鼻腔盥洗对血管运动性鼻炎治疗作用的初步研究

Nasal irrigation for the treatment of vasomotor rhinitis： a pilot study

目的 观察单纯3％高渗盐水鼻腔盥洗及与鼻用糖皮质激素联合的方法对血管运动性鼻炎（vasomotor rhinitis,VMR）的治疗作用;通过检测鼻腔盥洗液中P物质（substance P,SP）和黏蛋白（mucin,MUC）5B的含量,初步探讨鼻腔盥洗治疗VMR的机制.方法 就诊于复旦大学附属华山医院耳鼻咽喉头颈外科的101例VMR患者被随机分为4组：对照组24例,布地奈德鼻腔喷雾治疗组（布地奈德组）25例,鼻腔盥洗治疗组（鼻腔盥洗组）25例,布地奈德鼻腔喷雾＋鼻腔盥洗治疗组（联合治疗组）27例.对照组患者不予任何治疗措施,布地奈德组用布地奈德进行鼻腔喷雾,鼻腔盥洗组以3％的温盐水（40℃）进行鼻腔盥洗,联合治疗组应用上述两种治疗方法,干预期为3个月（90 d）.用视觉模拟量表（visual analog scale,VAS）评估患者鼻部症状,用健康调查量表（12-item short formhealth survey version 2.0,SF-12v2）评估患者生活质量.用酶联免疫吸附试验（ELISA）对布地奈德组和鼻腔盥洗组患者干预前和干预后3个月时的鼻腔盥洗液中SP和MUC 5B进行检测,并检测对照组鼻腔SP激惹和抗胆碱能药物阻滞后鼻腔盥洗液中的MUC5B浓度.应用Graphpad Prism 6统计软件进行统计学分析.结果 101例VMR患者中90例完成了该项研究.干预后第1个月末,布地奈德组和联合治疗组治疗前后的VAS评分降低[（5.91±0.21）分比（3.82±0.15）分,（6.18 ±0.17）分比（3.92±0.15）分,t值分别为8.193、10.060,P值均＜0.05],SF-12v2评分升高[（146.00±1.23）分比（152.30 ±0.97）分,（146.00±1.08）分比（155.40±0.90）分,t值分别为3.982、6.697,P值均＜0.05],但鼻腔盥洗组的VAS评分[（5.96±0.17）分比（5.72 ±0.15）分,t=1.038,P＞0.05]和SF-12v2评分[（146.10±1.17）分比（147.00±0.94）分,t=0.607,P＞0.05]的差异无统计学意义.第2个月末,布地奈德组和联合治疗组治疗前后的VAS评分降低[（5.91±0.21）分比（5.05 ±0.15）分,（6.18 ±0.17）分比（5.10±0.12）分,t值分别为3.374、5.351,P值均＜0.05],SF-12v2评分升高[（146.00±1.23）分比（150.90 ±0.76）分,（146.00±1.08）分比（153.60±0.94）分,t值分别为3.373、5.343,P值均＜0.05],但鼻腔盥洗组的VAS评分[（5.96±0.17）分比（5.78±0.17）分,t=0.716,P ＞0.05]和SF-12v2评分[（146.10±1.17）分比（148.10 ±0.80）分,t=1.438,P＞0.05]的差异无统计学意义.第3个月末,鼻腔盥洗组和联合治疗组治疗前后的VAS评分降低[（5.96±0.17）分比（4.80 ±0.12）分,（6.18 ±0.17）分比（4.44±0.13）分,t值分别为5.485、8.264,P值均＜0.05],SF-12v2评分升高[（146.10±1.17）分比（150.80±0.96）分,（146.00±1.08）分比（152.90 ±0.85）分,t值分别为3.163、5.008,P值均＜0.05],但布地奈德组的VAS评分[（5.91 ±0.21）分比（5.68±0.18）分,t=0.819,P ＞0.05]和SF-12v2评分[（146.00±1.23）分比（148.40±0.85）分,t=1.587,P＞0.05]的差异无统计学意义.布地奈德组干预3个月后鼻腔盥洗液中SP减少,MUC5B未出现明显变化,而鼻腔盥洗组的结果正好相反,并且,抗胆碱能药物未能使SP激惹后的鼻腔盥洗液中MUC5B的含量显著降低.结论 单纯3％高渗温盐水鼻腔盥洗或鼻用糖皮质激素联合鼻腔盥洗长期治疗VMR,其疗效优于单纯鼻用糖皮质激素治疗.糖皮质激素对鼻黏膜感觉神经纤维有一定的抑制作用,但神经递质在VMR的发病机制中作用有限.

