الفهرس 
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Abstract
Chronoc rhinosinusitis(CRS) is a persistent inflammatory disease of the nasal and sinus mucosa. It is believed to develop as a result of a host predisposition to exogenous bacteria or more commonly defects in the mechanical and innate immune barrier, which result in an abnormal microbiome, increased exposure to foreign material, and excessive compensatory immune responses Understandably, the reflux of gastric contents has been posited as a possible inducer and/or potentiator of the CRS disease process .(14)
GERD and CRS are prevalent disorders. Coexistence by chance is to be expected in a number of patients, and it,s Coexistence due to shared pathogenic mechanisms is controversial. Regardless of the precise mechanism, there is evidence that the association of GERD and impaired sinonasal function may predispose patients to develop CRS.(35)The present study sought to further explore the impact of GERD on CRS. In this study, we compared the sinonasal symptoms before and after medical treatment of GERD only in patients with CRS and GERD.
In this study GERD was diagnosed on the basis of clinical symptoms and diagnosis was strengthened by upper gastroscopy findings and/or results of 24-hour PH manometry. Patients with GERD who had sinonasal symptoms were examined endoscopicaly and radiological evaluation was done to confirm the diagnosis of CRS upon EPOS criteria and also to exclude any other aetiologies that may be the cause for their sinonasal symptoms. Our patients were maintained on proton pump inhibitors PPIs ( omeprazole 40 mg twice daily for 3 months ).
Our study included 40 patients in the start but 3 of them were lost in the follow-up, 19 of them were males and 18 were females with mean age 31.08+7,39 (range 18-55 years) (table1).
All our patients had PND and subsequent granular pharyngitis which improved at the end of the follow up with a significant p-value(0,000)(table13), this was in line with a similar study to ours, Nanda et al. who found that treating patients with refractory CRS and GERD using proton pump inhibitors (PPIs) in conjunction with functional endoscopic sinus surgery (FESS), constituted effective management of post-nasal drip and nasal congestion symptoms.(29) while these results were opposed by Flook and Kumar who concluded that there is no evidence of a causal link between these two common clinical conditions. Furthermore, they stated that there is no evidence that true refractory CRS is resolved by antireflux therapy to any great extent.(50) Also, a review of the investigation and management of recalcitrant CRS by Woodbury and Ferguson states that acid reflux has not been identified as a cause of CRS. However, they acknowledge that PPIs therapy decreases the frequency of postnasal drip and recommend antireflux therapy for patients with CRS who have postnasal drip as a dominant symptom.(51) Another study aimed at the effect of treatment with PPIs on the improvement of nasal symptoms in patients with CRS; Vaezi et al conducted a controlled, randomized, double-blind study to evaluate the effect of lansoprazole 30 mg twice daily in 75 patients with chronic rhinitis, a complaint of postnasal drip, no CT abnormalities in the sinuses, Patients receiving therapy with lansoprazole were 3.12 times (at 8 weeks of treatment) and 3.5 times (after 16 weeks of treatment) more likely to notice improvement of their postnasal drip compared to controls. After 16 weeks, the average improvement in the treatment arm was 50% compared to 5% in the placebo group.(28)
Nasal obstruction was found in the majority of our patients(78,4%). With significant improvement(p-value 0,000)(table14). This was compatible with the endoscopic nasal examination that showed 51.4% of our patients had nasal congestion and 70,3% of them had hypertrophied inferior turbinates which was evident also by radiological evaluation, these findings show significant improvement in the follow up (tables 14,15). These results were in line with Dagli and colleagues who conducted a prospective observational clinical study in which 50 patients with confirmed esophagitis and symptoms of LPR, making up the study group, were treated with a PPIs for 12 consecutive weeks and no other treatment for nasal obstruction, compared with a control group, consisting of 50 patients who had no symptoms of nasal obstruction. there was significant improvement in nasal obstruction.(52)
Thirty-six of our patients(97,3%) were complaining of headache, at the end of the follow-up, only eight of them still complaining with significant improvement (p-value 0,000). Headache could be attributed to nasal congestion, mucosal edema, occlusion of the osteomeatal complex that was evident by endoscopic examination in most of our patients and also confirmed by radiological findings of opacification of paranasal sinuses and osteomeatal complex that showed significant improvement at the end of our study (table14).
It should be considered that PND, headache, and nasal obstruction were the leading symptoms that pushed our patients to seek medical advice. These symptoms showed significant improvement after medical treatment of GERD, this matched with a similar prospective study conducted by DiBaise et al (31)who compared 11 patients who had failed clinical and surgical treatment of CRS, Treatment with 20 mg omeprazole twice daily for 12 weeks was instituted only in the CRS group, and this was reassessed on a monthly basis. The authors noted modest improvement in symptoms and overall satisfaction with the treatment among these patients. Also, Pincus et al(30) performed pH-metry in 30 patients with refractory CRS Of these, 25 had an associated diagnosis of GERD. For these patients, treatment with PPIs was started. Of the 15 patients who were reevaluated, 14 reported improvement of nasal symptoms, and seven fully improved their complaints. This matched with our results.
while on the other hand, Durmus et al (53)studied 50 patients with GERD and nasopharyngeal reflux(NPR), based on clinical and endoscopic diagnosis, and compared them to 30 healthy patients. All patients then underwent treatment with lansoprazole 30 mg twice daily for 12 weeks. There was no statistical difference between the results in the control and study groups before and after treatment. These authors concluded that both GERD and the NPR do not seem to affect the nasal mucociliary transport.
