Alkaline pH in middle meatus in cases of Chronic rhinosinusitis G.S. Bhawana, Sunil Kumar MS, DNB, Ajay Kumar MS, MCh, FICS, FAIS PII: DOI: Reference:
S0196-0709(14)00055-6 doi: 10.1016/j.amjoto.2014.02.017 YAJOT 1358
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
17 February 2014 23 February 2014
Please cite this article as: Bhawana GS, Kumar Sunil, Kumar Ajay, Alkaline pH in middle meatus in cases of Chronic rhinosinusitis, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.02.017
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Alkaline pH in middle meatus in cases of Chronic rhinosinusitis
RI P
Authors:
NU
1. Post Graduate Resident, 2. Professor, Dept. of Otorhinolaryngology Head & Neck Surgery,
SC
1. Dr. G. S .Bhawana 2. Dr. Sunil Kumar, MS, DNB 3. Dr. Ajay Kumar, MS, MCh, FICS, FAIS
MA
Lady Hardinge Medical College & Associated Hospitals New Delhi India 3. Director Professor & Head Of Department, Dept. of Surgery,
PT
ED
Lady Hardinge Medical College & Associated Hospitals New Delhi India
CE
Address for correspondence:
AC
Dr. G .S .Bhawana Room no:111 House surgeons block Lady hardinge medical college New delhi-110001 [email protected] Phone No: +91-9910829097
ACCEPTED MANUSCRIPT
ABSTRACT
T
Study type: Prospective and observational study.
RI P
Methods: The study group was divided in two groups consisted of 50 normal subjects (100
SC
meati) and 50 patients (100 meati) of chronic rhinosinusitis (CRS). All subjects underwent nasal endoscopy along with measurement of the pH of the middle
NU
meatus using a portable pH monitoring device. Statistical analysis was done to
The mean pH of normal 100 middle meati were measured to be 7.35(±0.82). The
ED
Results:
MA
compare mean pH of normal middle meatus with diseased one.
mean pH of 100 middle meatii in CRS patients was higher 7.81(±0.83), was found
PT
to be statistically significant. (p=0.00011)
CE
Conclusion:
Key words:
AC
Alkaline pH (7.81) was observed in middle meatus of CRS patients.
Chronic rhinosinusitis, pH, reflux, middle meatus
ACCEPTED MANUSCRIPT INTRODUCTION Chronic rhinosinusitis (CRS) is one of the most common chronic disease with a
T
prevalence of as high as 15% of population and believed to be increasing in both incidence and
RI P
prevalence.1 According to AAO-HNS, persistent symptomatic inflammation of the nasal and
SC
sinus mucosa, fluids within these cavities, and/or underlying bone is defined as CRS.2 Diagnosis is made by the presence of nasal obstruction, discharge, purulence, post-nasal drip and associated
NU
facial pressure and pain for more than 12 weeks. 2
MA
The inciting initial insult can be infection, allergy, anatomical causes or combination of these, leading to inflammation of the sinonasal mucosa, ostial obstruction and mucus stasis.
ED
Edema can appear in both acid and alkaline reactions leading to ciliostasis which is a known cause for development of CRS.4 Recently, beneficial effects of anti-reflux medication in CRS
PT
refractory to appropriate medical therapy have indicated gastro-esophageal reflux as a possible
CE
etiological factor for CRS. 3,5-8
AC
It was observed that there was a drop in nasopharyngeal pH which was more frequent in number and longer in duration in patient group suffering from chronic rhinopharyngitis without any obvious underlying cause like allergy, infected adenoids, nasal deformities etc.3 DelGaudio8 further demonstrated that cases of refractory chronic rhinosinusitis have more reflux at nasopharynx, upper and distal esophagus as compared with control group. Treatment of reflux leads to the improvement of symptoms of CRS refractory to medical management has been substantiated by many studies.9,10 However, the mechanism by which reflux may affect the nose and paranasal sinuses still remain unclear. It is doubtful that gastric contents reflux into the sinuses via natural ostia. It would be more likely that refluxate could
ACCEPTED MANUSCRIPT reach the nasopharynx and the posterior nasal passage. The acidity may induce the nasal mucosal edema, inflammation and secondarily obstruct the ostia. Another possible mechanism may be
T
reflux induced autonomic nervous system hyperactivity, causing nasal edema and obstruction
RI P
much like the patient with vasomotor rhinitis.6,11
SC
However, literature establishing the relationship between the pH at middle meatus and CRS is scant. The present study aims to determine the normal range of pH of middle meatus and
NU
explore any change in cases of chronic rhinosinusits.
