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Correlation between chronic rhinosinusitis and laryngopharyngeal reflux.

INTRODUCTION

Chronic rhinosinusitis (CRS) is a major problem affecting 5-15% of world population. [1] It is defined as inflammation of sinonasal mucosa lasting for more than 12 weeks. [2] It leads to impaired quality of life, emotional and functional impairment and high socioeconomic burden. [3] The present treatment for CRS is intranasal steroids (INS). [4] Those patients who fail to respond to medical treatment are diagnosed as refractory CRS. Functional endoscopic sinus surgery (FESS) is said to be the treatment of choice for refractory CRS. [5] However, some patients fail to respond to FESS, and the reflux disease is said to be an important cause for the same. [6] Other causes mentioned are poor surgical technique, allergy and smoking. [7]

Laryngopharyngeal reflux (LPR) is defined as reflux of stomach and esophageal contents into larynx and pharynx. [8,9] Proton pump inhibitors (PPI) are the mainstay of treatment of LPR. [10] There are some studies available regarding relationships between CRS and reflux disease in children. [11] However, there are very few studies regarding this relationship in adults. According to a study, in LPR the nasal and nasopharyngeal mucosa are exposed to gastric acid leading to inflammation of mucosa and impaired mucociliary clearance which leads to obstruction of sinus ostia and recurrent infections. [12] This leads to nasal congestion, excessive nasal secretions and post-nasal discharge (PND). [13]

Hence, this study was planned to study the incidence of LPR in patients of refractory CRS. This study also aims to study the impact of PPI (effective treatment of LPR) given as adjuvant therapy along with FESS in patients with refractory CRS.

MATERIALS AND METHODS

This randomized case--control study was conducted in the Department of Ear, Nose and Throat of our Medical College and Hospital from January 2017 to August 2017 and the patients were followed up for 3 months. The Approval of Institutional Ethics Committee was taken. Patients aged above 18 years with signs and symptoms of CRS who gave consent for the study were included in the study. These were confirmed by Diagnostic Nasal Endoscopy (DNE) and computed tomography scan paranasal sinuses (PNS) coronal plane if needed.

Only patients with refractory CRS who did not respond to medical management were included in this study. Patients with a history of allergic rhinitis, those with deviated nasal septum, those on anti-reflux drugs such as PPI or H2 receptor antagonists or with history of smoking were excluded from the study. Patients who were found unfit for surgery and general anesthesia (GA) were also excluded from the study. 40 patients were taken up for study.

All these 40 patients included in the study were evaluated for symptoms of LPR such as foreign body sensation in throat, change in voice, chronic cough, sore throat, and difficulty in swallowing. These patients also underwent throat examination and diagnostic laryngoscopy for signs of LPR such as laryngeal congestion and posterior pharyngeal wall congestion. The findings were noted.

A total of 40 patients included in this study were randomly divided into two equal groups of 20 each called study and control group. All these patients in both groups were evaluated at the initial visit for symptoms of CRS such as nasal obstruction, nasal discharge, headache, facial pain, loss of smell, and PND. All these patients underwent DNE for evaluation of signs such as nasal polyps, mucopurulent discharge, and mucosal edema.

All these patients with refractory CRS in both groups underwent FESS under GA. Post-surgery the patients in both groups were put on INS fluticasone propionate 50 mcg 2 sprays in each nostril once daily in the morning. The patients in the study group were also put on oral PPI tablet pantoprazole 40 mg once daily 1 h before breakfast whereas PPI was not given to the control group. The patients in both groups were followed up after 1 month, 2 months, and 3 months post-surgery.

The evaluation points were

1. Age and sex distribution of patients with CRS.

2. Incidence of LPR among patients with CRS.

3. Major signs and symptoms of patients with CRS.

4. Improvement of signs and symptoms of patients with CRS post-surgery in the study group as compared to control group at each visit.

5. Patient comfort level was assessed in both groups according to LIKERT Scale as 1 - very comfortable, 2 - comfortable, 3 - no change, and 4 - uncomfortable at each visit.

6. Effectiveness of PPI in CRS was evaluated.

RESULTS

Most of the patients were of middle age group (>50%). There was no major difference in the incidence of CRS among males and females [Table 1].

