Patients with chronic rhinosinusitis and simultaneous bronchial asthma suffer from significant extraesophageal reflux

Association Between Inferior Turbinate Hypertrophy and Extraesophageal Reflux

Importance

To the authors' knowledge, no prior studies have examined the association between inferior turbinate hypertrophy (ITH) and extraesophageal reflux (EER). If EER were a cause or cofactor of ITH, antireflux treatment can be considered prior to surgical intervention.

Objective

To evaluate EER presence and severity in patients with different degrees of ITH.

Design, Setting, and Participants

Prospective multicentric cohort study conducted at 3 referral centers treating patients with EER and certified for 24-hour monitoring of oropharyngeal pH. The monitoring was performed between October 2020 and October 2021. A total of 94 adult patients with EER symptoms were recruited, 90 of whom were analyzed.

Interventions

Nasal endoscopy was performed to determine the degree of ITH, according to the Camacho classification. Presence and severity of EER were examined using 24-hour monitoring of oropharyngeal pH.

Main Outcomes and Measures

Primary outcomes were presence of EER according to RYAN Score, total percentage of time below pH 5.5, and total numbers of EER events below pH 5.5.

Results

Of the 90 analyzed patients (median [IQR] age, 46 [33-58] years; 36 [40%] male patients), 41 had a maximum of second-degree ITH (group 1), and 49 patients had at least third-degree ITH (group 2), according to the Camacho classification. On the basis of the RYAN Score, EER was diagnosed more often in group 2 (69.4%) than in group 1 (34.1%; difference, 35.3% [95% CI, 13.5%-56.9%]). Moreover, compared with group 1, group 2 exhibited higher median total percentage of time below pH 5.5 (median [IQR], group 1: 2.1% [0.0%-9.4%], group 2: 11.2% [1.5%-15.8%]; difference, 9.1% [95% CI, 4.1%-11.8%]) and higher median total number of EER events (median [IQR], group 1: 6 [1-14] events, group 2: 14 [4-26] events; difference, 8 [95% CI, 2-15] events). Patients with proven EER demonstrated no difference in the degree of ITH between the right and left nasal cavity (Cohen g, -0.17 [95% CI, -0.50 to 0.30]), or between the anterior and posterior parts of the nasal cavity (Cohen g, -0.21 [95% CI, -0.50 to 0.17]).

Conclusions and Relevance

In this cohort study, patients with a higher degree of ITH had more severe EER. A possible association between severe ITH and EER was demonstrated.

Diagnostic Value of the PeptestTM in Detecting Laryngopharyngeal Reflux

BACKGROUND

The Peptest^TM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR.

METHODS

Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes.

RESULTS

Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively.

CONCLUSIONS

A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Allergic rhinitis is a risk factor of gastro-esophageal reflux disease regardless of the presence of asthma

Gastroesophageal reflux disease (GERD) can cause several upper airway symptoms and alter the physiology of nasopharyngeal mucosa, while upper airway diseases in turn might also exacerbate GERD symptoms. For a long time, asthma was considered a risk factor of GERD in the literature. Asthma and allergic rhinitis (AR) are usually identified as united airway disease according to similar epidemiology and pathophysiology; however, the association between AR and GERD is less elucidated. We aimed to evaluate whether AR would increase the development of GERD. Patients diagnosed as AR were identified from the National Health Insurance Research Database between January 1, 2000 and December 31, 2005 without prior history of gastroesophageal reflux disease. The outcome of interest was new-onset GERD. Cox regression models were applied to calculate the hazard ratio (HR) of GERD. We analyzed the data of 193,810 AR patients aged 18 years or older and being free of AR at baseline. The AR cohort (n = 96,905) had a significantly increased risk of GERD over a non-AR cohort (n = 96905) (adjusted HR (aHR) 1.94; 95% CI = 1.88–1.99, p < 0.001). AR may have stronger correlation with GERD than does asthma, although asthma might increase GERD risk by means of certain pathways shared with AR.

Comparison of Impedance and Pepsin Detection in the Laryngeal Mucosa to Determine Impedance Values that Indicate Pathological Laryngopharyngeal Reflux

OBJECTIVE

Recently, a 24-h impedance was used to detect laryngopharyngeal reflux (LPR). However, not every case of LPR is pathological. Thus, pathological pharyngeal impedance values need to be clearly established to diagnose pathological LPR. The aim of our study was to establish pathological 24-h pharyngoesophageal impedance/pH values for the diagnosis of LPR.

METHODS

The study was conducted in a tertiary care setting. A total of 30 patients who were referred to microlaryngoscopy for a laryngeal pathology that might be caused by LPR were included in this prospective study. All patients were off proton-pump inhibitor therapy. The 24-h pharyngoesophageal impedance-pH monitoring was performed 1 day before surgery. A biopsy of laryngeal tissue was obtained during microlaryngoscopy and was analyzed by immunohistochemistry to detect pepsin. The patients were divided into two groups: pepsin negative and pepsin positive (which indicated pathological LPR). The results of 24-h multichannel intraluminal impedance-dual-channel pH monitoring were compared between the groups. The number of LPR episodes in the pepsin-positive group was analyzed to establish a cutoff value for pathological LPR.

RESULTS

There were 18 participants in the pepsin-negative group and 12 in the pepsin-positive group. The median total pharyngeal refluxes detected were two (0-5) in the pepsin-negative group and 14 (6-39) in the pepsin-positive group (P<0.001), although the groups were otherwise homogeneous. There was a statistically significant difference in the number of all types of refluxes between groups. Six or more pharyngeal refluxes were the cutoff for the presence of pepsin in the laryngeal mucosa and, thereby, for the diagnosis of relevant/pathological LPR.

CONCLUSION

Six or more pharyngeal reflux episodes registered during the 24-h impedance/pH monitoring seem to be the cutoff for diagnosing pathological LPR. Therefore, it is possible to suggest establishing this value as the pathological impedance value indicating pathological LPR. These results must be interpreted with caution due to the small sample size.