MA
METHODS
A prospective study was conducted in the tertiary care centre, between August 2011 and
ED
April 2013. All patients of CRS, aged 15-60 years, admitted for FESS were included in the study. Diagnostic criteria were either two major or one major and two minor symptoms
PT
described by Rhinosinusitis Task Force, for at least twelve consecutive weeks.2 Cases with
CE
localized infection, acute/fungal/allergic rhinosinusitis, who had taken treatment elsewhere, were
AC
excluded. Fifty normal subjects, age and sex matched, were included as controls in the study who were under-going surgeries other then nasal/ear surgeries in the department. A detailed history was asked and patient with symptoms of gastro-esophageal reflux were excluded in the study. All patients underwent thorough otorhinolaryngological examination. Systemic examination was also done to rule out any systemic disorder. Subsequently, blood and urine samples were drawn for routine baseline investigation. The examination findings as well as investigation data were recorded on a Performa which was approved by ethical committee of institute. Informed and written consent was taken from all subjects. Hopkins rigid 0˚/30˚ nasal endoscope under general anesthesia was introduced in the nasal cavity without putting any
ACCEPTED MANUSCRIPT drug/spray. Once the probe is in the middle meatus reading was taken when constant pH value is obtained with the device (GastrograpH mark IV, SME Medizintechnik, GmbH, Germany). Fig.1
AC
CE
PT
ED
MA
NU
SC
RI P
decongestants. The statistical analysis was done on SPPS software.
T
Similar procedure was adopted in CRS patients who were posted for FESS before putting local
ACCEPTED MANUSCRIPT RESULTS The study population included 100 subjects (male and female) aged between 15-60 years.
T
There were 24 male and 26 female in the CRS group while in the control group males and
RI P
females accounted 25 each. The most common symptoms were nasal obstruction, headache and
SC
followed by nasal discharge as depicted in Fig. 2.
The mean values of pH are summarized in Table I. The mean pH of middle meatus in CRS
NU
group was 7.81±0.83 while in normal middle meatus it was 7.35±0.82 indicating relative
AC
CE
PT
ED
MA
alkalinity in the CRS group this difference was found to be statistically significant. (p=0.00011).
ACCEPTED MANUSCRIPT DISCUSSION Chronic rhinosinusitis is a specific clinical symptom complex. It is defined as an
T
inflammatory process of the mucosal lining unresolved for at least six weeks. The sinonasal
RI P
mucosal lining is affected by humidity, ventilation, environmental temperature changes, irritant exposure, and indigenous stimuli related to emotions. Chronic rhinosinusitis can result when
SC
there is digression among these factors.12 The movement of cilia is dependent on pH4 and
NU
temperature.13 Extremes of pH and temperature impair ciliary mobility which leads to mucus stasis, which is an etiological factor for pathogenesis of chronic rhinosinusitis. However, it is not
MA
known whether the changes in pH are caused by chronic rhinosinusitis, or if pH changes due to other putative factors are responsible for the development of chronic rhinosinusitis. Moreover,
ED
pH also varies with variation of ambient temperature, and this pH variation may also influence
PT
pathogenesis of chronic rhinosinusitis.
CE
In the present study the pH was recorded in the middle meatus (both sides) of normal subjects was found to be 7.35(±0.82). However, in one study pH at the anterior and posterior
AC
sites of the nasal cavity was measured by placing the electrodes 3 cm apart in the nasal cavity.14 The average pH in the anterior part of the nose was 6.40 (+0.11, -0.15 S.D) and posterior part of the nose was 6.27 (+0.13, -0.18 S.D). The overall range in pH was 5.17-8.13 for anterior part of nose and 5.20-8.00 for posterior part. These results are in agreement with the result of our study in which the mean pH of middle meatus was 7.35, which comes under the range of normal pH of nose as determined in above study. It implies that the pH of middle meatus is same as that of nasal pH. The mean pH of middle meatus in chronic rhinosinusitis patients was 7.81±0.83. The comparison with the pH of normal revealed that pH in CRS was relatively more alkaline.
