Download Treatment of Refractory Sinusitis with Integrative East

Treatment of Refractory Sinusitis with Integrative East-West Medicine
Marilene B. Wang, MD, Malcolm Taw, MD, and Chau Nguyen, MD
1.
Complementary/Alternative Medicine (CAM)
40% of US population seek out CAM for treatment of illness
1991--NIH established an Office of Alternative Medicine
1998--creation of the National Center for Complementary and Alternative Medicine (NCCAM)
2005--$122 million annual NIH budget set aside for funding of projects in NCCAM
2.
62% of US adults utilized CAM in the past 12 months (including prayer)
36% of US adults utilized CAM (excluding prayer for health reasons)
Commonly used CAM: natural products, deep breathing, meditation, chiropractic, yoga, massage, dietbased therapies
3.
Literature review
Yakirevitch et al. Use of Alternative Medicine in Israeli Chronic Rhinosinusitis Patients. Journal of
Otolaryngology-Head & Neck Surgery, Vol 38, No 4 (August), 2009: pp 517–520
Sertel et al. Acupuncture for nasal congestion: A prospective, randomized, double-blind, placebocontrolled clinical pilot study. Am J Rhinol Allergy 23, e23–e28, 2009
Brinkhaus et al. Acupuncture in patients with allergic rhinitis: a pragmatic randomized trial. Ann
Allergy Asthma Immunol. 2008 Nov;101(5):535-43.
Ernst, E. Acupuncture – a critical analysis. J Intern Med. 2006 Feb;259(2): 125-37.
Pletcher et al. Use of acupuncture in the treatment of sinus and nasal symptoms: results of a
practitioner survey. Am J Rhinol. 2006 Mar-Apr;20(2):235-7.
4. Implications for physicians
Modest support for CAM in sinusitis
Primum non nocere
Further study needed
5. UCLA East-West Medicine Center
Mission—to integrate the best of traditional Chinese medicine with the best of Western medicine
Board-certified internists
Licensed acupuncturists
6. Pilot Study
Traditional Chinese medicine (TCM) and acupuncture for treatment of patients with chronic sinusitis
5-25% of chronic sinusitis patients still have symptoms following maximal medical and surgical
treatment (Palmer and Kennedy, Curr Opin Otolaryngol Head Neck Surg 2003)
7. Inclusion criteria
a. Significant sinus symptoms despite maximal Western medical therapy, including antibiotics,
antihistamines, steroids, decongestants, and/or surgery
b. Age over 18
c. Ability to pursue treatment at UCLA East-West Medicine Center
8. Exclusion criteria
a. Sinus surgery within the last three months
b. Acupuncture or acupressure treatment within the last two months
c. HIV, Hep B or C positive
d. Samter’s triad, allergic fungal sinusitis, nasal polyposis
Treatment Protocol
9. Initial visit to UCLA Otolaryngologist
a. History, exam, nasal endoscopy, sinus CT scan if indicated
b. Overview of integrated treatment protocol
c. Fill out SNOT-20 and SF-36 surveys
10. Initial visit to UCLA East-West Medicine Center
a. History, exam, overview of treatment protocol
b. Acupuncture, acupressure, therapeutic massage,
c. Counseling on diet, lifestyle, stress management, instruction in self-massage
d. Patient to continue standard sinus medications
11. Subsequent weekly visits (over an 8 week period)
a. Acupuncture, trigger point injections, therapeutic massage
b. Follow-up counseling regarding diet, exercise, lifestyle modification
c. Opportunity for patient to ask questions
12. Study end-points
a. Changes in symptom scores, both sinusitis-specific (SNOT-20) and overall mental and physical
well-being (SF-36)
13. 11 patients completed protocol (Suh et al., Archives of Otolaryngology 2012)
a. SNOT-20 scores—mean scores improved in almost every category
b. No change in dizziness and wake up at night
c. Slightly worse in lack of a good night’s sleep
d. SF36 scores—mean scores for all 8 domains higher
14. Significant improvement in SNOT-20 items:
a. Need to blow nose
b. Ear fullness
c. Reduced concentration
d. Trend toward significance for facial pain/pressure
15. Significant improvement in SF36 scores:
a. Role-physical
b. Bodily pain
c. Social functioning
16. Scores improved in SF36 in all domains
Scores improved in most domains for SNOT-20
Not all differences were significant
No patient had worse overall scores after treatment
17. Challenges and limitations
Pilot Study
Small sample size
Logistics more difficult than anticipated
a. Access to CEWM clinic
i. Los Angeles area traffic/freeways/parking
b. Weekly visits for 8 weeks
c. Insurance coverage
18. Western vs. Eastern Medicine
Modern
Traditional
Western Medicine
Chinese Medicine
(MWM)
(TCM)
Reductionistic
Holistic
Microscopic
Macroscopic
Structure
Function
Quantitative
Qualitative
Separation of
Preservation of
Mind-Body
Mind-Body
19. Health Paradigm Shift*
19 -20th Century
Reductionism Æ
Single fxn
Miasma vs Germ theory
Chemistry
Physics
Physiology
Pathology
th
21st Century
Emergent Properties Æ
Multiple fxns
Systems Biology
Genomics
Proteomics
Metabolomics
Bioinformatics
*Institute of Medicine: Summit on Integrative Medicine & The Health of The Public, February, 2009
20.