Around 18 patients of the total patients with CRS (45%) had symptoms of LPR. The major symptom seen was foreign body sensation in throat seen in 15 patients and change in voice in 7 patients. On examination of the throat and diagnostic laryngoscopy, 12 of these 18 patients had congestion or edema of larynx or posterior pharyngeal wall. The most common finding was seen in posterior part of larynx - arytenoids and inter arytenoid region and posterior part of vocal cords [Table 2].

The most common symptom of patients of CRS in both groups was nasal obstruction (88%) followed by nasal discharge in 68% of patients. Among the findings on examination and DNE, mucosal edema, and mucopurulent discharge mainly in middle meatus were seen in 78% of patients. Nasal polyps were found in 7 patients (35%) in the study group and 8 patients (40%) in control group [Table 3].

Regarding the improvement of signs and symptoms post-treatment in both groups, there was almost equal reduction of symptoms in both groups at 1st visit after 1 month. However, more improvement was seen in the symptoms of nasal obstruction, nasal discharge, PND and signs of mucopurulent discharge and mucosal edema in a study group where PPI were given as compared to control group without PPI at the end of 2nd month post-treatment (2nd post-treatment visit). This difference was more marked at the end of 3rd post-treatment visit [Tables 4 and 5].

Regarding the comfort level and relief among patients in both groups, more patients had relief or felt comfortable at the end of 3rd visit in the study group (80%) where PPI were added to treatment as compared to control group (60%) without PPI. 30% of patients had no improvement in the control group as compared to only 10% in study group [Tables 6 and 7].

The odds ratio for the significance of PPI in the treatment of CRS was calculated regarding the relief among patients in study group where PPI were given as compared to control group without PPI, and it was found to be around 2.6 which was statistically significant.

DISCUSSION

There were more incidences of CRS among middle age group in our study. There was no major difference between males and females in our study [Table 1]. Other studies have shown equal incidence among sexes and age groups. [14] 45% of patients with refractory CRS had symptoms of LPR in our study. Ozmen et al. had also shown the relationship between CRS and LPR. [15] DiBaise et al. showed a higher number 81.8% of patients with CRS had reflux disease [16] and Phipps et al. had reported 63% of patients with CRS had reflux. [17] Foreign body sensation in throat was the most common symptom, and posterior laryngeal congestion was the most common sign in our study [Table 2]. Ulualp et al. also found signs of posterior laryngitis in patients with refractory CRS. [18]

Nasal obstruction and nasal discharge were the most common symptoms in our study. Nasal polyps were seen in 38% of patients of refractory CRS in our study [Table 3]. In our study, there was an almost equal reduction of symptoms in both groups at 1st visit after 1 month. However, more improvement was seen in the symptoms of nasal obstruction, nasal discharge, PND and signs of mucopurulent discharge and mucosal edema in study group where PPI were given as compared to control group without PPI at the end of 2nd month post-treatment (2nd post-treatment visit). This difference was more marked at the end of 3rd post-treatment visit [Tables 4 and 5]. Regarding the comfort level and relief among patients in both groups, more patients had relief or felt comfortable at the end of 3rd visit in study group (80%) where PPI were added to treatment as compared to control group (60%) without PPI [Tables 6 and 7]. The odds ratio regarding the relief of symptoms of the study group with PPI as compared to without was also statistically significant. This shows that PPI do have a role as an adjuvant therapy along with FESS in patients of refractory CRS.

Similar results were obtained by other studies by Phipps et al. who showed 80-90% patients had improvement with PPI. [17] Pincus et al. also reported 56% improvement of sinonasal symptoms with PPI. [19] DiBiase et al. reported the improvement most discreet after 3 months of treatment with PPI [16] which goes along with our study results. Vaezi et al. showed that patients receiving PPI (lansoprazole) had maximum improvement of PND. [20] Our study also showed greater improvement of PND in the study group as compared to control group. However, a study by Durmus et al. showed no improvement in symptoms of refractory CRS in patients with PPI. [21] Studies have shown that reflux leads to poor post FESS symptomatic outcomes. [6] In our study also we found that in patients of control group where PPI were not added to treatment, patients had much lesser improvement with FESS alone as treatment as compared to study group.

