RU2711525C1 - Method of treating patients with allergic rhinitis with disturbed microbe landscape of nasal mucosa - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and can be used for treating patients with allergic rhinitis with disturbed microbial landscape of nasal mucosa. That is ensured by a three-stage conservative therapy: at the first stage, administering the poly-oxidonium immunomodulator in tablet form 12 mg twice a day orally for 10 days according to scheme 1, 2, 4, 6, 8, 11, 14, 17, 20, 23 days, in accordance with the patient's immune system changes; at the second stage, from the fifth day from reception of polyoxidonium, on the basis of bacteriological research taking into account sensitivity the antibacterial therapy and elimination therapy by a preparation of dolphin 2 times a day is carried out for 10 days; at the third stage, after the course of the antibacterial and elimination therapy, Maxillac synbiotic is administered orally 1 capsule per day for 20 days and polyvalent bacteriophage 5 drops in each half of nose 3 times/day for 14 days.EFFECT: method has a stable therapeutic effect with more complete recovery of nasal breathing and olfaction, reduced or disappearing intensity of paroxysmal sneezing attacks, rhinorrhea, manifestations of conjunctivitis and chronic sinusitis.1 cl, 7 tbl, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in the treatment of year-round and seasonal allergic rhinitis in patients with a disturbed microbial landscape of the nasal mucosa.

There is a method of treating patients with allergic rhinitis, which consists in performing intranasal injections of diphenhydramine with splenin and the simultaneous administration of phonophoresis of hydrocortisone or emulsion "Ziksorin" (Trofimenko S.L. On the tactics of local interventions in chronic polyposis-allergic rhinosinusopathy // Ross. Rinol. - 1993. Appendix 1. S. 54-55). The drug is introduced into the anterior end of the inferior nasal concha, followed by phonophoresis of hydrocortisone or Zixorin emulsion.

The disadvantage of the described analogue is that the authors do not indicate the exact proportional ratio of the administered drugs. In addition, this treatment was used only in patients with chronic polyposis-allergic rhinosinusopathy.

Also known is a method of treating patients with allergic rhinitis, which consists in introducing diprospan into the lower nasal concha - a prolonged-acting corticosteroid with anti-inflammatory and anti-allergic properties (Izvin A.I., Prokopyev V.Ya., Kerimov A.A. Physical performance indicators in patients with allergic rhinitis at various stages of treatment // Ross. rinol. - 2002. - No. 2. - S. 196-197). With the introduction of diprospan in the anterior end of the inferior nasal concha, the reflexogenic zone of the receptor apparatus of the mucous membrane of the inferior nasal concha is affected. Dosage of 1.0 ml of diprospan solution once a week alternately (4 endonasal blockade per treatment course).

The disadvantage of the described analogue is that, firstly, to achieve the desired result, the use of corticosteroids is advisable for moderate and severe forms of allergic rhinitis, as well as for complications of allergic rhinitis with bronchial asthma, polypous rhinosinitis, in association with a focus of chronic infection. Secondly, in official medical sources there were reports of cases of blindness as a result of the introduction of diprospan into the lower nasal concha. Due to the generality of blood flow, particles of suspension from the vessels of the nasal concha can enter the arteries of the retina and cause their embolism. Thirdly, the nasal concha has good blood supply, a few minutes after the introduction of any drug into the conch, it enters the systemic circulation. Further, it has a systemic effect, which could be obtained with a different route of administration. Systemic administration of large doses of hormones inhibits the work of your own adrenal glands. Fourth, the effect of hormones is always temporary. This procedure successfully reduces swelling of the nasal concha only for a period of 3 to 6 weeks.

