The impact of comorbid gastroesophageal reflux disease on endoscopic sinus surgery quality-of-life outcomes

Association Between Chronic Rhinosinusitis and Reflux Diseases in Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last few decades, reflux diseases, such as laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD), have been identified as significant contributors to inflammatory upper aerodigestive tract diseases. Establishing a direct relationship between reflux disease and chronic rhinosinusitis (CRS) is challenging due to the high prevalence of both diseases and their potential for independent coexistence.

OBJECTIVE

The purpose of this study is to review the existing literature and evaluate the evidence of an association between reflux diseases and CRS.

METHODS

A comprehensive electronic search was conducted across multiple databases to identify all studies that investigated the relationship between LPR, GERD, and CRS from January 1, 1950, to June 16, 2022. Only studies with English manuscripts involving adult populations were included, while case series, case reports, and in vitro studies were excluded. The risk of bias was evaluated using The Newcastle-Ottawa Scale for case-control studies and the NIH quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

The search strategy yielded a total of 427 articles, out of which 25 studies examined the correlation between reflux diseases and CRS. The meta-analysis indicated a significant association between the presence of GERD and CRS compared to control groups (P < .001; CI 3.56 [2.25, 5.65]), as well as significantly higher pH values and pepsin detection in CRS patients when compared to healthy individuals (P = .003). Furthermore, all studies that evaluated proton pump inhibitor (PPI) therapy in CRS patients reported positive outcomes, with 93% of CRS patients showing improvement on PPIs.

CONCLUSION

The existing literature provides suggestive evidence of an association between reflux diseases and CRS, with regards to both prevalence and treatment. Nonetheless, further studies are required to confirm this relationship.

Laryngopharyngeal reflux in chronic rhinosinusitis patients and the role of endoscopic sinus surgery

OBJECTIVES

Latest literature proposes laryngopharyngeal reflux (LPR) as the underlying contributory factor for chronic inflammation in both upper and lower airways. In this study, we investigated LPR symptoms and signs of CRS patients and the various factors on their LPR symptoms and signs. We also evaluated the effect of the LPR symptoms and signs of CRS patients after endoscopic sinus surgery (ESS).

METHODS

We performed a retrospective analysis from 91 patients who underwent primary ESS. They were assessed for LPR symptoms with Reflux Symptom Index (RSI) and Reflux Finding Scores (RFS) before ESS. Sino-Nasal Outcome Test (SNOT)-22, Lund-Mackay (LM) scoring system, and Lund-Kennedy (LK) scoring system were evaluated for CRS severity. They had to fulfill SNOT-22, RSI, and RFS at 6 months after surgery.

RESULTS

Nasal polyps, smoking, asthma, allergy, LM scores and LK scores didn't have significant correlations with preoperative RSI and RFS (P > .05 for all). RSI had significant correlations with SNOT-22 preoperatively and postoperatively (P < .05 for all). RFS had a significant correlation with postoperative SNOT-22 (P = 0.034). RSI and RFS decreased significantly more after ESS (P < 0.001 for both). Smoking had a significant effect on the postoperative RFS (P = 0.003). Non-smoker showed significantly lower scores of postoperative RFS (P = .0.003).

CONCLUSION

Our study suggests that subjective CRS symptoms were related with subjective LPR symptoms and ESS was effective in reducing signs and symptoms of LPR in CRS patients. Especially, smoking was associated with less improvement of laryngoscopic findings after ESS.

Association of gastro-oesophageal reflux disease and quality of life in patients with chronic rhinosinusitis

Objective

We determined the influence of gastro-oesophageal reflux disease (GERD) on quality of life (QOL) before and after functional-endoscopic-sinus-surgery (FESS) for chronic rhinosinusitis (CRS).

Methods

Medically-recalcitrant CRS patients were recruited prior to FESS. GERD was diagnosed endoscopically. QOL was compared between patients with vs without GERD at baseline and one-year post-FESS.

