Prevalence and Clinical Findings of Nasopharyngeal Reflux in Patients With Idiopathic Nasal Symptoms: A Preliminary Study

Abstract

Importance

Recent studies suggested that laryngopharyngeal reflux disease may be associated with chronic nasal symptoms.

Objective

To investigate the prevalence and the pre- to posttreatment clinical findings of nasopharyngeal reflux disease (NRD) in patients with idiopathic chronic nasal complaints without allergy or chronic rhinosinusitis.

Design

Prospective uncontrolled preliminary study.

Setting

University Hospital.

Participants

Patients with chronic idiopathic nasal complaints, without rhinosinusitis, allergic rhinitis, or other common sinonasal diseases.

Intervention

From July 2022 to November 2024, patients underwent a 24 hour nasopharyngeal pH-testing (Dx-pH system) for detecting NRD. Patients with NRD were treated with alginates or antacids for 3 months.

Main Outcomes

Laryngopharyngeal and nasal symptoms and findings were evaluated from pre- to posttreatment with reflux symptom score (RSS), Sinonasal Outcome Test-22 (SNOT-22), and reflux sign assessment (RSA).

Results

Thirty-three patients (15 females; mean age 50.1 ± 16.4 years) were evaluated. NRD was identified in 26 patients (78.8%) with a mean of 85.6 ± 64.3 reflux events, predominantly alkaline (pH > 6.0). Endoscopic findings included mulberry inferior turbinate (72.2%), crusts (38.9%), and dry nasal mucosa (27.8%). Posttreatment analysis revealed a significant reduction in RSS from 141.4 ± 100.9 to 95.2 ± 82.6 (P = .015). While baseline SNOT-22 scores showed nonsignificant reduction posttreatment (46.2 ± 19.1 vs 36.0 ± 31.0), nasal RSA decreased significantly (P = .023). Nasal dryness was positively associated with the total upright reflux time (pH < 6.5; r_s = .575; P = .016) and the number of acid reflux events (r_s = .523; P = .026), while the RSA pharynx was associated with the supine reflux time (r_s = .573; P = .016).

Conclusion

Nasopharyngeal reflux, predominantly alkaline, shows high prevalence (78.8%) with characteristic endoscopic findings. Anti-reflux treatment significantly improves reflux symptoms and nasal scores, though overall sinonasal quality of life shows modest change.

Graphical Abstract.

Introduction

The prevalence of rhinitis and related nasal symptoms ranged from 6.7% to 42.0% in the Western countries’ populations, with a mean of 14% of the United States population.^1-3 Rhinitis can be categorized as allergic, infectious, and nonallergic rhinitis. ³ The most common nonallergic rhinitis phenotypes include medicamentosa (14%), occupational (8%), smokers’ (6%), hormonal (4%), gustatory (4%) rhinitis, and rhinorrhea of the elderly (4%). ⁴ In 39% of cases, the etiology is not identified. ⁴ Recent data suggested that laryngopharyngeal reflux disease (LPRD) can be associated with chronic nasopharyngeal, nasal, ear, and eye symptoms and findings through the deposit of pepsin in the nasal and eye fluids.^5-7 Pepsin has been found in the secretions of patients with recalcitrant chronic rhinosinusitis.^5,7 Moreover, growing literature reports that pepsin may be measured in the tears of patients with dry eye syndrome, suggesting gastric content deposition in the nasal fossae close to the nasolacrimal duct. ⁶ Despite these findings, the involvement of LPRD in nasal disorders remains poorly studied. To date, there is no study investigating the prevalence of LPRD in idiopathic rhinitis with an objective approach for confirming the LPRD diagnosis. The classical probes of 24 hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) have no nasopharyngeal sensors because such catheter were developed to measure esophageal and hypopharyngeal reflux events. Moreover, the saliva pepsin test is associated with low-to-moderate sensitivity and specificity, while it was not developed for nasal analysis. ⁸ In a recent study, our group investigated the tolerance of Dx-pH measurement for diagnosing NRD, but no pre- to posttreatment clinical features were reported. ⁹

This preliminary study aimed to investigate the prevalence and pre- to posttreatment clinical findings of nasopharyngeal reflux disease (NRD) in patients with idiopathic rhinitis.

