Can Gastroesophageal Reflux Disease (GERD) cause rhinosinusitis?

Can GERD Cause Rhinosinusitis?

Yes, GERD can cause rhinosinusitis, particularly in cases of refractory rhinosinusitis, though the relationship is not fully established with high-level evidence. 1

Evidence for GERD-Rhinosinusitis Connection

Pathophysiological Mechanisms

The relationship between GERD and rhinosinusitis is supported by several potential mechanisms:

1. Direct Reflux Pathway: Gastric acid may reflux directly into the pharynx and subsequently to the nasopharynx, causing inflammation of the sinus ostium and leading to sinusitis 1

2. Nasal-Esophageal Reflex: Wong and colleagues demonstrated that instillation of hydrochloric acid at the gastroesophageal junction triggered a vagal reflex causing increased nasal mucus production and worsening of nasal symptoms 1

3. Genetic Association: Recent Mendelian randomization analysis suggests GERD may increase the risk of developing chronic rhinosinusitis by 36% (OR 1.360,95% CI 1.179-1.568), indicating a potential genetic link between these conditions 2

Clinical Evidence

• pH Monitoring Studies: In children with chronic sinusitis, 63% showed gastroesophageal reflux (significantly higher than the 5% expected in the general population), with 32% demonstrating nasopharyngeal reflux 1

• Adult Studies:

  • 7 of 11 (64%) patients with CT-confirmed chronic sinusitis had documented gastroesophagopharyngeal reflux compared to only 2 of 11 healthy volunteers 1
  • 78% of adults with chronic sinusitis had abnormal esophageal pH probe results 1

• Prospective Research: A 10-year follow-up study found that subjects with nocturnal GERD (≥3 episodes per week) had 1.6 times higher odds (95% CI 1.0-2.5) of developing noninfectious rhinitis/rhinosinusitis, even after adjusting for confounders 3

• Prevalence Studies: The prevalence of chronic rhinosinusitis among GERD patients was found to be 20.7%, significantly higher than the 8.5% prevalence in the general population 4

Treatment Implications

• Medical Management: Treatment of GERD in patients with chronic sinusitis has been shown to result in significant improvement in sinusitis symptoms 1

• Treatment Sequencing: In patients with rhinosinusitis refractory to conventional medical therapy, treatment of associated GERD should be considered before surgical intervention 1

• Symptom Improvement: Proton pump inhibitors have been shown to significantly reduce symptoms of postnasal discharge in patients with rhinitis compared to placebo 1

Clinical Approach to Suspected GERD-Related Rhinosinusitis

1. Consider GERD evaluation in patients with:

   • Refractory or recurrent rhinosinusitis not responding to conventional therapy
   • Concurrent symptoms of heartburn, regurgitation, or other typical GERD manifestations
   • Rhinosinusitis symptoms that worsen at night or when lying down

2. Diagnostic considerations:

   • pH probe monitoring may be warranted in refractory cases
   • Evaluate both esophageal and nasopharyngeal reflux when possible

3. Treatment algorithm:

   • Start with conventional rhinosinusitis treatment
   • For refractory cases, add GERD treatment (typically proton pump inhibitors)
   • Consider GERD treatment before proceeding to surgical intervention for rhinosinusitis

Important Caveats

• The relationship between GERD and rhinosinusitis is supported by increasing evidence, but high-level evidence from large randomized controlled trials is still lacking 1

• Most studies supporting this association are small case series or observational studies 1

• While GERD and rhinosinusitis often coexist and share similar symptoms, whether treating mild or subclinical GERD can affect rhinosinusitis outcomes remains uncertain 1

• Nasal mucociliary clearance time may be significantly increased in GERD patients (23.79±5.58 vs 8.15±2.06 min in controls), suggesting GERD may impair this important defensive mechanism 5