THE TREATMENT OF NASAL POLYPOSIS:
A Review of the Current Biomedical and Chinese Medical Causes and Cures
Laura Varga
Oregon College of Oriental Medicine
September 2010
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Introduction of self. Good Morning. My name is Laura Varga. I graduated from the University
of Pennsylvania with a Bachelor’s of Psychology, cum laude, received my Masters of
acupuncture and oriental medicine from the Oregon College of Oriental Medicine (OCOM) and
am currently enrolled in OCOM’s doctoral program. I have clinical research experience working
at the University of Pennsylvania and the University of California, San Diego. This gave me the
experience to work with Phase 1-4 trials and gain better understanding of the inner workings of
research studies. The following presentation will explore the diagnosis and treatment of nasal
polyposis from the perspectives of biomedicine and chinese medicine. We will also look at
current biomedical and chinese medical research and the potential for future research.
definition and classification “Nasal polyposis is a chronic eosinophilic inflammatory disease in
the nasal and paranasal mucosa, considered a subgroup to chronic rhinosinusitis and a disease in
itself with an unknown etiology.” (Fokkens, Lund, & Mullol, 2007). Rhinosinusitis is both an
inflammatory and infectious process that affects the nasal passages and the paranasal sinuses
(Fokkens et al., 2007). And it has recently been classified into four categories: acute bacterial
rhinosinusitis (ABRS) and/or acute viral rhinosinusitis (AVRS); chronic sinusitis with nasal
polyposis (CSNP); chronic rhinosinusitis with nasal polyposis (CRSNP); and allergic fungal
rhinosinusitis (AFRS) (Chan & Kuhn, 2009). So although the two diseases are related
rhinosinusitis does not necessitate the presence of nasal polyps.
epidemiology/prevalence The prevalence of nasal polyposis is usually reported between 1 and
4% (Bateman, Fahy, & Woolford, 2003; Hedman, Kaprio, Poussa, & Nieminen, 1999; Klossek et
al., 2005; Johansson, Akerlund, Holmberg, Melen, & Bende, 2003; Fokkens, Lund, & Mullol,
2007). Two researchers have reported a prevalence as high as 32% (Larson & Tos, 2004).
Although the same authors reported that of patients who have nasal polyposis, only a subset
develop symptoms (Larsen & Tos, 2002). This points to the relationship of the presence of
polyps and the patients symptoms. Some researchers have found polyp size to be correlated more
strongly to nasal congestion than to nasal blockage (Johansson et al., 2000). Later we will see see
further evidence that polyp size and computed tomography results are poor predictors of
symptomatology.
Diagnosis of nasal polyps The diagnosis of nasal polyposis is confirmed by: nasal endoscopy;
nasal computed tomography (CT); and/or magnetic resonance imaging (MRI). (Becker, 2009).
signs/symptoms. Patients with nasal polyposis may experience a myriad of symptoms including:
a reduction in or loss of sense of smell, nasal obstruction, nasal secretion/discharge, headache
and a feeling of pressure over the sinuses (Blomqvist, 2009; Fokkens et al., 2007). The blockage
of the nasal passages can cause significant sleep disruption and many patients with nasal
polyposis report sleep disturbances (Serrano et al., 2005). Patients also experience a significant
decrease in their quality of life (QOL) (Radenne et al., 1999; Alobid et al.,2005). Patients with
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rhinosinusitis and concomitant nasal polyposis experience a more severe nasal obstruction and
disease state than patients with rhinosinusitis alone (Deal & Kountakis, 2004).
etiology. The diagnosis of nasal polyposis falls under the generality of chronic rhinosinusitis but
why some patients develop polyps and other do not remains unclear (Larsen & Tos, 2002).
Currently, the etiology of nasal polyposis remains unknown (Becker, 2009). Nasal polyposis is
often associated with eosinophilia. Some researchers suggest that this may possibly be due to an
ineffective Th1-based immune response with concomitant increase of Th2 activity; or an increase
in survivin with resultant reduction in eosinophilic apoptosis (Qui, Han, Zhang, et al., 2008). It
has also been suggested in the literature that an increased expression of chemokines (Meyer, et
al., 2005; Olze et al., 2006); increased pro-inflammatory cytokines (Ohori et al., 2007; Rudack,
Stoll, & Bachert, 1998); and failure of lymphangiogenesis (Kim et al., 2007) play essential roles
in the eosinophilia seen in nasal polyposis.
pathophysiology Nasal polyps are a byproduct of sinonasal inflammation (Becker, 2009). The
source of inflammation may arise from: mechanical trauma, bacteria, viruses, fungi, and
environmental allergens (Norlander, Westrin, & Fukami, 1996). The resultant disruption in the
epithelial lining sets up an inflammatory cascade that when chronic, consolidates the stromal
edema resulting in polyp formation (Norlander, et al., 1996). Secondarily, the nasal polyps block
the passage of air and drainage of fluids creating an environment favorable to inflammation
(Becker, 2009).
