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Table of Contents
ORIGINAL ARTICLE
Year : 2010  |  Volume : 12  |  Issue : 1  |  Page : 14-17

Helicobacter pylori and its role in vocal folds minimal lesions


1 Otorhinolaryngology Head and Neck Surgery, Ain Shams University, KSA
2 Clinical Pathology Department, Ain Shams University, KSA

Date of Web Publication24-Dec-2019

Correspondence Address:
MD M Tiba
Consultant & Chief of ORL Department Magrabi Hospital - Aseer
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273967

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  Abstract 


Background: Chronic laryngitis and/or vocal fold minimal lesions (VFML) are a common association with gastro esophageal reflux disease (GERD). Helicobacter Pylori (HP) is a Gram negative spiral organism accused of being a common cause of gastritis, gastro-esophageal reflux disease and peptic ulcer. HP has been recently isolated from tonsils, adenoids, sinus and middle ear mucosa in patients with chronic sinusitis or chronic middle ear effusion.
Objective: To assess the presence of HP in (VFML).
Methods: The study included fourteen patients with vocal folds minimal lesions (6 cases with vocal fold polyps and 4 cases with vocal fold nodules, and 4 cases with posteri-or granulomas; one of them associated with right VF nodule); all underwent Carbon 13 urea breath test (UBT), esophago-gastro-duodenoscopy (OGD) with gastric biopsy and direct laryngoscopy with microlaryngosurgery (MLS) to extract the VF lesions. Biopsies were subjected for two tests; detection of the 23S ribosomal RNA gene of HP by real-time polymerase chain reaction (RT-PCR) and Immunohistochemical reactions (IHC).
Results: HP was detected by (RT-PCR) in ten of fourteen patients with VFML, HP was also detected by IHC in the same number of VFML and gastric mucosa specimens.
Conclusion: HP is a common finding in cases of VFML; its eradication should be considered when dealing with a patient with VFML.

Keywords: helicobacter pylori, vocal folds, GERD, vocal folds minima lesion


How to cite this article:
Tiba M, Osman H. Helicobacter pylori and its role in vocal folds minimal lesions. Saudi J Otorhinolaryngol Head Neck Surg 2010;12:14-7

How to cite this URL:
Tiba M, Osman H. Helicobacter pylori and its role in vocal folds minimal lesions. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2010 [cited 2022 Dec 2];12:14-7. Available from: https://www.sjohns.org/text.asp?2010/12/1/14/273967




  Introduction Top


Over the last three decades, many reports have implicated refluxed gastric acid as a cause of, or as a contributory factor in, development of chronic laryngeal and pharyngeal disorders[1]. Although this putative cause-effect relationship has been strengthened by more recent evidence, the body of evidence on causation, diagnosis, and treatment of these increasingly diagnosed disorders is still evolving [1],[2]. A variety of symptoms, functional and structural abnormalities involving the larynx, and other contiguous structures positioned proximal to the esophagus constitute the spectrum of these disorders. Various terms such as supraesophageal gastroe-sophageal reflux disease (GERD), atypical GERD, laryngopharyngeal reflux (LPR), and extraesophageal complications of GERD have been used to describe this group of symptoms and signs [3]. Helicobacter pylori is a microaerophilic, Gram negative spiral organism that can be found in colonies in dental plaque, saliva, tonsils, and adenoids [4]. It was suggested that tonsil and adenoid tissues might act as a reservoir for H.Pylori [5],[6]. H.Pylori was also detected in sinus mucosa of patients with chronic sinusitis [4], which indicates a possible role in the pathogenesis of chronic sinusitis, and other chronic aerodigestive inflammations [7] and chronic middle ear effusion [8]. Many authors discussed its role in chronic laryngitis but very few discussed its role in vocal fold polyps, nodules or granulomas.


  Objective Top


The objective of our study was to study the role of H.Pylori infection as an etiology in the pathogenesis of minimal laryngeal lesions such as vocal folds polyps, nodules and granulomas.


  Patients and Methods Top


After the present study was approved by the Ethics and Scientific Research Committee, all patients gave informed consent before enrollment in the study. The study was performed in Saudi German Hospital-Riyadh and Ain shams university hospitals- Cairo, from November 2006 to December 2007. Fourteen patients suffering from chronic hoarseness were subjected to telescopic laryngeal examination to detect any VF lesion. Patients with polyps, granulomas or nodules were enrolled in the study. All patients underwent Carbon 13 urea breath test (UBT) based on the detection of the products created when urea is split by the organism. Patients were asked to drink urea (usually with a beverage) labeled with a carbon isotope (carbon 13 or carbon 14). After 30 minutes, the concentration of the labeled carbon was measured in the breath. The concentration is high only when urease is present in the stomach.