The limitation of our study was a shorter follow-up period for 3 months to study the impact of treatment. Longer follow-up studies for a year or more are needed. Second, studies with larger sample size as compared to our study are needed in the future.

CONCLUSION

There is a strong incidence of LPR symptoms and signs in patients with refractory CRS. The adjuvant therapy of PPI along with FESS gives greater relief of signs and symptoms of CRS mainly nasal obstruction, nasal discharge, and PND. PPI as an adjuvant therapy along with FESS leads to better relief and improvement among patients with refractory CRS. Further studies are needed to be done in this field with larger sample size and for a longer follow-up period.

ACKNOWLEDGMENTS

The authors would like to thank the Medical College and Hospital for its support and the patients for cooperating with the study. Special thanks to the Institutional Ethics Committee for supporting our study.

REFERENCES

[1.] Wong IW, Omari TI, Myers JC, Rees G, Nair SB, Jamieson GG, et al. Nasopharyngeal pH monitoring in chronic sinusitis patients using a novel four channel probe. Laryngoscope 2004;114:1582-5.

[2.] Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114:155-212.

[3.] Halawi AM, Smith SS, Chandra RK. Chronic rhinosinusitis: Epidemiology and cost. Allergy Asthma Proc 2013;34:328-34.

[4.] Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, BaroodyFM, et al. International consensus statement on allergy and rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016;6:S22-09.

[5.] Kennedy DW, Wright ED, Goldberg AN. Objective and subjective outcomes in surgery for chronic sinusitis. Laryngoscope 2000;110:29-31.

[6.] Chambers DW, Davis WE, Cook PR, Nishioka GJ, Rudman DT. Long-term outcome analysis of functional endoscopic sinus surgery: Correlation of symptoms with endoscopic examination findings and potential prognostic variables. Laryngoscope 1997;107:504-10.

[7.] Briggs RD, Wright ST, Cordes S, Calhoun KH. Smoking in chronic rhinosinusitis: A predictor of poor long-term outcome after endoscopic sinus surgery. Laryngoscope 2004;114:126-8.

[8.] Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: A global evidence-based consensus. Am J Gastroenterol 2006;101:1900-20.

[9.] Bhatt M, Thapa B. Lower esophageal sphincter pressures in gastroesophageal reflux disease: Where do they stand? Natl J Physiol Pharm Pharm 2015;5:170-3.

[10.] Chiba N, De Gara CJ, Wilkinson JM, Hunt RH Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: A metaanalysis. Gastroenterology 1997;112:1798-810.

[11.] Barbero GJ. Gastroesophageal reflux and upper airway disease. Otolaryngol Clin N Am 1996;29:27-38.

[12.] Loehrl TA, Smith TL, Darling RJ, Torrico L, Prieto TE, Shaker R, et al. Autonomic dysfunction, vasomotor rhinitis, and extraesophageal manifestations of gastroesophageal reflux. Otolaryngol Head Neck Surg 2002;126:382-7.

[13.] Wong IW, Rees G, Greiff L, Myers JC, Jamieson GG, Wormald PJ, et al. Gastroesophageal reflux disease and chronic sinusitis: In search of an esophageal-nasal reflex. Am J Rhinol Allergy 2010;24:255-9.

[14.] Kim HY, Dhong HJ, Chung SK, Chung KW, Chung YJ, Jang KT. Intranasal Helicobacter pylori colonization does not correlate with the severity of chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;136:390-5.

[15.] Ozmen S, Yucel OT, Sinici I, Ozmen OA, Suslu AE, Ogretmenoglu O, et al. Nasal pepsin assay and pH monitoring in chronic rhinosinusitis. Laryngoscope 2008;118:890-4.

[16.] DiBaise JK, Olusola BF, Huerter JV, Quigley EM. Role of GERD in chronic resistant sinusitis: A prospective, open label, pilot trial. Am J Gastroenterol 2002;97:843-50.

[17.] Phipps CD, Wood WE, Gibson WS, Cochran WJ. Gastroesophageal reflux contributing to chronic sinus disease in children: A prospective analysis. Arch Otolaryngol Head Neck Surg 2000;126:831-6.