comorbidity Adult patients with cystic fibrosis, asthma, age > 60 years, Churg-Strauss
syndrome, sarcoidosis, or male sex have increased rates of nasal polyposis (Olsen, Neel, &
Deremee, 1980; Settipane, 1996; Rugina, Serrano, & Klossek, 2002; Hadfield, Rowe-Jones, &
Mackay, 2000). Samter’s triad, defined by the presence of asthma + sinus polyposis +
intolerance to aspirin or NSAIDS, was discovered in the late 1960s by Dr. Samter (Samter &
Beers, 1968). More current research shows that of patients with nasal polyposis referred to Ear
Nose and Throat (ENT) departments 30% were found to have a coexisting diagnosis of asthma.
And of patients with nasal polyposis referred to an allergist 70% of those were found to have a
coexisting diagnosis of asthma. (Larsen, 1996) Finally, the presence of nasal polyposis in
children often suggests cystic fibrosis (McPhee & Papadakis, 2009).
treatment “Because the pathway that leads to the formation of sinonasal polyps has not been
completely elucidated, effective long-term treatments remain difficult to pinpoint” (Becker,
2009, p.1). The objective in the treatment of nasal polyposis is to: reduce or eliminate polyps,
open the nasal airway, improve or restore the sense of smell, prevent polyp recurrence, and
improve patients’ quality of life (Mygind, 1999) (Tuncer, Sovlu, Avdogan, Karakus, & Akcali,,
2003). Patients with nasal polyposis are treated medically and/or surgically. Medical treatment
includes topical and oral steroids, macrolide antibiotics, diuretic nasal washes and intrapolyp
steroid injection (Becker, 2009). Surgical treatment includes polypectomy and functional
endoscopic sinus surgery (FESS) (Becker, 2009). FESS is a, “functional endoscope-guided
removal of nasal as well as ethmoid polyps with clearance of mucous drainage and aeration of
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the sinuses” (Ehnage et al., 2009). Sinus surgery is successful in the excision of nasal polyps.
However, the polyps will recur without continued medical treatment. Therefore surgery is part of
the management of nasal polyposis and not its cure (Becker, 2007). Systemic steroids are used
before and after surgery to prevent the need for and frequency of revision surgery (Wright &
Agrawal, 2007). The mechanism by which steroids treat nasal polyposis has been suggested to
come from a decreased concentration of eosinophils and IgE via the up-regulation of antiinflammatory genes (Tao, 2003; Benson, 2005); and increased apoptosis of inflammatory cells
and fibroblasts (Meagher, 1996; Saunders, 1999; Sumiko, 2003).
Current Research: biomedical
There is much debate as to the efficacy of medical and surgical methods in the treatment of nasal
polyposis. Researchers Blomqvist, Lundblad, Bergstedt, and Stjarne (2009) conducted a
Randomized Controlled Trial (RCT) to look at the efficacy of medical versus medical-surgical
treatment of nasal polyposis. In their study, thirty-two patients underwent unilateral endoscopic
sinus surgery (ESS). Study participants were given oral prednisolone for 10 days and nasal
budesonide (inhaled corticosteroid) for one month prior to ESS. After ESS, all patients continued
nasal budesonide for one year. Outcome measures were: nasal endoscopy findings, symptom
scores, olfactory thresholds and computerized tomography (CT) evaluation. One year after
surgery, a statistically significant difference of improvement in the total CT scores, osteomeatal
complex (OMC) CT scores, and scores of the maxillary sinus were found between the nasal
passages with and without surgery. However there were no differences found in the other
sinuses: anterior ethmoidal sinus, posterior ethmoidal sinus, frontal sinus and sphenoid sinus
(Blomqvist et al., 2009). Thus, CT evaluation, one of the primary outcome measures, yields
unclear results. Scores improved for some sinuses but not all. In addition, the relationship
between CT scores of the operated and unoperated nasal passages compared to olfactory
thresholds, polyp scores, and symptoms, is unclear. This suggests that CT imaging may be a poor
indicator of the patients’ symptoms. A previous study has shown a relationship between the
severity of CT results and the severity of sinus symptoms (Kenny, 2001). Blomqvist et al. (2009)
however found that “the CT scores of individual sinuses and the total CT scores are of little
prognostic value as regards these parameters [olfactory thresholds, polyp scores and symptoms].
[Therefor the benefits to the patient] from surgery must be based mainly on the patient’s
symptoms and not on the degree of polyposis scored on CT” (Blomqvist et al., 2009, p.548).
observations of the study. Here we see that surgery, FESS, in addition to nasal steroids, helps
reduce overall polyp burden and specifically polyp density in the osteomeatal complex and
maxillary sinus. However statistically significant results were not seen in the other sinuses.
