chronic rhinosinusitis ( crs ) is a disease that significantly affects the patient s quality of life . regarding the pathophysiology of the disease , several etiologies have been proposed including obstructive factors , fungi , biofilm , and bacterial agents with different mechanisms such as staphylococcus aureus as a super antigen and helicobacter pylori as a possible pathological cause for chronic rhinosinusitis ( 1 - 5 ) . experimental studies indicate that after exposure of nasopharyngeal mucosa to gastric acid , eustachian tube dysfunction occurs . reflux of stomach content into the nasopharynx and nose causes edema in nasopharynx and sinonasal mucosa , which will lead to disruption in pressure regulation and clearing of the middle ear and paranasal sinuses . this process prepares the way for inflammation in diseases of the upper respiratory system ( 6 - 8 ) . infections caused by h. pylori are common bacterial infections in humans with a global spread . prevalence of the disease in developed countries is 30 - 40% while it is 80 - 90% in developing countries . human gastric system was thought to be the sole source of h. pylori until it was found in human dental plaques , mouth , saliva , tonsils , adenoid tissue , middle ear , nasal polyps and sinus mucosa ( 1 , 7 , 8) . today , h. pylori is not only recognized as a cause of gastritis , but it is also known as a microorganism causing systemic infections ( 6 , 8 , 9 ) . studies suggest that h. pylori infected gastric fluid enters the nasopharyngeal cavity by gastroesophageal reflux disease ( gerd ) and colonizes in dental plaques , adenoid tissues and tonsils ( 7 , 8 , 10 ) . the bacteria ascend to the middle ear and paranasal sinuses directly or by reflux from these locations and may trigger some pathological changes . isolation of h. pylori from the respiratory and gastrointestinal tracts in several studies suggests that there may be a close relationship between h. pylori and pathogenesis of various ear , nose and throat problems . detection of h. pylori in nasal mucosa of patients with crs has significantly increased by the pcr method ( 5 , 6 , 8) . considering that rhinosinusitis is a common public health issue and treatment of crs is not easy , determining the pathogenesis and pathological mechanisms of this disease is extremely important . with regards to the prevalence of crs and its impact on patients quality of life , the aim of this study was to detect h. pylori in the middle turbinate mucosa of patients with crs , and determine the association of h. pylori with crs . in this case - control study , the subjects were consecutively selected from patients who had referred to educational hospitals and had a diagnosis of chronic rhinosinusitis or nasal obstruction caused by concha bullosa ( 50 patients with chronic rhinosinusitis and 50 patients with concha bullosa ) , during august 2010 to june 2012 . patients were divided to two groups : the study group included patients with refractory crs and the control group included patients with concha bullosa without inflammation and sinus infection . we included subjects with rhinosinusitis symptoms for over 12 weeks and proof of anterior and posterior ethmoid sinuses inflammation by imaging ( ct scan ) of at least one side , with or without involvement of sphenoid sinus , after at least four weeks of antibiotic therapy . in the control group , we included those with complaints of nasal congestion and proof of existence of obstruction causing middle turbinate pneumatization by imaging ( ct scan ) . we excluded those with a history of antacid use , use of h2-blocker and proton pump inhibitor drugs a week before surgery , cystic fibrosis , immotile - cilia syndrome and immune deficiency , from both groups ; furthermore , symptoms of fungal sinusitis in ct scan in the study group and involvement and opacification of sinuses in the control group were other exclusion criteria . the samples were taken during surgery from the infected tissue in the case group and from the middle turbinate mucosa in the control group . next , bacterial dna was extracted by the roche extraction kit and the extracted dna was used as a template for pcr . the primer pairs used for pcr included baba2s sa , sb , cag1 , cag2 , cag3 and cag4 , which are appropriate primers for amplification of all h. pylori strains . the pcr products were electrophoresed on agarose gel ( 2 % ) and stained by ethidium bromide . the intended band ( bp520 ) data analysis was performed for the 100 subjects including 50 patients in the case group and 50 subjects in the control group . data analysis was performed using the spss ( version 18.0 ) software ( statistical procedures for social sciences ; chicago , illinois , usa ) . chi - square , fisher , and independent sample s t - test were used and were considered statistically significant at p values