Tesis

Perbandingan Nilai Heart Rate Variability Sebagai Surrogate Marker Disfungsi Saraf Otonom Pada Penderita Refluks Laringofaring Dibandingkan Populasi Non Refluks. Kajian Terhadap Temuan Pulse Photoplethysmography, Risiko Terjadinya Sleep Disordered Breathing, dan Kejadian Ansietas Depresi = Comparison of Heart Rate Variability As Surrogate Marker of Autonomic Nerve Dysfunction in Patient with Laryngopharyngeal Reflux Compare to NonReflux Population. The Study of Pulse Photoplethysmography Finding, Risk of Having Sleep Disordered Breathing, and Its Inclination Towards Anxiety and Depression.

Pendahuluan: Patogenesis refluks laringofaring (RLF) belum dapat dijelaskan sepenuhnya secara konklusif, mekanisme yang diusulkan saat ini terkait relaksasi transien dari sfingter esofagus atas yang diregulasi oleh saraf otonom vagus. Perubahan aktivitas saraf vagus yang disebabkan oleh regulasi otonom yang terganggu terbukti bertanggung jawab atas kegagalan fungsi sfingter esofagus bawah pada Penyakit Refluks Gastroesofagus (PRGE). Masih belum jelas peranan disfungsi saraf otonom dalam patogenesis RLF. Kaitan RLF dengan disfungsi saraf otonom juga diduga berhubungan dengan entitas lain, seperti status ansietas depresi dan kejadian sleep disordered breathing. Perlu elaborasi lebih lanjut antara keempat entitas ini: RLF, disfungsi saraf otonom, SDB, dan ansietas depresi. Tujuan: Penelitian ini dilakukan untuk mengetahui proporsi kejadian dan karakteristik disfungsi saraf otonom berdasarkan temuan Heart Rate Variability (HRV) pada penderita RLF dan kelompok non refluks. Faktor-faktor risiko lainnya yang dapat berkontribusi terhadap kejadian RLF dan disfungsi saraf otonom, seperti risiko SDB dan status kecenderungan ansietas depresi, juga dinilai dalam penelitian ini. Metode: Penelitian dilakukan selama Periode Agustus 2021 hingga September 2021 di Poliklinik THT-KL dan Ruang Prosedur Terpadu Psikosomatik RSCM. Desain penelitian yang digunakan adalah potong lintang komparatif dengan 40 subjek kelompok RLF dan 33 subjek kelompok non-refluks. Pemeriksaan rinofaringolaringoskopi serat lentur, HRV dengan metode Pulse Photoplethysmography, penilaian risiko SDB (kuesioner ESS, PSQI, STOP-BANG) dan penilaian kecenderungan ansietas depresi (kuesioner HADS) dilakukan pada seluruh subjek, baik kelompok kasus maupun kontrol. Hasil: Proporsi kejadian disfungsi saraf otonom pada kelompok RLF mencapai 71,4 %. Terdapat perbedaan proporsi bermakna kejadian disfungsi saraf otonom penderita RLF dibandingkan kelompok non-refluks (p=0,001). Terdapat perbedaan bermakna pada 10 gejala dan temuan refluks penderita RLF dengan disfungsi saraf otonom dibandingkan kelompok non RLF tanpa disfungsi saraf otonom (p0,05). Gejala rasa mengganjal, temuan hipertrofi komisura posterior, adanya mukus kental endolaring, dan obliterasi ventrikel adalah gejala dan temuan yang paling bermakna setelah analisis multivariat. Terdapat perbedaan bermakna risiko terjadinya SDB dan gangguan tidur berdasarkan nilai ESS, PSQI, dan STOP-BANG penderita RLF dibandingkan kelompok non refluks (p0,05). Terdapat perbedaan bermakna status ansietas berdasarkan nilai HADS penderita RLF dibandingkan kelompok non refluks (p=0,001). Kesimpulan: Proporsi kejadian disfungsi saraf otonom pada kelompok RLF lebih tinggi dibanding kelompok non RLF, dengan karakteristik temuan HRV didominasi oleh adanya reduksi pada nilai SDNN dan rasio LF/HF serta berjenis parasimpatis dominan. Risiko SDB dan kejadian ansietas depresi berhubungan dengan kejadian RLF dan disfungsi saraf otonom.
Kata kunci: Disfungsi saraf otonom, heart rate variability, HRV, refluks laringofaring, sleep disordered breathing, SDB


Background: Pathogenesis of laryngopharyngeal reflux (LPR) has not been conclusively explained, with current mechanism proposed is transient relaxation of the upper esophageal sphincter regulated by the autonomic vagal nerve. Altered vagal nerve activity caused by impaired autonomic regulation was thought to be responsible for lower esophageal sphincter dysfunction in Gastroesophageal Reflux Disease (GERD). The role of autonomic nerve dysfunction in the pathogenesis of LPR still remains unclear. The association of LPR with autonomic nerve dysfunction is also thought to be associated to other clinical entities, such as anxiety-depression status and the incidence of sleep disordered breathing. Further elaboration between these four entities is required: LPR, autonomic nerve dysfunction, SDB, and anxiety-depression. Aim: This study was aimed to determine the proportion and characteristics of autonomic nerve dysfunction based on the findings of Heart Rate Variability (HRV) in patients with LPR and non-LPR group. Other risk factors that may contribute to the incidence of LPR and autonomic nerve dysfunction, such as the risk of SDB and anxiety-depression status, were also assessed. Methods: This study was conducted in August to September 2021 at ENT Outpatient Clinis and Psychosomatic Outpatient Procedure Room Dr. Cipto Mangunkusumo General Hospital. The design used in this study is a cross-sectional comparative study. Fourty patients were enrolled in the LPR group and 33 patients in the non-LPR group. Fiberoptic rhinopharyngolaryngoscopy examination, HRV with Pulse Photoplethysmography method, SDB risk assessment (ESS, PSQI, STOP-BANG questionnaire) and anxiety depression assessment (HADS questionnaire) were performed on both groups. Result: The difference in the proportion of autonomic nerve dysfunction between LPR group and the control group was significant (p=0.001), with the proportion of autonomic nerve dysfunction in the LPR group was 71.4%. Significant differences between LPR group with autonomic nerve dysfunction and the non-LPR group without autonomic nerve dysfunction was found in ten components of reflux symptoms index and finding score (p0,05). Sensation of globus, posterior commissure hypertrophy, thick endolaryngeal mucus, and ventricular obliteration were the most significant based on multivariate analysis. The difference in the risk of SDB and sleep disturbances based on the ESS, PSQI, and STOP-BANG was significant in LPR group compared to the non-reflux group (p0,05). The tendency of anxiety status based on the HADS value of LPR group was also significantly different compared to the control group (p=0,001). Conclusion: The proportion of autonomic nerve dysfunction in the LPR group was higher than the non-RLF group, with the HRV finding was dominated by a reduction in the SDNN value and the LF/HF ratio, with parasympathetic type dominant. The risk of SDB and the inclination towards anxiety depression are related to the incidence of LPR and autonomic nerve dysfunction.
Keywords: Autonomic nerve dysfunction, heart rate variability, HRV, laryngopharyngeal Reflux, LPR, sleep disordered breathing, SDB