Moreover CT scores did not correlate to patient symptoms.
One of the main symptoms of nasal polyposis is a decrease in olfaction. Nasal polyps are known
to be strongly associated with olfactory disorders resistant to treatment (Duncan, Doty, &
Murphy, 2003). Danielides et al. (2009) conducted a prospective study looking at the effect of
Endoscopic Sinus Surgery (ESS) on olfaction in patients with nasal polyposis. They also sought
to evaluate the role of previous sinus surgery and duration of olfactory deficit as prognostic
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factors for ESS in the treatment of olfaction. In their study, they followed 116 patients who
underwent ESS. Diagnosis of nasal polyposis was made by: history and clinical examination,
nasal endoscopy, and computerized tomography (CT) scan. Patients who did not respond to
medical treatment: antibiotics (clarthromycin or amoxicillin, 20 days), oral steroid (50 mg
prednisolone daily for 14 days and then tapered over 10 days) and nasal steroids (budesonide
100mg, bid for 3 weeks) were candidates for ESS. Evaluative Measures were Sniffin’ Sticks test
preoperatively, and one, three, and six months postoperatively. For evaluation purposes they used
a “composite threshold-discrimination-identification score” (TDI). The TDI is a combination of
three individual Sniffin’ Sticks tests: odor threshold, odor discrimination, and odor identification
(Danielides et al., 2009). Preoperatively 85% (99) of patients were anosmics and 17 (15%) were
hyposmics. Results were that all patients had a statistically significant stepwise increment of
TDI score over time. However patients with a duration of symptoms in excess of ten years and
previous sinus surgery had the poorest results.
Ehnage et al. (2009) found that patients with nasal polyposis and stable persistent asthma,
defined as asthma controlled with inhaled corticosteroids and not requiring oral corticosteroids
(OCS), had an improvement in olfaction as well as asthma symptoms and peak expiratory flow
rate (PEFR) after FESS. Their study investigated the effects of FESS and fluticasone proprionate
nasal drops (FPND) on lower airway function (evaluated by pulmonary function, bronchial
histamine sensitivity, and diary card data) in patients with concomitant asthma and nasal
polyposis.The design was a 21 week prospective study (n=68) to examine the benefits of FESS
on nasal and lower airway parameters. This trial included a randomized, double-blind, placebocontrolled 14 week trial (n=68) examining the efficacy of FPND on lower airway function. They
found that FESS improved mean asthma symptom scores, daily PEFR scores and all nasal
parameters (Ehnage et al., 2009). Similar results were found in a study evaluating the effects of
FESS on OCS-dependent asthma. They found improvement in lung function (FEV1) and a
reduction in OCS use after FESS (Batra et al., 2003). Another research study investigating the
effects of FESS on lower airway function found that FESS did not improve asthma in patients
with massive polyposis (Uri et al, 202). They did however find that the use of OCS and
bronchodilator to decrease (Uri et al, 2002). An older study found that removal of polyps by
polypectomy resulted in a deterioration of lower airway disease (Samter, 1958). The second part
of the Ehnage study found no significant difference between topical treatment of FPND or
placebo in nasal or lower airway variables (Ehnage et al., 2009). The two above referenced
studies on OCS dependent and non OCS dependent (“stable”) asthma found improvements in
lower airway function defined by PEFR, asthma symptom scores, and OCS use after FESS. The
Ehnage et al. study did not find improvement in nasal or lower airway function with FPND.
Inhaled corticosteroids are standard of care in the treatment of nasal polyposis. Here we see that
their use may not be of benefit to the patient with nasal polyposis and concomitant asthma. This
opens the door for other treatments to be combined with FESS to maintain the benefits to upper
and lower airway function gained after surgery.
Due to chronic nasal obstruction, patients with nasal polyposis have a higher incidence of sleep
disturbances (Serrano, Neukirch, & Pribil 2005). Nasal breathing with a closed jaw during sleep
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maintains normal respiratory rhythm in part by stabilizing the upper respiratory airway. Oral
breathing with the jaw open causes a greater pressure gradient in the nasopharynx. This increased
pressure gradient combined with turbulent airflow through the nasal passage ways creates
conditions such as snoring, obstructive sleep apnea and other sleep disorders (Tosun et al., 2009).
The goal of surgery in patients with nasal polyposis and sleep disturbance is to: relieve the
chronic nasal obstruction and thereby decrease the negative pressure gradient in the nasopharynx
during sleep; and to prevent snoring by preventing vibration of the uvula and the soft palate.
