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

Sella, Guilherme Constante Preis; Tamashiro, Edwin; Anselmo-Lima, Wilma Terezinha; Valera, Fabiana Cardoso Pereira

doi:10.1016/j.bjorl.2016.05.012

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Brazilian Journal of Otorhinolaryngology

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Artigos de revisão • Braz. j. otorhinolaryngol. 83 (3) • May-Jun 2017 • https://doi.org/10.1016/j.bjorl.2016.05.012 copy

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review^☆ ☆ Please cite this article as: Sella GC, Tamashiro E, Anselmo-Lima WT, Valera FC. Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review. Braz J Otorhinolaryngol. 2017;83:356-63.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

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.

KEYWORDS
Rhinosinusitis; Laryngopharyngeal reflux; Gastroesophageal reflux disease; pH-metry; Proton pump inhibitor

Last month, how these problems affected you?	0 = No problem
	5 = important problem
1. Hoarseness or voice problem	0	1	2	3	4	5
2. Clearing the throat	0	1	2	3	4	5
3. Excessive throat or nose secretions	0	1	2	3	4	5
4. Difficulty swallowing food, liquids or tablets	0	1	2	3	4	5
5. Cough after eating or after lying down	0	1	2	3	4	5
6. Difficulties breathing or choking episodes	0	1	2	3	4	5
7. Excessive cough	0	1	2	3	4	5
8. Sensation of something sticking on the throat	0	1	2	3	4	5
9. Heartburn, chest pain, indigestion or stomach acid in the mouth	0	1	2	3	4	5

Endolaryngeal reflux findings score
Infraglottic edema	0 absent
Infraglottic edema	2 present

