Application of Wen Yang Tong Qiao Tang in the perioperative period of chronic rhinosinusitis type II
Objective To observe the effect of Wenyang Tongjiao Tang in the perioperative period of chronic sinusitis type II (combined with allergic rhinitis). Methods 132 patients with chronic sinusitis type II (combined with allergic rhinitis) were divided into two groups randomly or in consultation with themselves before and after surgery, and the treatment group was treated with oral Wenyang Tongjiao Tang before and after surgery. The control group was treated with conventional perioperative treatment and followed up for 6 months. The postoperative efficacy of the two groups was observed. Results The total effective rate of the treatment group was 92.18%, and the total effective rate of the control group was 86.76%, and there was a significant difference between the clinical efficacy of the two groups (P<0.05). Conclusion The application of Wanyang Tongkang Tang can improve the clinical efficacy of surgery for chronic sinusitis type II (combined with allergic rhinitis).
Chronic rhinosinusitis type II combined with allergic rhinitis is a common clinical disease. Over the years, the clinical efficacy of functional endoscopic sinus surgery (FESS) and comprehensive treatment during the recovery period for chronic sinusitis and nasal polyps is evident to all, but at the same time, we can still see some patients who underwent comprehensive treatment during the perioperative period after surgery, although the surgery was successful, they still have mucosal edema in the operative cavity and sinus opening after a period of time, with more nasal discharge or recurrence of polyps requiring secondary surgical treatment. We selected 132 patients with chronic rhinosinusitis type II combined with allergic rhinitis from January 2003 to October 2007, and through the application of Chinese herbal medicine to 64 of them during the perioperative period, we clinically showed that the use of Chinese herbal medicine during the perioperative period of FESS could not only reduce recurrence and improve the cure rate, but also reduce postoperative complications, shorten the course of the disease and greatly reduce the reoperation The results are reported as follows.
Materials and methods
1. Clinical data
1.1, diagnostic criteria
The clinical staging of chronic rhinosinusitis nasal polyps is based on the staging criteria of the Haikou Conference [1]: diagnosis is made based on history, symptoms, nasal endoscopic examination signs and sinus CT. Typing staging: Type I: simple chronic rhinosinusitis. (1) stage: solitary sinusitis; (2) stage: multiple sinusitis; (3) stage: whole group sinusitis. type II: (1) stage: solitary sinusitis with solitary nasal polyps; (2) stage multiple sinusitis with multiple nasal polyps; (3) stage whole group sinusitis with multiple nasal polyps. type III: multiple sinusitis or whole group sinusitis with multiple, recurrent nasal polyps/ or septal sinus osteophytes.
Diagnostic criteria for perennial allergic rhinitis Haikou Conference: (1) Score criteria: (1) perennial onset, with three main clinical manifestations of sneezing (more than 3 in a row each time), runny nose and swollen nasal mucosa, with a cumulative number of onset days exceeding 6 months in a year and a cumulative onset time exceeding 0.5 hours in a day; (2) disease duration of at least one year. (2) Scoring criteria: there are clear clues of inhalant allergens, personal and/or family history of allergic diseases, and typical symptoms and signs during the attack, 1 point each, a total of 3 points. Positive allergen skin test reaction, at least one of which is (++) or (+++) or more; positive specific IgE antibody test or positive allergen nasal excitation test, and consistent with the skin test and medical history, each scored 2 points, total 4 points. Positive eosinophils on nasal secretion smear and/or positive mast cells (basophils) on nasal mucosal scrapings scored 1 point. (3) Score: 6 to 8 points for diagnosis of perennial allergic rhinitis, 3 to 5 points for suspected allergic rhinitis, and 0 to 2 points for possible non-allergic rhinitis.
1.2. Chinese medicine identification criteria
Identification is based on the TCM identification criteria in “Otolaryngology of Chinese Medicine” [2]. Lung-Qi deficiency type: ① persistent nasal congestion, nasal runny nose with sticky white, decreased sense of smell, sneezing, easy to catch a cold, and fear of wind and cold. ②Examination shows pale nasal muscle membrane or nasal polyps with pale color, high transparency, moist or with mucous white drainage. The whole body or see pale face, short breath, dizziness and head swelling, dullness, loose stool, cough and sputum white. (iii) The tongue is pale red with thin white coating and thin pulse. We and based on clinical observation of changes in the color and shape of nasal and sinus mucosa and secretions under the nasal endoscope to provide a basis for local visualization and identification in Chinese medicine: pale/edematous nasal mucosa, white polyps, clear snot, and edema of the mucosa of the sinus orifice.