(Tosun, et al., 2009). Previous research on patients with chronic nasal obstruction has shown
improvement in sleep-related breathing disorders such as snoring and daytime sleepiness after
nasal surgeries (Kim, Choi, & Jeon, 2004; Verse, Maurer, & Pirsig, 2002; Elsherif & Hussein,
1998; Friedman, Tanyeri, & Lim, 2000). Other studies have shown no improvement (Kalam,
2002; Virkkula, Bachour, & Hytonen, 2006). In these studies, the nature of the chronic nasal
obstruction was heterogeneous as was the types of nasal surgeries the patients underwent. These
variables can confuse the results making it difficult to determine which surgeries prove effective/
ineffective for various nasal obstructive disorders. The goal of the Tosun et al. (2009) study was
to specifically look at the effect of FESS on sleep quality for patients whose nasal obstruction is
due to nasal polyposis. Subjects’ nasal polyposis was confirmed by nasal endoscopy. Evaluative
measures were: visual analog scale, Epworth sleepiness scale, acoustic rhinometry, and
polysomnography. Patients were evaluated before surgery and three months post-operation. Their
study found: a decrease in nasal resistance, improvement in snoring scores, and a decrease in
mean daytime sleepiness. However there was no significant difference between preoperative and
postoperative mean values of the apnea-hypopnea index (AHI). The authors conclude that FESS
alone is not enough for the treatment of sleep apnea in patients with nasal polyposis (Tosun et al.,
2009).
Long term outcomes of surgery. A recent systematic review of the literature revealed a lack of
comparative studies evaluating the benefit of functional endoscopic sinus surgery (FESS) over
simple polypectomy in patients with nasal polyposis (Dalziel, Stein, Round, Garside, & Royle,
2003). In response to this, researchers in England conducted a large prospective cohort study to
clarify the long term (5 year) outcomes of patients with chronic rhinosinusitis (CRS) with or
without nasal polyps who underwent nasal polypectomy or more extensive nasal surgery, FESS.
FESS needed to have been performed to at least one of the following: middle meatus/uncinate,
anterior or posterior ethmoids, sphenoid or frontal sinuses (Hopkins et al., 2009). Outcome
measures for their study were: percentages of those who had revision surgeries and the SinoNasal Outcome Test (SNOT-22, a questionnaire on sinonasal symptoms, sleep, emotional and
psychosocial functioning). Results of their study showed that 20.6% of patients with polyps had
revision surgery versus 15.5% of patients with CRS alone. Those patients who received simple
polypectomy alone had a 21.2% revision rate. Those who underwent more extensive sinonasal
surgery had a 20.0% revision rate Statistical analysis yielded significant results in favor of more
extensive sinus surgery, FESS compared to polypectomy in the reduction of revision surgery
rates. (Hopkins et al., 2009, p. 5). Other studies have shown similar percentages. A study by
Senior et al. found that patients who underwent FESS had an 18% revision rate at 7.8 years
(Senior et al., 1998). And another study with a 9 year follow up reported that 21% of patients
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with nasal polyposis required revision surgery following functional endoscopic sinus surgery
(FESS) (Pentilla, Rautiainen, Pukander, & Kataja, 1997). Surgery revision rates for CRS patients
undergoing simple polypectomy have been reported at up to 75% (Larsen & Tos, 1997). The
second outcome measure, SNOT-22 scores, showed no significant difference at 36 months
(Browne, Hopkins, & Slack, 2006). Interestingly patients with polyps had lower SNOT-22 scores
than those without polyps at the five year mark. Although all patients showed an improvement in
baseline SNOT-22 scores over five years (Hopkins et al., 2009). Since the complication rates of
simple polypectomy and FESS are similar, it is considered good practice to clear the obstruction
beyond the nasal passageway (Hopkins, Browne, & Slack, 2006).The literature suggests that
FESS versus simple polypectomy has a lower surgery revision rate in the treatment of nasal
polyposis. Revision rates have been reported between 18%-21%. It has been reported that FESS
is but one part of the treatment of nasal polyposis. Revision rates corroborate the notion that
surgery is management and not cure for the disease. And indeed we see no difference in
SNOT-22 scores between those who received FESS or simple polypectomy at 36 months. And all
patients showed improvement in their scores over the course of five years. As we see no
significant improvement in SNOT-22 scores for patients who underwent FESS, the benefits to
FESS lie in reduced surgical revision rates and not necessarily related to patient symptoms.
Traditional Chinese Medicine - Nasal Polyps:
History of Otorhinolaryngology. Yap et al. (2009). Although there is not much published in the
modern research literature, otorhinolaryngology has a rich history in chinese medicine. Diseases
of the Ear, Nose and Throat are documented in the Chinese Medical literature as early as 18th
century B.C. And the first practicing otolaryngologist is recorded in the 5th century B.C.
Treatments included: acupuncture, moxibustion, herbal therapy and massage.
Otorhinolaryngology was recognized as its own medical specialty in the 7th century A.D.
