Patients with higher degree of Inferior Turbinate Hypertrophy have more severe Extraesophageal Reflux: JAMA
Inferior turbinate hypertrophy (ITH), a frequent problem encountered in ear, nose, and throat practice, is associated with obstruction of nasal breathing and several health risks leading to mouth breathing, which is nonphysiological. Air inhaled through the mouth is not filtered, warmed, or humidified. This leads to more frequent respiratory infections, drying of the airways, and burning in the throat and can contribute to snoring and sleep apnea. Nasal obstruction results in a significantly reduced quality of life. Conservative treatment with topically applied corticosteroids is often ineffective, thus necessitating surgical reduction of the lower turbinates under local or general anesthesia. This operation is another cause of discomfort for the patient, carries risks, and should thus only be performed after the failure of conservative treatment.
Extraesophageal reflux (EER) is considered a possible factor contributing to multifactorial pathogenesis of nasal disorders. Previous investigations of the role of EER in chronic rhinosinusitis, especially in difficult-to-treat conditions, indicate that EER is a likely cofactor. Moreover, EER seems to play a role in the pathogenesis of chronic otitis media with effusion and other chronic ear problems. If EER contributes to ITH formation, then EER treatment could be another nonsurgical therapeutic approach for patients with ITH. Authors Karol ZelenÃk et al aimed to elucidate a possible association by examining EER severity using 24- hour monitoring of oropharyngeal pH in patients with varying degrees of ITH.
Prospective multicentric cohort study was 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. 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. 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
Of the 90 analyzed 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%). Moreover, compared with group 1, group 2 exhibited higher median total percentage of time below pH 5.5 and higher median total number of EER events. Patients with proven EER demonstrated no difference in the degree of ITH between the right and left nasal cavity, or between the anterior and posterior parts of the nasal cavity.
In this cohort study, the results demonstrated that there is a possible association between ITH and EER. Using 24-hour monitoring of oropharyngeal pH in study population, EER was detected more often in patients with more severe ITH. Notably, authors did not find differences in other factors that may contribute to ITH, namely smoking and allergies.
There is presently no reference standard for EER examination. Analysis of 24-hour esophageal pH impedance seems to provide the most accurate data for determining EER presence, type, and severity. Data from 24-hour esophageal pH–impedance analysis provide important information about reflux episodes in the esophagus, hypopharynx, and near the larynx. However, it cannot determine how many reflux episodes reach the nasopharynx and nasal cavity. Therefore, determination of reflux in the nasopharynx and nasal cavity is more complicated and less standardized than in the hypopharynx. To date, the most suitable tool for that purpose seems to be 24-hour monitoring of oropharyngeal pH (Restech system) with a probe positioned at the level of the nasopharynx.
"In our study, we used this method for detecting and quantifying reflux episodes that reached the nasopharynx and nasal cavity. The detailed results of our study demonstrate that the degree of ITH did not differ between the right and left nasal cavity or between the anterior and posterior parts of the nasal cavity among patients with proven EER. Probable interpretation is that EER reaches both posterior sides of the nasal cavity and causes secondary inflammation of the entire turbinate and nasal tissue. "
In summary, EER seems to be a currently underestimated factor associated with ITH. It is not clear how EER causes chronic inflammatory changes in the nasal mucosa, but low pH and pepsin seem to play a role. Low pH leads to increased junctional permeability through the disruption of protein bridge formation with cell-to-cell adhesion molecules, such as E-cadherin. Moreover, even under neutral pH, pepsin can increase the expression of the heat shock protein HSP70 in human nasal epithelial cells by activating the JNK/MAPK signaling pathway. This appears to be 1 mechanism through which EER can contribute to ITH and chronic rhinosinusitis.
In this cohort study, patients with a higher degree of ITH were more commonly diagnosed with more severe EER using 24- hour monitoring of oropharyngeal pH. A possible association between severe ITH and EER was reported.
Source: Karol ZelenÃk, MD, PhD; Zuzana Javorská, MD; Renata Taimrová; JAMA Otolaryngol Head Neck Surg.
doi:10.1001/jamaoto.2022.1638