Ventricular obliteration	2 partial
Ventricular obliteration	4 complete

Erythema/hyperemia	2 only of arytenoids
Erythema/hyperemia	4 diffuse

Vocal fold edema	1 mild
	2 moderate
	3 severe
	4 polypoid

Diffuse laryngeal edema	1 mild
	2 moderate
	3 severe
	4 obstructive

Posterior commissure hypertrophy	1 mild
	2 moderate
	3 severe
	4 obstructive

Granuloma/granulation tissue	0 absent
Granuloma/granulation tissue	2 present

Thick endolaryngeal mucus	0 absent
2 present

Author	Type	Sample	Selection criteria	Measure	Risk of bias/EBM level	Result
Ozmen et al. (2008)²⁶26 Ozmen S, Yücel OT, Sinici I, Ozmen OA, Süslü AE, Oğretmenoğlu O, et al. Nasal pepsin assay and pH monitoring in chronic rhinosinusitis. Laryngoscope. 2008;118:890-4.	Case-control	33 vs. 22	Waiting for nasal surgery for CRS vs. without CRS	Pharyngeal and esophageal pH monitoring (2 channels); middle meatus suction for analysis of nasal pepsin	Mod/2b	Reflux that is more present in the group of CRS (88%) than in controls (55%); pepsin found in most reflux patients
DelGaudio (2005)²⁷27 DelGaudio JM. Direct nasopharyngeal reflux of gastric acid is a contributing factor in refractory chronic rhinosinusitis. Laryngoscope. 2005;115:946-57.	Case-control	38 vs. 10 vs. 20	CRS that is refractory to surgery vs. CRS solved vs. absence of CRS	Nasal, pharyngeal and esophageal pH monitoring (3 channels)	Mod/2b	More reflux in refractory CRS (76%) than on the other 2 groups (24%)
Ulualp et al. (1999)²⁸28 Ulualp SO, Toohill RJ, Shaker R. Pharyngeal acid reflux in patients with single and multiple otolaryngologic disorders. Otolaryngol Neck Surg. 1999;121:725-30.	Case-control	18 vs. 34	CRS that is refractory to surgery vs. absence of CRS	Pharyngeal and esophageal pH monitoring (3 channels)	Mod/2b	Higher percentage of reflux in patients with CRS with laryngitis (67%) and CRS patients (33%) when compared to controls (21%)
Ulualp et al. (1999)²⁹29 Ulualp SO, Toohill RJ, Hoffmann R, Shaker R. Possible relationship of gastroesophagopharyngeal acid reflux with pathogenesis of chronic sinusitis. Am J Rhinol. 1999;13:197-202.	Case-control	11 vs. 11	CRS that is refractory to medical treatment vs. absence of CRS	Pharyngeal and esophageal pH monitoring (3 channels)	Mod/2b	Higher percentage of reflux in CRS patients (64%) compared to control (18%)
Loehrl et al. (2012)³⁰30 Loehrl TA, Samuels TL, Poetker DM, Toohill RJ, Blumin JH, Johnston N. The role of extraesophageal reflux in medically and surgically refractory rhinosinusitis. Laryngoscope. 2012;122:1425-30.	Case-control	20 vs. 5	CRS that is refractory to medical treatment vs. absence of CRS	pH monitoring via dual-channel tube; nasopharyngeal biopsy (all patients) and lavage of nasal sinus for pepsin investigation (5 patients)	Mod/2b	LFR present in 95% of patients. Pepsin absent in nasopharyngeal biopsies but present (5/5) in lavages
Wong et al. (2004)⁹9 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.	Cohort	37	CRS that is refractory to medical treatment	pH monitoring via 4-channel tube	Mod/4	32.4% had GERD; LPR and reflux in nasopharynx was rare
Jecker et al. (2005)³¹31 Jecker P, Orloff LA, Wohlfeil M, Mann WJ. Gastroesophageal reflux disease (GERD), extraesophageal reflux (EER) and recurrent chronic rhinosinusitis. Eur Arch Otorhinolaryngol. 2006;263:664-7.	Case-control	20 vs. 20	CRS that is refractory to surgery vs. absence of CRS	pH monitoring via 2-channel tube	Mod/2b	GERD more present in the CRS group compared to control, but absence of LPR
Dinis and Subtil (2006)³²32 Dinis P, Subtil J. Helicobacter pylori and laryngopharyngeal reflux in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2006;134:67-72.	Case-control	15 vs. 5	CRS that is refractory to medical treatment vs. absence of CRS	Analysis of nasal biopsy for pepsin and H. pylori	High/2b	No intranasal pepsin was identified. No difference of H. pylori among the groups

Author	Type	Sample	Selection criteria	Measure	Risk of bias/EBM level	Result
Vaezi et al. (2010)³³33 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, 1887-1893.e1.	Controlled randomized test	75	Postnasal drip with no CRS or allergy	Symptoms evaluation and pH-metry using PPI	High/	Important improvement of symptoms compared to control group
DiBaise et al. (2002)³⁴34 DiBaise JK, Olusola BF, Huerter JV, Quigley EMM. Role of GERD in chronic resistant sinusitis: a prospective, open label, pilot trial. Am J Gastroenterol. 2002;97:843-50.	Cohort	11	CRS that is refractory to medical and surgical treatment	Symptoms score, pH-metry via dual-channel tube, nasolaryngoscopy after PPI treatment for 3 months	Mod/4	Mild improvement of symptoms
Pincus et al. (2006)³⁵35 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.	Cohort	30	CRS that is refractory to medical and surgical treatment	Evaluation of symptoms and pH-metry using PPI	High/4	25 of 30 had LPR or nasal reflux events. 14 of 15 improved with PPI
Durmus et al. (2010)³⁶36 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.	Case-control	50 vs. 30	GERD and LPR vs. absence of GERD	Nasal saccharin test and clinical evaluation before and after treatment with PPI	Mod/2b	No difference on saccharin test. There was significant improvement of symptoms

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] * Corresponding author. E-mail:facpvalera@uol.com.br (F.C. Valera).

Symptoms	Nasal blockage/obstruction
	Nasal congestion or rhinorrhea (anterior/posterior nasal drip):
	- ±facial pain/pressure
	- ±Smell reduction or loss

Endoscopic signs	Nasal polyps, and/or
	Mucopurulent discharge, mainly from middle meatus, and/or
	Mucosa obstruction/edema mainly on middle meatus

and/or CT changes	Changes on the mucosa within ostiomeatal complex, and/or paranasal sinuses