A 10-Year Follow-Up of a Randomized Prospective Study of 2 Treatments for Chronic Rhinosinusitis Without Nasal Polyps and Investigation of the Impact of Gastroeosophageal Reflux Disease in the Resistance to Treatment

Abstract

Objectives: To compare the 2 long-term medical strategies in chronic rhinosinusitis without nasal polyps (CRSnNP) and to identify the role of gastroesophageal reflux disease (GERD) and Helicobacter pylori as factors of treatment failure. Material and Methods: Fifty-seven patients with CRSnNP were randomized into 2 therapeutic groups. The first group was treated with 4 weeks of amoxicillin/clavulanate and a short course of oral steroids. The second group received 8 weeks of clarithromycin. Sinonasal Outcome Test-20 (SNOT-20) and Lund and Mackay scores were assessed at baseline and after treatment, and GERD Health-Related Quality of Life (GERD-HRQL) questionnaire was evaluated in all patients. Patients with a GERD-HRQL score >8 received esogastroscopy and H pylori detection. Patients were followed during a 10-year period for clinical course and GERD evolution. The 10-year evolution of patients was described in terms of recurrence, medical, and surgical treatments. Results: Thirty-seven patients completed the study; SNOT-20 and Lund and Mackay scores similarly improved in both groups. Amoxicillin/clavulanate group had significantly more adverse reactions than the clarithromycin group (P = .03). After the therapeutic course, 35% (amoxicillin/clavulanate) and 41% (clarithromycin) of patients needed functional endoscopic sinus surgery (FESS). During the long-term follow-up, 54% (amoxicillin/clavulanate) and 40% (clarithromycin) of patients had late CRSnNP recurrence; FESS was performed in less than 15% of cases of recurrence. Gastroesophageal reflux disease complaint’s severity was associated with late recurrence of CRSnNP. Conclusion: Amoxicillin/clavulanate and clarithromycin would be competitive treatments for CRSnNP. Gastroesophageal reflux disease seems to be a negative factor for treatment response and recurrence.

Association Between Inferior Turbinate Hypertrophy and Extraesophageal Reflux

“…Overall, the available data suggest an association between EER and severe chronic rhinosinusitis. [6][7][8][9][10] There is presently no reference standard for EER examination. 13 Analysis of 24-hour esophageal pH impedance seems to provide the most accurate data for determining EER presence, type, and severity.…”

“…Yet it is possible that EER likely plays some role in the pathogenesis of nasal and ear chronic inflammatory conditions, such as chronic rhinosinusitis, recurrent otitis media, chronic otitis media with effusion, and others. [6][7][8][9][10][11][12][13] Notably, the European Position Paper on Rhinosinusitis and Nasal Polyps sup-ports further studies to elucidate the association between EER and chronic nasal inflammatory conditions. 4 Extraesophageal reflux (also called laryngopharyngeal reflux) is currently defined as an inflammatory condition of the upper aerodigestive tract tissues associated with the direct and indirect effects of gastric or duodenal content reflux, inducing morphological changes in the upper aerodigestive tract.…”

“…Previous investigations of the role of EER in chronic rhinosinusitis, especially in difficult-to-treat conditions, indicate that EER is a likely cofactor. [6][7][8][9][10] Moreover, EER seems to play a role in the pathogenesis of chronic otitis media with effusion and other chronic ear problems. [11][12][13] However, to our knowledge, the association between ITH and EER has not yet been studied.…”

Is there a role for antibiotics in the treatment of chronic rhinosinusitis?

“…However, macrolides also possess several anti-inflammatory and immunomodulatory activities that may be important in their role in the treatment of CRS. [51][52][53][54][55] The immunomodulatory properties of macrolides are shared by the 14-membered lactone ring macrolides (erythromycin, clarithromycin, and roxithromycin) and the 15-membered lactone ring macrolides (azithromycin). 56 The precise mechanism of the immunomodulatory properties is unknown, though it has been proposed that macrolides inhibit mucus hypersecretion, 57 activate mucociliary function, 58 modulate the production of cytokines and chemokines, 59 have a suppressive effect on lymphocytic activity, 52 and inhibit bacterial functions such as quorumsensing and biofilm formation.…”

Chronic Otitis Media in Patients with Chronic Rhinosinusitis: A Systematic Review

“…Secondly, the paranasal sinuses and the middle are close and contiguous anatomic structures. Therefore, some conditions, such as gastropharyngeal reflux, viral infections, and immunologic disorders, can have inflammatory actions on both ears and paranasal sinuses [ 7 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ].…”