ACCEPTED MANUSCRIPT Furthermore, it was also found that difference of pH in middle meatus in CRS group was statistically significant (p=0.000). In the past, few studies have documented gastro-esophageal
T
reflux into the nasopharynx as one of the causes of chronic rhinosinusitis.5,7,11 If low pH gastric
RI P
contents come in contact with upper respiratory mucosa, it leads to mucosal irritation resulting in mucosal edema. Mucosal edema in the nasopharynx or sinonasal tract can lead to obstruction of
SC
sinus ostia with the subsequent development of sinusitis. In a study where in 24-hrs monitoring
NU
of pH at esophagus, pharynx and larynx was done and it was postulated that acidic pH (4-6) may act as a potential irritant leading to structural pathology and clinical symptoms.15 In an another
MA
study, a comparison was done between pH nasopharynx in normal subjects and in patients with refractory chronic rhinosinusitis and concluded that gastroesophageal reflux can reach up to level
ED
of nasopharynx and this can be an etiological factor for chronic rhinosinusitis.8 In contrast, our
PT
study reveals that alkaline pH at middle meatus in cases of chronic rhinosinusitis contradicting
CE
the other studies.
It is difficult to explain these findings whether sinusitis led to change in pH in middle
AC
meatus or some other factors are responsible for this. If we postulate that reflux can lead to acidic changes then it should be acidic pH in middle meatus although reflux was excluded in our study. However, alkaline pH may be independent of the disease process or local changes/or purulent material causes the alkaline pH at middle meatus in CRS patients.
CONCLUSION The pH of middle meatus of nose was found to be alkaline in cases of chronic rhinosinusitis 7.81(±0.83) and pH of normal group was 7.35(±0.82). Our study had certain limitations like, small numbers of patients and was undertaken in short span of time, hence a large prospective randomized control trial is contemplated over a long duration to validate the
ACCEPTED MANUSCRIPT results of the present study. Also a combined study measuring pH at middle meatus in chronic rhinosinusitis along with measurement of hypopharynx and gastroesophageal pH is required to
AC
CE
PT
ED
MA
NU
SC
RI P
T
solve this puzzle.
ACCEPTED MANUSCRIPT
T
BIBILIOGRAPHY
RI P
1. Suh JD, Kennedy DW. Treatment options for Chronic Rhinosinusitis. Proc Am Thorac Soc. 2011; 8:132-140.
SC
2. Benninger, Ferguson BJ, Hadley JA. Adult chronic rhinosinusitis: definitions, diagnosis,
NU
epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129:S1-S32.
MA
3. DiBaise JK, Olusola BF, Huerter JV, Quigley EMM. Role of GERD in chronic resistant sinusitis: A prospective, open label, pilot trial. Am J Gastroenterol. 2002 Apr;97(4):843-850.
ED
4. Holma BO, Lindegren M, Andersen MLJM. pH effects on ciliomotility and morphology of
PT
respiratory mucosa. Arch Environ Health. 1977 Sep-Oct;32(5):216-226.
CE
5. Contencin P, Narcy P. Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol. 1991;22: 249-256.
AC
6. Wong IWY, Omari TI, Myers JC, Nair SB, Jamieson GG. Nasopharyngeal pH monitoring in chronic sinusitis patients using a novel four channel probe. Laryngoscope. 2004;114:15821586. 7. Vaezi MF, Schroeder PL, Richter JE. Reproducibility of proximal probe pH parameters in 24-hrs ambulatory esophageal pH monitoring. Am j Gastroenterol. 1997;92:825-829. 8. DelGaudio JM. Direct Nasopharyngeal reflux of gastric acid is a contributing factor in refractory chronic rhinosinusitis. Laryngoscope. 2005;115: 946-957. 9. Di Baise,J. Huerter JV, Quigley EMM. Sinusitis and gastroesophageal reflux disease. Ann
ACCEPTED MANUSCRIPT Intern Med. 1998;129(12),1078. 10. Phipps CD, Wood WE, Gibson WS, Cocharan WJ. Gastroesophageal reflux contributing to
RI P
T
chronic sinus disease in children. Arch Otolaryngol Head Neck Surg. 2000;126:831-36. 11. Jecker P, Orloff LA, Wohlfeil M, Mann WJ. Gastroesophageal reflux disease (GERD),
SC
extraesophageal reflux (EER) and recurrent chronic rhinosinusitis. Eur Arch
NU
Otorhinolaryngol. 2006;263:664-667.
