【作者】 王武章；

【导师】 李万瑶；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2012， 博士

【摘要】 目的：采用文献研究,系统回顾中西医对鼻渊的认识,综述针灸迎香穴治疗鼻渊的临床研究文献；根据循证医学的理念和方法,采用国际公认的试验报告统一标准CONSORT声明和报告针刺临床试验中干预措施的国际标准STRICTA对相关随机对照试验进行质量评价；客观评价指压迎香穴对鼻渊的临床疗效,将其与药物苍耳散和搓鼻疗法治疗鼻渊进行疗效比较,为寻求疗效快、无副作用且操作性强的保健治疗方式提供科学的临床证据。方法：一、文献研究：采用系统回顾的方法,主要从现代医学对鼻渊的认识、中医对鼻渊的认识、古文献中迎香穴主治病症概述、迎香穴治疗鼻渊的临床研究进展四个方面,总结中医、西医对鼻渊的认识,综述针灸迎香穴治疗鼻渊的临床研究文献。二、质量评价研究：采用国际公认的试验报告统一标准CONSORT声明和报告针刺临床试验中干预措施的国际标准STRICTA来评价国内针灸治疗鼻渊随机对照试验的报告质量。文献纳入标准：①采用随机分配,在文中有提示性术语如“随机分配”、“随机”、“对照”等。②同期比较的两种或多种干预措施,将受试者分入不同处理组③采用针灸或针灸与其他疗法结合为试验组治疗手段。文献排除标准：①综述、评论、探讨等不属于临床试验。②动物实验。③非随机对照试验。④病例/对照(疾病组与非疾病组的比较)研究。⑤重复发表文献。⑥非中、英文文献。文献获取方法：计算机检索：中国生物医学文献数据库(CBM,1978-2012),中国知网(CNKI,1979-2012),维普(VIP,1989-2012),万方(1998-2012)。检索词为“鼻渊、鼻窦炎”及“针灸、针刺、针刺疗法、电针”。手工检索：所有中文针灸期刊、中医药核心期刊及已纳入文献的参考文献。检索日期均截至到2012-03-31。检索结果下载后用NoteExpress2.2进行管理,用Excel进行文献资料提取分析。检测策略为：#1.缺省状态下“针灸”or“针刺”or“电针”or“灸”or“穴位”or“针灸疗法”or“针”or“磁疗”or“激光”or“红外线”#2.缺省状态下“鼻渊”or“鼻窦炎”#3.#1and#2#4.主题词：鼻渊/穴位疗法,针灸疗法#5.#3or#4文献质量评价：采用CONSORT的25条标准及STRICTA的6条标准对文献报告质量进行评价。评价前,对研究人员进行系统培训,对评价标准进行仔细理解和讨论。然后,两位研究人员采用CONSORT和STRICTA的每一条目根据文献作者是否报告,各自作出“是”或“否”的回答,当意见不一致时由第三位研究员决定。最后,计算CONSORT和STRICTA标准中每一条目报告的数目及所占百分比。三、临床随机对照研究：采用非盲法,随机、对照研究方法,将90例鼻渊患者随机分为3组,指压组30例,药物组30例,撮鼻组30例,其中搓鼻组脱落2例。药物组采用汪昂《医方集解》之苍耳散为药物组处方。各组操作方法如下：(1)指压组：首先双手中指轻掐鼻翼两旁迎香穴药1-2分钟,再轻揉穴道,以消除因指掐引起之不适感。其次做颤动式地点按约1分钟。最后自迎香穴沿鼻翼下方底部,做轻揉抚摩,双指相碰于鼻子准头下(人中穴)药1-2分,抚摩时双指轻触鼻翼更有疗效,按摩后喝1杯热开水。按摩迎香具有通鼻窍、散风热作用。指压按摩手法要轻,避免皮肤受伤,一般病患自己每日指压早、中、晚、睡前四次。(2)药物组：取汪昂《医方集解》之苍耳散为药物组处方。白芷主手足阳明,上行头面,通窍表汗,除湿散风。辛夷通九窍散风热,助胃中清气上行头脑。苍耳疏风散热,上通脑顶,外达皮肤。薄荷泄肺疏肝,清利头目。葱白升阳通气。茶苦寒下行,清升浊降,风热散脑液固。服药方式：使用顺天制药厂之汉方浓缩药剂,每日服用3次,每次服用3.5克,时间为1个月。(3)搓鼻组：搓揉鼻根部及鼻的两侧并在迎香穴呆稍微久一点。双眼轻轻的闭合,用双手食指指腹由上至下,缓慢地搓揉鼻根部及鼻的两侧并在迎香穴呆稍微久一点,重复几次至鼻部出现胀、酸感为止,症状就消失或减轻,按摩后喝1杯热开水。注意轻轻搓揉,避免皮肤受伤,病患自己每天至少搓揉4次(早、中、晚、睡前),搓揉后喝1杯热开水。以鼻渊之鼻塞、鼻涕、脸痛、头痛、口臭、嗅觉减损、鼻脓涕、鼻粘膜及鼻窦开口9种鼻渊症状及其总积分为观察指标。观察时间点是治疗前、治疗后7天、治疗后14天及治疗后21天,观察周期为1个月。试验结束后采用国家中医药管理局1994年发布的中医病证诊断疗效标准P109进行疗效评价。结果：一、文献研究显示：迎香穴是针灸治疗鼻渊的重要腧穴之一。其中针灸大全,千金要方,针灸资生经,三本书籍强调鼻渊不知香臭皆以迎香穴为主。刺激迎香穴可以疏通手阳明经气,宣通鼻窍。近年来,临床研究表明常规针刺、电针、耳穴、穴位注射、穴位埋线等多种针灸干预方法均可用于鼻渊的治疗。二、质量评价研究显示：采用CONSORT声明和STRICTA标准对国内外针灸治疗鼻渊的临床随机对照试验的质量评价结果表明文献质量普遍较低。这给读者了解研究设计的合理性、研究实施的正确性、研究结果的真实性和在临床推广应用造成一定困难。纳入的14篇文献中大部分存在随机方法描述不清和无随机隐藏、无意向治疗分析、针刺细节报道不充分等问题。且样本含量偏小,得出的结论不可靠。三、临床随机对照试验研究显示：指压组、药物组和搓鼻组三组治疗前后9种鼻渊症状积分比较均有显著性差异(P<0.05),表明三种疗法均能明显改善鼻渊症状；治疗后三组间9种鼻渊症状积分及其总积分比较均无显著性差异(p>0.05),表明三种疗法对9种鼻渊症状的疗效比较无明显差别。搓鼻组治疗鼻渊疗效稍差,原因可能深透力不如指压,有待进一步的观察。汪昂的《医方集解》之苍耳散用来治疗鼻渊是有一定疗效的,不过临床运用时,辨证论治很重要。结论：一、本次研究结果显示,指压组、药物组和撮鼻组三组治理前后鼻渊症状积分比较具有显著性差异,即三组疗法对鼻渊症状均具有改善。可以说指压疗法治疗鼻渊效果明显。同样运用手法,指压组和搓鼻组疗效差异不大。两者在迎香穴治疗鼻渊有一个共同作用,就是具有祛风通窍,理气止痛,改善局部及其临近组织的血液回流,增强局部对气候变化的适应能力和对病邪的防御能力。二、病因方面以患者抵抗力差最多。青少年身体生长发育迅速,体内免疫能力生长未能跟上脚步,容易感染鼻渊。指压按摩迎香穴,可改善局部组织的血液回流,增强适应气候变化和抵抗病邪的能力。三、三组各诊次间鼻塞、鼻涕、脸痛、头痛、口臭、嗅觉减损、鼻脓涕、鼻粘膜、鼻窦开口等症状积分比较,均具有显著性差异(P<0.05)。三组的疗法均值得临床选择运用。四、搓鼻组治疗鼻渊疗效差一点,经疗效观察统计结果显示勉强可使用,原因可能深透力不如指压,有待进一步的观察。五、汪昂的《医方集解》之苍耳散用来治疗鼻渊是有一定疗效的,不过临床运用时,辨证论治很重要。六、古代在《针灸大全》、《千金要方》、《针灸资生经》中均有迎香穴治疗鼻渊之嗅觉减退、不知香臭的记载。本研究结果显示,确有一定的疗效。目前西医治疗鼻渊以磺胺药、抗生素及滴鼻剂为主,首选是抗生素的治疗,但长期应用抗生素可能产生不可避免的副作用,患者与家属会有疑虑而怯步,故用指压来治疗鼻渊是一种值得考虑的治疗方式。七、鼻渊在治疗过程相当漫长的,鼻渊不只是鼻粘膜肿胀而己,由于鼻腔的发炎反应而造成,如果迟延治疗会导致很多并发症的产生,宜早期诊断积极治疗根除后患。鼻渊主要是鼻腔发炎,鼻窦粘膜的化脓性炎症形成的,会影响患者生活品质及健康,宜早期诊断积极治疗,避免并发症的产生,若采用指压的方式,疗效上简、便、快、效、廉、验且患者接受度高,临床上多加运用,再以适当的运动,规律的生活,均匀的营养和环境管控的配合,可以期待获得减缓鼻渊症状。更多还原