Results

Of 187 CRS patients receiving FESS, 40 had GERD. Pre-operative QOL was significantly worse in CRS patients with vs without GERD. Pre-operative GERD health-related QOL (GERD-HRQL) and reflux symptom index (RSI) scores were both correlated with pre-operative SNOT-22 scores. Compared with non-GERD CRS patients, GERD patients demonstrated larger SNOT-22 improvements after FESS, such that post-operative SNOT-22 values were no longer significantly different between GERD and non-GERD groups. However, post-FESS, in patients with CRS without nasal polyps (unlike those with nasal polyps), the GERD (vs non-GERD) group suffered from greater sleep dysfunction and otologic/facial symptoms.

Conclusions

Compared to CRS patients without GERD, those with GERD experienced poorer pre-operative QOL and greater QOL improvement after FESS.

Comorbidities Known to Affect Physical Function Negatively Impact Baseline Health-Related Quality-of-Life in Patients With Chronic Rhinosinusitis

BACKGROUND

Medical comorbidities are commonly encountered in chronic rhinosinusitis (CRS) and may impact both physical function and patient reported health-related quality-of-life (HRQOL). The functional comorbidity index (FCI) is designed to elucidate the role of comorbidities on functional prognosis. The objective of this study was to understand the impact of comorbidities known to impact physical function on baseline HRQOL using the FCI.Methodology: Patients meeting diagnostic criteria for CRS were prospectively enrolled in a cross-sectional study. Responses from the Sinonasal Outcomes Test-22 (SNOT-22), a measure of patient HRQOL, as well as the Lund-Kennedy and Lund-Mackay scores were recorded at enrollment. FCI was calculated retrospectively using the electronic medical record. Information was collected and compared for patients without (CRSsNP) and with nasal polyps (CRSwNP) using chi-square and t-tests. Spearman's correlations, followed by multivariate regression analysis, were used to assess the association between FCI and SNOT-22 scores.

RESULTS

One hundred and three patients met inclusion criteria for analysis. There were no significant differences in age, gender, and SNOT-22 scores between patients with CRSsNP and those with CRSwNP. FCI was significantly and independently associated with worse SNOT-22 scores (P = .012). FCI did not correlate with endoscopy and computed tomography scores. The mean FCI for patients with CRSsNP and CRSwNP was 2.02 and 2.24, respectively, and did not differ significantly between the two cohorts (P = .565).

CONCLUSIONS

Major medical comorbidities known to affect physical function are associated with worse SNOT-22 scores in patients with CRS as measured by the FCI.

The prognostic variables affecting the frontal sinusotomy patency outcome and how to manage: A prospective study

OBJECTIVES

The study aimed to assess the factors affecting the frontal sinus patency after endoscopic frontal sinusotomy.

DESIGN

A prospective cohort study.

SETTING

Tertiary centre hospital.

MAIN OUTCOME MEASURES

Fifty patients with refractory chronic frontal sinusitis (83 operated frontal sinuses) had frontal sinusotomy and followed up for six months. Multiple operative factors were included the type of the procedure, intraoperative sinus findings, degree of mucosal preservation and middle turbinate stability. Other factors were also assessed, including smoking, the presence of allergic rhinitis, asthma, gastroesophageal reflux and other associated medical comorbidities.

RESULTS

The sinus patency success rate was 75.9%. There was a significant difference regarding the intraoperative anteroposterior sinus ostium diameter (5.36 ± 1.45 mm vs 8.88 ± 2.38 mm, P-value: .001* in the failed group and the success group, respectively). There was a significant association between the patency outcome and the presence of associated medical comorbidities (P-value: .001*), the presence of allergic rhinitis (P-value: .001*), the degree of sinus mucosal preservation (P-value: .012*) and the degree of middle turbinate stability (P-value: .001*). The multivariate analysis showed that the intraoperative anteroposterior diameter of the sinus ostium, middle turbinate stability and presence of allergic rhinitis were significant predictors (P-value: .012*, .042* and .013*, respectively).