12. Steinberg J, Modi P. Chronic sinusitis. Can Fam Physian. 1990 Apr;36:749-75.
MA
13. Braverman I, Wright ED, Wang CG, Eidelman D, Frenkiel S. Human Nasal ciliary- beat frequency in normal and chronic sinusitis subjects. J otolaryngol. 1998;27(3):145-152.
ED
14. Washington N, Steele RJC, Jackson SJ, Bush D, Mason J, Gill DA, et al. Determination of
CE
2000;198:139-146.
PT
baseline human nasal pH and the effect of intranasally administered buffers. Int J Pharm.
15. Barbereo GJ. Gastroesophageal reflux and upper airway disease. Otolaryngol Clin North Am.
AC
1996;29(1):27-38.
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
Fig. 1: Probe in left middle meatus measuring pH
ACCEPTED MANUSCRIPT TABLE 1 Mean(SD) pH of Middle Meatus 7.35± .82 0.00011
RI P
T
Normal group (n=50)
P-value
pH of Middle Meatus 7.81± .83
SC
CRS group (n=50)
AC
CE
PT
ED
MA
NU
Table I. Mean pH of middle meatus in Normal and CRS group
ACCEPTED MANUSCRIPT
T
Frequency of symptoms in CRS n=50 45
RI P
50
40 36
35
NU
35
SC
43
30 25
MA
20
24
20 15
ED
11
10
8
6
5
PT
5
AC
CE
0
Fig.2 Symptoms in CRS
5
4 1
1
S0196-0709(14)00055-6 doi: 10.1016/j.amjoto.2014.02.017 YAJOT 1358
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
17 February 2014 23 February 2014
Please cite this article as: Bhawana GS, Kumar Sunil, Kumar Ajay, Alkaline pH in middle meatus in cases of Chronic rhinosinusitis, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.02.017
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Alkaline pH in middle meatus in cases of Chronic rhinosinusitis
RI P
Authors:
NU
1. Post Graduate Resident, 2. Professor, Dept. of Otorhinolaryngology Head & Neck Surgery,
SC
1. Dr. G. S .Bhawana 2. Dr. Sunil Kumar, MS, DNB 3. Dr. Ajay Kumar, MS, MCh, FICS, FAIS
MA
Lady Hardinge Medical College & Associated Hospitals New Delhi India 3. Director Professor & Head Of Department, Dept. of Surgery,
PT
ED
Lady Hardinge Medical College & Associated Hospitals New Delhi India
CE
Address for correspondence:
AC
Dr. G .S .Bhawana Room no:111 House surgeons block Lady hardinge medical college New delhi-110001 [email protected] Phone No: +91-9910829097
ACCEPTED MANUSCRIPT
ABSTRACT
T
Study type: Prospective and observational study.
RI P
Methods: The study group was divided in two groups consisted of 50 normal subjects (100
SC
meati) and 50 patients (100 meati) of chronic rhinosinusitis (CRS). All subjects underwent nasal endoscopy along with measurement of the pH of the middle
NU
meatus using a portable pH monitoring device. Statistical analysis was done to
The mean pH of normal 100 middle meati were measured to be 7.35(±0.82). The
ED
Results:
MA
compare mean pH of normal middle meatus with diseased one.
mean pH of 100 middle meatii in CRS patients was higher 7.81(±0.83), was found
PT
to be statistically significant. (p=0.00011)
CE
Conclusion:
Key words:
AC
Alkaline pH (7.81) was observed in middle meatus of CRS patients.