【Abstract】 Objective:To review the understanding on nasosinusitis in Chinese and Western medicine systematically with literature research, and summarize the clinical research literatures of the acupuncture treatment of nasosinusitis with YingXiang(LI20). To evaluate the quality of the relevant randomized controlled trials with international standards of the internationally recognized test Consolidated Standards of Reporting CONSORT statement and reporting clinical trials of acupuncture interventions STRICTA according to the concepts and methods of evidence-based medicine. To evaluate the clinical effect of the finger-pressure therapy of YingXiang(LI20) on nasosinusitis, comparing with drug (xanthium powder) therapy and twist nose therapy, then provide a scientific clinical evidence for seeking the effect of fast, no side effects and operable health treatment.Methods:Literature research:Summarized the understanding on nasosinusitis in Chinese and western medicine and reviewed the clinical research literatures of the acupuncture treatment of nasosinusitis with YingXiang(LI20) through the understanding on nasosinusitis of modern medicine, the understanding on nasosinusitis in Chinese medicine, the overview of main symptoms and diseases with YingXiang(LI20) in ancient literatures and the clinical research progress of the treatment of nasosinusitis with YingXiang(LI20) with system review method.Quality Evaluation:Evaluated the quality of domestic acupuncture treatment reporting on nasosinusitis of randomized controlled trials with international standards of the internationally recognized test Consolidated Standards of Reporting CONSORT statement and reporting clinical trials of acupuncture interventions STRICTA. Literature inclusion criteria:①Random allocation, having suggestive terminology in the text such as randomly assigned, the random control and so on.②Comparing two or multiple interventions, and the subjects were divided into different groups.③Used acupuncture or acupuncture combined with other therapies as the treatment means of the test group. Literature exclusion criteria:①Summary, Comments, Discussion, etc. do not belong to the clinical trials.②animal experiments.③non-randomized controlled trials. The④case/control (disease group and the non-disease group comparison) studies.⑤Repeat published literature.⑥non-English and non-Chinese literatures. The methods of obtaining literatures:computer retrieval:Chinese Biomedical Literature Database (CBM,1978-2012), china knowledge network (the CNKI from1979to2012), VIP (the VIP1989through2012), Articles (1998-2012). The key words nasosinusitis, sinusitis and acupuncture and moxibustion, acupuncture, acupuncture therapy, electro-acupuncture. Manual retrieval:all Chinese acupuncture journals, core journals of Chinese medicine, and literature references have been included up to2012-03-31. The search results downloaded managed with NoteExpress2.2and extracted and analyzed them with Excel. Detection strategy is:#1default state "acupuncture" and "moxibustion" or "acupuncture" or "electro-acupuncture" or "moxibustion" or "acupoint" or "acupuncture therapy" or "needle" or "magnetotherapy" or "laser" or "infrared"#2default state "nasosinusitis" or "sinusitis"#3#1and#2#4subject word:nasosinusitis/acupoint therapy, acupuncture therapy#5#3or#4Quality