal alterations. © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Abbreviations: AR, acid reflux; BEI, bolus exposure index; ENT, ear-nose-throat; GER, gastroesophageal reflux; GERD, ger-disease; LPR, laryngopharyngeal reflux; MII-PH, esophageal ph-impedance; PPI, proton pump inhibitors; RFS, reflux finding score; RI, reflux index, acid exposure percent time at MII-pH; RSI, reflux symptom index; SAP, symptom association probability; SI, symptom index; TNR, total number of reflux episodes; WAR, weakly acidic reflux. ✩ Level of evidence: not properly applicable as it is a non-interventional diagnos- tic evaluation study ✩✩ Financial Disclosure: No source of support. No honorarium or other form of payment was given for the collection of data or the writing of the paper * Corresponding author. E-mail address: silvia.salvatore@uninsubria.it (S. Salvatore). Introduction The reflux of gastric content into the esophagus (known as gas- troesophageal reflux or GER) and up to the larynx and/or oro-naso- pharynx, defined as laryngopharyngeal reflux (LPR) may cause res- piratory manifestations such as laryngitis, voice disorders, chronic cough and asthma [1,2]. However these symptoms are non specific and frequently due to other conditions such as infections and al- lergy or, more rarely, to anatomical abnormalities [3,4]. In adults, alterations of different laryngeal areas have been cor- related to LPR and GER-disease (GERD) [5]. A reflux finding score (RFS), based on laryngoscopy, and a reflux symptom index (RSI) are often used and guide therapeutic approach with proton pump inhibitors (PPI) in these patients [6,7,8]. In both adults and pe- diatric patients, the diagnosis of both LPR and GERD is challeng- https://doi.org/10.1016/j.dld.2020.05.001 1590-8658/© 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Please cite this article as: C. Mantegazza, S. Mallardo and M. Rossano et al., Laryngeal signs and pH-multichannel intraluminal impedance in infants and children: The missing ring, Digestive and Liver Disease, https://doi.org/10.1016/j.dld.2020.05.001