Correlation between nasal mucociliary clearance time and gastroesophageal reflux disease: our experience on 50 patients

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.

Mulberry Posterior Inferior Nasal Turbinate Is Associated with a Lower Pharyngeal pH Environment

OBJECTIVES

Mulberry-like changes of the posterior inferior nasal turbinate (MPINT) can lead to nasal obstruction. Extraesophageal reflux (EER) characterized by lower pH causes mucosal inflammation and therefore can contribute to sinonasal pathologies. No prior studies have objectively examined the possible association between acidic pH and MPINT formation. Therefore, this study is aimed to investigate the 24-h pharyngeal pH value in patients with MPINT.

STUDY DESIGN

Prospective case-control multi-center study.

METHODS

Fifty-five patients with chronic EER symptoms were included in the study. They filled in questionnaires aimed at reflux and sinonasal symptoms (RSI®, SNOT-22) and underwent video endoscopy evaluating the laryngeal findings (RFS®) and the presence or absence of the MPINT. And, 24-h oropharyngeal pH monitoring was used to detect the acidic pH environment in the pharynx.

RESULTS

Out of the 55 analyzed patients, 38 had the MPINT (group 1), and in 17 patients, the MPINT was absent (group 2). Based on the pathological RYAN Score, in 29 (52.7%) patients, severe acidic pH drops were detected. In group 1, the acidic pH drops were diagnosed significantly more often (68.4%) compared with those in group 2 (p = 0.001). Moreover, in group 1, a significantly higher median total percentage of time spent below pH 5.5 (p = 0.005), as well as a higher median number of events lasting more than 5 min (p = 0.006), and higher median total number of events with pH drops (p = 0.017) were observed.

CONCLUSION

In this study, the MPINT was significantly more often present in patients with acidic pH events detected by 24-h oropharyngeal pH monitoring. Acidic pH in the pharynx might lead to MPINT formation.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:62-68, 2024.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Gastritis and gastroesophageal reflux disease are strongly associated with non-allergic nasal disorders

Background

Gastroesophageal reflux disease (GERD) has been reported to be significantly associated with chronic rhinosinusitis, but the strength of the association is still debated.

Aims

To evaluate the strength of the association between gastritis/GERD and non-allergic rhinitis (NAR)/allergic rhinitis (AR)/sinusitis.

Methods

We investigated 2887 subjects aged 20–84 years, who underwent a clinical visit in seven Italian centres (Ancona, Palermo, Pavia, Terni, Sassari, Torino, Verona) within the study on Gene Environment Interactions in Respiratory Diseases, a population-based multicase-control study between 2008 and 2014. Subjects were asked if they had doctor-diagnosed “gastritis or stomach ulcer (confirmed by gastroscopy)” or “gastroesophageal reflux disease, hiatal hernia or esophagitis”. The association between NAR/AR/sinusitis and either gastritis or GERD was evaluated through relative risk ratios (RRR) by multinomial logistic regression.

Results

The prevalence of gastritis/GERD increased from subjects without nasal disturbances (22.8% = 323/1414) to subjects with AR (25.8% = 152/590) and further to subjects with NAR (36.7% = 69/188) or sinusitis (39.9% = 276/691). When adjusting for centre, sex, age, education level, BMI, smoking habits and alcohol intake, the combination of gastritis and GERD was associated with a four-fold increase in the risk of NAR (RRR = 3.80, 95% CI 2.56–5.62) and sinusitis (RRR = 3.70, 2.62–5.23) with respect to controls, and with a much smaller increase in the risk of AR (RRR = 1.79, 1.37–2.35)..

Conclusion

The study confirmed the association between gastritis/GERD and nasal disturbances, which is stronger for NAR and sinusitis than for AR.

Impact of gastric Helicobacter pylori infection on nasal mucociliary clearance

OBJECTIVES

This study aimed to investigate the relationship between the presence of gastric Helicobacter pylori (HP) infection and nasal mucociliary clearance (NMC) time and to analyze the effect of HP eradication on NMC time.