Chronic rhinosinusitis, pH, reflux, middle meatus
ACCEPTED MANUSCRIPT INTRODUCTION Chronic rhinosinusitis (CRS) is one of the most common chronic disease with a
T
prevalence of as high as 15% of population and believed to be increasing in both incidence and
RI P
prevalence.1 According to AAO-HNS, persistent symptomatic inflammation of the nasal and
SC
sinus mucosa, fluids within these cavities, and/or underlying bone is defined as CRS.2 Diagnosis is made by the presence of nasal obstruction, discharge, purulence, post-nasal drip and associated
NU
facial pressure and pain for more than 12 weeks. 2
MA
The inciting initial insult can be infection, allergy, anatomical causes or combination of these, leading to inflammation of the sinonasal mucosa, ostial obstruction and mucus stasis.
ED
Edema can appear in both acid and alkaline reactions leading to ciliostasis which is a known cause for development of CRS.4 Recently, beneficial effects of anti-reflux medication in CRS
PT
refractory to appropriate medical therapy have indicated gastro-esophageal reflux as a possible
CE
etiological factor for CRS. 3,5-8
AC
It was observed that there was a drop in nasopharyngeal pH which was more frequent in number and longer in duration in patient group suffering from chronic rhinopharyngitis without any obvious underlying cause like allergy, infected adenoids, nasal deformities etc.3 DelGaudio8 further demonstrated that cases of refractory chronic rhinosinusitis have more reflux at nasopharynx, upper and distal esophagus as compared with control group. Treatment of reflux leads to the improvement of symptoms of CRS refractory to medical management has been substantiated by many studies.9,10 However, the mechanism by which reflux may affect the nose and paranasal sinuses still remain unclear. It is doubtful that gastric contents reflux into the sinuses via natural ostia. It would be more likely that refluxate could
ACCEPTED MANUSCRIPT reach the nasopharynx and the posterior nasal passage. The acidity may induce the nasal mucosal edema, inflammation and secondarily obstruct the ostia. Another possible mechanism may be
T
reflux induced autonomic nervous system hyperactivity, causing nasal edema and obstruction
RI P
much like the patient with vasomotor rhinitis.6,11
SC
However, literature establishing the relationship between the pH at middle meatus and CRS is scant. The present study aims to determine the normal range of pH of middle meatus and
NU
explore any change in cases of chronic rhinosinusits.
MA
METHODS
A prospective study was conducted in the tertiary care centre, between August 2011 and
ED
April 2013. All patients of CRS, aged 15-60 years, admitted for FESS were included in the study. Diagnostic criteria were either two major or one major and two minor symptoms
PT
described by Rhinosinusitis Task Force, for at least twelve consecutive weeks.2 Cases with
CE
localized infection, acute/fungal/allergic rhinosinusitis, who had taken treatment elsewhere, were
AC
excluded. Fifty normal subjects, age and sex matched, were included as controls in the study who were under-going surgeries other then nasal/ear surgeries in the department. A detailed history was asked and patient with symptoms of gastro-esophageal reflux were excluded in the study. All patients underwent thorough otorhinolaryngological examination. Systemic examination was also done to rule out any systemic disorder. Subsequently, blood and urine samples were drawn for routine baseline investigation. The examination findings as well as investigation data were recorded on a Performa which was approved by ethical committee of institute. Informed and written consent was taken from all subjects. Hopkins rigid 0˚/30˚ nasal endoscope under general anesthesia was introduced in the nasal cavity without putting any
ACCEPTED MANUSCRIPT drug/spray. Once the probe is in the middle meatus reading was taken when constant pH value is obtained with the device (GastrograpH mark IV, SME Medizintechnik, GmbH, Germany). Fig.1
AC
CE
PT
ED
MA
NU
SC
RI P
decongestants. The statistical analysis was done on SPPS software.
T
Similar procedure was adopted in CRS patients who were posted for FESS before putting local
ACCEPTED MANUSCRIPT RESULTS The study population included 100 subjects (male and female) aged between 15-60 years.
