Inter-rater and intra-rater reliability
The inter-rater and intra-rater reliability for grading of redness of
nasopharynx was 0.84 (95% CI: 0.68-0.99, P<0.01) and 0.80
(95% CI: 0.64-0.96, P<0.01) respectively. The inter-rater and
intra-rater reliability for granular posterior pharyngeal wall was 0.72
(95% CI: 0.52-0.91, P<0.01) and 0.79 (95% CI 0.61-0.96,
P<0.01) respectively. The inter-rater and intra-rater score
for the RFS was 0.63(95% CI :0.31-0.80, P<0.01) and 0.99
(95% CI:0.98-0.99, P <0.01).
DISCUSSION
There were more than half of patients who complained of bothersome PND
among patients with rhinitis and this is related to the severity of
rhinitis symptoms and the presence of secretions in the posterior nasal
cavity. It is well known that rhinitis impairs the quality of life (QoL)(10) but PND is often overlooked. This is comparable
to Jaruvongvanich et al (11) which reported that
56.3% of patients with allergic rhinitis had at least moderately severe
postnasal drip.
.
The presence of secretions was associated with the PND group among this
rhinitis population and is 78% sensitive with a likelihood ratio
positive of 1.41%. This suggests that the secretions in the posterior
nasal cavity are contributing to the PND sensation bothering the
patients and should alert ORL doctors to treat the associated PND. This
can be done with routine intranasal steroids (11) and
nasal douching but its efficacy for PND needs further study(12).
Surprisingly, redness of the nasopharynx was found to be higher among
patients with rhinitis only compared to the postnasal drip group. This
would suggest that the erythema in the nasopharynx is due to
inflammation associated with rhinitis itself (13)rather than irritation from PND. This inflammation may also lead to
hyposensitivity of the inflamed mucosa. It was previously reported that
patients with PND have nasopharyngeal hyposensitivity secondary to
inflamed mucosa which may also explain why certain patients with
secretions in the posterior nasal cavity do not complain of postnasal
drip (14). The presence of hemorrhagic spots and the
granular posterior pharyngeal wall was equally present among rhinitis
patients with or without PND. These endoscopic features are likely due
to other stimulating factors such as rhinitis itself, LPR, and breathing
in dry air (7,15).
Among these rhinitis participants, LPR was only present in 10.2% in the
whole study population and the proportion of LPR was not significantly
different (13 v 5%, P=0.2). This suggests that LPR may not play a major
role for the symptoms of PND among rhinitis patients. Physicians should
not be too hasty to prescribe anti- reflux medications for PND among
rhinitis. These patients should be treated with intranasal steroids and
nasal douching first. Secretions found in the posterior nasal cavity may
potentially be a useful sign that the PND is due to rhinitis and not
LPR. Although the RSI is higher in the PND group, this is not surprising
as RSI also assess for symptoms similar to PND. Furthermore, RSI has
been reported to be associated with more severe rhinitis symptoms(16). Therefore, RSI should not be used as standalone
to diagnose LPR among rhinitis patients and should always be combined
with RFS.
The redness of the nasopharynx and granular posterior pharyngeal wall
that was assessed appeared to have good test characteristics. Both
inter-and intra-observer Cohen’s Kappa and ICCs were good and, likely
that the use of reference images and predefining the appearance of
redness and granularity of posterior pharyngeal wall contributed to this
finding. The limitation of this study is the lack of a
Hypopharyngeal-Esophageal Multichannel Intraluminal Impedance with dual
pH probe (HEMII-pH) testing which is considered as gold standard to
confirm the diagnosis of LPR. Although RSI and RFS have been proposed as
a diagnostic tool for LPR, there is still debate about this since both
tools are subjective in nature. Future studies in investigating the
relationship of postnasal drip with LPR should include this test(17). Another limitation is that diffuse redness of
the nasopharynx was not further graded according to the severity (mild,
moderate to severe) and this is best performed using specifically
designed software. Redness of nasopharynx and hemorrhagic spots without
secretions may be more suggestive of LPR, but this requires further
study which separates LPR, rhinitis only and healthy control.
In conclusion, majority rhinitis patients suffer from PND which is
bothersome. Secretion seen in posterior nasal cavity may be a useful
sign to support presence of PND among rhinitis patients. These nasal
endoscopic features should be studies in other patient population to
further define its diagnostic utility for PND.