MATERIALS AND METHODS

Patients who underwent gastric biopsy and had a positive result for HP constituted the study group, while the control group consisted of the patients who had a negative biopsy result. Two groups were compared in terms of NMC times. Quadruple medication therapy was given to HP-positive patients for 14 days for eradication and NMC time was measured again in these patients 8 weeks after eradication. Statistical analyses were performed with SPSS software (version 22.0; SPSS, Chicago, Illinois, USA).

RESULTS

There were 60 patients in the study group (HP +), while the control group (HP -) included 50 patients. Mean NMC times were 12.86 ± 2.62 and 8.32 ± 2.24 for the study and control groups, respectively (p < 0.001). Pre- and post-eradication mean NMC times of the HP + patients were 12.71 ± 2.58 and 8.62 ± 1.39, respectively (p < 0.001).

CONCLUSION

We determined that NMC time was significantly higher in HP-positive patients when compared with HP-negative patients, and the NMC times went back to normal after eradicating the HP infection. Because NMC dysfunction plays an essential role in the pathogenesis of chronic rhinosinusitis (CRS), we propose that eradication of HP can have positive effects on the prognosis of CRS. Further studies are needed to establish this relationship.

Direct Visualization of Laryngeal Mucociliary Clearance in Adults

OBJECTIVES

Mucociliary clearance is a protective mechanism of the respiratory tract that facilitates the removal of foreign particles and microorganisms. There is a paucity of data on the mucociliary clearance in the adult larynx. Our study aims to visualize and describe the mucociliary clearance of the adult larynx in healthy subjects.

METHODOLOGY

Subjects were identified from a volunteer database. Exclusion criteria included laryngeal disease, previous laryngeal surgery, recent upper respiratory infection, and current smoking. A high-definition videolaryngoscope was used to visualize the larynx. The larynx was topicalised with local anesthetic. Methylene blue was placed on both false vocal cords and at the petiole of the epiglottis. Dye clearance was recorded and analyzed.

RESULTS

In total, 10 participants participated, 7 men and 3 women, with a mean age of 42 ± 15.7 years (range: 25-71). The average reflux symptom index score was 1.4. Clearance of the dye from the false vocal cords followed a uniform lateral flow, up onto the aryepiglottic folds. The dye from the petiole had minimal vertical movement. Swallowing cleared dye from the aryepiglottic folds. The average time for dye clearance to the aryepiglottic fold was 2.21 ± 1.14 minutes.

CONCLUSIONS

This is the first study visualizing the mucociliary clearance of the larynx. Ciliary directionality was consistent in the participants studied, with dye moving superolateral from the false cords to the aryepiglottic fold. Swallowing was an effective mechanism for clearance from the endolarynx, when the dye had reached the aryepiglottic fold. Future research can study potential alterations in laryngeal mucociliary clearance in chronic disease states.

The Effect of Gastric Helicobacter pylori Colonization on Nasal Functions

The aim of this study is to investigate the effect of gastric Helicobacter pylori colonization on nasal functions. The study enrolled patients (n = 100) who underwent endoscopy for gastroesophageal reflux disease. Patients with laryngopharyngeal reflux (LPR) were identified by Reflux Symptom Index (RSI) and Reflux Finding Score (RFS). Patients were divided into 2 groups: LPR (+) (n = 64) H pylori (+), RSI > 13, RFS > 7; LPR (-) (n = 36) H pylori (+), RSI < 13, RFS < 7. Visual analog scale (VAS), sinonasal outcome test-22 (SNOT-22), peak nasal inspiratory flowmeter (PNIF), mucociliary clearance (MCC), and olfactory tests were used to evaluate the nasal functions. The average VAS for nasal obstruction, PNIF, and MCC did not differ significantly between the LPR (+) and LPR (-) groups (P > .05). However, the average olfactory test scores were lower in the LPR (+) patients than the LPR (-) patients (P < .05). Also, the SNOT-22 scores were significantly higher in LPR (+) patients than in LPR (-) (P < .01). Nasal functions and symptom scores were also evaluated according to the H pylori grading. The PNIF, MCC, SNOT-22, and olfactory test results deteriorated as the gastric mucosal H pylori colonization increased (P < .05). In conclusion, nasal functions differed between LPR disease and GERD only, while the density of H pylori colonization in the gastric mucosa had an effect on nasal function.

