title: The role of extraesophageal reflux in medically and surgically refractory rhinosinusitis.
abstract: OBJECTIVE
  To clarify the relationship between chronic rhinosinusitis (CRS) and extraesophageal reflux (EER) using state-of-the-art technology. We hypothesized that patients with medically and surgically refractory CRS would have a greater prevalence of EER. We also hypothesized that there would be evidence of gastric refluxate reaching the nasopharynx and paranasal sinuses.
  
  
  METHODS
  Case-control analysis.
  
  
  METHODS
  Twenty-two patients with medically and surgically refractory rhinosinusitis were enrolled in the study. Subjects all underwent comprehensive testing for EER including 24-hour pharyngeal pH probe, aerosolized nasopharyngeal pH testing, and nasopharyngeal tissue biopsy for pepsin analysis. In addition, the last five subjects underwent nasal lavage pepsin analysis. A control group of healthy subjects underwent the same nasal secretion pepsin analysis.
  
  
  RESULTS
  Twenty subjects completed the study. The pharyngeal pH probe results were positive in 19/20 (95%), where the DeMeester score was positive in 9/19 (47%). The nasopharyngeal pH probe data were available in 17/20 patients and correlated poorly with the pharyngeal pH probe testing. In all 20 subjects, nasopharyngeal tissue biopsies were negative for pepsin. However, in the five subjects who underwent nasal lavage pepsin analysis, all were pepsin positive while five healthy control nasal lavage pepsin analysis were negative.
  
  
  CONCLUSIONS
  This study supports an association of EER with medically and surgically refractory CRS. The finding of pepsin in nasal lavages suggests that direct contact of the refluxate with the paranasal sinus mucosa may play a role in the pathophysiology of CRS in this patient population. Finally, evaluation for pepsin in nasal fluid may be a viable method for determining the presence of refluxate in the nose and paranasal sinuses.
authors.affiliation: Division of Otolaryngology, Medical College of Wisconsin/Zablocki VA Medical Center, Wood, Wisconsin, Milwaukee, Wisconsin, USA. tloehrl@mcw.edu
authors.forename: Todd A
authors.initials: TA
authors.lastname: Loehrl
authors.forename: Tina L
authors.initials: TL
authors.lastname: Samuels
authors.forename: David M
authors.initials: DM
authors.lastname: Poetker
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Toohill
authors.forename: Joel H
authors.initials: JH
authors.lastname: Blumin
authors.forename: Nikki
authors.initials: N
authors.lastname: Johnston
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012220:Rhinitis / Q000150:complications / Q000209:etiology* / Q000601:surgery / Q000628:therapy; D012852:Sinusitis / Q000150:complications / Q000209:etiology* / Q000601:surgery / Q000628:therapy