Methods of treatment included: exercise, food therapy, and surgery (the excision of nasal polyps
with a copper wire). Dr. Thu, a physician who practiced during the eastern Zhou period (770-221
B.C. ) specialized in removing nasal polyps (Gwei-Djen & Needham, 1976). ShenNong
(3217-3077 B.C.) whose work is the basis of the ShenNong-Ben-Cao-Jin [The Herbal] is dated
around 1st century A.D. It was comprised of 365 herbs, 53 of which were reported to be used in
the field of otorhinolaryngology (Wang, Gan, & Ling, 1988; Sun, 1998; Zheng, 1985). BencanGangmu [Compendium of Materia Medica] written by physician Li Shizhen during the 16th
century A.D. included 1892 herbs, half of which were reported to be used in the field of
otorhinolaryngology (Wang, Gan, & Ling, 1998; Zeng & Fu, 2001; Chen, 1969; Lu, 1976; Li,
1981). The Zhenjiu-Jiayi-Jing [Classic on Acupuncture and Moxibustion] by physician HuangFumi (214-282 A.D.) included reports on the development of the use of acupuncture in the
treatment of Ear, Nose and Throat disorders (Wang, Gan, & Ling, 1998) and (Zeng & Fu, 2001).
Giovanni Maciocia in his book, The Practice of Chinese Medicine: The treatment of diseases
with acupuncture and chinese herbs, writes that symptoms of nasal polyposis include: runny
nose, persistent stuffiness, chronic sinus infections, diminished sense of smell, dull headaches,
and snoring (Maciocia, 2008). He lists three differential diagnosis: i. lung heat with stagnation;
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ii. damp phlegm with stagnation; and iii. lung and spleen qi deficiency with damp phlegm
(Maciocia, 2008). For the diagnosis of lung heat with stagnation, the polyps are red, shiny, soft
and slippery. The patient will have a diminished sense of smell, yellow-sticky discharge, and
headache. Points used are: LU-7, L.I.-4, LU-5, L.I.11, BL-2, ST-8, Bitong, and P-6. H erbal
prescription is Huang qin qing fei yin plus cang er zi san Patients with damp phlegm and stasis
have polyps that are white, sticky, and shiny. The patient often has a diminished sense of smell,
white sticky or runny nasal discharge, headache, a feeling of heaviness of the head, a feeling of
oppression of the chest, and expectoration of sputum. Points used LU-7, L.I.-4, BL-2, ST-8,
Bitong, Ren-9, SP-6, SP-9, and ST-40. Herbal Prescription is: Dao Tan Tang plus cang er zi san.
For lung and spleen qi deficiency with damp phlegm polyps are white and shiny and return after
surgery. The patient experiences a diminished sense of smell, runny or sticky nasal discharge, a
feeling of oppression of the chest, expectoration of sputum, tiredness, loose stools, poor appetite,
weak voice, and a propensity to catching colds. Points used are: LU-7, L.I.-4, BL-2, ST-8,
Bitong, Ren-9, SP-6, SP-9, ST-40, Ren-12, ST-36, BL-20, LU-9, BL-13. Herbal prescription: bu
zhong yi gi tang plus er chen tang (Maciocia, 2008, pp.211-213).
In Maclean & Lyttleton’s book “Clinical Handbook of Internal Medicine: The treatment of
disease with Traditional Chinese Medicine, volume 1, lung, kidney, liver, heart”, nasal polyps
have two differential diagnosis: blood stagnation; and lung and spleen qi deficiency. Blood
stagnation sinus congestion is often the result of a chronic pathology of the sinus and nasal
passages. Nasal polyps appear dark and swollen (Maclean & Lyttleton, 1998). Acupuncture
prescription is: L.I. 20; Du. 20; Du. 23; yin tang; bi tong; L.I.4; Bl.2; GB.20; SP.6; BL.17. Herbal
prescription is: dang gui shao yao san modification: dang gui 12g; fu ling 12g, bai zhu 9g; ze xie
9g; xin yi hua 9g; ju hua 9g; di long 9g; chuan xiong 6g; bo he 6g; huang qin 6g; gan cao 3g.
Lung and spleen qi deficiency with phlegm presents with profuse and persistent mucous. In
Western society this pattern is often due to excessive consumption of dairy products and sugar.
(Maclean & Lyttleton, 1998). Acupuncture prescription is: St.40; SP.3; St.36; Lu.7; Bl.20; Bl.13;
GB.20; LI.20; LI.19; Du.23; LI.4. Herbal prescription is Liu Jun Zi Tang modified: ren shen 9g;
bai zhu 9g; fu ling 9g; gan cao 3g; ban xia 9g; chen pi 6g; huang qi 15-30g; he zi 9g; xin yi hua
9g; wu wei zi 6g; shi chang pu 6g.