1.3. Inclusion criteria
Patients who also meet the diagnostic criteria of chronic rhinosinusitis type II and perennial allergic rhinitis and the TCM identification criteria of lung and spleen qi deficiency type, and who are intended to undergo surgical treatment.
Exclusion criteria (including indications or exclusion criteria) Pre-operative and post-operative diagnosis of serious or specific infections, such as mycobacterial infections, etc.; those under 18 years of age or over 65 years of age; combined with serious primary diseases such as cardiovascular, hepatic, renal and hematopoietic systems, psychiatric patients; those who do not meet the inclusion criteria, do not take medication as prescribed, fail to complete the entire treatment process for various reasons, cannot judge the efficacy or have incomplete information The efficacy of the treatment can not be judged or the information is incomplete.
1.4. Criteria for judging the efficacy (based on nasal endoscopy, Haikou meeting standards)
Cured: the symptoms disappear, the sinus opening is well opened by endoscopy, the mucosa of sinus cavity is epithelialized, and there is no purulent discharge; Improved: the symptoms improve significantly, the endoscopy shows edema, hypertrophy or granulation tissue formation in some areas of sinus cavity mucosa, and there is a small amount of purulent discharge; Ineffective: the symptoms do not improve, the endoscopy shows adhesions in the operative cavity, the sinus opening is narrowed or atretic, polyps are formed, and there is purulent discharge.
2.Study methods
2.1.Case source
Cases were obtained from ENT inpatients, and 132 qualified subjects were selected according to the above inclusion and exclusion criteria, 81 males and 51 females; age 18-64 years old. The average age was 45.2 years, and the duration of the disease was 1-20 years. Chronic sinusitis nasal polyps were staged according to the 1997 Haikou standard, and all cases were chronic sinusitis type II, including 27 cases in stage 1, 89 cases in stage 2, and 16 cases in stage 3. All cases were diagnosed as perennial allergic rhinitis according to the 1997 Haikou standard. All cases were diagnosed as pulmonary spleen qi deficiency type according to the Chinese medicine identification criteria of the Science of Otolaryngology of Chinese Medicine. Among them, 82 cases were combined with deviated nasal septum.
2.2. Case grouping
The above-mentioned cases were divided into two groups randomly or in consultation with the patients before surgery, of which 64 cases were treated with Chinese herbal medicine Wanyang Tongluo Tang during the perioperative period (referred to as the treatment group); 68 cases were treated with comprehensive treatment (antibiotics, prednisone, anti-allergic drugs and steroid nasal spray, nasal endoscopic maintenance of the operative cavity, operative cavity rinsing, etc.) during the recovery period of surgery in Western medicine (referred to as the control group). Patients in both groups were treated preoperatively with allergen skin test, nasal endoscopy, and sinus CT scan. Postoperative pathological sections confirmed the diagnosis of chronic sinusitis, nasal polyps, and allergic rhinitis.
2.3. Treatment method
All 132 cases underwent FESS surgery under local anesthesia plus Shinan analgesia. For those whose nasal septum curvature affected the surgery or should be corrected, 65 cases of nasal septum correction were performed first. For those with polyp-like changes or excessive enlargement of the middle and lower turbinates, double middle turbinates were repaired or partially resected and double inferior turbinates were externally displaced or partial ablation of inferior turbinates by low-temperature plasma radiofrequency in 52 cases, according to the specific conditions. After surgery, both groups were filled with 2-4 expansion sponges to stop bleeding. After 36-48 hours postoperatively, the expansion sponges were removed and the nasal endoscopic cavity was routinely maintained. Systemic antibiotics were given for 4-6 days and discharged 5-10 days after surgery.