Materials and Methods

Setting and Patients

Patients with suspected NRD presenting with idiopathic rhinitis symptoms were consecutively recruited from July 2022 to November 2024 at the Dour Medical Center and CHU Saint-Pierre of Brussels (Belgium). To establish a rigorous diagnostic framework distinguishing nasopharyngeal reflux from other rhinitis subtypes, a two-stage selection process was implemented. First, patients were screened for idiopathic rhinitis based on the presence of 2 or more cardinal symptoms (nasal running, nasal congestion, sneezing, and nasal itching) occurring for more than an hour daily and persisting for >2 weeks. ¹⁰ All patients underwent complete diagnostic evaluation including sinonasal computed tomography, skin prick testing, specific immunoglobulin E (IgE) measurements [Radioallergosorbent Test (RAST)], and pulmonary function testing (for those with concomitant respiratory symptoms). Second, alternative etiologies were systematically excluded through both clinical and laboratory assessments, including rhinosinusitis [based on computed tomography (CT) findings and symptom profile], allergic rhinitis (confirmed by negative skin prick tests and serum-specific IgE), infectious rhinitis (based on clinical presentation), tobacco-induced rhinitis (through detailed smoking history), vasomotor rhinitis (based on symptom pattern, triggers such as temperature changes or strong odors, and lack of response to anticholinergic nasal sprays during a 2 week trial period), occupational rhinitis (through comprehensive occupational exposure history), and medicamentosa rhinitis (via detailed medication history). Additional exclusion criteria included upper respiratory tract infection within the preceding month; concurrent use of anti-reflux therapy; oral or nasal corticosteroid treatment; neurological or psychiatric comorbidities; head and neck malignancy or history of radiotherapy; seasonal allergies; and asthma. The remaining cohort, having no identifiable cause for their persistent rhinitis symptoms despite evaluations, was considered as having suspected NRD and subsequently underwent the specific diagnostic procedures described in the following sections.

Nasopharyngeal Dx-pH testing was proposed to patients. The NRD diagnosis was considered positive when more than 8 pharyngeal reflux events (pH < 6.5) were detected during the 24 hour Dx-pH system monitoring (Respiratory Technology Corp, San Diego, CA, USA) of acid-suppressive medication. This threshold was based on a normative data review ¹¹ and the European reflux guideline paper. ¹² The normative review combined studies where asymptomatic individuals underwent Dx-pH system evaluation for establishing normative thresholds for this examination. Based on the data found in this review, the European group of LPRD proposed the diagnosis of NRD for more than 8 pharyngeal reflux events. ¹² According to the Dubai consensus, ¹³ the following criteria were considered to indicate upper gastrointestinal endoscopy in patients: gastroesophageal reflux disease (GERD)-related symptoms; undetermined weight loss; hematemesis; and history of Barrett’s metaplasia.

This study has been approved by the ethics committee of CHU Saint Pierre (reference B0762022220217). Patients consented to participate.

Nasopharyngeal Dx-pH System

The 24 hour detection of reflux events was carried out using the Restech® Dx-pH measurement system, which consists of a single transnasal probe, a reusable transmitter, and a wireless recorder system (Respiratory Technology Corp) detecting aerosolized reflux events. Its antimony pH probe, featuring specialized hydration technology, functions reliably in both wet and dry environments of the upper airway. The probe was transnasally placed according to 2 steps. First, the probe was inserted into the nasal cavity to see transorally the light of the sensor in the posterior wall of the oropharyngeal cavity. In the second step, the probe was pulled back to the nasopharyngeal cavity, which was confirmed by the light of the probe. During the 24 hour test, patients were instructed to record the symptoms, meals, and their position (upright or supine) with a button press on the recorder. Otherwise, patients were encouraged to maintain their normal daily activities.