CONCLUSION

Sinuses with anteroposterior ostium diameters less than 5.36 mm are more susceptible to restenosis. The flail middle turbinate increases the risk of postoperative middle meatus synechia and frontal sinus patency failure. The presence of allergic rhinitis has a negative impact on the patency outcome.

Evidence of Pepsin-Related Ocular Surface Damage and Dry Eye (PROD Syndrome) in Patients with Laryngopharyngeal Reflux

Background: patients with laryngopharyngeal reflux (LPR) showed detectable levels of tear pepsin that explain the nasolacrimal obstruction. The purpose of this study was to determine whether patients with LPR show ocular surface changes and to investigate the relationship between lacrimal pepsin concentration and ocular alterations. Methods: Fifty patients with positive endoscopic signs for LPR and an equal or higher score of 13 and 7 for Reflux Symptom Index and Reflux Finding Score were enrolled. Twenty healthy patients with no reflux disease and dry eye were included as the control group. After evaluation of ocular discomfort symptoms, the tear break-up time test, corneal staining, and tear sampling were performed. Tear pepsin levels were measured using Pep-test^TM kit. Results: Patients with LPR showed ocular surface changes including epithelial damage (48%) and impairment of lacrimal function (72%). Tear pepsin levels were detectable in 32 out of 50 (64%) patients with LPR (mean ± SD: 55.4 ± 67.5 ng/mL) and in none of the control subjects. Most of the LPR patients complained of ocular discomfort symptoms, including itching (38%), redness (56%), or foreign body sensation (40%). Tear pepsin levels were significantly correlated with the severity of LPR disease and with ocular surface changes. Conclusions: A multidisciplinary approach, including ophthalmological evaluation, should be considered in order to improve the management of patients with LPR.

The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

OBJECTIVE

This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR.

METHODS

In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains.

RESULTS

A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003).

CONCLUSION

Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

Systematic Review and Meta-analysis of SNOT-22 Outcomes after Surgery for Chronic Rhinosinusitis with Nasal Polyposis

Objective Wide variation exists regarding reported outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). This study seeks to combine data across studies to generate a summary measure and explore factors that might lead to variation. Data Sources OVID Medline, Scopus, EbscoHost, Database of Abstracts and Reviews of Effects, Health Technology Assessment, and National Health Service Economic Evaluation Database. Review Methods A search was performed following the PRISMA guidelines. Two independent researchers conducted a search using the mentioned data sources. Studies published before August 29, 2016, that involved ESS to treat CRSwNP were included. Mean changes in Sinonasal Outcome Test-22 (SNOT-22) scores were determined through metaregression of the following independent variables: publication year, sex, age, allergy status, asthma, tobacco use, prior surgery, follow-up length, and preoperative SNOT-22. Results Fifteen articles with 3048 patients treated with ESS met inclusion criteria. Pooled analyses of SNOT-22 scores revealed a mean change of 23.0 points (95% CI, 20.2-25.8; P < .001). A metaregression of patient factor effects on the mean change of SNOT-22 scores demonstrated that age ( r = 0.71, P = .01), asthma ( r = 0.21, P = .01), prior ESS ( r = 0.29, P = .01), and preoperative SNOT-22 score ( r = 0.4, P < .01) correlated with greater improvement in SNOT-22 scores. Tobacco use ( r = -0.91, P = .01) and longer lengths of follow-up ( r = -0.45, P < .01) were associated with less improvement in SNOT-22 scores. Conclusions Quality-of-life outcomes are significantly improved after ESS among patients with CRSwNP. Patient-specific factors may affect the degree of SNOT-22 change after surgery.

Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature.

METHODS

A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression.

RESULTS

The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score.

CONCLUSIONS

Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is considered a therapeutic option after failure of maximal medical therapy (MMT) for chronic rhinosinusitis (CRS). There is currently no consensus on the definition of MMT. The objective of this systematic review is to describe the various MMT criteria employed prior to considering ESS.