Case Study. Although there is a rich history in chinese otorhinolaryngology, currently there are
no randomized controlled trials investigating the use of Chinese Medicine in the treatment of
nasal polyposis. The following is a case study published in 2002. A 38 year old male patient with
an 18-year history of diagnosed nasal polyps had a history of previous treatment with western
medical treatment [type unknown]. The acupuncture treatment used was taken from Dr. So’s
book Treatment of Disease with Acupuncture. “Step 1: Needle LI-4 (he gu), LI-11 (qu chi). Step
2: needle GB-20 (feng chi), DU-16 (feng fu), BL-12 (feng men), DU-26 (shui gou), LI-20 (ying
xiang), M-HN-14 (bi tong), and DU-25 (su liao). Step 3: burn 5 mung bean sized moxa cones at
DU-22 (xin hui) and DU-23 (shang xing). Step 4: Burn indirect moxa with ginger over the entire
nose. This needs to be done daily and may take as long as 30 treatments if the person has had the
polyps longer than a few years. Surgery may be required to eliminate the polyps, after which this
treatment can help keep the polyps from returning” (So, 1987, p.155). SP-10 (xue hai) and a
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medicinal salve [type not given] were added to stop bleeding in the right inferior nasal concha.
The frequency of treatment was five times per week for three weeks. Follow-up at one month
and six months post treatment found the patient had unobstructed breathing and no bleeding in
his right nostril (Chaffee, 2002).
Due to the lack of current research on the treatment of nasal polyposis with chinese medicine, I
have included studies on the treatment of rhinitis/sinusitis(not specific to nasal polyposis). These
studies may give us insight into the management of the symptoms of nasal polyposis as it is a
subcategory of chronic rhinosinusitis. By managing the symptoms we are also influencing the
environment of the nasal passageways to be less inducive to nasal polyps.
10 cases. The following report is an observation of treating 6 cases of invasion of wind-cold and
4 cases of chronic rhinitis with PC-9. “Puncture the right Zhongchong (PC-9) for the obstruction
of the left nostril and the left Zhongchong for obstruction of the right nostril because of the nerve
crossing.” (Yu, 1999, p.451). Needles were inserted to a depth of 0.1-0.2 cun and retained for 4-5
minutes. Manipulation was even method turning left and right continuously while the patient
inhaled and exhaled deeply. The reported effective rate of acute nasal obstruction was 99% and
60-70% for chronic nasal obstruction (Yu, 1999). Here is an example of treating nasal
congestion, a symptom of nasal polyposis. Further studies would need to be done to examine the
use of PC-9 in the treatment of nasal congestion in patients with nasal polyposis. Outcome
measures would need to be more specific and replicable. And long-term follow-up would need to
be included.
QOL Chui, 2010. Researchers in China and England looked at the effects of Allergic Rhinitis
Nose Drops (ARND) on the Quality of Life (QOL) in patients with perennial allergic rhinitis.
They used a randomized, double-blinded and placebo-controlled, cross-over design. Outcome
measures were the Clinical Symptoms Score (CSS) and Chinese Quality of Life Instrument
(ChQOL) (Leung et al., 2005). The CSS included questions about: nasal obstruction, sneezing,
nasal itching and runny nose. The ChQOL includes questions about: “(1) physical form
composed of the facets of complexion, sleep, stamina, appetite and adaptation to climate; (2)
vitality composed of consciousness, thinking, spirit of the eye and verbal expression; (3) emotion
composed of joy, anger, depression and fear; and (4) the domain of overall qualty of life” (Chui
et al., 2010). ARND was composed of: Herba Centipedae 23%; Herba Menthae 16%; Radix
Paeoniae Alba 16%; Radix Scutellariae 10%; Radix Glycyrrhizae 6%; Radix Patcodi 6%; Floz
Lonicerae 5%; Fructus Zizyphi Jujubae 5%; Rhizoma Coptidis 4%; Radix Ledebouriellas 5%
Pericarpium Citri Reticuulatae 4%. No adverse effects were seen. Laboratory testing for renal
function, liver function and haematological tests, including C Reactive Protein, showed no
abnormal results at weeks 0, 2, 5, and 7. A significant decrease in CSS was seen in both groups
after treatment with ARND. No change in CSS was seen in either group after placebo. Group A
showed significant improvements in complexion and sleep after treatment with ARND. Group B
showed significant improvements in appetite and digestion and joy. (joy is included in the
ChQOL, see above) With both groups there was no change with placebo. This study lends
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support to treating some of the symptoms of nasal polyposis, which can support an environment
less favorable to nasal polyps.