evaluation of literatures:Evaluated the quality of literatures with 25standards of CONSORT and6standards of STRICTA. Before evaluating, the researchers must conduct a systematic training, the evaluation criteria must be understanded and discussed deeply. Then, two researchers made a "yes" or "no" answers respectively according to the literature writer report wether or not with each entry of CONSORT and STRICTA. If they are disagree with each other, then decided by the third researcher. Finally, calculate the number and percentage of each entry report in the CONSORT and STRICTA standards.Clinical randomized controlled trials:The90patients of nasosinusitis were randomly assigned to the finger-pressure therapy group, the drug therapy group and twist nose therapy group. And each group was30cases. But the twist nose group had2shedding cases. The prescription of drug group was xanthium powder in Collection of Prescriptions with Notes of WangAng. And the follows were each group’s operations:(1) The finger-pressure group:First, pressed lightly YingXiang (LI20) on the both sides of the nose about1-2minutes with the middle fingers, then did massage at the points gently in order to eliminate the discomfort caused by the pressing. Second, clicked the place flickeringly about1minute. Finally, do massage gently with two fingers from YingXiang(LI20) along the bellow of ala nasi about1-2minutes, and the fingers touched bellow the tip of the nose (philtrum). And it is more effect touching ala nasi gently with two fingers when doing the massage. Then drink a cup of hot water after doing this. Doing the massage at Yingxiang(LI20) can relieve stuffy nose and dispel the evil-wind and the thermal. The massage techniques had to be gently to avoid injuring the skin. Generally, the patient pressed four times everyday by themselves at morning, noon, night and before going to bed respectively.(2) The drug group:The prescription was xanthium powder in Collection of Prescriptions with Notes of WangAng. The channel tropism of angelica was the YangMing meridian of hand and foot. Angelica went up to face and head. Its functions were inducing resuscitation, diaphoresis, dispelling pathogenic wind and removing dampness. Flos Magnoliae can induce all resuscitation, scatter wind-heat and help the stomach clear gas go up to the head. Cocklebur can dispel wind and reduce heat, go up to the top of the head and reach to the skin. Peppermint can adjust lung qi, disperse stagnated liver qi, and remove heat for treating head and ocular disease. Scallion can raise yang and benefit qi. Tea was bitter and cold, ascending lucidity and descending turbidity. The way to take the medicines:The patients took the drug three times a day with3.5grams each time for a month, which was Kampo concentrated pharmaceutical products produced by Sunchon Pharmaceutical Factory.