T
There were 24 male and 26 female in the CRS group while in the control group males and
RI P
females accounted 25 each. The most common symptoms were nasal obstruction, headache and
SC
followed by nasal discharge as depicted in Fig. 2.
The mean values of pH are summarized in Table I. The mean pH of middle meatus in CRS
NU
group was 7.81±0.83 while in normal middle meatus it was 7.35±0.82 indicating relative
AC
CE
PT
ED
MA
alkalinity in the CRS group this difference was found to be statistically significant. (p=0.00011).
ACCEPTED MANUSCRIPT DISCUSSION Chronic rhinosinusitis is a specific clinical symptom complex. It is defined as an
T
inflammatory process of the mucosal lining unresolved for at least six weeks. The sinonasal
RI P
mucosal lining is affected by humidity, ventilation, environmental temperature changes, irritant exposure, and indigenous stimuli related to emotions. Chronic rhinosinusitis can result when
SC
there is digression among these factors.12 The movement of cilia is dependent on pH4 and
NU
temperature.13 Extremes of pH and temperature impair ciliary mobility which leads to mucus stasis, which is an etiological factor for pathogenesis of chronic rhinosinusitis. However, it is not
MA
known whether the changes in pH are caused by chronic rhinosinusitis, or if pH changes due to other putative factors are responsible for the development of chronic rhinosinusitis. Moreover,
ED
pH also varies with variation of ambient temperature, and this pH variation may also influence
PT
pathogenesis of chronic rhinosinusitis.
CE
In the present study the pH was recorded in the middle meatus (both sides) of normal subjects was found to be 7.35(±0.82). However, in one study pH at the anterior and posterior
AC
sites of the nasal cavity was measured by placing the electrodes 3 cm apart in the nasal cavity.14 The average pH in the anterior part of the nose was 6.40 (+0.11, -0.15 S.D) and posterior part of the nose was 6.27 (+0.13, -0.18 S.D). The overall range in pH was 5.17-8.13 for anterior part of nose and 5.20-8.00 for posterior part. These results are in agreement with the result of our study in which the mean pH of middle meatus was 7.35, which comes under the range of normal pH of nose as determined in above study. It implies that the pH of middle meatus is same as that of nasal pH. The mean pH of middle meatus in chronic rhinosinusitis patients was 7.81±0.83. The comparison with the pH of normal revealed that pH in CRS was relatively more alkaline.
ACCEPTED MANUSCRIPT Furthermore, it was also found that difference of pH in middle meatus in CRS group was statistically significant (p=0.000). In the past, few studies have documented gastro-esophageal
T
reflux into the nasopharynx as one of the causes of chronic rhinosinusitis.5,7,11 If low pH gastric
RI P
contents come in contact with upper respiratory mucosa, it leads to mucosal irritation resulting in mucosal edema. Mucosal edema in the nasopharynx or sinonasal tract can lead to obstruction of
SC
sinus ostia with the subsequent development of sinusitis. In a study where in 24-hrs monitoring
NU
of pH at esophagus, pharynx and larynx was done and it was postulated that acidic pH (4-6) may act as a potential irritant leading to structural pathology and clinical symptoms.15 In an another
MA
study, a comparison was done between pH nasopharynx in normal subjects and in patients with refractory chronic rhinosinusitis and concluded that gastroesophageal reflux can reach up to level
ED
of nasopharynx and this can be an etiological factor for chronic rhinosinusitis.8 In contrast, our
PT
study reveals that alkaline pH at middle meatus in cases of chronic rhinosinusitis contradicting
CE
the other studies.
It is difficult to explain these findings whether sinusitis led to change in pH in middle
AC
meatus or some other factors are responsible for this. If we postulate that reflux can lead to acidic changes then it should be acidic pH in middle meatus although reflux was excluded in our study. However, alkaline pH may be independent of the disease process or local changes/or purulent material causes the alkaline pH at middle meatus in CRS patients.
