Outcome of an outpatient specialty clinic for chronic epipharyngitis

Use of Nasopharyngoscopy Severity Classification of Chronic Epipharyngitis and Its Application for Evaluating the Treatment Outcomes of Epipharyngeal Abrasive Therapy

Background Chronic epipharyngitis causes postnasal drip, pharyngeal pain, pharyngeal discomfort, headache, and shoulder stiffness. Additionally, autonomic nervous system symptoms such as dizziness, general fatigue, and sleeplessness may occur. It can also contribute to the development of focal diseases. Although epipharyngeal abrasive therapy (EAT) is effective for chronic epipharyngitis involving the abrasion of the epipharynx with a zinc chloride solution, there is a lack of clear diagnostic criteria, and treatment outcomes are rarely reported. Methodology A classification of the severity of chronic epipharyngitis was attempted in 154 cases based on nasopharyngeal endoscopic findings, with a subsequent examination of treatment outcomes using EAT. Diagnosis of chronic epipharyngitis involved identifying redness, swelling, postnasal drip, and crusting of the epipharyngeal mucosa. Severity classification relied on a four-point scale measuring the degree of redness and swelling, with additional points assigned for the presence of postnasal drip and crusting. This classification also served as a criterion for judging treatment effectiveness. The prevalence and improvement rate of black spots and granular changes were assessed through nasopharyngeal endoscopy with narrow-band imaging. Subjective symptoms were evaluated using before and after treatment questionnaires, employing a four-point scale for symptoms commonly associated with chronic epipharyngitis (headache, postnasal drip, nasal obstruction, pharyngeal discomfort, pharyngeal pain, shoulder stiffness, tinnitus, ear fullness, dizziness, cough, and sputum). A 10-point numerical rating scale (NRS) was used to assess the physical condition. Results Following EAT, the severity of nasopharyngeal endoscopic findings notably improved, with a 76.0% (117/154) improvement rate (remarkable improvement: 19.5% (30), improvement: 56.5% (87)). The improvement rate for the chief complaint reached 85.7% (132/154), demonstrating significant enhancement in the score for each symptom. NRS scores also improved at a rate of 76.0% (117/154). A significant correlation was observed between the improvement in local findings and chief complaints. The prevalence of black spots and granular changes before EAT was 83.8% (129/154) and 64.3% (99/154), exhibiting improvement rates of 65.9% (87/132) and 54.8% (57/104), respectively. Conclusions Nasopharyngeal endoscopy proves valuable for diagnosing and assessing the severity of chronic epipharyngitis, as well as evaluating treatment effectiveness. The findings indicate that EAT is an effective treatment for chronic epipharyngitis, with improvements in local findings correlating with enhancements in the chief complaint. This underscores the importance of employing aggressive EAT in managing patients with chronic epipharyngitis.

Differences Between Patients With Chronic Epipharyngitis With and Without Previous COVID-19 Infection

Objective Epipharyngeal abrasive therapy (EAT) is effective in patients with chronic epipharyngitis who previously had coronavirus disease 2019 (COVID-19). The study aimed to evaluate differences between patients with chronic epipharyngitis with (long COVID) or without a history of COVID-19 (non-long COVID). Methods This is a retrospective study based on the analysis of medical records of patients who visited the Mogitate ENT Clinic in Kawasaki, Japan, for six months from March 2022. Results Patients with long COVID were significantly younger (p=0.018). Fatigue and brain fog were prevalent in patients with long COVID, whereas throat discomfort, postnasal drip, and sputum were more common in those with non-long COVID. Epipharyngeal endoscopic findings in patients with long COVID showed significantly higher scores (p<0.001) compared with patients with non-long COVID. Conclusions The primary differences between patients with long COVID and non-long COVID were age, symptoms, and severity scores of endoscopic findings. The EAT should be aggressively implemented in patients with chronic epipharyngitis with or without COVID-19 infection, as there is no reason not to treat a patient with a condition caused by COVID-19 infection.