Particularities and Clinical Applicability of Saccharin Transit Time Test

Introduction  The importance of mucociliary clearance (MCC) for the respiratory system homeostasis is clear. Therefore, evaluating this defense mechanism is fundamental in scientific research and in the clinical practice of pulmonology and of associated areas. However, MCC evaluation has not been so usual due to the complexity of methods that use radiolabeled particles. Nevertheless, as an interesting alternative, there is the saccharin transit time (STT) test. This method is reproducible, simple to perform, noninvasive, does not demand high costs, and has been widely used in studies of nasal MCC. Although the STT test is widely used, there is still lack of a detailed description of its realization. Objective  The present literature review aims to provide basic information related to the STT test and to present the findings of the previous studies that used this method, discussing variations in its execution, possible influences on the obtained results and limitations of the method, as well as to relate our experience with the use of STT in researches. Data Synthesis  There are several factors that can alter the results obtained from STT tests, which would raise difficulties with proper interpretation and with the discussion of the results among different studies. Conclusions  Saccharin transit time is a widely used method for the evaluation of nasal MCC, and therefore, the standardization related to the previous and concurrent to test orientations, and also its execution, become essential to improve its accuracy, and allow comparisons among different studies.

The evaluation of nasal mucociliary clearance in patients with Helicobacter pylori infection

OBJECTIVE

This study aimed to examine nasal mucociliary clearance time in patients with Helicobacter pylori infection.

METHODS

Fifty patients who were newly diagnosed with H pylori infection using gastric biopsy in the gastroenterology out-patient clinic, and 50 age- and gender-matched healthy adults who were admitted to the otorhinolaryngology out-patient clinic, were included in this study. After an otorhinolaryngological examination (anterior rhinoscopy and nasal endoscopic examination), the nasal mucociliary clearance time of each subject was calculated using the saccharine test.

RESULTS

The mean mucociliary clearance time was 06:29 ± 3:31 minutes (range, 00:55-15:19 minutes) in the control group and 10:12 ± 06:09 minutes (range, 01:28-32:00 minutes) in the study group. Comparisons of the two groups revealed a statistically significant difference (p = 0.002).

CONCLUSION

Nasal mucociliary clearance time was significantly increased in patients with H pylori infection. The results suggest that H pylori infection may have an unfavourable effect on nasal mucociliary clearance.

Association of Oral Antireflux Medication With Laryngopharyngeal Reflux and Nasal Resistance

Importance

Laryngopharyngeal reflux (LPR) is thought to be a potential exacerbating factor in upper airway diseases.

Objective

To describe the effect of pharmacologic therapy of laryngopharyngeal reflux on nasal resistance.

Design, Setting, and Participants

Prospective observational study performed between August 30, 2014, and October 1, 2015, at a tertiary care academic center including 50 patients with Reflux Symptom Index higher than 13 and Reflux Finding Score higher than 7 and 50 controls with no history of LPR and nasal disease.

Interventions

Oral antireflux medication was given to the LPR group for 12 weeks.

Main Outcomes and Measures

The measurements of total nasal resistance (TNR) were performed by means of active anterior rhinomanometry technique and Nasal Obstruction Symptom Evaluation (NOSE) was assessed.

Results

The LPR group had 29 (58%) women and a median age of 41.5 years (range, 18-64 years). The control group had 27 (54%) women and a median age of 38.5 years (range, 19-63 years). After treatment, a significant decrease was observed in all parameters. The median (range) TNR scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median TNR score of the control group was 0.20 (range, 0.11-0.32). Whereas the TNR scores of the LPR group were higher than those of the control group before treatment (difference, -0.77; 95% CI, -0.10 to 0.05), they were almost the same after treatment (difference, 0.01; 95% CI, -0.01 to 0.03). The median (range) NOSE scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median NOSE score of the control group was 0.20 (range, 0.11-0.32).