The Dx-pH system sensor detects the type of reflux (aerosolized and/or liquid), the pH, the number, duration, and timing of the nasopharyngeal reflux episodes. The catheter was placed in the morning before breakfast (8:30 AM). The Restech® data were analyzed by the DataView software (AEMC Instruments, Foxborough, MA, USA), which generated a graphical tracing and a report of the reflux events. Time spent eating and drinking was excluded from the analyses. The following event parameters were extracted from the analysis at the different pH thresholds (<6.5, <6.0, <5.5, <5.0): total time of all pH events, total % pH below baseline, total time below baseline pH, upright, total % pH below baseline, upright, total time below baseline pH, supine, total % pH below baseline, supine, longest time of a pH event, number of events >5 minutes, and the total number of events. The RYAN score was automatically measured. This score included the number of reflux episodes, the duration of the longest reflux episode, and the percent time of pH below the pH threshold of 5.5 in the upright (daytime) and 5.0 in the supine (nocturnal) periods. ¹⁴ While there is no large cohort study reporting normative data for Dx-pH, a recent systematic review of normative impedance-pH testing and Dx-pH data ¹¹ suggested that healthy individuals have less than 9 pharyngeal reflux events at the 24 hour Dx-pH system. GERD was defined according to the Lyon consensus. ¹⁵

Clinical Assessment

Laryngopharyngeal symptoms were assessed with the French version of the reflux symptom score (RSS), ¹⁶ which rates the frequency and severity of laryngopharyngeal, digestive, and respiratory symptoms. Due to the lack of validated and standardized patient-reported outcome questionnaires documenting nasopharyngeal and nasal findings associated with LPRD, the authors used the French version of the Sinonasal Outcome Test-22 (SNOT-22) ¹⁷ to document the nasal symptoms. The oral, laryngeal, and pharyngeal findings were assessed using the reflux sign assessment (RSA), with investigators blinded to patients’ symptoms. ¹⁸ The RSA was evaluated by 2 practitioners in a semi-blind manner (specific subject LPRD symptoms were unknown). Note that nasal findings were documented in the “additional findings” section of the RSA. The RSA item scores (posterior commissure hypertrophy, tongue tonsil hypertrophy, etc) were established in the initial RSA validation study based on the prevalence of oral, laryngeal, and pharyngeal signs. ¹⁸ Because nasal findings were not included in this initial validation study, they were simply rated as present (1/1) or absent (0/1) in the current study. Three signs were searched: mulberry posterior turbinate, crusting, and dryness (/3). RSS, SNOT-22, and RSA were evaluated at pre- to posttreatment. In addition to the mean item scores, the presence of symptoms was documented and considered for an item score ≥1.

Treatments

Based on the nasopharyngeal pH findings, patients were treated with a standardized anti-reflux diet, ¹⁹ and a combination of proton pump inhibitors (PPIs; 40 mg once in the morning), post-meal alginate (Gaviscon®, Reckitt Benckiser, Slough, UK; 3/d) or antacids (magaldrate; Riopan®, Takeda, Zaventem, Belgium; 3/d) for 3 months (Figure 1).^20,21 Patients with a majority of acid (pH < 4.0) or weakly acid (pH = 4.1-6.0) reflux events received a combination of PPI and alginate, while patients with a majority of alkaline reflux events (pH > 6.5) were treated with alginate or magaldrate only. The therapeutic response was assessed at 3 months posttreatment with the RSS.

Figure 1.

Chart flow. PPI, proton pump inhibitors; RSA, reflux sign assessment; RSS, reflux symptom score; SNOT-22, Sinonasal Outcome Test-22.

