International Journal of Pediatric Otorhinolaryngology
Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis
Introduction
Chronic rhinosinusitis (CRS) has a severe impact on the health related quality of life in the pediatric population and is a challenging disease for physicians to treat [1]. Studies have demonstrated that gastroesophageal reflux disease (GERD) occurs more frequently than expected in patients with CRS [2]. The signs and symptoms of pediatric sinusitis include chronic cough, rhinorrhea, nasal congestion, and post nasal drip. Some common pediatric symptoms of GERD include nasopharyngeal inflammation and secretions, sore throat, chronic cough, recurrent pneumonia, and chronic and/or recurrent middle ear infections [3], [4], [5]. The similarity in nasal symptoms of discharge and congestion from nasal inflammation makes an accurate diagnosis of GERD and/or CRS challenging.
CRS is one of the most common diseases in the pediatric population [6], and the diagnosis is made primarily clinically. Practice guidelines have been issued by the American Academy of Pediatrics [7], however the pathogenesis and management of this disease continues to be relatively undetermined [8]. Sinus aspiration with recovery of bacteria in high density (≥104 colony-forming units/mL) from the paranasal sinuses remains the gold standard for the diagnosis of acute or chronic bacterial sinusitis [9]. CRS in children has multiple etiologies including viral and bacterial upper airway infections, allergies, GERD, smoking irritants, cystic fibrosis, immunodeficiency, mucociliary disorders, and nasal and sinus anatomical abnormalities [10], [11], [12]. The bacteriology of CRS includes the 3 main pathogens associated with acute disease: Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis. Chronic sinusitis also includes Staphylococcus aureus, Pseudomonas, anaerobic bacteria, and fungi. Studies have shown that the role of bacterial infection as a primary cause of chronic infection has not been defined and that noninfectious factors such as GERD, allergy, may play more of a role in the chronic inflammation of the paranasal sinuses [13], [14]. It is estimated that 5–13% of viral upper respiratory infections are complicated by secondary bacterial sinusitis [15], 5–10% of which do not respond to conventional antimicrobial therapy [16]. Studies have found that children in the 1–5 year old age group are found to respond more frequently to a single course of antibiotics, compared to the older children in the 4–7 year-old group that tend to have more chronic symptoms [17].
Most healthy infants have occasional regurgitation known as physiologic reflux. Nelson reported an incidence of gastroesophageal reflux (GER) in up to 60% of infants aged 6 months, which declined to 5% at the end of the first year of life [18]. GER at this age is due mainly to lower esophageal sphincter immaturity and a predominantly liquid diet. Reflux fades by 1 year of age as solids are introduced into the diet and the lower esophageal sphincter matures [19]. Persistent and bothersome gastroesophageal reflux in children resulting in secondary conditions such as respiratory symptoms, apnea, and failure to thrive; is considered pathologic and thus termed GERD. In children, GERD is associated with an increased risk of sinusitis, asthma, laryngitis, and bronchiectasis [20]. Studies have shown that 10% of infants suffer from GERD, and that up to 25% of asymptomatic children have GERD with 8% having nasopharyngeal reflux [21], [22]. The “gold standard” for the diagnosis of GERD is the 24-h pH probe [23], and the double electrode pH probe with distal esophageal plus pharyngeal or proximal esophageal electrodes is considered the “gold standard” for diagnosis of nasopharyngeal reflux and the extraesophageal manifestations of GERD [3]. Esophageal biopsy showing histologic esophagitis is a rapid, safe and effective diagnostic test for GERD that can be done during rigid esophagoscopy [24].
Laryngopharyngeal reflux (LPR) is defined as the extraesophageal reflux of gastric contents into the larynx and hypopharynx and when the reflux reaches the nasopharynx it is termed nasopharyngeal reflux (NPR). LPR is considered a distinct entity from GERD, as patients with LPR do not have the complaints of heartburn or other esophagitis symptoms [25]. LPR is commonly associated with hoarseness, dysphagia, globus sensation, and chronic throat clearing [26], [27]. The reflux of gastric contents into the pharynx is also associated with the nasal symptoms, and it has been demonstrated that NPR plays a role in refractory sinusitis [28]. Wise et al. provided evidence using pH probe testing, that patients with pathological NPR and LPR have the increased symptom of postnasal drip [29].
Both CRS and GERD are common diseases affecting patients, however studies demonstrate that GERD occurs more frequently than expected in patients with CRS [2]. The objective of this study was to further explore the relationship of CRS and GERD by studying the incidence of simultaneous or independent CRS and GERD, using maxillary antral cultures and esophageal biopsies as presumptive diagnostic tests, in children with symptoms of nasal rhinorrhea, congestion, and chronic cough.
Section snippets
Methods
The study was designed as a retrospective chart review of the medical records of 63 children ages 6 months to 10 years old at Wayne State University who presented to clinic with symptoms of nasal congestion, rhinorrhea, and cough lasting longer than 12 weeks, refractory to first line antimicrobial therapy. Approval from the institutional review board at Wayne State University was obtained before proceeding with the retrospective chart review. The following information was acquired: age, sex,
Results
Twenty-seven of the 63 children had esophageal biopsies that were positive for esophagitis. Eighteen (66%) children were in the 6-month to 5-year-old age group, and 9 (34%) were in the 6–10 year old age group. When analyzing all the patients as one group (n = 63), 15 (24%) patients were found to have simultaneous positive maxillary antral cultures and positive esophageal biopsies, 12 (19%) patients had positive esophageal biopsies alone, 26 (41%) patients had positive maxillary antral cultures
Discussion
The symptomatic etiologies between the two age groups of children are shown to be different. The younger children in this study were found to have the symptoms of nasal congestion, nasal drainage, and cough secondary to either CRS only, or GERD only, while 14% were found to suffer from these diseases simultaneously. In comparison, the older children tended to either suffer from both CRS and GERD simultaneously, or have these symptoms from a different etiology all together. Thirty-five percent
Conclusion
In conclusion, symptoms of nasal congestion, nasal drainage, and cough are common symptoms in children. CRS and GERD are very common diseases found in children, however the incidence of simultaneous or independent disease in children belonging to the 6-month to 5-year-old age group is different compared to children in the 6–10 year old age group. Children in the younger age group were more likely to have independent CRS or GERD, while the older children were more likely to have these diseases
Conflict of interest
No conflict of interest to disclose for any of the authors.
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