Upper Oesophago-gastro-duodenoscopy was done to all patients under sedation and topical anesthesia with extraction of gastric biopsy for immunohistochemistry. Direct laryngoscopy with microlaryngoscopy was done under general anesthesia and the vocal fold lesions were excised. The biopsy was divided into two pieces for two different procedures. The first was placed immediately into Tris—EDTA buffer, immediately frozen and stored at -20C°. DNA extraction was done using the Invisorb Spin Tissue Mini Kits (Invitek, Berlin, Germany), to be stored at -20C° until polymerase chain reaction (PCR) amplification. The supernatant was used for the amplification of a highly conserved region of the 23S ribosomal RNA (rRNA) gene of H. pylori. The real-time PCR Amplification (RT-PCR) for the gene encoding the 23S ribosomal RNA of H.Pylori was performed in an automatized system (ABI PRISM 7700 SDS) (Applied Biosystems, USA) with TaqMan Mix (Applied Biosystems, USA). The curves were evaluated after 40 cycles in this system. The sequences of oligonucleotide primers and TaqMan probe were as follows: Forward primer, 5 CCT ACC CGC GGC AAG ACG 3 ; Reverse primer, 5 TAC TTC AAA GCC TCC CAC CTA TCC 3 ; TaqMan probe, 5 FAM ACC CCG TGG ACC TTT ACT ACAACT TAG CAC T TAMRA 3 [8].The second half of the specimen was fixed in 10% formalin and embedded in paraffin. Then, 3-μm thick sections were cut and mounted. Immunohistochemical staining was performed by an automated system (Ventana NX system using a Ventana diaminobenzidine [DAB] kit). The primary antibody was the purified immunoglobulin fraction of rabbit antiserum for HP (Dako B471 [1:100], Dako Immunoglobulins, Copenhagen, Denmark). Staining was performed with biotinylated goat anti-rabbit immunoglobulin, followed by peroxidase-conjugated streptavidin. Color was revealed by incubation with DAB solution, followed by washing and counterstaining with hematoxylin. When immunoreactive structures were observed on the surface of the epithelium, or in the tissue of nodules, polyps or the granulomas, immunoreactivity was defined as being positive. The average number of round and long, thin immunoreactive structures per field (original magnification_400) was calculated, and the grades of immunore- activity were expressed as follows: -, negative; +, 1–9; ++,10-99; and +++,>100. The average number of organisms seen in the immunostained or H&E-stained sections of the gastric biopsy specimens was calculated and graded as mentioned above. In every run, control sections were incubated with omission of the primary antibody or with purified immunoglobulin from normal rabbit serum (Dako Immunoglobulins). Sections stained with H&E were also made and were compared with the immunostained sections [8].


  Results Top


The current study included 14 patients suffering from vocal fold minimal lesions, 10 males and 4 females. Six cases had vocal fold polyps, 4 cases had vocal fold nodules, and 4 cases had posterior granulomas; one of them associated with right vocal fold nodule. The mean age of the patients was 38.5 (age range 25-52 years). UBT was +ve in 8cases (57%), -ve in 6cases (42.8%), the 23S ribosomal RNA (rRNA) gene of HP was detected by (RT-PCR) in 10 cases (71.4%) and was found -ve in 4 cases (28.5%).

Immunostained sections revealed immunoreactive structures on the surface epithelium of 10 (71.4%) of the14 vocal fold lesions. HP was observed in the gastric mucosa of 4 patients by Immunohistochemical and H&E staining and they were partially degraded. In addition, Spiral-shaped bacteria were also seen on the gastric surface in H&E-stained sections of another 2 patient’s .Clusters of round and long, thin immunoreac- tive structures seen in the vocal folds lesions closely resembled the partially degraded organisms in the gastric specimens. The grades of immunoreactive structures in the vocal fold specimens were lower than those shown by Immunohistochemical or H&E staining in the gastric specimens.


  Discussion Top


GERD is the most common esophageal disease, and laryngeal symptoms are significantly more frequent in patients with GERD—up to 50% of patients with laryngeal complaints such as chronic cough, sore throat or hoarseness, have a gastroesophageal-related underlying cause [9]. Koufman defined GERD as the primary cause in 62% of otolaryngological patients with laryngeal and voice disorders [10]. Helicobacter pylori (H. pylori) is one of the frequently encountered microorganisms in the aerodigestive tract. Although infections caused by H. pylori are common, the exact mode of transmission has not been fully understood yet. Oral–oral, fecal–oral and gastrointestinal–oral routes are the possible modes of transmission. This infection is usually acquired in childhood and may persist for the whole life of the patient. However, about 80% of the infected humans are asymptomatic [9]. H.Pylori organism can be found in colonies in dental plaque, saliva, tonsils, and adenoids [4]. It has been investigated in several other organ systems, but has not been investigated to any major degree in laryngeal disorders, a region that could be directly exposed to the bacterium from pharyngolaryngeal reflux [11]. Borkowski and others (1997) detected H.Pylori bacterium in 17.1% of patients with chronic hoarseness. Six (17.1%) of our case revealed a positive urease test [12]. Jaspersen and others (1998) reported that 36.8% of patients with chronic laryngitis were H. pylori positive [13]. In correspondence to those authors, we found that 57% of our cases with various benign laryngeal lesions were positive for urea breath test (UBT), that is based on the detection of the products created when urea is split by the organism, By detection of the concentration of labeled carbon, as it is high only when urease is present in the stomach. And because the human stomach does not produce urease, such reaction is possible only with H.Pylori infection. In addition, we verified our results for presence of helicobacter pylori in the vocal fold lesions by the real-time PCR Amplification (RT-PCR) for the gene encoding the 23S ribosomal RNA of H.Pylori, as we found that it is positive in 71% of our cases.