Conclusions and Relevance

In this study, laryngopharyngeal reflux had a negative effect on nasal resistance and nasal congestion. Treatment was associated with improved subjective and objective nasal findings.

An assessment of olfactory function in patients with laryngopharyngeal reflux disease

CONCLUSIONS

The results reported here indicate that there was a statistically significant difference in the olfactory functions of laryngopharyngeal reflux patients vs the healthy group. To the best of the authors' knowledge, this study is the first to evaluate the olfactory function of patients diagnosed with laryngopharyngeal reflux using an objective method, 24-h pH monitoring.

OBJECTIVES/HYPOTHESIS

The aim of this study was to investigate olfactory functions in laryngopharyngeal reflux (LPR) patients and compare the results with healthy controls.

METHODS

A total of 60 participants; 30 men and women with a diagnosis of laryngopharyngeal reflux and 30 healthy controls, were included in the study. Patients in the laryngopharyngeal reflux group were evaluated by the Reflux Symptom Index (RSI), Reflux Finding Scores (RFS), and finally 24-h pH monitoring to confirm the diagnosis of laryngopharyngeal reflux. The Sniffin' Sticks olfactory test results of the laryngopharyngeal reflux and control groups were compared, and the relationship between the study findings and the olfactory parameters were evaluated.

RESULTS

The odor threshold, odor discrimination, odor identification, and TDI scores of the laryngopharyngeal reflux group were significantly lower than those of the control group. Also there was a statistically significant negative correlation detected between the olfactory test and some symptom and finding scores.

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review

Introduction

The relationship between gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) is still a controversial issue in literature.

Objective

A systematic review of the association between these two diseases in adult patients.

Methods

Systematic review in PubMed and Cochrane Database with articles published between 1951 and 2015. We included all articles that specifically studied the relationship between CRS and GERD.

Results

Of the 436 articles found, only 12 met the inclusion criteria. Eight cross-sectional articles suggest a relation between CRS and GERD, especially on CRS that is refractory to clinical or surgical treatment. However, the groups are small and methodologies are different. Four other longitudinal studies have assessed the effect of treatment with proton pump inhibitors (PPIs) on the improvement of symptoms of CRS, but the results were conflicting.

Conclusions

There seems to be relative prevalence of reflux with intractable CRS. There is still a lack of controlled studies with a significant number of patients to confirm this hypothesis. Few studies specifically assess the impact of treatment of reflux on symptom improvement in patients with CRS.

Gastroesophageal reflux disease related asthma: From preliminary studies to clinical practice

The diagnosis of asthma requires the presence of episodic respiratory difficulties characterized by variable and reversible airway obstruction. It has a high prevalence worldwide and is traditionally considered to be an allergic disease. Most cases are responsive to treatment with bronchodilators and anti-inflammatories, as recommended by national and international guidelines; however, approximately 10% of asthmatic patients are refractory even to optimal therapy. Gastroesophageal reflux disease (GERD) is a common disorder in asthmatic patients and the two disorders may be linked pathophysiologically. Here we review data from preliminary studies that suggest asthma could be induced or exacerbated by gastroesophageal reflux. The optimal strategies for the diagnosis of GERD-related asthma and its therapy are still debated. However, there is evidence to suggest that antireflux treatment is effective and practical for asthmatic patients with well-defined reflux disease.

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

BACKGROUND

Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are common entities that overlap in patient demographics. The pathophysiologic role of GERD has yet to be elucidated, but it is postulated that extraesophageal reflux may contribute to worsening symptoms of CRS. This study seeks to investigate whether patients with CRS with and without a history of GERD experience comparable quality-of-life (QOL) improvement after endoscopic sinus surgery (ESS).