As the closest analogue (prototype), a method of treating allergic rhinitis was selected, which consists in the introduction of an antibacterial drug and an immunomodulator of polyoxidonium in the lower nasal concha (RF patent No. 2314104 from 01.10.2008, Gappoeva ET, Boliev L.Z.). The antibiotic is selected on the basis of instrumental and laboratory examination methods, including the study of the microbial landscape of the mucous membrane of the nasal cavity, taking into account individual sensitivity to the revealed pathogenic microflora. Antibacterial therapy is carried out once a day in a single dose to the front end of the inferior nasal concha on both sides for 10 days, and then 6 mg polyoxidonium immunomodulator is administered in the same areas for 5 days after 48 hours. The course of treatment is 15 procedures.

The disadvantage of the prototype is that, firstly, injections into the lower nasal concha are painful, and secondly, despite the local administration of an antibacterial drug, after a while it enters the systemic circulation. As a result of this, the metabolic function of the intestinal microflora is seriously affected, the trophism of the intestinal mucosa is impaired.

The objective of the invention is to develop a method for the treatment of patients with allergic rhinitis with a disturbed microbial landscape of the mucous membrane of the nasal cavity, which contributes to the disappearance of paroxysmal sneezing attacks, the termination of discharge from the nasal cavity, the complete restoration of nasal breathing and a significant improvement in the general condition of the patient for a long period of time.

The problem is solved due to the fact that the following differences are provided in the method of treating allergic rhinitis with a disturbed microbial landscape of the nasal mucosa, including elimination therapy, immunomodulating, antibacterial drugs, synbiotic and bacteriophage:

1) the proposed method is characterized in that, in contrast to the prototype, in the claimed invention, in addition to immunomodulating and antibacterial drugs, elimination therapy, the appointment of a synbiotic and bacteriophage are proposed;

2) the proposed method is characterized in that, in contrast to the prototype, the claimed invention proposes a three-stage treatment regimen for the patient: at the first stage, an immunomodulator of polyoxidonium is prescribed according to a certain scheme, in accordance with the changes in the immune system available to patients; on the second (from the fifth day from the start of taking polyoxidonium), antibacterial and elimination therapy is carried out in order to restore the normal microbial landscape of the nasal mucosa; on the third (from the eleventh day from the start of taking the antibiotic) - a synbiotic is prescribed orally and topically, a bacteriophage;

3) in addition, in the prototype, medicinal substances are introduced into the lower nasal concha. In the claimed invention, drugs are administered orally, exerting a systemic effect. In the prototype, the method of intraoral administration of medicinal substances combines the elements of reflex and pharmacotherapy, in the claimed invention only pharmacotherapy.

The essence of the proposed method is as follows: the patients underwent a thorough clinical examination, which consisted of a study of complaints, an anamnesis of the disease (identifying the seasonality of the disease, elucidating the etiological factors of deterioration of nasal breathing, the occurrence or intensification of symptoms of allergic rhinitis in direct contact with a particular allergen (contact with pollen, pet, aggravation when cleaning an apartment, connection with any professional factor, etc.), the presence or absence of eff elimination, the influence of weather factors, food, a change in the climatic zone, the presence of allergic diseases in immediate relatives - allergic rhinitis, atopic dermatitis, bronchial asthma, polypous rhinosinusitis; data of an objective examination of ENT organs with endoscopy, laboratory examination data (hemogram, immunogram , bacteriological examination of smears taken from the nasal cavity to identify pathogenic microflora and sensitivity to antibiotics); consultations of a therapist, immunologist, optometrist.

The course of treatment included the appointment of several groups of drugs when the patient is on outpatient treatment. The treatment was carried out according to a three-stage scheme: at the first stage, an immunomodulator of polyoxidonium was prescribed in tablet form, 12 mg 2 times a day, orally for 10 days according to scheme 1, 2, 4, 6, 8, 11, 14, 17, 20, 23 days, in accordance with existing changes in the immune system in patients. On the second (from the fifth day from the appointment of polyoxidonium) antibiotic and elimination therapy was carried out for 10 days in order to restore the normal microbial landscape of the nasal mucosa. The antibiotic was selected in accordance with the bacteriological examination of smears from the nasal cavity for pathogenic microflora and sensitivity to antibiotics. Elimination therapy was carried out with dolphin 2 times a day. The third stage (the day after the end of the course of antibacterial and elimination therapy) consisted in the appointment of a synbiotic maxylac orally 1 capsule per day for 20 days and a polyvalent bacteriophage 5 drops in each half of the nose 3 times a day - 14 days.