Statistical Methods

Statistical analyses were conducted using the Statistical Package for the Social Sciences for Windows (SPSS version 29.0; IBM Corp, Armonk, NY, USA). The pre- to posttreatment evolution of RSS, SNOT-22, and RSA was evaluated with the Wilcoxon signed-rank test. The predictive value of demographic and clinical outcomes on the therapeutic response, and the outcome associations were evaluated with the Spearman correlation coefficient and the chi-squared test according to the type of data. A level of significance of P < .05 was used.

Results

Clinical Presentations and Nasopharyngeal Dx-pH

Of the 33 consecutive patients (15 females), 26 (78.8%) demonstrated a positive diagnosis for NRD (Table 1). The mean number of nasopharyngeal reflux events in patients with NRD was 85.6 ± 64.3, with most of them being alkaline (pH < 6.5). The Ryan score, considering acidic reflux, was positive in upright position only. There was no patient completing the Lyon criteria for GERD diagnosis. The clinical otolaryngological, respiratory, digestive, and nasal patterns of patients with NRD are described in Tables 2 and 3. The most prevalent symptoms of patients with nasopharyngeal reflux included throat clearing and postnasal drip (88.5%), heartburn (88.5%), excess throat mucus (84.5%), regurgitations/burps (84.5%), abdominal distension (84.5%), and cough (84.6%). Excess throat mucus, throat clearing/postnasal drip, abdominal distension/flatus, and heartburn were symptoms associated with the highest item scores in the RSS (Table 2). Sneezing and runny nose were the most prevalent nasal symptoms, while runny nose, postnasal discharge, lack of a good night sleep, and fatigue were the symptoms associated with the highest item score in the RSS (Table 3). Posterior mulberry inferior turbinate, nasal dryness, and crusts were found in 72.2%, 27.8%, and 38.9%, respectively (Figure 2).

Table 1.

Patient Features.

Characteristics	All patients (N = 33)	NRD patients (N = 26)
Age (range; years old)	50.1 ± 16.4	47.5 ± 17.2
Body mass index (m; SD)	24.1 ± 3.1	24.2 ± 2.6
Gender (N, %)
Male	18 (54.5)	16 (61.5)
Female	15 (45.5)	10 (38.5)
Gastrointestinal endoscopy (N, %)	14 (42.4)	11 (42.3)
Normal	4 (12.1)	4 (15.4)
Esophagitis	4 (12.1)	4 (15.4)
Hiatal hernia	4 (12.1)	2 (7.7)
Lower esophageal sphincter insufficiency	8 (24.2)	5 (19.2)
Gastritis	3 (9.1)	2 (7.7)
Helicobacter Pylori infection	0 (0)	0 (0)
Nasopharyngeal impedance-pH feature
Nasopharyngeal events (mean, SD)
Nasopharyngeal pH < 6.5	64.5 ± 64.0	85.6 ± 64.3
Nasopharyngeal pH < 6.0	21.9 ± 27.1	27.0 ± 27.3
Nasopharyngeal pH < 5.5	9.1 ± 16.3	10.9 ± 17.5
Nasopharyngeal pH < 5.0	3.4 ± 9.4	4.0 ± 10.2
Ryan score upright position	37.1 ± 118.0	44.5 ± 128.4
Ryan score supine position	1.6 ± 4.4	1.9 ± 4.8

Abbreviations: m, mean; N, number; NRD, nasopharyngeal reflux disease; SD, standard deviation.

Table 2.

Laryngopharyngeal, Digestive, and Respiratory Symptoms of NRD Patients.