Epipharynegal Abrasive Therapy Downregulates the Number of Epipharyngeal Abrasive CD4 Cells With Symptomatic Recovery

OBJECTIVE

In this study, the author focused on CD4 and CD8 profiles in epipharyngeal abrasive cells in patients with chronic epipharyngitis and investigated how the profiles differ from those in normal healthy subjects and how epipharyngeal abrasive therapy (EAT) influences these profiles.

METHODS

This study included 18 patients (one male and 17 females, median age: 46 (30.0-56.5) years) who had been treated for chronic epipharyngitis between June 2021 and September 2021. Epipharyngeal abrasive cells were collected from patients with chronic epipharyngitis before EAT and three months after repeated EAT and were subjected to two-color flow cytometric analyses for CD4 and CD8 expression. The severity of participants' symptoms was monitored using the visual analog scale.

RESULTS

Symptoms of chronic epipharyngitis were significantly abated after three months of repeated EAT (p <0.001). The number of epipharyngeal abrasive CD4(+) T cells in patients with chronic epipharyngitis before EAT, which was significantly higher than that in normal healthy subjects (p <0.01), significantly decreased by the third month of repeated EAT (p = 0.01), alongside symptomatic recovery.

CONCLUSION

These results suggest that epipharyngeal CD4(+) T cells may have a critical role in treating the persistent inflammation of chronic epipharyngitis, and EAT may reduce the number of CD4 cells, which results in symptomatic recovery.

Autonomic Nervous System Regulation Effects of Epipharyngeal Abrasive Therapy for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Associated With Chronic Epipharyngitis

OBJECTIVE

To evaluate the autonomic nerve stimulation effect of epipharyngeal abrasive therapy (EAT) on myalgic encephalomyelitis/chronic fatigue syndrome (CFS) associated with chronic epipharyngitis. Heart rate variability analysis was performed. The study was conducted by analyzing heart rate variability.

SUBJECTS AND METHODS

A total of 29 patients with chronic epipharyngitis who underwent EAT from July 2017 to April 2018 were classified into two groups: 11 patients in the CFS group and 18 patients in the control group without CFS. The patients were classified as phase 1 during bed rest, phase 2 during nasal endoscopy, phase 3 during nasal abrasion, and phase 4 during oral abrasion. Electrocardiographic recordings were made, and autonomic function was compared and evaluated by measuring heart rate, coefficient of variation on R-R interval (CVRR), coefficient of component variance high frequency (ccvHF), and low frequency/ccvHF ratio (L/H) for each of the four phases. The Shapiro-Wilk test was performed to confirm the normality of the two groups, and the parametric test was selected. A repeated measures analysis of variance was performed to assess changes over time between the four events in the two groups. Multiple comparisons were corrected by the Bonferroni method. Comparisons between resting data and three events within each group were performed by paired t-test.

RESULTS

The CFS group had an increased baseline heart rate compared to the control group, and the CFS group had a greater increase in parasympathetic activity and a decrease in heart rate with nasal abrasion. Oral abrasion elicited a pharyngeal reflex and increased heart rate and both sympathetic and parasympathetic activity.

CONCLUSION

The CFS group was in a state of dysautonomia due to autonomic overstimulation, with an elevated baseline heart rate. The CFS group was considered to be in a state of impaired autonomic homeostasis, with an increased likelihood that overstimulation would induce a pathological vagal reflex and the Reilly phenomenon would develop. The direct effects of EAT on the autonomic nervous system were considered to be vagus nerve stimulation and the regulation of autonomic function by opposing stimulation input to sympathetic and parasympathetic nerves. As an indirect effect, bleeding from the epipharyngeal mucosa due to abrasion was thought to restore the function of the cerebral venous and lymphatic excretory systems and the autonomic nerve center.

Laryngopharyngeal reflux induced sleep-related laryngospasm

BACKGROUND

Sleep-related laryngospasm (SRL) has been defined as the sustained closure of the vocal cords during sleep. Studies have suggested that it is a rare manifestation of laryngopharyngeal reflux (LPR). Difficulties in diagnosing SRL and LPR have led to the condition being under-recognised in the clinical setting.