This method of treatment was used in 135 patients with perennial and seasonal allergic rhinitis complicated by a bacterial infection of the nasal cavity. The age of patients ranged from 18 to 68 years, of which 74 women (54.9%) and 61 men (45.1%).

Sensitization to plant pollen was observed in 28.3% of patients; to household allergens - in 31%; combined - in 40.7%. Bacteriological examination of smears taken from the nasal cavity showed that in patients with hay fever in 43% of cases Staphylococcus aureus was detected; in 24.4% - Staphylococcus epidermidis; 20.8% Streptococcus pyogenes; in 11.8% - Klebsiella; in patients with perennial rhinitis in 52.4% - Staphylococcus aureus; in 19.1% - Staphylococcus epidermidis; 17.3% Streptococcus pyogenes; in 11.2% - Klebsiella.

When considering the state of cellular immunity for patients with allergic rhinitis during the exacerbation period, a decrease in the number of total T-lymphocytes, a sharp decrease in the level of T-helpers and immunoregulatory index were characteristic. The remaining parameters of the lymphocytes practically did not change. Another feature of the immune status in allergic rhinitis is disimmunoglobulinemia (table 1). This fact suggests that allergic rhinitis occurs against a background of impaired control of immune functions.

Patients were treated according to the method described above.

Immunocorrection had a pronounced positive effect on the dynamics of immune parameters: the number of CD 3 and CD 4 lymphocytes increased significantly, reaching the level of normal values. As a result, the value of the immunoregulatory index increased and also approached the norm. The parameters of the immune status at the end of the course of treatment are within normal values.

Based on the results presented in Table 2, most patients showed improvement in general condition, complete restoration of nasal breathing, disappearance of watery or mucous secretions, sneezing attacks, full or partial restoration of smell. In some patients with conjunctivitis or chronic sinusitis, the symptoms disappeared. The lack of treatment effect was observed in 27.4% of patients.

Upon repeated examination 6 months after treatment, it was noted that the symptoms of allergic rhinitis significantly decreased, recovery occurred in 52 (38.5%) patients, improvement - in 46 (34.1%) patients, which practically did not affect the comfort of life.

Thus, the obtained results show that the inventive method of treating patients with allergic rhinitis with a disturbed microbial landscape of the nasal mucosa, which consists in the oral administration of an immunomodulator of polyoxidonium and an antibacterial drug along with the appointment of a synbiotic, bacteriophage and elimination therapy in comparison with analogues (use of intranasal injection of diphenhydramine with splenin with the simultaneous appointment of phonophoresis of hydrocortisone or emulsion "Zixorin" and the introduction of diprospan into the lower nasal concha) and the prototype (the introduction of antibacterial drugs and an immunomodulator of polyoxidonium 6 mg into the lower nasal concha) contributes to a more complete restoration of nasal breathing, partial or complete restoration of olfaction, reduction or disappearance of the intensity of paroxysmal sneezing, rhinorrhea, conjunctival manifestations and conjunctival manifestations chronic sinusitis and has a persistent therapeutic effect (table 3).

Example 1: Patient M., 47 years old (ambulatory card No. 201723105), went to the clinic complaining of difficulty in nasal breathing, periodic attacks of paroxysmal sneezing, profuse mucous discharge from the nose, and a decrease in smell. According to the patient, the manifestation of these signs of the disease has been observed over the past three years.

