2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

ACTA OTO-LARYNGOLOGICA

Table 2. Comparison of microbial growth in the vallecula, pharynx, and larynx between the patient and control groups. Control vallecula Case vallecula Control pharynx Case pharynx

Control larynx

Case larynx

n (%)

n (%)

p

n (%)

n (%)

p

n (%)

n (%)

p

5 0.001 12/27 (44.4%) 5 0.001 0/27 (0%)

5 0.001 13/27 (48.1%) 5 0.001 0/27 (0%)

5 0.001 5 0.001

CNS VGS

11/27 (40.7%)

35/39 (89.7%) 27/39 (69.2%) 1/39 (2.6%) 8/39 (20.5%)

34/39 (87.2%) 27/39 (69.2%) 2/39 (5.1%) 7/39 (17.9%)

35/39 (89.7%) 27/39 (69.2%) 1/39 (2.6%) 7/39 (17.9%) 1/39 (2.6%) 2/39 (5.1%)

0/27 (0%) 0/27 (0%) 0/27 (0%)

Klep. C.alb

0.402 0/27 (0%) 0.012 0/27 (0%)

0.232 0/27 (0%) 0.020 0/27 (0%)

0.402 0.020

5 0.001 18/27 (66.7%)

5 0.001 19/27 (70.4%)

5 0.001

N-VAHS

17/27 (63.0%)

0/39 (0%) 3/39 (7.7%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 1/39 (2.6%)

0/39 (0%) 3/39 (7.7%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 0/39 (0%) 0/39 (0%)

E.coli

1/27 (3.7%)

0.504 0/27 (0%)

0.140 0/27 (0%)

0.232

5 0.001 13/27 (48.1%) 5 0.001 9/27 (33.3%)

5 0.001 13/27 (48.1%) 5 0.001 8/27 (29.6%) 0.226 0/27 (0%) N/A 0/27 (0%) N/A 1/27 (3.7%) N/A 0/27 (0%)

5 0.001 5 0.001

Neisseria spp Basilus spp Lactobasillus Asidovorans Enterokok spp

14/27 (51.9%) 10/27 (37.0%)

0/39 (0%) 0/39 (0%) 0/39 (0%) 1/39 (2.6%) 0/39 (0%) 0/39 (0%)

0/27 (0%) 0/27 (0%) 0/27 (0%) 0/27 (0%)

N/A 1/27 (3.7%) N/A 0/27 (0%) N/A 0/27 (0%)

N/A

0.402 0.226

Parapsilosis

0.402 0/27 (0%)

N/A

N/A, Not eligible for statistical evaluation. CNS: Coagulase-negative staphylococci; VGS: Streptococcus viridians; Klep: Klebsiella spp; C.alb: Candida albicans ; N-VAHS: Non-viridans alpha-hemolytic streptococcus; E.coli: Escherichia coli .

interaction of the local immune system of the airway tract [ 7 , 8 ]. These changes lead to colonization by opportunistic micro-organisms at times or host microflora changes. Non- viridans alpha-hemolytic streptococci are considered the normal flora of the oropharynx [ 9 ]. In our study, non-viridans alpha- hemolytic streptococci were detected to be significantly higher in the control group in all three anatomic localizations compared with the patient group. This may be related to the change in the microflora due to ICS usage in the patient group. These changes in microflora may cause colonization of opportunistic micro-organisms. Long-term inhaled steroid usage is emphasized to cause microflora changes in the oropharynx in many studies [ 8 , 10 ]. In our study, coagulase- negative staphylococci (CNS), Streptococcus viridians (VGS), and candida albicans were detected to grow significantly more in the patient group in the pharynx, vallecular, and larynx compared with the control group. In addition to the studies mentioned above, it was detected that, in our study CNS and VGS identified as opportunistic pathogens and candida albicans proliferation was observed in the larynx, that is, accepted as sterile under normal conditions [ 11–13 ]. Although well-known, candida development in the oral cavity and oropharynx in cases of inhaled steroid usage [ 7 , 8 ] studies about the larynx usually remained at the level of laryngoscopic sign and symptom evaluation [ 14 , 15 ]. Studies about microflora changes in the larynx are limited [ 14 , 16 ]. These studies were also limited to candida detection as a micro-organism in the larynx. In our study, CNS and VGS were also shown to be able to colonize in the larynx in addition to candida, that is, opportunistic pathogens. The statistically significantly higher growth rate of CNS, VGS, and Candida Table 3. Comparison of microbial growth in different anatomic localizations in the patient group. Vallecula Pharynx Larynx ( n ¼ 39) n (%) n (%) n (%) p CNS 35/39 (89.7%) 34/39 (87.2%) 35/39 (89.7%) 0.917 VGS 27/39 (69.2%) 27/39 (69.2%) 27/39 (69.2%) 1.000 Klep. 1/39 (2.6%) 2/39 (5.1%) 1/39 (2.6%) 0.772 C.alb 8/39 (20.5%) 7/39 (17.9%) 7/39 (17.9%) 0.946 N-VAHS 0/39 (0%) 0/39 (0%) 1/39 (2.6%) 0.365 E.coli 3/39 (7.7%) 3/39 (7.7%) 2/39 (5.1%) 0.874 CNS: Coagulase-negative staphylococci; VGS: Streptococcus viridians; Klep: Klebsiella spp; C.alb: Candida albicans ; N-VAHS: Non-viridans alpha-hemolytic streptococcus; E.coli: Escherichia coli .

albicans in all three anatomic localizations of the cases in the patient group compared with the control group indicates that steroid inhaler usage may change in the microflora. CNS is accepted as a nosocomial pathogen, particularly related to infections in immunocompromised patients [ 12 ]. Ohlin et al. [ 17 ] show that the infants had at least one sepsis episode and coagulase-negative staphylococci was the most common pathogen. Balletto et al. [ 18 ] determined that CNS and Enterobacteriaceae are the most frequent pathogens in Hematopoietic Stem Cell Transplant patients. Similarly, VGS is generally considered to be low pathogenic potential in immunocompetent individuals. However, in certain patient populations, VGS can cause invasive disease, such as endo- carditis, intra-abdominal infection, and shock [ 13 ]. In our study it is determined that the statistically significantly more growth of VGS and CNS in all three anatomic localizations of the cases in the patient group compared with the control group. Despite no systemic immune deficiency in patient group, proliferation of these micro-organisms could indicate that immunity is weakened due to anti-inflammatory effect of ICS locally in the upper airway tract. These bacteria which are evaluated as opportunistic pathogens were shown to be significantly increased compared with the healthy group and it is thought that in cases of systemic immune system depression by various effectors it could cause serious threat for the airway tract. Oropharyngeal candida development due to ICS administration is known [ 7 , 8 ]. In addition, Xu et al. [ 19 ] found that Streptococcus oralis colonization of the oral and gastrointestinal tract was aug- mented in the presence of C. albicans , S. oralis , and C. albicans co-infection significantly augmented the frequency and size of oral thrush lesions by using a novel murine oral mucosal co- infection. Importantly, S. oralis promoted deep organ dissem- ination of C. albicans [ 19 ]. High proliferation rates of CNS and VGS in the oropharynx in the study group might have provided suitable conditions for candida development. In addition to these micro-organisms, candida proliferation was also detected to be higher in the larynx in the study group compared with the control group. As mentioned in the study performed by Xu et al. [ 19 ], these micro-organisms could increase the pathogenicity of candida infection by synergistic effect.

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