Chronic sinusitis and GERD or extraesophageal reflux disease

Chronic sinusitis and GERD

chronic sinusitis is a common clinical condition.  There is increasing evidence from observational studies that  both paediatric and adult patients with chronic sinusitis  frequently have associated GORD and EOR and that these  patients may benefit from medical antireflux therapy. GORD  and EOR may contribute to the pathogenesis of chronic  sinusitis by causing sinonasal congestion, compromised sinus  drainage, and inflammation.29  Otitis media  Otitis media with effusion (OME) is a prevalent condition  and the most common cause of hearing loss in childhood.  Recently, Tasker et al reported high concentrations (up to a  1000-fold greater than serum levels) of pepsin/pepsinogen in  59 of 65 middle ear effusion samples from children with  OME. The authors concluded that reflux of gastric juice into  the middle ear may be the primary factor in the initiation of  OME in children.  Using upper gastrointestinal endoscopy and 24 hour pH  monitoring, we prospectively assessed the coexistence of  GORD in consecutive adult patients with chronic secretory  otitis media (CSOM) or with a chronic refractory feeling of  pressure in the ear(s) (CRFP). All patients with CSOM and  most patients with CRFP had evidence of GORD (oesophagitis  and/or abnormal pH metry). Medical antireflux therapy  with open label PPI led to cessation of middle ear drainage  and CRFP after, on average, 11 weeks and four weeks,  respectively. These studies indicate that GORD may  directly cause or contribute to chronic ear problems, both in  children and in adults. RCTs evaluating the effect of  antireflux therapy are lacking.  Excessive throat phlegm and postnasal drip  It has been suggested that unexplained excessive throat  phlegm may also be a manifestation of GOR but formal  .( Chang A,et al ,2005)

so if any one suffering from chronic sinusitis with no response to treatment we should consider gerd as main cause if there are any digestive trouble or if the patient is on medical treatment for reflux.

laryngopharyngeal reflux  Gastroesophageal reflux disease

laryngopharyngeal reflux  Gastroesophageal reflux disease (GERD) in children is a common physiological occurrence. Accurate epidemiological studies on the incidence and prevalence of GERD are lacking. Vandenplas and Sacre-Smits estimated that the incidence of reflux in all infants is around 18%. In some conditions, such as tracheoesophageal fistula, neurological impairment, or oral motor dysphagia, the incidence is thought to be as high as 70% . Infants are predisposed to reflux due to a shorter intra-abdominal esophagus and an immature lower esophageal sphincter. Older children have an increased risk of nocturnal reflux due to a reduced rate of swallowing. In addition, esophageal acid neutralization by the alkaline saliva is less at night in children than in adults. Up to 50% of normal infants have regurgitation, which in the majority of cases, spontaneously resolves by the age of 2 years. Reflux predominantly occurs during the postprandial period and typically presents as regurgitation or vomiting . (Burton DM,  et al ,2010)

These symptoms, however, tend to resolve after the first year of life . Persistent reflux may, however, give rise to complications. Pediatric laryngopharyngeal reflux (PLPR) is thought to be implicated in the development of various respiratory and otolaryngological conditions, including refractory asthma, recurrent bronchitis, laryngomalacia, and subglottic stenosis (SGS) . Recent studies, linking reflux with otitis media, have fueled a new theory for the pathogenesis of this common childhood disease . (Rozmanic V,et al ,2011)

so if you have persistent upper respiratory symptoms not responding to treatment

you should first consider  GERD as extra oesophageal reflux may lead or reach upper respiratory lead to laryngopharyngeal reflux .

and when you receive treatment for gerd you will get improved as the main cause of your symptoms is the extraoesophageal acid reflux reaching the upper respiratory and the main target of our treatment is to stop the cause

when to change your life style or to improve diet to act against gerd it will decrease the extra-esophageal symptoms or respiratory symptoms

gerd and respiratory system

Extraesophageal reflux disease (EERD) represents a wide spectrum of manifestations mainly related with the upper and the lower respiratory system such as laryngitis, asthma, chronic obstructive pulmonary disease, cough, hoarseness, postnasal drip disease-sinusitis, otitis media, recurrent pneumonia and laryngeal cancer. Non-cardiac chest pain is commonly grouped among the esophageal syndromes by the Montreal Classification. but is not one of the common symptoms of typical gastroesophageal reflux (GER) which are heartburn and regurgitation . The diagnosis and recommendations on initial empiric therapy for patients with suspected reflux related non-cardiac chest pain is similar to those of extraesophageal reflux which is why it is included in this chapter. GER contributes to extraesophageal syndromes by two mechanisms: direct (aspiration) or indirect (vagally-mediated) mechanisms .