AIMS

The aim of this study was to determine if LPR was the cause of the SRL symptoms seen in our patients.

METHODS

A retrospective chart assessment of patients with SRL. Patients with risk factors for LPR were identified. These included smoking status, alcohol intake, a history of dyspepsia or history of gastroesophageal reflux disease, a history of late-night eating and a history of eating spicy or fatty foods before bed. A clinical diagnosis based on the history and response to management was made for the diagnosis of LPR. All were advised to refrain from late meals and those with signs of nasopharyngitis were commenced on proton pump inhibitor therapy.

RESULTS

Nineteen patients (mean age ± SD: 57.21 ± 15.18) were included in the study. All had at least one risk factor for LPR. Ten (52.6%) had signs of nasopharyngitis on nasendoscopy. Following treatment, 17 (89.5%) reported no further SRL symptoms at 1-year follow-up.

CONCLUSION

SRL is a largely unknown and under-diagnosed condition. We believe this study provides supportive evidence for the causal relationship between LPR and SRL.

A Potential Novel Treatment for Chronic Cough in Long COVID Patients: Clearance of Epipharyngeal Residual SARS-CoV-2 Spike RNA by Epipharyngeal Abrasive Therapy

A major target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the epipharyngeal mucosa. Epipharyngeal abrasive therapy (EAT) is a Japanese treatment for chronic epipharyngitis. EAT is a treatment for chronic epipharyngitis in Japan that involves applying zinc chloride as an anti-inflammatory agent to the epipharyngeal mucosa. Here, we present a case of a 21-year-old man with chronic coughing that persisted for four months after a diagnosis of mild coronavirus disease 2019 (COVID-19), who was treated by EAT. We diagnosed chronic epipharyngitis as the cause of the chronic cough after the SARS-CoV-2 infection. SARS-CoV-2 spike RNA had persisted in the epipharyngeal mucosa of this Long COVID patient. EAT was performed once a week for three months, which eliminated residual SARS-CoV-2 RNA and reduced epipharyngeal inflammation. Moreover, a reduction in the expression of proinflammatory cytokines was found by histopathological examination. We speculate that the virus was excreted with the drainage induced by EAT, which stopped the secretion of proinflammatory cytokines. This case study suggests that EAT is a useful treatment for chronic epipharyngitis involving long COVID.

Effectiveness of Epipharyngeal Abrasive Therapy on Chronic Epipharyngitis and the Exhaled Nitric Oxide Levels

Objective Considering the possibility that eosinophilic inflammation is involved in the pathogenesis of chronic epipharyngitis, this study determined whether or not the exhaled nitric oxide level of patients changed after epipharyngeal abrasive therapy (EAT). The diagnosis and follow-up of patients with chronic epipharyngitis were based on the endoscopic findings. If the exhaled nitric oxide level reflects the pathology of a patient with chronic epipharyngitis, the exhaled nitric oxide test can be performed for a follow-up examination as an objective test for chronic epipharyngitis. Methods The study period was 12 months, starting from February 2020. The age distribution and patients' median age and gender were retrospectively reviewed using medical records. Exhaled nitric oxide levels were measured before and after endoscopic EAT at the initial examination and before and after blind EAT at the follow-up examination. Patients or Materials Ninety-six new patients were included in this study. Results The study included 27 men and 69 women (median age [range], 45 [17-82] years old). When patients with chronic epipharyngitis were treated using EAT, exhaled nitric oxide levels were significantly lower after EAT than before EAT at the initial visit. Six months after EAT, the exhaled nitric oxide level was significantly lower than that at the initial visit. Conclusion During the follow-up examination of patients with chronic epipharyngitis, the exhaled nitric oxide test may be an effective objective test, along with changes in endoscopic findings.