less than 0.05 . in this case - control study , the subjects were consecutively selected from patients who had referred to educational hospitals and had a diagnosis of chronic rhinosinusitis or nasal obstruction caused by concha bullosa ( 50 patients with chronic rhinosinusitis and 50 patients with concha bullosa ) , during august 2010 to june 2012 . patients were divided to two groups : the study group included patients with refractory crs and the control group included patients with concha bullosa without inflammation and sinus infection . we included subjects with rhinosinusitis symptoms for over 12 weeks and proof of anterior and posterior ethmoid sinuses inflammation by imaging ( ct scan ) of at least one side , with or without involvement of sphenoid sinus , after at least four weeks of antibiotic therapy . in the control group , we included those with complaints of nasal congestion and proof of existence of obstruction causing middle turbinate pneumatization by imaging ( ct scan ) . we excluded those with a history of antacid use , use of h2-blocker and proton pump inhibitor drugs a week before surgery , cystic fibrosis , immotile - cilia syndrome and immune deficiency , from both groups ; furthermore , symptoms of fungal sinusitis in ct scan in the study group and involvement and opacification of sinuses in the control group were other exclusion criteria . the samples were taken during surgery from the infected tissue in the case group and from the middle turbinate mucosa in the control group . next , bacterial dna was extracted by the roche extraction kit and the extracted dna was used as a template for pcr . the primer pairs used for pcr included baba2s sa , sb , cag1 , cag2 , cag3 and cag4 , which are appropriate primers for amplification of all h. pylori strains . the pcr products were electrophoresed on agarose gel ( 2 % ) and stained by ethidium bromide . the intended band ( bp520 ) data analysis was performed for the 100 subjects including 50 patients in the case group and 50 subjects in the control group . data analysis was performed using the spss ( version 18.0 ) software ( statistical procedures for social sciences ; chicago , illinois , usa ) . chi - square , fisher , and independent sample s t - test were used and were considered statistically significant at p values less than 0.05 . in the study group , 50 patients with chronic rhinosinusitis including 45 ( 90% ) males and five ( 10% ) females underwent sinus endoscopy surgery . in the control group , there were 50 patients with concha bullosa including 26 ( 52 % ) males and 24 ( 48% ) females who underwent sinus endoscopy surgery . there was no difference in frequency distribution of genders across the two groups ( p > 0.05 ) . the patients with crs were in the age range of 22 - 74 years , with a mean age of 39.6  8.7 years . in the control group , the age range of patients was 7 - 60 years , with a mean age of 29.7  7.2 years . in this study , sinus samples of nine patients ( 18% ) from 50 patients with chronic rhinosinusitis were positive for h. pylori , ( chart 1 ) while in the control group , h. pylori was found only in two patients ( 4% ) from patients with concha bullosa ; this difference was statistically significant ( p = 0.025 ) . of the nine patients in the crs group , eight patients ( 17.8% ) were male and one patient ( 20% ) was female . of the two patients in the control group , one patient ( 3.8% ) was male and one patient ( 4.2% ) was female . according to these results , the difference between the two groups was not statistically significant in terms of the relative frequency of h. pylori in male patients ( p > 0.05 ) . moreover , this indicator in females was not statistically significant between the two groups ( p > 0.05 ) . there was no statistically significant difference between the case and control groups in terms of relative frequency of h. pylori in different age groups ( p > 0.05 ) . odds ratio ( or ) of incidence of h. pylori in patients with crs and h. pylori in patients with concha bullosa was determined to be 5.26 . in this study , the sensitivity of h. pylori was 81.8% and the specificity was 96% . l = ladder ( 100 bp ) , p = positive control , lanes are numbered in the following order from 1 to 2 : case h. pylori - positive ( 286 bp ) , case h. pylori - negative l = ladder ( 100 bp ) , p = positive control , lanes are numbered in the following order from 1 to 3 : case h. pylori - positive ( 630 bp ) , negative control , case h. pylori - negative chronic rhinosinusitis is one of the most common chronic diseases which significantly reduces quality of life , in addition to the costs imposed on the health system ( 4 ) . there has been increasing evidence regarding h. pylori and reflux as possible pathological causes for chronic rhinosinusitis . in addition drug therapy of gerd together with antibiotics