Objective To observe the therapeutic effect of simple 3.0% saline nasal irrigation and combined treatment of 3.0% saline nasal irrigation and budesonide nasal spray for vasomotor rhinitis （VMR）,and explore the long-term effect for VMR.Through examination of levels of substance P （SP） and mucin （MUC）5B in nasal lavage fluid,the mechanisms of nasal irrigation treatment for VMR was discussed.Methods One hundred and one patients from Department of Otorhinolaryngology Head and Neck Surgery,Huashan Hospital of Fudan University with VMR were randomly divided into 4 groups.The number of patients was 24 in control group,25 in budesonide nasal spray treatment group （budesonide group）,25 in nasal irrigation treatment group （nasal irrigation group） and 27 in budesonide nasal spray ＋ nasal irrigation group （combined treatment group）.Control patients were left untreated.Budesonide group was under budesonide nasal spray treatment,nasal irrigation group was treated using 3.0% saline with a temperature of 40℃ and combined treatment group was given both treatments.The duration of the intervention period was 3 months （90 days）.Visual Analog Scale （VAS） was used to evaluate nasal symptoms,and the healthrelated quality of life was assessed using the 12-item Short Form Health Survey version 2.0 （SF-12v2）.Enzyme-linked immunosorbent assay （ELISA） was used to assess the contents of SP and MUC5B in nasal lavage fluid before and after 3-month treatments in budesonide and nasal irrigation group in the study.MUC5B in nasal lavage fluid after the SP challenge and anticholinergic drug intervention in control group were also evaluated with ELISA.Results Nighty out of 101 patients completed the study.In the budesonide and combined treatment group after relevant interventions,the total VAS score of nasal symptoms decreased （5.91 ±0.21 vs 3.82 ±0.15,6.18±0.17 vs 3.92 ±0.15,t value was 8.193,10.060,respectively,all P 〈 0.05） and SF-12v2 score increased （146.00 ± 1.23 vs 152.30 ± 0.97,146.00 ± 1.08 vs155.40 ± 0.90,t value was 3.982,6.697,respectively,all P 〈 0.05）,with both scores showed no significant differences in the nasal irrigation group （5.96 ± 0.17 vs 5.72 ± 0.15,146.10 ± 1.17 vs 147.00 ±0.94,t value was 1.038,0.607,respectively,all P 〉 0.05） after the first month.In the budesonide and combined treatment group after relevant interventions,the total VAS score of nasal symptoms decreased （5.91 ±0.21 vs 5.05 ±0.15,6.18 ±0.17 vs 5.10 ±0.12,t value was 3.374,5.351,respectively,all P 〈 0.05） and SF-12v2 score increased （146.00 ± 1.23 vs 150.90 ± 0.76,146.00 ± 1.08vs 153.60 ± 0.94,t value was 3.373,5.343,respectively,all P 〈 0.05）,with both scores showed no significant differences in the nasal irrigation group （5.96 ± 0.17 vs 5.78 ± 0.17,146.10 ± 1.17 vs 148.10 ±0.80,t value was 0.716,1.438,respectively,all P 〉0.05） after the second month.By the end of the third month,in nasal irrigation and combined treatment group,the VAS score was diminished （5.96±0.17 vs 4.80 ±0.12,6.18 ±0.17 vs 4.44 ±0.13,t value was 5.485,8.264,respectively,all P 〈0.05） and SF-12v2 score was elevated （146.10 ± 1.17 vs 150.80 ±0.96,146.00 ± 1.08 vs 152.90 ±0.85,t value was 3.163,5.008,respectively,all P 〈 0.05）,but there were no significant differences in budesonide group （5.91 ±0.21 vs 5.68 ±0.18,146.00 ± 1.23 vs 148.40 ±0.85,t value was 0.819,1.587,respectively,all P 〉 0.05）.Additionally,SP in nasal lavage fluid decreased and MUC5B showed no statistical changes in budesonide group after three months,however,SP showed no any changes and MUC5B reduced significantly in nasal lavage fluid in nasal irrigation group.Furthermore,the anticholinergic drug could not decrease the concentration of MUC5B after the SP challenge in nasal cavity in control group.Conclusions The therapeutic effect of simple nasal irrigation with 3.0% saline or combined treatment of 3.0% saline nasal irrigation and nasal corticosteroids is superior to simple nasal corticosteroids.Nasal corticosteroids plays a role in the inhibition of sensory nerve endings in nasal mucosa,but neurotransmitter plays a limited role in the pathogenesis of VMR.