REFERENCES
- Dobell H. Appendix. Postnasal catarrh. In: On Winter Cough, Catarrh,
Bronchitis. 1st ed. London, England: Kessinger Publishing;
1866:172-174.
- Mackenzie M. Diseases of the throat and nose. London: J. & A.
Churchill 1884. Section IV. Diseases of the nasopharynx, chronic
catarrh of the nasopharynx, pages 482-493.
- Forer M, Ananda S. The management of postnasal drip. Aust.Family
Physician. 1999;64:55-68.
- Deborah C. Sylvester, Petros D. Karkos, Casey Vaughan, James Johnston,
Raghav C. Dwivedi, Helen Atkinson, Shah Kortequee. Review Article.
Chronic cough, reflux, Postnasal Drip Syndome and the
Otolaryngologist. Hindawi PublishingCorporation.International Journal
of Otolaryngology.Volume 2012,Article ID 564852.
- Masaany, M., Marina, M., Sharifa Ezat, W., & Sani, A. (2011).
Empirical treatment with pantoprazole as a diagnostic tool for
symptomatic adult laryngopharyngeal reflux. The Journal of
Laryngology & Otology, 125 (5), 502-508.
doi:10.1017/S0022215111000120.
- Yu JL, Becker SS. Postnasal dripand postnasal drip-related cough.
CurrOpinOtolaryngol Head Neck Surg. 2016 Feb;24(1):15-9. doi:
10.1097/MOO.0000000000000226. PMID: 26731683.
- La Mantia, I, Andaloro C. Cobblestone Appearance of the Nasopharyngeal
Mucosa. Eurasian J Med 2017; 49: 220-
- Belafsky
PC, Postma
GN, Koufman JA. Validity and reliability of the reflux symptom index
(RSI).J
Voice. 2002 Jun; 16(2): 274-7.
- Belafsky
PC, Postma
GN, Koufman JA. Validity and reliability of the reflux symptom score
(RFS).Laryngoscope. 2001
Aug; 111(8):1313-7
- Stuck BA, Czajkowski J, Hagner A-E, Klinek L, Verse T, Hormann K, et
al.Changes in daytime sleepiness, quality of life, and objective sleep
patterns in seasonal allergic rhinitis: a controlled trial. J Allergy
Clinical Immunology 2004;113:663-8.
- Jaruvongvanich, Veeravich & Mongkolpathumrat, Pungjai &
Chantaphakul, Hiroshi & Klaewsongkram, Jettanong. (2016). Extranasal
symptoms of allergic rhinitis are difficult to treat and affect
quality of life. Allergology International. 65.
10.1016/j.alit.2015.11.006.
- Sarina Bucher, MMed; Peter Schmid-Grendelmeier, MD; and Michael B.
Soyka, MD. Altered Viscosity of Nasal Secretions in Postnasal
Drip.2019 Oct; 156(4):659-666.
- Min, Y.-G. (2010). The Pathophysiology, Diagnosis and Treatment of
Allergic Rhinitis. Allergy, Asthma and Immunology Research, 2(2), 65.
- Janet Rimmer, Johan Hellgren, Richard J. Harvey. Simulated postnasal
mucus fails to reproduce the symptoms of postnasal drip in rhinitics
but only in healthy subjects. Rhinology 53: 129-134, 2015.
DOI:10.4193/Rhino14.210
- Stewart R. Leason, Henry P. Barham, Gretchen Oakley, Janet Rimmer,
John M. DelGaudio6, Jenna M. Christensen, Raymond Sacks, Richard J.
Harvey. Association of gastro-oesophageal reflux and chronic
rhinosinusitis: systematic review and meta-analysis.Rhinology 55: 3-16, 2017.
- Hamizan AW, Choo YY, Loh PV, Abd Talib NF, Mohd Ramli MF, Zahedi FD,
Husain S. The association between the reflux symptoms index and nasal
symptoms among patients with non-allergic rhinitis. J Laryngol Otol
2021;135:142–146.
- Horvath, L.; Hagmann, P.; Burri, E.; Kraft, M. Evaluation of
Oropharyngeal pH-Monitoring in the Assessment of Laryngopharyngeal
Reflux. J. Clin. Med. 2021 , 10,
2409.https://doi.org/10.3390/jcm10112409