Nasal Regurgitation in SLE Patients
Nasal regurgitation in SLE patients is most commonly caused by esophageal dysmotility leading to gastroesophageal reflux with subsequent nasopharyngeal reflux, rather than a direct manifestation of lupus itself. 1, 2
Primary Mechanism: Esophageal Dysfunction
Esophageal motility abnormalities occur frequently in SLE patients who report symptoms of heartburn and regurgitation. While severe esophageal aperistalsis is less common in SLE compared to mixed connective tissue disease, significant motility dysfunction can still occur, particularly in patients with Raynaud's phenomenon. 1 The pathophysiology involves:
- Impaired esophageal peristalsis causing retrograde flow of gastric contents 1
- Lower esophageal sphincter dysfunction allowing gastroesophageal reflux 1
- Direct nasopharyngeal reflux (NPR) when refluxate reaches above the upper esophageal sphincter and enters the nasopharynx 2, 3
Nasopharyngeal Reflux as the Direct Cause
Direct nasopharyngeal reflux occurs when gastric acid reaches the nasopharynx and nasal cavity, causing regurgitation through the nose. This phenomenon has been documented with pH probe studies showing reflux events with pH <5 in the nasopharynx. 2, 3 The severity of NPR correlates with:
- Timing of aspiration events - when aspiration occurs before NPR, both phenomena are more severe 2
- Degree of esophageal dysmotility - more severe motility disorders produce more frequent NPR 1, 2
- Upper esophageal sphincter dysfunction - allowing refluxate to reach the nasopharynx 3
Differential Considerations
While esophageal dysmotility with NPR is the primary mechanism, other potential contributing factors in SLE include:
- Velopharyngeal dysfunction from neuropsychiatric lupus affecting cranial nerves, though this would more typically cause nasal speech rather than regurgitation 4
- Rare bullous mucosal disease affecting the esophagus (epidermolysis bullosa acquisita variant), though this presents primarily as dysphagia rather than nasal regurgitation 5
- Laryngopharyngeal reflux as a component of the reflux spectrum, contributing to upper airway symptoms 6
Clinical Evaluation Approach
Patients presenting with nasal regurgitation should be evaluated for:
- Symptoms of gastroesophageal reflux including heartburn, regurgitation, and dysphagia 1
- Presence of Raynaud's phenomenon which correlates with esophageal aperistalsis 1
- Constitutional SLE symptoms to assess overall disease activity 7
- Videofluoroscopic swallowing study (VFSS) to document NPR and assess aspiration risk 2
- Esophageal manometry to quantify motility abnormalities if diagnosis remains unclear 1
- 24-hour pH probe study with nasopharyngeal sensor to document NPR events if needed 3
Management Strategy
Treatment should target the underlying gastroesophageal reflux disease:
- Proton pump inhibitors to reduce gastric acid production and minimize NPR events 3
- Lifestyle modifications including elevation of head of bed, avoiding late meals, and dietary modifications 6
- Treatment of concurrent SLE disease activity with appropriate immunosuppression if esophageal involvement is inflammatory 8
- Evaluation for aspiration risk given the association between NPR and aspiration 2
Critical Pitfall to Avoid
Do not assume nasal regurgitation is a direct neuropsychiatric manifestation of SLE without first evaluating for esophageal dysmotility and gastroesophageal reflux. The vast majority of cases result from reflux-related mechanisms rather than primary neurological involvement. 1, 2, 3 However, if neurological symptoms coexist (facial numbness, cranial nerve deficits), neuropsychiatric lupus should be considered and evaluated with appropriate neuroimaging and CSF analysis. 6, 4