[18.] Ulualp SO, Toohill RJ, Shaker R. Pharyngeal acid reflux inpatients with single and multiple otolaryngologic disorders. Otolaryngol Neck Surg 1999;121:725-30.

[19.] Pincus RL, Kim HH, Silvers S, Gold S. A study of the link between gastric reflux and chronic sinusitis in adults. Ear Nose Throat J 2006;85:174-8.

[20.] Vaezi MF, Hagaman DD, Slaughter JC, Tanner SB, Duncavage JA, Allocco CT, et al. Proton pump inhibitor therapy improves symptoms in postnasal drainage. Gastroenterology 2010;139:1887-930.

[21.] Durmus R, Naiboglu B, Tek A, Sezikli M, Cetinkaya ZA, Toros SZ, et al. Does reflux have an effect on nasal mucociliary transport? Acta Otolaryngol 2010;130:1053-7.

Manpreet Singh Nanda (1), Mandeep Kaur (2), Vipan Gupta (1)

(1) Department of Otolaryngology, Head and Neck Surgery, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, Himachal Pradesh, India, (2) Department of Anaesthesia, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, Himachal Pradesh, India

Correspondence to: Mandeep Kaur, E-mail: panav66@yahoo.com

Received: November 17, 2017; Accepted: December 01, 2017

How to cite this article: Nanda MS, Kaur M, Gupta V. Correlation between chronic rhinosinusitis and laryngopharyngeal reflux. Natl J Physiol Pharm Pharmacol 2018;8(4):544-549.

Source of Support: Nil, Conflict of Interest: None declared.

DOI: 10.5455/njppp.2018.8.1145801122017
Table 1: Age and sex distribution among patients with CRS

Age group (years)  Males  Females  Total

18-40               6      7       13
41-60              11     10       21
>60                 2      4        6
Total              19     21       40

CRS: Chronic rhinosinusitis

Table 2: Signs and symptoms of LPR among patients with CRS

Signs and symptoms                     Number of patients
                                       n - 40 and (%)

Symptoms
 Foreign body sensation                15 (38)
 Change in voice                        7 (18)
 Chronic cough                          6 (15)
 Sore throat                            6 (15)
 Heartburn                              4 (10)
 Difficulty in swallowing               1 (3)
Signs
 Posterior larynx congestion or edema   9 (23)
 Anterior larynx congestion or edema    3 (8)
 Posterior pharyngeal wall congestion   5 (13)
 or edema

n: Number of patients, %: Percentage of patients, CRS: Chronic
rhinosinusitis, LPR: Laryngopharyngeal reflux

Table 3: Signs and symptoms of CRS among patients in both groups at
initial visit

Signs and symptoms          Study group n - 20  Control group n - 20

Symptoms
 Nasal obstruction          17                  18
 Nasal discharge            14                  13
 Headache                    9                  11
 Facial pain                10                   8
 Loss of smell               8                   9
 Posterior nasal discharge   8                   8
Signs
 Nasal polyp                 7                   8
 Mucopurulent discharge     15                  16
Mucosal edema               16                  15

Signs and symptoms          Total n - 40 (%)

Symptoms
 Nasal obstruction          35 (88)
 Nasal discharge            27 (68)
 Headache                   20 (50)
 Facial pain                18 (45)
 Loss of smell              17 (48)
 Posterior nasal discharge  16 (40)
Signs
 Nasal polyp                15 (38)
 Mucopurulent discharge     31 (78)
Mucosal edema               31 (78)

n: Number of patients, %: Percentage of patients, CRS: Chronic
rhinosinusitis

Table 4: Signs and symptoms of CRS among patients in study group at
each visit

Signs and symptoms          Initial evaluation  First follow-up
                            n - 20 (%)          n - 20 (%)

Symptoms
 Nasal obstruction          17 (85)             8 (40)
 Nasal discharge            14 (70)             7 (35)
 Headache                    9 (45)             4 (20)
 Facial pain                10 (50)             4 (20)
 Loss of smell               8 (40)             2 (10)
 Posterior nasal discharge   8 (40)             4 (20)
Signs
 Nasal polyp                 7 (35)             0 (0)
 Mucopurulent discharge     15 (75)             7 (35)
 Mucosal edema              16 (80)             7 (35)