Reflux symptom score	NRD patients
	N (%)	Mean score (SD)
Otolaryngological symptoms
Voice disorder	16 (61.5)	4.5 ± 7.1
Throat pain	19 (73.1)	6.3 ± 8.1
Odynophagia	17 (65.4)	4.9 ± 7.2
Dysphagia	15 (57.7)	4.0 ± 7.0
Throat clearing & postnasal drip	23 (88.5)	11.8 ± 9.4
Globus sensation	19 (73.1)	8.4 ± 9.0
Excess throat mucus	22 (84.6)	13.9 ± 9.8
Ear pressure/pain	19 (73.1)	6.1 ± 6.6
Tongue burning	17 (65.4)	7.7 ± 9.3
Digestive symptoms
Heartburn	23 (88.5)	9.2 ± 7.4
Regurgitations or burps	22 (84.6)	7.5 ± 8.1
Abdominal pain	17 (65.4)	5.4 ± 9.2
Diarrheas	19 (73.1)	4.9 ± 7.4
Constipation	14 (53.8)	5.9 ± 9.2
Indigestion	17 (65.4)	4.6 ± 7.0
Abdominal distension/flatus	22 (84.6)	9.3 ± 8.8
Halitosis	17 (65.4)	5.0 ± 6.1
Nausea	19 (73.1)	4.3 ± 5.4
Respiratory symptoms
Cough after eating/lying down	18 (69.2)	5.4 ± 7.5
Cough	22 (84.6)	6.0 ± 6.8
Breathing difficulties	14 (53.8)	2.5 ± 5.8
Chest pain	16 (61.5)	4.3 ± 6.6

Abbreviations: m, mean; N, number; NRD, nasopharyngeal reflux disease; SD, standard deviation.

Table 3.

Nasal Clinical Presentation.

SNOT-22 items	NRD patients
	N (%)	Mean score (SD)
Need to blow nose	23 (88.5)	2.7 ± 1.6
Sneezing	24 (92.3)	2.0 ± 1.3
Runny nose	25 (96.2)	2.8 ± 1.5
Cough	22 (84.6)	2.2 ± 1.4
Postnasal discharge	22 (84.6)	2.8 ± 2.0
Thick nasal discharge	19 (73.1)	2.1 ± 2.1
Ear fullness	17 (65.4)	1.4 ± 1.9
Dizziness	14 (53.8)	0.7 ± 1.2
Ear pain	18 (69.2)	1.4 ± 1.7
Facial pain/pressure	18 (69.2)	1.8 ± 2.0
Difficulty falling asleep	17 (65.4)	1.3 ± 1.7
Wake up at night	23 (88.5)	2.7 ± 1.9
Lack of a good night’s sleep	23 (88.5)	2.8 ± 1.9
Wake up tired	22 (84.6)	2.7 ± 2.0
Fatigue	23 (88.5)	2.8 ± 1.7
Reduced productivity	23 (88.5)	2.1 ± 1.4
Reduced concentration	23 (88.5)	2.1 ± 1.5
Frusated/restless/irritable	22 (84.6)	2.3 ± 1.6
Sad	22 (84.6)	1.9 ± 1.3
Embarrassed	22 (84.6)	2.2 ± 1.7
Decreased sense of smell/taste	18 (69.2)	1.9 ± 2.0
Nasal blockage	21 (80.8)	3.0 ± 2.1

Abbreviations: m, mean; N, number; NRD, nasopharyngeal reflux disease; SD, standard deviation; SNOT-22, Sinonasal Outcome Test-22.

Figure 2.

Nasal findings associated with nasopharyngeal reflux disease. Common or narrow band imaging nasal endoscopic findings may include the following: dry mucosa and crusts (A, B), sticky mucus (A, C), mucosa inflammation (A, B, D), nasopharyngeal erythema (E, F), and mild (G) and moderate (H) mulberry inferior turbinate.

Pre- to Posttreatment Symptom and Sign Changes

The pre- to posttreatment RSS, RSA, and SNOT-22 changes are reported in Table 4. RSS, RSS Quality-of-Life, digestive and respiratory RSS significantly reduced at 3 months posttreatment. SNOT-22 did not change throughout treatment. Among signs, only laryngeal RSA significantly reduced from pre- to posttreatment (Table 4). The nasal RSA score of patients with NRD significantly reduced from baseline to 3 month posttreatment (P = .023). The proportion of posterior mulberry inferior turbinate (72.2% vs 41.7%), nasal dryness (27.8% vs 12.5%), and crusts (38.9% vs 12.5%) reduced from baseline to 3 month post-reatment.