In the current study, Immunostained sections revealed immunoreactive structures on the surface epithelium of the various benign vocal fold lesions (nodules, polyps, and granulomas) in 71.4%. While immunohistochemical and H&E staining of gastric mucosa revealed that H.Pylori was observed in the gastric mucosa only in 28.5% and they were partially degraded. In addition, Spiral-shaped bacteria were also seen on the gastric surface in H&E-stained sections in another14%.

Collectively, the clusters of round and long, thin immunoreactive structures seen in the vocal folds lesions closely resembled the partially degraded organisms in the gastric specimens. While the grades of immunoreactive structures in the vocal fold specimens were lower than those shown by Immunohistochemical or H&E staining in the gastric specimens. The authors suggested that chronic laryngitis is associated with the underlying acid reflux not with H. pylori infection [13]. Interestingly, Issing (2003) suggests that H. pylori-infection may have a protective effect in the development of GERD [14]. However, the mechanism underlying the suggested association between H. pylori infection and laryngeal symptoms remains unclear.


  Conclusion Top


According to our results, we can conclude that H.Pylori infection has a role in the etiology and hence pathogenesis of various minimal benign laryngeal lesions; such as nodules, polyps, and granulomas in certain patients and can be important for clinical diagnosis and hence treatment. Future studies should be planned concerning controlled clinical trials using antireflux and H. pylori eradication therapy for the treatment of laryngitis.
Table 1: Clinical data of the patients and their results

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  References Top

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Curran AJ, Barry MK, Callanan V, et al: A prospective study of acid reflux and globus pharyngeus using a modified symptom index. Clin Otolaryngol. 1995; 20 (6): 552-4.  Back to cited text no. 1
    
2.
El-Serag HB, Sonnenberg A: Comorbid occurrence of laryngeal or pulmonary disease with esophagitis in United States military veterans. Gastroenterol. 1997 ; 113 (3): 755-60.  Back to cited text no. 2
    
3.
Farkkila MA, Ertama L, Katila H, et al: Globus pharyngis, commonly associated with esophageal motility disorders. Am J Gastroenterol. 2001; 89 (4): 503-8.  Back to cited text no. 3
    
4.
J.H. Van de Bovenkamp, J. Mahdavi, A.M. Korteland-Van Male, H.A. Buller, A.W. Einerhand, T. Boren, J. Dekker, The MUC5AC glycoprotein is the primary receptor for Helicobacter pylori in the human stomach, Helicobacter. 2003, 521-532.  Back to cited text no. 4
    
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C. Birek, R. Grandhi, K. McNeill, D. Singer, G. Ficarra, G. Bowden, Detection of Helicobacter pylori in oral aphthous ulcers, J Oral Pathol Med. 1999; 28: 197-203.  Back to cited text no. 5
    
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Yellon RF, Coticchia J, Dixit S. Esophageal biopsy for the diagnosis of gastroesophageal reflux-associated otolaryn- gologic problems in children. Am J Med. 2000; 108:131S-138S.  Back to cited text no. 6
    
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Setsuko Morinaka, Masato Ichimiya, Hiroyuki Nakamura: Detection of Helicobacter pylori in Nasal and Maxillary Sinus Specimens From Patients With Chronic Sinusitis. Laryngoscope 2003;113:1557–1563.  Back to cited text no. 7
    
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Mustafa Deniz Y?lmaz, Orhan Aktepe, Yeliz C^etinkol and Ali Altuntas: Does Helicobacter pylori have role in development of otitis media with effusion? Internat Pediatr Otorhinolaryngol. 2005;69:745 -749.  Back to cited text no. 8
    
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Kurtaran H, Erkmen Uyar M, Kasapoglu B, Turkay C, Yilmaz T, Akcay A, and Kanbay M. Role of Helicobacter Pylori in Pathogenesis of Upper Respiratory System Diseases. J Nat Med Ass. 2008; 100: 1224- 1230.  Back to cited text no. 9
    
10.
Koufman JA. The otolaryngologic manifestation of gastroesophageal reflux disease. Laryngoscope. 1991; 101:1-78.  Back to cited text no. 10
    
11.
Rubin J, Benjamin E, Prior A, Lavy J, and Ratcliffe P . The Prevalence of Helicobacter Pylori Infection in Benign Laryngeal Disorders  Back to cited text no. 11
    



 
 
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Abstract
Introduction
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Patients and Methods
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