METHODS

An adult cohort (n = 229) with medically refractory CRS was prospectively assessed following ESS using 3 disease-specific QOL constructs. A patient subset with a history of comorbid GERD was retrospectively identified (n = 72) and preoperative and postoperative QOL were compared to patients without GERD (n = 157).

RESULTS

Patients with comorbid GERD and CRS were comparable across all baseline patient characteristics (p > 0.050) with the exception of patients with a history of GERD; those patients were less likely to have undergone allergy testing (p < 0.002) and were older (53.8 years vs 47.6; p < 0.002). Similarly, baseline objective and subjective measures of disease were comparable between patients with CRS with and without GERD (p > 0.050). Both groups experienced significant QOL improvement across all QOL constructs (p ≤ 0.021), and no difference was detected in the magnitude of that improvement between patients with and without a history of GERD (p > 0.050). Similarly, patients on active medical therapy for GERD (n = 49) had QOL gains comparable to patients not reporting GERD medical therapy (p > 0.050).

CONCLUSION

Patients electing ESS for CRS with and without comorbid GERD have comparable baseline characteristics and QOL outcomes following surgery.

Adenoid ciliostimulation in children with chronic otitis media

OBJECTIVE

Adenoid hypertrophy and chronic adenoiditis are associated with an increased incidence of chronic otitis media. This study intends to determine the relationship between chronic otitis media and dynamic ciliary beat frequency in children undergoing adenoidectomy.

STUDY DESIGN

Prospective, controlled study.

SETTING

Pediatric tertiary care hospital.

SUBJECTS AND METHODS

Children undergoing adenoidectomy were enrolled. Patients were stratified according to their indication for surgery, including adenotonsillar hypertrophy with obstructive sleep apnea, chronic otitis media with effusion, or recurrent episodes of acute otitis media. Adenoids were harvested using the curette. Tissue was sectioned and allowed to equilibrate in basal media for 24 hours. Cilia-bearing tissue was then stimulated using isoproterenol or methacholine. Ciliary beat frequency was serially reordered and analyzed using the Sisson-Ammons Video Analysis software program.

RESULTS

Baseline ciliary beat frequency was similar in all groups (N = 47, total). Using isoproterenol, children with chronic otitis media with effusion demonstrated a blunted dynamic ciliary response at 2 and 3 hours relative to control (P = .0176 and P = .0282). Methacholine-stimulated ciliary beat frequency was not different between each group.

CONCLUSION

At 2 and 3 hours following isoproterenol stimulation, there was a significant blunting of dynamic ciliary beat frequency in children with chronic otitis media with effusion. This ciliary dysfunction may provide a physiological explanation related to chronic adenoiditis in children with chronic otitis media.

Does reflux have an effect on nasal mucociliary transport?

CONCLUSION

Gastroesophageal and laryngopharyngeal reflux were found to have no effect on nasal mucociliary transport.

OBJECTIVE

Gastroesophageal and laryngopharyngeal reflux have been recognized as causative factors for chronic rhinosinusitis but no definite mechanism has been described yet. We aimed to determine whether gastroesophageal and laryngopharyngeal reflux impair nasal mucociliary transport.

METHODS

This was a prospective cohort study in a tertiary referral center. Fifty patients with both laryngopharyngeal and gastroesophageal reflux comprised the study group. Reflux syndrome index and reflux finding score were calculated for each patient before and after treatment. Antireflux medication was given for 12 weeks. The control group consisted of 30 healthy volunteers. Nasal mucociliary transport was assessed by means of the saccharine test. It was performed before and after the treatment. Statistical analysis was performed using the saccharine test results of the study and control groups.

RESULTS

No statistical difference was found between the saccharine test results of the study group and control group before treatment. The differences between the pretreatment and post-treatment reflux symptom index and reflux finding scores were statistically significant. The difference between the post-treatment saccharine test results of the patients in whom reflux scores returned to normal and those with remaining high scores was not statistically significant.