Table 4.

Pre- to Posttreatment Symptom and Sign Changes.

Clinical scores	NRD patients (N = 26)		Z	P-value
	Baseline	3 mo
Reflux symptom score	141.4 ± 100.9	95.2 ± 82.6	–2.43	.015
Otolaryngological score	67.6 ± 53.2	48.3 ± 45.8	–1.74	.083
Digestive score	55.8 ± 48.5	36.3 ± 35.4	–2.55	.011
Respiratory score	18.0 ± 19.4	10.6 ± 14.0	–2.22	.026
RSS – QoL	38.4 ± 24.0	7.5 ± 8.3	–2.35	.019
Reflux sign assessment	24.2 ± 9.7	20.9 ± 6.7	–1.02	.307
Oral score	5.1 ± 7.1	4.3 ± 2.2	–0.64	.524
Pharyngeal score	9.4 ± 2.7	7.4 ± 3.9	–1.69	.091
Laryngeal score	13.6 ± 4.5	8.9 ± 3.9	–2.55	.011
Nasal findings	1.4 ± 0.9	0.6 ± 0.8	–2.27	.023
SNOT-22	46.2 ± 19.1	36.0 ± 31.0	–1.57	.116

Abbreviations: m, mean; mo, month; N, number; NRD, nasopharyngeal reflux disease; RSS, reflux symptom score; QoL, quality-of-life; SD, standard deviation; SNOT-22, Sinonasal Outcome Test-22.

Clinical Associations

Nasal dryness was positively associated with the total upright reflux time (pH < 6.5; r_s = .575; P = .016) and the number of acid reflux events (r_s = .523; P = .026), while the RSA pharynx was associated with the supine reflux time (r_s = .573; P = .016).

Discussion

The primary findings of the present study are the detection of reflux disease in 78.8% of idiopathic rhinitis cases, and the demonstration of nasal signs associated with LPRD. The LPRD has long been suggested as a contributing factor in recalcitrant rhinosinusitis, Eustachian tube dysfunction, and chronic otitis media. ²² However, to date, there was no study investigating the prevalence of NRD in idiopathic rhinitis patients with an objective diagnostic tool documenting acidic, weakly acidic, and alkaline reflux events. In 1998, Ulualp et al reported that patients with recalcitrant chronic rhinosinusitis had a significantly-higher number of acidic hypopharyngeal reflux events at the triple-probe pH monitoring than healthy individuals. ²³ Similar findings were observed by Wong et al who reported a prevalence of 27.0% and 5.4% of acidic hypopharyngeal and nasopharyngeal reflux events at the triple-probe pH monitoring in patients with resistant chronic rhinosinusitis. ²⁴ Other teams investigating the prevalence of GERD in chronic rhinitis or rhinosinusitis found a prevalence of reflux ranging from 32% to 91% of cases. ²² The lower prevalence of NRD in previous studies than in our study can be attributed to the use of dual- or triple-probe pH monitoring devices, which cannot detect weakly acidic or alkaline reflux events. From a clinical standpoint, recent studies demonstrated that most hypopharyngeal reflux events are weakly acidic or alkaline at the 24 hour HEMII-pH.^25,26 Therefore, it can be assumed that nasopharyngeal reflux events are mostly weakly acidic or alkaline, which makes the use of Dx-pH system interesting for detecting nasopharyngeal reflux events.