CONCLUSION The pH of middle meatus of nose was found to be alkaline in cases of chronic rhinosinusitis 7.81(±0.83) and pH of normal group was 7.35(±0.82). Our study had certain limitations like, small numbers of patients and was undertaken in short span of time, hence a large prospective randomized control trial is contemplated over a long duration to validate the
ACCEPTED MANUSCRIPT results of the present study. Also a combined study measuring pH at middle meatus in chronic rhinosinusitis along with measurement of hypopharynx and gastroesophageal pH is required to
AC
CE
PT
ED
MA
NU
SC
RI P
T
solve this puzzle.
ACCEPTED MANUSCRIPT
T
BIBILIOGRAPHY
RI P
1. Suh JD, Kennedy DW. Treatment options for Chronic Rhinosinusitis. Proc Am Thorac Soc. 2011; 8:132-140.
SC
2. Benninger, Ferguson BJ, Hadley JA. Adult chronic rhinosinusitis: definitions, diagnosis,
NU
epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129:S1-S32.
MA
3. DiBaise JK, Olusola BF, Huerter JV, Quigley EMM. Role of GERD in chronic resistant sinusitis: A prospective, open label, pilot trial. Am J Gastroenterol. 2002 Apr;97(4):843-850.
ED
4. Holma BO, Lindegren M, Andersen MLJM. pH effects on ciliomotility and morphology of
PT
respiratory mucosa. Arch Environ Health. 1977 Sep-Oct;32(5):216-226.
CE
5. Contencin P, Narcy P. Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol. 1991;22: 249-256.
AC
6. Wong IWY, Omari TI, Myers JC, Nair SB, Jamieson GG. Nasopharyngeal pH monitoring in chronic sinusitis patients using a novel four channel probe. Laryngoscope. 2004;114:15821586. 7. Vaezi MF, Schroeder PL, Richter JE. Reproducibility of proximal probe pH parameters in 24-hrs ambulatory esophageal pH monitoring. Am j Gastroenterol. 1997;92:825-829. 8. DelGaudio JM. Direct Nasopharyngeal reflux of gastric acid is a contributing factor in refractory chronic rhinosinusitis. Laryngoscope. 2005;115: 946-957. 9. Di Baise,J. Huerter JV, Quigley EMM. Sinusitis and gastroesophageal reflux disease. Ann
ACCEPTED MANUSCRIPT Intern Med. 1998;129(12),1078. 10. Phipps CD, Wood WE, Gibson WS, Cocharan WJ. Gastroesophageal reflux contributing to
RI P
T
chronic sinus disease in children. Arch Otolaryngol Head Neck Surg. 2000;126:831-36. 11. Jecker P, Orloff LA, Wohlfeil M, Mann WJ. Gastroesophageal reflux disease (GERD),
SC
extraesophageal reflux (EER) and recurrent chronic rhinosinusitis. Eur Arch
NU
Otorhinolaryngol. 2006;263:664-667.
12. Steinberg J, Modi P. Chronic sinusitis. Can Fam Physian. 1990 Apr;36:749-75.
MA
13. Braverman I, Wright ED, Wang CG, Eidelman D, Frenkiel S. Human Nasal ciliary- beat frequency in normal and chronic sinusitis subjects. J otolaryngol. 1998;27(3):145-152.
ED
14. Washington N, Steele RJC, Jackson SJ, Bush D, Mason J, Gill DA, et al. Determination of
CE
2000;198:139-146.
PT
baseline human nasal pH and the effect of intranasally administered buffers. Int J Pharm.
15. Barbereo GJ. Gastroesophageal reflux and upper airway disease. Otolaryngol Clin North Am.
AC
1996;29(1):27-38.
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
Fig. 1: Probe in left middle meatus measuring pH
ACCEPTED MANUSCRIPT TABLE 1 Mean(SD) pH of Middle Meatus 7.35± .82 0.00011
RI P
T
Normal group (n=50)
P-value
pH of Middle Meatus 7.81± .83
SC
CRS group (n=50)
AC
CE
PT
ED
MA
NU
Table I. Mean pH of middle meatus in Normal and CRS group
ACCEPTED MANUSCRIPT
T
Frequency of symptoms in CRS n=50 45
RI P
50
40 36
35
NU
35
SC
43
30 25
MA
20
24
20 15
ED
11
10
8
6
5
PT
5
AC
CE
0
Fig.2 Symptoms in CRS
5
4 1
1