METHODS

A systematic review was performed using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were adults with CRS based on guideline diagnostic criteria, enrolled to undergo ESS, and study publication within the last 5 years (January 1, 2009, to December 30, 2014). Studies were excluded if the study population included non-CRS indications for ESS. Primary outcome was the MMT criteria employed prior to considering a patient a candidate for ESS. A subgroup analysis was performed based on polyp status.

RESULTS

Of 387 reviewed studies, 21% reported MMT criteria. When reported, criteria included topical nasal corticosteroids (91% of studies) for a mean of 8 ± 8 weeks, oral antibiotics (89%) for 23 ± 8 days, systemic corticosteroids (61%) for 18 ± 12 days, saline irrigations (39%), oral antihistamines (11%), oral mucolytics (10%), and topical/oral decongestants (10%).

CONCLUSION

A minority of studies report MMT criteria used as the indication for ESS. When reported, the majority included an 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics. Use of systemic corticosteroids did not differ based on polyp status. Because of variation in current MMT criteria, there is a need to develop standardized indications for ESS that will work to improve the appropriateness of care for patients with.

Increased Risk of Chronic Sinusitis in Adults With Gastroesophgeal Reflux Disease: A Nationwide Population-Based Cohort Study

Although gastroesophageal reflux disease (GERD) has been reported to coexist with chronic rhinosinusitis (CRS), it remains controversial whether it increases risk of CRS in adults. This study accesses risk of CRS in adults with newly diagnosed GERD. We identified 15,807 adult patients with newly diagnosed GERD from Taiwan's National Health Insurance Research Database for January 1, 2006 to December 31, 2009. We also randomly selected 47,421 subjects without this disease and matched them with patients by age, sex, index year, and comorbidity to create a control cohort. A Cox proportional hazards model was conducted to estimate the development of CRS, including CRS without nasal polyps and CRS with nasal polyps. Subjects were followed for a median of 2.12 years. In total, CRS developed in 964 (1.52%) of the subjects: 406 patients with GERD (2.57%) and 558 without it (1.18%). After adjustment, those with GERD were found to have a 2.36 times greater risk of CRS (95% confidence interval = 2.08-2.68; P < .001). Risk of this CRS without nasal polyps was higher than the disease with polyps (adjusted hazard ratio: 2.48 vs 1.85). The individuals with GERD in this study were at significantly greater risk of CRS, most often without nasal polyps.

Does comorbid obesity impact quality of life outcomes in patients undergoing endoscopic sinus surgery?

BACKGROUND

Both obesity and chronic rhinosinusitis (CRS) are characterized by inflammation. Furthermore, both disease processes are independently associated with decreases in quality-of-life (QOL). We sought to investigate the role of comorbid obesity in QOL outcomes in CRS patients undergoing endoscopic sinus surgery (ESS).

METHODS

Adult patients with medically refractory CRS (n = 241) were prospectively enrolled into a multi-institutional treatment outcomes investigation. Body mass index (BMI) calculations were used to differentiate patient weight groups (normal weight: 18.5 to 24.9, overweight: 25.0 to 29.9; and obese: ≥30.0). Preoperative and postoperative QOL (Rhinosinusitis Disability Index [RSDI] and the 22-item Sino-Nasal Outcome Test [SNOT-22]) were evaluated compared across BMI groups and obesity subclasses.

RESULTS

The prevalence of comorbid obesity was 41% (n = 99). Higher prevalence of comorbid disease was found across increasing BMI groups including diabetes mellitus, asthma, and depression. No significant differences were found in mean preoperative QOL measures between any BMI groups. Significant improvement between preoperative and postoperative QOL mean scores (p ≤ 0.050) was found for all BMI groups. Despite no significant difference in mean QOL improvement between BMI groups (p ≥ 0.142), overweight and obese patients reported reduced relative mean percentage (%) improvement compared to normal weight participants on the RSDI total score (33% and 37% vs 55%, respectively) and SNOT-22 total score (29% and 40% vs 48%, respectively).