In the treatment group: 5-7 days preoperatively and 3-6 months postoperatively (after 2 months, it was taken every other day or every other week), the Chinese herbal soup Wen Yang Tong Qiao Tang was taken internally, one dose daily, divided into morning and evening. The main ingredients are: Astragalus membranaceus 20g, Poria 30g, Yam 20g, Radix et Rhizoma Pinelliae 3g, Phyllanthus nigra 9g, Radix et Rhizoma Sinensis 10g, Acorus calamus 9g, Apis mellifera 4g, Shengma 3g. Add or subtract with evidence when applied.
Control group: Western medicine perioperative comprehensive treatment: in addition to routine postoperative endoscopic maintenance of the nasal cavity, oral prednisone 15mg QD 3-5 days before and the first 3 days after surgery, reduced to 5mg after 3 days and discontinued after 6 days; preoperative and postoperative antibiotic saline intraoperative cavity rinsing twice daily; oral Keratan 10mg QD 5 days before and 3-6 months after surgery; topical Berkner or Reynocort nasal spray, twice a day, once in the morning and once in the evening, two snaps in each nostril, adhere to the medication for 3-6 months.
2.4. Observation index
The patient’s general condition, specialist examinations, imaging examinations, preoperative staging, allergic rhinitis score and Chinese medicine identification according to the standard preoperative, preoperative and postoperative nasal endoscopic findings were recorded. Judgment of efficacy: 6 months after surgery, the efficacy was judged according to the criteria for judging efficacy.
2.5. Statistical processing
All data were processed using the statistical software SPSS11.0, and the chi-square test was used for counting data to compare the differences between the two groups.
Discussion
Over the years, with the development of FESS surgery, the cure rate of chronic rhinosinusitis has also been greatly improved. However, there are also many problems plaguing us, such as: the high postoperative recurrence rate of chronic sinusitis type II combined with allergic rhinitis. According to the observation of Prof. Xu Geng: patients with combined allergic rhinitis chronic sinusitis have poor postoperative recovery [3]. Prof. Bing Zhou also found that about 1/4 of patients with chronic sinusitis type II had combined allergic rhinitis. About 1/4 of patients with allergic rhinitis combined with chronic sinusitis type II had a history of FESS surgery [4]. How to improve the efficacy of surgery and reduce recurrence becomes an imminent topic. Many scholars believe that strengthening comprehensive treatment after successful surgery is the key to improve the cure rate [5]. Among them, herbal intervention is a good idea to improve clinical efficacy and reduce recurrence [6]. Our clinical experience on this issue is summarized below.
There are three causative factors of chronic sinusitis: abnormal nasal structure, infection, and allergic reaction, while combined allergic rhinitis and chronic sinusitis type II are the result of the combination of the three causes.FESS surgery to correct the deviated nasal septum, open the sinuses, and remove polyps and diseased tissues aims to restore the normal form and function of the nasal cavity-sinus, however, in terms of chronic sinusitis and nasal polyps However, in terms of mucosal inflammatory response in chronic rhinosinusitis and nasal polyps, it is clinically reported that even after more than 3 months or a longer period of perioperative comprehensive treatment, the inflammatory state of the sinus mucosa still exists through clinicopathological histological experiments [7], and the effect of adjusting the dosage of drugs is not significant and the efficacy of long-use drugs is still mediocre. The endoscopic surgery for chronic rhinosinusitis and sinusitis has created favorable conditions for the reduction of local inflammation of the mucosa of the nasal cavity and sinuses, and the comprehensive perioperative treatment has an important role in improving the efficacy, but there are still limitations in terms of changing the local inflammatory state of the nasal cavity and sinuses.
The development of chronic rhinosinusitis and allergic rhinitis is the result of a variety of systemic, local and environmental factors, and this view has been agreed upon by the rhinological community. Even if antihistamine and glucocorticosteroid treatments are used, the efficacy is in a sense limited due to the long-term use of drugs with reduced luminescence and side effects, but the basic theory of traditional Chinese medicine reflects the relevance of the “individual differences” in the etiology of Chinese medicine and the principles of treatment. However, the basic theory of traditional Chinese medicine reflects the academic thought of “holistic concept” in the etiology of Chinese medicine and the relevance of “individual differences” in the pathogenesis and “holistic concept” in the treatment principles, and establishes an individualized treatment system based on the medical model of holistic view and flexible evidence-based treatment, which fully reflects the unique characteristics of Chinese medicine.