Signs and symptoms          2nd follow-up  3rd follow-up
                            n - 20 (%)     n - 20 (%)

Symptoms
 Nasal obstruction          5 (25)         4 (20)
 Nasal discharge            4 (20)         4 (20)
 Headache                   2 (10)         1 (5)
 Facial pain                2 (10)         2 (10)
 Loss of smell              1 (5)          1 (5)
 Posterior nasal discharge  2 (10)         1 (5)
Signs
 Nasal polyp                0 (0)          0 (0)
 Mucopurulent discharge     4 (20)         4 (20)
 Mucosal edema              4 (20)         4 (20)

n: Number of patients, %: Percentage of patients, CRS: Chronic
rhinosinusitis

Table 5: Signs and symptoms of CRS among patients in control group at
each visit

Signs and symptoms  Initial evaluation  First follow-up n - 20 (%)
                    n - 20 (%)

Symptoms
 Nasal obstruction  18 (90)             9 (45)
 Nasal discharge    13 (65)             7 (35)
 Headache           11 (55)             5 (25)
 Facial pain         8 (40)             4 (20)
 Loss of smell       9 (45)             2 (10)
 Posterior nasal     8 (40)             5 (25)
 discharge
Signs
 Nasal polyp         8 (40)             0 (0)
 Mucopurulent       16 (80)             8 (40)
 discharge
 Mucosal edema      15 (75)             8 (40)

Signs and symptoms  2nd follow-up n - 20 (%)  3rd follow-up n - 20 (%)


Symptoms
 Nasal obstruction  7 (35)                    7 (35)
 Nasal discharge    6 (30)                    6 (30)
 Headache           3 (15)                    2 (10)
 Facial pain        2 (10)                    2 (10)
 Loss of smell      2 (10)                    1 (5)
 Posterior nasal    5 (25)                    5 (25)
 discharge
Signs
 Nasal polyp        0 (0)                     0 (0)
 Mucopurulent       6 (30)                    6 (30)
 discharge
 Mucosal edema      7 (35)                    7 (35)

n: Number of patients, %: Percentage of patients, CRS: Chronic
rhinosinusitis

Table 6: Comfort level and relief among patients in study group at each
visit

Comfort level                    1st follow-up visit n - 20 (%)

Very comfortable (total relief)  5 (25)
Comfortable (improvement)        6 (30)
No change                        7 (35)
Uncomfortable (worsening)        2 (10)

Comfort level                    2nd follow-up visit n - 20 (%)

Very comfortable (total relief)  8 (40)
Comfortable (improvement)        8 (40)
No change                        2 (10)
Uncomfortable (worsening)        2 (10)

Comfort level                    3rd follow-up visit n - 20 (%)

Very comfortable (total relief)  9 (45)
Comfortable (improvement)        7 (35)
No change                        2 (10)
Uncomfortable (worsening)        2 (10)

n: Number of patients, %: Percentage of patients

Table 7: Comfort level and relief among patients in control group at
each visit

Comfort level                    1st follow-up visit n - 20 (%)

Very comfortable (total relief)  4 (20)
Comfortable (improvement)        6 (30)
No change                        8 (40)
Uncomfortable (worsening)        2 (10)

Comfort level                    2nd follow-up visit n - 20 (%)

Very comfortable (total relief)  6 (30)
Comfortable (improvement)        6 (30)
No change                        6 (30)
Uncomfortable (worsening)        2 (10)

Comfort level                    3rd follow-up visit n - 20 (%)

Very comfortable (total relief)  6 (30)
Comfortable (improvement)        6 (30)
No change                        6 (30)
Uncomfortable (worsening)        2 (10)

n: Number of patients, %: Percentage of patients
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Title Annotation:RESEARCH ARTICLEd
Author:Nanda, Manpreet Singh; Kaur, Mandeep; Gupta, Vipan
Publication:National Journal of Physiology, Pharmacy and Pharmacology
Article Type:Report
Date:Apr 1, 2018
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