Six of our patients had anterior nasal discharge that disappeared in the first follow-up (after 1 month)(table 13) this may be due to concurrent infection or sequelae of nasal congestion. A retrospective chart by Nation and colleagues reviewed 63 children, aged 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough who had maxillary cultures, adenoidectomy, and distal third esophageal biopsies. In all of these patients GERD plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.(54) nasal itching was found in about one-third(17 patients) with statistically significant improvement.
It was noticed that hyposmia was detected in about one fourth(10 patients) and table2) but had no significant improvement at the end of our study (table13). This was against some theories that found a correlation between GERD and these symptoms, A study of seventy-six subjects, healthy controls (n = 13), gastroparesis alone (n = 30), GERD alone (n = 10), and both gastroparesis and GERD (n = 23) that was conducted by Kabadi and colleagues found that Taste and smell disturbances were higher in patients with gastroparesis, GERD, and both gastroparesis and GERD compared to healthy controls. Taste and smell abnormalities were associated with increasing symptoms severity of GERD and may contribute to the food intolerance that many of these patients experience. There was a dramatic improvement of smell and taste after treatment of GERD but the study did not assess a causal relationship between these two parameters and recommend Further investigations.(55)
Finocchio et al conducted another study that investigated 2887 subjects aged 20–84 years, who underwent a clinical visit in seven Italian centers, the combination of gastritis and GERD was associated with a four-fold increase in the risk of non-allergic rhinitis(NAR) with symptoms of rhinorrhea, nasal congestin, nasal itching, and nasal obstruction.(25)
Regarding endoscopic nasal examination and multislice computed tomography(MSCT) evaluation of our patients, we found that a large number of our patients had mucosal congestion, ethmoidal opacity, maxillary opacity in the form of maxillary mucosal thickening or maxillary retention cyst, bilateral hypertrophied inferior turbinates and osteomeatal complex occlusion, with significant improvement at the end of our study (tables13,14) these findings follow other studies that support the relation between GERD and sinonasal symptoms, for example, Numerous groups have suggested that direct contact of acidic gastric contents from GERD with sinonasal tissues may perpetuate and even initiate the mucosal inflammation seen in CRS, one of them was Delgaudio who explored this possibility by studying NPR via 24-hour pH monitoring of patients with refractory CRS. Compared to control groups, patients with refractory CRS experienced significantly more NPR events (pH < 5, 24% vs 76%, P = .00003). Per the reflux area index (RAI), reflux at the upper esophageal sphincter (UES) was designated abnormal if more than 6.9 reflux events were noted or an RAI greater than 6.3 was measured. Based on these parameters, 58% of the study group, compared to 21% of controls, demonstrated abnormal UES RAI (P = .007).(21)Another study conducted by Katle and colleagues revealed an increased average total number of reflux events in patients with CRS compared to healthy controls (56.5 vs 33; P < .0005). (15)Also, Ulualp et al.(23) also observed a higher prevalence of GERD in a group of 11 patients with CRS, who had not responded to conventional treatment (7 of 11, or 64%) compared to 11 healthy controls (2 of 11, or 18%), he evaluated patients with sinonasal complaints with a three-channel pH-metry, found a higher prevalence of acid reflux in the hypopharynx and signs of posterior laryngitis at endoscopy in patients with CRS and persistent complaints after endoscopic nasal surgery (4 of 6 patients, or 67%) when compared to healthy controls (7 of 34, or 21%), He concluded that the GERD can play an important role in patients with CRS.
Also, it was found that ten of our patients(27%) had left and six (16,2%) had right dull tympanic membrane either due to middle ear effusion or eustachian tube dysfunction which was confirmed by tympanogram evaluation, there was a significant improvement in the follow-up of patients with dull left tympanic membrane but interestingly not in those with dull right one, no definite explanation of this comparison and in our opinion further studies are recommended with more focus on this point. It should be considered that in the 2015 Eustachian Tube Dysfunction (ETD) Consensus Statement published in ‘Clinical Otolaryngology, ETD is characterized by signs and symptoms of pressure dysregulation in the middle ear. The Consensus Statement panel mentioned that “When functioning normally, the Eustachian tube protects the middle ear against inflammation and infection by viruses, bacteria, and gastroesophageal reflux disease (GERD), Clearly, they agree that due to extraesophageal reflux caused by GERD, gastric contents can affect the Eustachian tube and can cause ETD and otitis media.(56)
Finally, regardless of the precise mechanism, GERD has a significant role in development of many sinonasal symptoms, some limitations faced us during this study, for example, it was difficult to measure pepsin in the PND or even in nasal biopsy, also we couldn’t find multichanel PH-metry to determine acidic reflux in the nasopharynx.
Summary and conclusion
Summary and conclusion
Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are common entities that overlap in patient demographics. CRS is a common condition characterized by inflammation and swelling of the cavities around the nasal passages (sinuses) for at least 12 weeks despite treatment attempts. GERD has been reported to occur in CRS more frequently than expected.
Our study is considered a analytic observational study in which 37 patients above 18 years who were comlaining of sinonasal symptoms and diagnosed to have gasrtic reflux were treated by medical treatment of gastric reflux only and they were followed up for 3 months to evalute if there was improvement in their sinonasal symptoms or not.
This study was conducted in otorhinolaryngology department with the help of Tropical Medicine and gastroenterology department to confirm diagnosis of gastric reflux by upper endoscopy or ph-manometry. All patients had MSCT of nose and PNS to evaluate their sinus condition in the first visit and after 3 months.
At the end of our study we concluded that many sinonasal symptoms improved with medical treatment of gastric reflux only especially PND, nasal obstruction, nasal itching, and headache.