Ancestral medicine believes that human being is an organic whole with high vitality and has a strong ability to resist diseases and repair itself, and this self-healing instinct is the basis for overcoming diseases. This self-healing instinct is the basis for overcoming diseases. The state of the patient’s whole body (immune status, underlying diseases, and even mental and psychological factors) is an essential part of the patient’s healing and prognosis. Chinese medicine treatment is to stimulate and improve the patient’s self-healing and disease-resistance ability by regulating the patient’s certain constitution (vegetative body). Therefore, in the perioperative period, for patients with poor systemic status (such as combined allergic rhinitis), limited use of western drugs (such as hormones) or unsatisfactory efficacy after use, the use of TCM to improve the patient’s self-healing and anti-disease ability is an idea worthy of attention to improve clinical efficacy and reduce recurrence.
Chronic sinusitis and nasal polyps combined with allergic rhinitis belong to the category of “nasal abyss” and “congested nose” in Chinese medicine. Chinese medicine believes that the disease local reaction in the nose, the whole body organs in the lung and spleen and kidney, the disease is more deficiency, more cold: the disease mechanism is if the lung is weak, the surface is not solid, the couples are loose, wind and cold external evil is easy to take advantage of the weakness and entry, evil gathered in the nasal orifices, the lung is not pronounced, fluid stagnation, the development of nasal disease, the course of the disease over time, lung deficiency and spleen for the cold and water-damp stagnation for the symptoms. The treatment for deficiency cold is warming and tonic, so warming Yang and clearing the orifices with soup. In this formula, Astragalus, Poria, and Yam are beneficial to the lung and strengthen the spleen, while Black Saposhnikovia, Hesperidin, Acorus calamus, Sinensis, and Beehive warm the yang and disperse the cold, dispel wind and water, and open the nasal passages, while Asclepias leads the medicine upward. The combination of these medicines tonifies the lung and strengthens the spleen, disperses cold and clears the orifices. During the perioperative period, by improving the patient’s weakness and abnormal transportation, the patient’s immune system (called “Wei Qi” in Chinese medicine) was activated and enhanced, thus accelerating the patient’s ability to heal himself and achieving the long-term clinical goal of reducing recurrence.
Ancestral medicine considers human being as an organic whole, whose illness, disease nature, severity, duration and regression of disease all depend on individual differences. Here, we analyze the etiology and pathogenesis of chronic sinusitis and nasal polyp combined with allergic rhinitis at this stage by using Chinese medicine theory, so that the main pathological characteristics of deficiency and cold are understood by using the idea of combining Chinese medicine diagnosis with modern medicine diagnosis and the method of combining overall diagnosis with local diagnosis. Therefore, according to the Chinese medicine’s idea of differentiation and treatment, in the treatment of medicine, we should not only pay attention to alleviating and improving the local symptoms of nasal cavity, but also grasp the key points of deficiency of lung and spleen yang qi in the treatment, so that the lung qi can be filled, the spleen yang can be invigorated, the cold evil can be dispersed, and the fluid can be dispersed. The cold can be dispersed and the fluids can run, so that the disease can be effectively treated.
Because chronic sinusitis and nasal polyps combined with allergic rhinitis often have a long duration of illness and are characterized by “deficiency at the root and actuality at the symptoms” in Chinese medicine, we observed the changes of nasal and sinus cavity mucosa in the two groups two weeks after the operation. In the first 1-2 months, it is the key of treatment to review and change the medication for local identification of mucous membrane and secretion of nasal and sinus cavity. Analysis, after 2 months can choose intermittent medication according to the condition, (such as every other day to take, etc.) often play a positive role in consolidating the efficacy of treatment.
The combined Chinese and Western medicine method of local surgery + systemic conditioning (traditional Chinese medicine) has its own advantages over local treatment with hormones and anti-allergic drugs. Moreover, we observed significant changes in operation time, bleeding volume, and postoperative local wound healing speed. Therefore, the use of traditional Chinese medicine should be a good alternative treatment method in the comprehensive perioperative treatment of FESS.