RCT Sertel et al. (2009) looked at acupuncture in the treatment of nasal congestion due to
hypertrophic inferior turbinates or chronic sinusitis without polyposis. A differential diagnosis
was made according to the Heidelberg model of traditional chinese medicine (TCM). Verum
acupoints used were: LI-4, LI-20, and yintang. And “placebo” points, nonspecific control
acupoints, were HT-3, DU-20, and LV-7. Outcome measures were: the visual analog scale (VAS)
to rate the severity of nasal congestion; and nasal airflow (NAF) measured by active anterior
rhinomanometry (ARM). VAS and NAF scores were measured before, 15, and 30 minutes after
acupuncture. Results were that verum acupuncture showed highly significant improvements in
both VAS and NAF. Although this study did not include patients with chronic sinusitis with nasal
polyposis, it holds promising results in the treatment of nasal congestion associated with CSNP.
antibiotics, laser, acupuncture, In 1982 researchers in Germany investigated the effects of
antibiotics, acupuncture, and laser acupuncture in the treatment of chronic sinusitis in children.
They found,acupuncture to be twice as effective as antibiotics in the treatment of chronic
maxillar sinusitis. (Pothman & Yeh, 1982). Acupuncture points used were: Du-20, L.I.-4, L.I.-20,
and S.I.-18. Patients received six treatments over the course of three weeks. Freedom from
symptoms for more than three months constituted successful treatment. Acupuncture had a
success rate of 72.2% versus 36.8% for antibiotics. The authors concluded, “Perhaps there is
already an interaction on the thalamic or brain stem level. The pain inhibiting influence in the
therapy of sinusitis could mainly trace back to the point Hegu (L.I.-4). According to traditional
Chinese thinking there is a connection between lungs and the large intestine, relative to their
excretory function. This supposition may be attributed to their common ontogenetic
predisposition. The clearance-function of the sinus mucosa, which belongs to the respiration
system (called ‘lung’ in Chinese ), could thus be understandable by a point on the large intestine
meridian”. (Pothman & Yeh, 1982, p.57). Perhaps in the treatment of nasal polyposis,
acupuncture can be used to treat and prevent associated infection of the paranasal sinuses.
Qin Jie Tang and IgG levels The following two studies were reported in the chinese journal,
“Chinese Journal of Modern Developments in Traditional Medicine”. Translation was difficult
even with the assistance of a Chinese professor. The first study evaluated the treatment of nasal
sinusitis with a cang er zi tang and qin jie tang modification. The herbal prescription was : jie
geng 15g; huang qin 15g; bai zhi 15g; chai hu 15g; cang er zi 10g; xin yi hua 10g; bo he 10g; gan
cao 10g. Outcome measures were IgG levels. Results showed an increase in IgG levels after
taking Qin Jie Tang (Su, 1984). Although this study did not directly study the effects of Qin Jie
Tang on CSNP, it may help combat the chronic infection associated with CSNP.
Ping Zhi Pian The second study investigated the treatment of chronic sinusitis with Ping Zhi
Pian. Unfortunately I am unable to find this formula in english texts. This highlights one of the
difficulties in chinese medicine research. While there is much research done in China on chinese
medicine, we often do not have access to this data due to poor translation and reporting methods.
11
Outcome measures included: changes of bacteria in quantity, morphology and toxicity in the
nasal sinus; and the effect on humoral immunity and cell-mediated immunity. Details of this
study are difficult to translate. In general they found ping zhi pian to work through strengthening
the immune system rather than by directly attacking bacteria (Liu, 1986). Although the herbal
formula is different, this study supports the study done by Su, in that the immune system is
strengthened after herbal treatment.
practitioner survey, To evaluate the use of Chinese Medicine in the treatment of sinus and nasal
symptoms, Pletcher, Goldberg, Lee, and Acquah (2006) sent out a practitioner survey to
practitioners in the greater Bay Area of California. Of those practitioners who responded, it was
found that on average patients with sinus and nasal symptoms comprise 19% of their patient
population. 99% of practitioners reported that they treat patients with sinus and nasal symptoms
with acupuncture. The most commonly used points were: LI4, LI20, Yintang, Bitong, ST36,
LU7, LI11, GB20, GV23, ST40. And 92% of the practitioners reported to use herbal medicine to
treat nasal and sinus symptoms. Average perceived efficacy rates was 4.2/5.0. And the mean cost
of care was $730.00 (Pletcher et al.,, 2006). Again, while direct evidence for the treatment of
nasal polyposis is unknown, this study supports the use of Chinese Medicine to treat symptoms
associated with CSNP.