Reflux of gastroduodenal contents into the esophagus and hypophayrnx may be classified as either “high” or “distal” . The pathogenesis of “high” esophageal reflux involves reflux that traverses the esophagus and induces cough either by direct pharyngeal or laryngeal stimulation or aspiration and causes a tracheal or bronchial cough response. In “distal” esophageal reflux, cough can be produced by a vagally-mediated trachealbronchial reflex . Embryologic studies show that esophagus and bronchial tree share a common embryologic origin and neural innervation via the vagus nerve. Pressure gradient changes between the abdominal and thoracic cavities during the act of coughing, may lead to a cycle of cough and reflux . A disturbance in any of the normal protective mechanisms such as disruption of the mechanical barrier for reflux (lower esophageal sphincter) or esophageal dysmotility may allow direct contact of noxious gastroduodenal contents with the larynx or the airway . In this article we will discuss the latest knowledge of the association between extraesophageal manifestations of GER such as chronic cough, laryngitis and asthma as well as non-cardiac chest pain of esophageal origin.We will discuss the current recommendations on diagnosis and treatment options for this difficult group of patients  (Burton DM,  et al ,2010)


Complicated GERD gastroesophageal acid reflux disease

Numerous complications have been associated with persistent GERD (gastroesophageal acid reflux disease), especially when it is nocturnal. In a study comparing daytime GERD(gastroesophageal acid reflux disease), nighttime GERD or a combination of both, the incidence of esophagitis was higher among individuals with nocturnal symptoms than those with daytime GERD(gastroesophageal acid reflux disease), although patients who had both experienced the highest rate of esophagitis . Poh et al.  recently demonstrated that the duration of nocturnal reflux events is longer and usually asymptomatic. The potential esophageal complications of persistent GERD(gastroesophageal acid reflux disease) include esophagitis, peptic strictures, esophageal ulcerations and bleeding, Barrett’s esophagus and esophageal adenocarcinoma. Management of complicated GERD(gastroesophageal acid reflux disease) includes dilation for benign peptic stricture in patients presenting with dysphagia. These patients should be supplemented with long-term PPI to reduce the need for repeated dilations (Poh CH, et al , 2010).

Patients presenting with bleeding esophageal ulcers can be treated endoscopically with adrenaline injections, hemoclips and heater probes. They should be on long-term PPI to ensure healing of the ulcer. The management of Barrett’s esophagus and esophageal adenocarcinoma is beyond the scope of this review. GERD(gastroesophageal acid reflux disease) in the elderly Gastrointestinal disorders are common in elderly patients. A population-based study from Finland showed that the prevalence of daily GERD(gastroesophageal acid reflux disease) symptoms in those aged 65 years and older was 8% in males and 15% in females . (Plant RL.1998)

Furthermore, Zhu et al. observed that abnormal  gastroesophageal reflux occurred more frequently in the elderly than in younger individuals. The mean time pH\4 was significantly higher in the elderly as compared to younger individuals, 32.5 versus 12.9%. In addition, more elderly patients (21%) have grade III–IV erosive esophagitis (based on Savary–Miller criteria) compared to younger patients (3.4%), p\0.002 . Aging may result in various physiological changes in the gastrointestinal tract . These changes may increase the risk of development of disorders such as GERD (gastroesophageal acid reflux disease). Co-morbidity and concomitant use of medications in the elderly can diminish esophageal sphincter tone, esophageal clearance mechanisms and saliva production. Some of the common medications that can predispose the elderly to reflux are calcium channel blockers, nitrates, narcotics, medications with anti-cholinergic effects and theophylline. The manifestation of GERD(gastroesophageal acid reflux disease) in the elderly differs from that in younger individuals. Heartburn occurs less frequently, and acid regurgitation is present in less than 25% of patients.( Mold JW, et al ,1991)

Mold et al.  reported that only 54% of elderly patients complained of heartburn. In contrast, atypical symptoms such as vomiting, anorexia, dysphagia, respiratory symptoms, belching, dyspepsia and postprandial fullness are common presentations in the elderly with GERD(gastroesophageal acid reflux disease) . The main clinical concern of atypical presentation of GERD in the elderly is the delay in diagnosis and hence the delay in giving the appropriate treatment. Diagnostic modalities for GERD (gastroesophageal acid reflux disease)that are available for elderly patients parallel those for younger patients. Upper endoscopy is usually advocated in the elderly because they present with atypical symptoms and are at increased risk for malignancy and peptic ulcer disease.   Treatment of GERD(gastroesophageal acid reflux disease) in the elderly is similar to the treatment in younger patients. However, a very aggressive therapeutic approach should be considered in elderly patients with GERD(gastroesophageal acid reflux disease) because they tend to present with more severe disease. When treating elderly patients with acid suppression therapy such as H2RAs and PPIs, caution needs to be exercised for potential drug interactions considering that polypharmacy in the elderly is not uncommon. Several recent studies suggested that elderly patients on long-term PPI treatment have an increased risk of bone fracture, community-acquired pneumonia and hospitalacquired Clostridium difficile diarrhea . While most of these studies were population based, not prospective studies, and remain to be proven, elderly patients should receive the lowest dose of PPI that controls their symptoms, and usage of PPI should be limited to peptic-related disorders. (Laheij RJF,, et al,2004)

Digestive Enzymes and acid reflux

Digestive Enzymes

Supplemental digestive enzymes may reduce GERD symptoms. Delayed gastric emptying and a large volume of food in the stomach are associated with GERD symptoms, and supplementation using digestive enzymes may reduce these factors. Digestive enzymes are commonly included in combination products, including lipase, amylase, protease, maltase, lactase, sucrase, phytase, and cellulase. Clinically, some patients actually benefit from hydrochloric acid and pepsin supplementation, including individuals who have low levels of stomach acid and delayed gastric emptying. ( Mahmood A,,2007)