From a pathophysiological standpoint, the deposit of gastroduodenal enzymes in nasal mucosae can lead to local inflammation, and related symptoms and findings. Previous studies have found pepsin in the nasal fluids of patients with chronic rhinosinusitis or rhinitis, and related inflammation of mucosa.^6,27 In laryngeal and pharyngeal studies, pepsin has been shown to reduce the expression of mucin and carbonic anhydrase genes, which was associated with the dehydration of mucus.^28,29 Similar mechanisms could occur in patients with NRD complaining of sticky nasal secretions and crusts. This hypothesis can be strengthened by the observation of nasal mucosa dryness and crusts in 27.8% and 38.9% of patients with NRD in the present study. The nasal mucosa edema in reflux patients was similarly observed by Javorska et al in a prospective controlled study reporting that 69.1% of patients with oropharyngeal reflux disease had mulberry turbinate. ³⁰

In patients with typical LPRD symptoms (eg, dysphonia, globus sensation, sticky throat mucus, or throat clearing), the 24 hour HEMII-pH studies reported that reflux events mostly occur in the upright, during daytime, and are weakly acidic and gaseous,^25,26 which strengthens the use of alginate or antacids rather than PPIs for the treatment. Patients with a positive NRD diagnosis at the 24 hour Restech Dx-pH system were treated with a combination of PPIs, alginate, or magaldrate, which was associated with a significant reduction in laryngopharyngeal symptoms and nasal findings. However, SNOT-22 scores did not significantly decrease, which can be attributed to the low number of patients and the resulting low statistical power, while it is not excluded that nasal symptoms may require more time for relief. The reduction in laryngopharyngeal symptoms and nasal signs can, however, support the use of an empirical therapeutic trial in patients consulting in otolaryngology offices for idiopathic rhinitis and allergy-like symptoms without identified etiology. The effectiveness of alginate and antacid therapies should be related to the raft mechanism and the related mucosal protection, and their role in chelation. Specifically, compared to alginate, antacids are chelators of pepsin and bile salts, which are eliminated in the feces. ³¹ Despite a primary focus on pepsin in the past few studies, the clinical efficacy of antacids could support a potential role of other gastroduodenal enzymes in the development of nasal symptoms and findings. This hypothesis is being assessed in a large cohort study (LPRD European project) based on preliminary studies identifying bile salts, trypsin, and elastase in the saliva of patients with LPRD. ³¹

The low number of patients and the lack of a control group are the primary limitations of the study. From a technical standpoint, despite its utility in detecting pharyngeal reflux event, the Restech Dx-pH system exhibits notable limitations, including its inability to detect event with a pH > 6.5. Moreover, the single-sensor design precludes characterization of refluxate composition or volume. Furthermore, the absence of standardized normative values across varied patient populations and limited correlation with impedance-pH findings may limit the result interpretation. In the present study, a control group composed of asymptomatic individuals would have been valuable for establishing a threshold (normative data) of nasopharyngeal reflux events for diagnosis (via receiver operating characteristic curve). Indeed, the cutoff used in the current study was based on normative studies that placed the pH sensor in the oropharynx rather than in the nasopharynx. ¹² Future studies are therefore important given both the lack of HEMII-pH probes with nasopharyngeal sensors and the limitations of triple probe pH monitoring devices in the detection of weakly acidic or alkaline reflux events.

In a recent study of 23 patients, ⁹ Mantione et al demonstrated that patients tolerated the placement of the pH probe into the nasopharynx; however, at that time, we did not assess pre- to posttreatment changes in symptoms and findings associated with NRD. The findings of the present study provide additional insights about the clinical presentation of patients and the evolution of nasal and nasopharyngeal signs and symptoms. The novel application of using a new objective reflux testing device for detecting nasopharyngeal reflux events and the use of validated and standardized patient-reported outcome questionnaires are the strengths of the study. We used SNOT-22 for nasal symptoms because this questionnaire is the most complete questionnaire validated in the French population, but SNOT-22 was not primarily designed to document nasal symptoms associated with reflux disease.

Conclusion

NRD is a potential cause of idiopathic rhinitis, accounting for 78.8% of the patients in this study with chronic rhinitis and no identified etiology. Treatment addressing acidic, weakly acidic, and alkaline reflux events can significantly reduce laryngopharyngeal symptoms and nasal signs. Future controlled studies are needed to establish normative data to define diagnostic thresholds for NRD using nasopharyngeal Dx-pH system monitoring.