Conclusions: Nasal polyposis presents a challenge to the clinician because of its severity and
unknown etiology (Benninger et al., 2003). In the treatment of CSNP with FESS there is a 20%
revision rate. And although fewer patients had revision surgery with FESS rather than simple
polypectomy, there was not a correlating decrease in sinonasal symptoms. This lack of
correlation between subjective and objective findings in sinonasal disease is well documented in
the literature. (Hopkins et al., 2009). Although FESS surgery has been reported to be safe and to
have low complication rate (Hopkins et al., 2006), there are always inherent risks to major
surgery. Oral corticosteroids have many potential adverse effects (See Appendix B). Inhaled
nasal corticosteroids carry less systemic effects, however at higher dosages, there is the risk of
the more severe adverse effects especially in children. (See Appendix B). When considering the
efficacy, cost and risk of biomedicine, we have seen inconclusive results to address the
symptoms of CSNP. There is an unclear relationship between polyp size/density found on CT
exam and the patients symptoms. And although surgery revision rate is approximately 20% for
FESS, it is unclear how the surgery affects the patients overall quality of life and disease severity.
Biomedicines carry inherent risks and side effects and their efficacy and safety in the long term
is unclear. Current research in chinese medicine in the treatment of nasal polyposis, or chronic
sinusitis/rhinitis without polyps shows promising results in helping to manage the symptoms of
CSNP. The rich history of otorhinolaryngology in chinese medicine, gives credence to its use in
the treatment of nasal polyposis. Indeed, today, practitioners of chinese medicine are treating
sinonasal symptoms with success and relatively low cost. The evidence suggests chinese
medicine should play an important role in an integrative approach to treat this difficult disease.
12
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25
APPENDIX A
Clear Criteria (3 articles)
Chui, 2010
1. yes
2. yes
3. yes, no
4. yes, age and smoking history
5. stated, “is claimed to be effective in relieving symptoms inpatients with AR”.
6. yes, (herbs)
7. yes
8. yes
9. no
10. no
Sertel, 2009
1. no
2. yes
3. yes, yes
4. yes
5. yes
6. yes, (yes, this is a german study!)
7. yes
8. yes
9. no
10. no
Pothman & Yeh, 1982
1. no
2. no
3. no
4. no
5. yes (in biomedical terms)
6. no
7. no (not detailed enough, vague)
8. no
9. no
10. yes, 6 months and 1 year
26
27
APPENDIX B
Adverse Reactions for Oral prednisolone
Fluid and Electrolyte Disturbances: Sodium retention. Fluid retention. Congestive heart failure
in susceptible patients. Potassium loss. Hypokalemic alkalosis. Hypertension. Musculoskeletal
Muscle weakness. Steroid myopathy. Loss of muscle mass. Osteoporosis. Vertebral compression
fractures. Aseptic necrosis of femoral and humeral heads. Pathologic fracture of long bones.
Gastrointestinal:Peptic ulcer with possible perforation and hemorrhage. Pancreatitis.
Abdominal distention. Ulcerative esophagitis.Dermatologic Impaired wound healing. Thin
fragile skin. Petechiae and ecchymoses. Facial erythema. Increased sweating. May suppress
reactions to skin tests. Neurological: Convulsions. Increased intracranial pressure with
papilledema (pseudotumor cerebri) usually after treatment. Vertigo. Headache. Endocrine:
Menstrual irregularities. Development of Cushingoid state. Suppression of growth in children.
Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in
trauma, surgery, or illness. Decreased carbohydrate tolerance. Manifestations of latent diabetes
mellitus. Increased requirements for insulin or oral hypoglycemic agents in diabetics.
Ophthalmic: Posterior subcapsular cataracts. Increased intraocular pressure. Glaucoma.
Exophthalmos. Metabolic: Negative nitrogen balance due to protein catabolism.
- http://www.drugs.com/pro/prednisolone-tablets.html
Effects of Intranasal Fluticasone Proprionate: Observed During Clinical Practice
Practice: In addition to adverse events reported from clinical trials, the following events have
been identified during postapproval use of intranasal fluticasone propionate in clinical practice.
Because they are reported voluntarily from a population of unknown size, estimates of frequency
cannot be made. These events have been chosen for inclusion due to either their seriousness,
frequency of reporting, or causal connection to fluticasone propionate or a combination of these
factors.
General: Hypersensitivity reactions, including angioedema, skin rash, edema of the face and
tongue, pruritus, urticaria, bronchospasm, wheezing, dyspnea, and anaphylaxis/anaphylactoid
reactions, which in rare instances were severe.
Ear, Nose, and Throat: Alteration or loss of sense of taste and/or smell and, rarely, nasal septal
perforation, nasal ulcer, sore throat, throat irritation and dryness, cough, hoarseness, and voice
changes.
Eye: Dryness and irritation, conjunctivitis, blurred vision, glaucoma, increased intraocular
pressure, and cataracts. Cases of growth suppression have been reported for intranasal
corticosteroids, including Fluticasone Propionate Nasal Spray, USP (see PRECAUTIONS:
Pediatric Use).
- http://www.drugs.com/pro/fluticasone-nasal-spray.html
28