(3) The twist nose group:Rubbed the root and the both sides of the nose. And rubbed the YingXiang(LI20) a little longer. Closed the eyes gently, and rubbed the the root and the both sides of the nose from top to bottom with the index finger pulp of the both hands, and stayed a little longer at YingXiang(LI20), repeated several times until to the nose appeared bulge acid sense. The symptoms would disappeared or mitigated after massage. Then drank a cup of hot water. The massage techniques had to be gently to avoid injuring the skin. Generally, the patient rubbed four times everyday by themselves at morning, noon, night and before going to bed respectively.The observation indexes were the nasosinusitis symptoms integration which contained nasal congestion, nasal mucus, facial pain, headache, bad breath, smell impairment, nasal purulent discharge, nasal mucosa and sinus openings and the their total score. The observation time was before treatment, seven days after treatment,14days after treatment and21days after treatment respectively, and the observation period was1month.After the test, evaluated clinical effect according to diagnostic and effect standards P109of diseases in TCM released in1994by the State Administration of Traditional Chinese MedicineResults:The literature research shows:YingXiang(LI20) is one of the important acupoints for treatment nasosinusitis with acupuncture. Nasosinusitis all treated mainly with YingXiang(LI20) in Zhen Jiu Da Quan, Qian Jin Yao Fang and Experience on Acupuncture and Moxibustion Therapy. Stimulate YingXiang(LI20) can dredge Hand YangMing meridian gas, declared the nasal passage. In recent years, clinical studies have shown that regular acupuncture, electro-acupuncture, auricular point, acupoint injection, acupoint catgut embedding and other acupuncture interventions can be for nasosinusitis treatment.Quality evaluation research showed:The quality evaluation results of the clinical randomized controlled trials about nasosinusitis treatment with acupuncture showed that the literatures were generally low quality wether domestic or foreign according CONSORT statement and STRICTA standards. This gave the reader some difficulties to understand the rationality of the study design, study the correctness of implementation and promote the clinical application. There are some problems in most of included14literatures. Such as the description of random method was unclear and non-random hidden, no intention to treat analysis, acupuncture details reported inadequate and so on. And the sample size was too small, the conclusions were not reliable.The researches of clinical randomized controlled trials had showed:nine kinds nasosinusitis symptoms integration scores of the finger-pressing group, the drug group and the twist nose group were significant differences (P<0.05) before and after treatment, suggest that the three kinds of therapies could improve the nasosinusitis symptoms significantly; The compare of nine kinds nasosinusitis symptoms and their total integration scores showed no significant difference (p>0.05) among three groups after treatment, indicating that no significant differences for three kinds of therapies on the nine kinds of nasosinusitis symptoms efficacy. The twist nose group was less effective, probably due to the deep penetration force was less than finger-pressing group, which was pending further observations. The xanthium powder in Collection of Prescriptions with Notes of WangAng used to treat nasosinusitis had a certain effect, but syndrome differentiation and treatment was important in the clinical application.Conclusion:The nasosinusitis symptoms integration scores of the finger-pressing group, the drug group and the twist