Epipharyngeal Abrasive Therapy (EAT) Reduces the mRNA Expression of Major Proinflammatory Cytokine IL-6 in Chronic Epipharyngitis

The epipharynx, located behind the nasal cavity, is responsible for upper respiratory tract immunity; however, it is also the site of frequent acute and chronic inflammation. Previous reports have suggested that chronic epipharyngitis is involved not only in local symptoms such as cough and postnasal drip, but also in systemic inflammatory diseases such as IgA nephropathy and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and Long COVID. Epipharyngeal Abrasive Therapy (EAT), which is an effective treatment for chronic epipharyngitis in Japan, is reported to be effective for these intractable diseases. The sedation of chronic epipharyngitis by EAT induces suppression of the inflammatory cytokines and improves systemic symptoms, which is considered to be one of the mechanisms, but there is no report that has proved this hypothesis. The purpose of this study was to clarify the anti-inflammatory effect of EAT histologically. The study subjects were 8 patients who were not treated with EAT and 11 patients who were treated with EAT for chronic epipharyngitis for 1 month or more. For immunohistochemical assessment, the expression pattern of IL-6 mRNA, which plays a central role in the human cytokine network, was analyzed using in situ hybridization. The expression of IL-6 in the EAT-treated group was significantly lower than those in the EAT nontreated group (p = 0.0015). In addition, EAT suppressed the expression of tumor necrosis factor alpha (TNFα), a crucial proinflammatory cytokine. As a result, continuous EAT suppressed submucosal cell aggregation and reduced inflammatory cytokines. Thus, EAT may contribute to the improvement of systemic inflammatory diseases through the suppression of IL-6 expression.

Epipharyngeal Abrasive Therapy (EAT) Has Potential as a Novel Method for Long COVID Treatment

COVID-19 often causes sequelae after initial recovery, referred to collectively as long COVID. Long COVID is considered to be caused by the persistence of chronic inflammation after acute COVID-19 infection. We found that all long COVID patients had residual inflammation in the epipharynx, an important site of coronavirus replication, and some long COVID symptoms are similar to those associated with chronic epipharyngitis. Epipharyngeal abrasive therapy (EAT) is a treatment for chronic epipharyngitis in Japan that involves applying zinc chloride as an anti-inflammatory agent to the epipharyngeal mucosa. In this study, we evaluated the efficacy of EAT for the treatment of long COVID. The subjects in this study were 58 patients with long COVID who were treated with EAT in the outpatient department once a week for one month (mean age = 38.4 ± 12.9 years). The intensities of fatigue, headache, and attention disorder, which are reported as frequent symptoms of long COVID, were assessed before and after EAT using the visual analog scale (VAS). EAT reduced inflammation in the epipharynx and significantly improved the intensity of fatigue, headache, and attention disorder, which may be related to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). These results suggest that EAT has potential as a novel method for long COVID treatment.

Title IgA Nephropathy and Oral Bacterial Species Related to Dental Caries and Periodontitis

A relationship between IgA nephropathy (IgAN) and bacterial infection has been suspected. As IgAN is a chronic disease, bacteria that could cause chronic infection in oral areas might be pathogenetic bacteria candidates. Oral bacterial species related to dental caries and periodontitis should be candidates because these bacteria are well known to be pathogenic in chronic dental disease. Recently, several reports have indicated that collagen-binding protein (cnm)-(+) Streptococcs mutans is relate to the incidence of IgAN and the progression of IgAN. Among periodontal bacteria, Treponema denticola, Porphyromonas gingivalis and Campylobacte rectus were found to be related to the incidence of IgAN. These bacteria can cause IgAN-like histological findings in animal models. While the connection between oral bacterial infection, such as infection with S. mutans and periodontal bacteria, and the incidence of IgAN remains unclear, these bacterial infections might cause aberrantly glycosylated IgA1 in nasopharynx-associated lymphoid tissue, which has been reported to cause IgA deposition in mesangial areas in glomeruli, probably through the alteration of microRNAs related to the expression of glycosylation enzymes. The roles of other factors related to the incidence and progression of IgA, such as genes and cigarette smoking, can also be explained from the perspective of the relationship between these factors and oral bacteria. This review summarizes the relationship between IgAN and oral bacteria, such as cnm-(+) S. mutans and periodontal bacteria.