has improved symptoms of sinusitis in 79% of patients ( 11 ) . isolation of h. pylori from the respiratory and gastrointestinal tracts in several studies suggests that there may be a close relationship between h. pylori and pathogenesis of various ear , nose and throat problems ( 12 ) . detection of h. pylori in nasal mucosa of patients with crs has significantly increased by the pcr method . in this study , the pcr method was used to identify h. pylori in sinonasal mucosa samples . the method used in some of the studies conducted so far was pcr and in some others , methods such as the urease test ( clo test ) or immunohistological analysis were used ( 13 , 14 ) . in previous studies , the sample size of the study and control groups was smaller than the current study . this study was conducted with a larger number of patients in crs and concha bullosa groups than the previous studies , in order to better represent the possible relationship between h. pylori and crs . helicobacter pylori were found in sinonasal mucosa of 18% of patients with crs while they were observed in only 4% of sinonasal samples of patients with concha bullosa where there was a statistically significant difference between the two groups . in a number of studies in which immunohistological and campylobacter - like organism test ( clo ) test methods were used , the relative frequency of h. pylori in sinonasal samples of the study group was reported between 20 - 26% and between 0 - 3.4% in the control group , where there were statistically significant differences between the two study and control groups . however , another study conducted with these two methods , reported no statistically significant difference between the two groups in terms of relative frequency of h. pylori ( 15 ) .   in a study conducted by ozdek et al . using the pcr method to detect h. pylori , the relative frequency of h. pylori in patients with chronic rhinosinusitis was 33% , whereas none of the controls were positive for h. pylori ( 16 ) . however , in another study , which also used the pcr method , the relative frequency of h. pylori in sinonasal samples of the study and control groups was similar with no statistically significant difference ( 14 ) . for instance , noorbakhsh et al . in 2007 conducted a study on the patients polyp tissue and inferior turbinate of control group and compared the serum levels of antibodies against h. pylori and its dna in tissues , and found that h. pylori was positive in 32.3% of patients and 4% of controls ; furthermore the authors suggested that pcr is the best method for detection of h. pylori infections ( 17 ) . however , in a study conducted by khademi et al . during years 2006 to 2008 , pcr was negative in all patients with nasal polyps and in the control group ( 18 ) . based on the results of this study it can be concluded that there is a significant relationship between crs and presence of h. pylori in sinonasal mucosa . this relationship may reflect the role of h. pylori as one of the pathogenic factors in the development of chronic rhinosinusitis . however , further studies with larger sample sizes are required to confirm the role of h. pylori in crs .
background : helicobacter pylori are becoming increasingly recognized as a possible pathological cause of chronic rhinosinusitis ( crs).objectives : considering the prevalence of crs and its impact on quality of life , we decided to determine the role of h. pylori in chronic sinus infections by using the pcr technique.patients and methods : in a case - control analytical epidemiologic survey , the study population was selected by consecutive sampling from patients with crs undergoing endoscopic sinus surgery during years 2010 - 2012 . 
 patients were divided into two groups . 
 the study group consisted of patients with crs and the control group consisted of patients with nasal obstruction caused by concha bullosa , without inflammation or infection of the sinuses . 
 sampling was performed during surgery from the infected tissue and from the middle turbinate mucosa . 
 eventually , bacterial dna was extracted and used for the pcr test , in order to isolate h. pylori.results:nine patients ( 18% ) with crs had h. pylori isolated from their samples whereas in the control group , h. pylori were only found in two patients ( 4% ) ; this difference was statistically significant ( p = 0.025 ) . 
 the indicator was nt statistically significant between males and females . 
 there was no statistical correlation in relative frequency of h. pylori   for different age groups ( p > 0.05).conclusions : there was a significant correlation between crs and presence of h. pylori in sinonasal mucosa . 
 this relationship may reflect the role of h. pylori as one of the pathogenic factors in the development of crs 
 . however , further studies are required to confirm this role .