The study of an organism, viewed as an integrated and interacting network of genes, proteins and biochemical
reactions which give rise to life. Instead of analyzing individual components or aspects of the organism, such as
sugar metabolism or a cell nucleus, systems biologists focus on all the components and the interactions among
them, all as part of one system.
Leroy Hood, M.D., Ph.D. Institute for Systems Biology
21. Integrative Medicine and Systemic Outcomes Research; Issues in the Emergence of a New Model for
Primary Health Care. Bell et al. Arch Intern Med 2002;162:133-140
22. Acupuncture
“Acupuncture restores the homeostatic balance by a differential effect of suppressing hyperfunction,
stimulating hypofunction, and regulating disturbed function”
Li, Y. et.al. The effect of acupuncture on gastrointestinal function and disorders. Am J Gastroenterol. 87(10):
1372-1381, 1992.
23. Meridians
• Extensive network of channels
in the human body (meridians)
• There are specific points found
along these meridians called
acupoints
• Qi is said to concentrate and
flow through these meridians
• Acupuncture maintains a free and
adequate flow of Qi and restores
balance to achieve optimal health
24. Therapeutics and Pharmacology
Modern
Traditional
Western Medicine
Chinese Medicine
(MWM)
(TCM)
“Active” ingredient
“Crude” form
Purification
Preservation
Focus on therapeutic response
Less potent but focus on
with acceptable side effects
balance of therapy with
minimal side effects
25. Food vs. Herbs
In general, herbs are viewed as potentially harmful,
while food is seen as benign
While physicians and patients alike can be averse
to trying herbs, people are more open to trying food
products as a form of therapy
26. “Food is Medicine, and Medicine is Food”
- Hippocrates, 500 B.C.
Foods classified by properties
y Taste: reflect function
y Temperature: energetic considerations
y Actions of lifting, lowering, floating, & sinking
y General categories: tonics, clearers, movers, miscellaneous
Food selection guided by TCM theory
27. Cold Condition
Aversion to cold, preference for warmth, tastelessness in the mouth, absence of thirst or preference of warm or
hot drinks, pale face, cold limbs, sleepy, loose stool, clear and profuse urine, pale tongue, white and moist
coating
28. Heat Condition
Feverish, preference for coolness, thirst with preference for cold drinks, red face or eyes, irritability,
restlessness, constipation, deep and dark urine, red tongue and yellow coating
29. Nature of Food
Hot/warm:
Chicken, beef, lamb, ginger, walnut, sesame, garlic, green onion, cayenne pepper
Neutral:
Pork, lotus root, Chinese yam, carrot, tomato, Chinese cabbage
Cold/cool:
Seaweed, kelp, mung bean, watermelon, honey, banana, pear, tofu
30. Fresh ginger
For common cold or flu with chills, nasal congestion, running nose with clear discharge, HA, body ache,
For nausea/vomiting, morning sickness
Aids with digestion
For cough with clear phlegm
For sinusitis or allergic rhinitis with cold TCM pattern
31. Summary
Paucity of solid level I evidence to support CAM treatment of chronic sinusitis
Plethora of anecdotal and level 3-4 evidence to support CAM treatment of sinusitis
Be aware of CAM treatments that your patients are trying
Emphasize lifestyle modification, environmental control, stress management in addition to standard
medical/surgical treatment
Encourage CAM treatment by licensed professionals