nose group were significant differences before and after treatment, suggest that the three kinds of therapies could improve the nasosinusitis symptoms significantly. We can say, the effect of treating nasosinusitis with finger-pressing was obvious. Both There were little difference between finger-pressing group and the twist nose group which both were manipulation treatment. They had a common role in the treatment of nasosinusitis with YingXiang(LI20), that was expelling wind and promoting the restoration of consciousness and regulating the circulation of Qi and alleviating pain, improving blood return of the local and adjacent tissue, and enhancing the adaptability to climate change and the capability defend from Evils.Pool resistance was the main etiology. The adolescent grow rapidly and the immunity growth in vivo failed to keep pace with it. So they are susceptible to infect with nasosinusitis. Press YingXiang(LI20) could improve blood return of local organizations, and enhance their adaptability to climate change and the capability defend from Evils.The integration scores of nasal congestion, nasal mucus, facial pain, headache, bad breath, smell impairment, nasal purulent discharge, nasal mucosa and sinus openings had significant difference (P<0.05) among the different examination of the there groups. The three therapies were worth to choose in the clinical.The twist nose group was less effective. The statistical results of clinical observation showed that it barely can be used. May be due to the deep penetration force was less than finger-pressing, which was pending further observations. The xanthium powder in Collection of Prescriptions with Notes of WangAng used to treat nasosinusitis had a certain effect, but syndrome differentiation and treatment was important in the clinical application. YingXiang(LI20) was used to treat nasosinusitis with acupuncture, which was recorded in Zhen Jiu Da Quan, Qian Jin Yao Fang and Experience on Acupuncture and Moxibustion Therapy. The results of this study showed that it did have a certain effect. In western medicine, it used sulfa drugs, antibiotics and nasal drops mainly to treat nasosinusitis at present. And the fist choice was antibiotics, but long-term use of antibiotics could cause inevitable side effects. Patients and their families would have doubts about it and prohibit it. So press YingXing(LI20) with finger was worth to be choose to treat nasosinusitis.The process of the treatment of nasosinusitis was a long time. Nasosinusitis is not just nasal swelling. It is caused by inflammation of the nasal cavity. If the patient treat it too late, it may lead to many complications. So the patients should diagnosed it early and treat it actively to eradicate troubles.Nasosinusitis is nasal inflammation, which is caused by purulent inflammation of the sinus mucosa. It will affect the patients quality of life and health. And it should be diagnosed early and be treated actively to avoid the complications. Finger-pressing therapy was Simple, convenient, fast, efficient, inexpensive and experience. So patients receive it easily. If the patients treated with it, and coupled with appropriate exercise, regularly life, balanced nutrition, and environmental control. It will alleviate nasosinusitis symptoms.更多还原