CONCLUSION

Patients with comorbid obesity experience significant improvement in average QOL gains following ESS though the percentage of relative improvement in QOL may be decreased in patients with comorbid obesity and CRS as compared to those without.

Health utility outcomes in patients undergoing medical management for chronic rhinosinusitis: a prospective multiinstitutional study

BACKGROUND

A health utility value represents an individual's preference for living in a specific health state and is used in cost-utility analyses. This study investigates the impact of continuing medical therapy on health utility outcomes in patients with chronic rhinosinusitis (CRS).

METHODS

The Medical Outcomes Study Short Form-6D (SF-6D) questionnaire was administered to patients prospectively enrolled in a longitudinal study examining treatment outcomes for CRS. Patients were prescribed robust, initial medical therapy and then elected to continue with medical therapy (n = 40) or undergo endoscopic sinus surgery (ESS), followed by medical therapy (n = 152). Patients observed through treatment crossover to ESS were also evaluated (n = 20). Health utility values (SF-6D) were generated at baseline, 6-months, and 12-months follow-up for both cohorts and evaluated using repeated measures analysis of variance (ANOVA).

RESULTS

Treatment crossover patients were found to have a significantly higher prevalence of previous sinus surgery compared to medical management (χ(2) = 6.91; p = 0.009) and surgical intervention (χ(2) = 8.11; p = 0.004) subgroups. Mean baseline utility value for the medical therapy cohort was significantly better compared to the ESS cohort (mean ± standard deviation; 0.76 ± 0.12 vs 0.70 ± 0.15; p = 0.023). Significant improvement in health utility was reported in the ESS cohort (F(2) = 37.69; p < 0.001), whereas values remained stable, without significant improvement, in both the medical therapy cohort (F(2) = 0.03; p = 0.967) and treatment crossover cohort (F(2) = 2.36; p = 0.115).

CONCLUSION

Patients electing continued medical management report better baseline health utility compared to patients electing ESS. Patients electing ESS show significant improvement in health utility, whereas those electing continued medical management demonstrate stable health utility over 12 months.

Does comorbid anxiety predict quality of life outcomes in patients with chronic rhinosinusitis following endoscopic sinus surgery?

BACKGROUND

Approximately 25% of patients with chronic rhinosinusitis (CRS) have comorbid anxiety and both conditions independently decrease quality of life (QOL). QOL outcomes for CRS and depression have garnered the majority of research attention, but efforts to better understand the impact of anxiety disorders on QOL are increasing. We evaluated the role of comorbid anxiety in patients with CRS undergoing endoscopic sinus surgery (ESS).

METHODS

Adult patients (n = 148) with CRS with and without comorbid anxiety were prospectively enrolled into a treatment outcomes investigation. History of comorbid anxiety was retrospectively identified (n = 30; 20%) and preoperative and postoperative QOL (Rhinosinusitis Disability Index [RSDI], and 22-item Sino-Nasal Outcome Test [SNOT-22]) scores were compared to patients without comorbid anxiety.

RESULTS

Compared to patients without anxiety, patients with anxiety were found to be younger (p = 0.02) and have a higher prevalence of female gender (p = 0.05), diabetes mellitus (p < 0.001), depression (p < 0.001), and tobacco use (p = 0.03). Participants with comorbid anxiety reported significantly worse preoperative psychological dysfunction as measured by SNOT-22 subdomain scores (p = 0.02), as well as worse preoperative functional (p = 0.04) and emotional (p = 0.001) impairment as evaluated by RSDI subdomain scores. After adjustment for other cofactors, patients with anxiety improved significantly less on SNOT-22 total scores compared to participants without anxiety after ESS (p = 0.02).

CONCLUSION

Anxiety occurs with higher prevalence in patients with CRS and the presence of comorbid anxiety is associated with worse preoperative QOL and reduced QOL improvement following ESS. These findings warrant improvement in screening, diagnosis, and treatment for patients with CRS and comorbid anxiety.