ENT status: anterior rhinoscopy - the lower nasal concha is edematous, with cyanotic spots of Voyachek, in the lumen of the nasal cavity the mucous discharge is large, the nasal septum along the midline is not deformed. Nasal breathing is difficult. After anemization (with a 0.1% solution of adrenaline hydrochloride) of the nasal mucosa - the mucous membrane is pale in color, nasal breathing improved slightly due to a slight reduction in the mucosa of the lower nasal concha. Otoscopy - AD et AS - the external auditory canals are wide, free, the tympanic membranes are gray, the identification marks are differentiated, the light cone is scattered on both sides. Pathology from the pharynx and larynx was not detected.

Additional diagnostic methods:

1) allergen-specific diagnosis (positive result of determination of sIgE for allergens Dermatophagoides pteronyssinus, Dermatophagoides farinae and birch);

2) a bacteriological examination of smears taken from the nasal cavity revealed Staph. aureus sensitive to azithromycin, amoxiclav, chloramphenicol, levofloxacin, ceftriaxone, ciprofloxacin;

3) immunodiagnostic methods (table 4).

Secondary immune deficiency was revealed for the T-cell link and the neutrophilic granulocyte system, disimmunoglobulinemia with a normal level of IgE and an increased level of cationic protein of eosinophils.

4) cytological examination of smears from the nasal cavity - the presence of neutrophils;

5) olfactometry - absence of a decrease in the sense of smell on both sides;

6) radiography of the paranasal sinuses - parietal thickening of the mucous membrane of both maxillary sinuses.

Diagnosed with persistent allergic rhinitis of moderate severity, sensitization to allergens Dermatophagoides pteronyssinus, Dermatophagoides farinae and birch.

The patient was treated according to the scheme:

Stage I: polyoxidonium 12 mg, 1 tablet 2 times a day - 10 days according to the scheme: 1, 2, 4, 6, 8, 11, 14, 17, 20, 23 days.

Stage II (from the fifth day from the appointment of polyoxidonium):

- levofloxacin 500 mg, 1 tablet per day - 10 days;

- Dolphin rinse your nose 2 times a day - 10 days;

Stage III (the day after the end of the course of antibacterial and elimination therapy):

- Maksilak 1 capsule per day with meals - 20 days;

- polyvalent bacteriophage of 5 drops in each half of the nose 3 times a day - 14 days.

At the end of the course of treatment, nasal breathing and smell were completely restored, there was a decrease in the intensity of paroxysmal sneezing and rhinorrhea attacks.

The parameters of the immune status are within normal values. Upon discharge from the clinic, the level of cationic protein of eosinophils is significantly lower than before treatment (table 5).

Example 2: Patient I., 38 years old (outpatient card No. 201858043), went to the clinic complaining of periodic dry, unproductive cough, nasal congestion, sneezing, and decreased sense of smell. The above symptoms worry for more than a year without a clear seasonality and provocative connection. Periodically takes mucolytics, decongestants - without a significant effect. An allergic history and heredity are not burdened. A dog lives at home for several years. Chronic diseases denied.

ENT status: anterior rhinoscopy - the lower nasal concha is moderately edematous, with cyanotic spots of Voyachek, in the lumen of the nasal cavity the mucous discharge is moderate, the nasal septum along the midline is not deformed. Nasal breathing is moderately difficult. After anemization (with a 0.1% solution of adrenaline hydrochloride) of the nasal mucosa - the mucous membrane is pale in color, nasal breathing improved slightly due to a slight reduction in the mucosa of the lower nasal concha. Otoscopy - AD et AS - the external auditory canals are wide, loose, the eardrum is gray, the identification marks are differentiated, the light cone is determined on both sides. Pathology from the pharynx and larynx was not detected.

Additional diagnostic methods:

1) allergen-specific diagnostics (positive result of determination of sIgE for dog dander allergens);

2) a bacteriological examination of smears taken from the nasal cavity revealed Strept. pyogenes sensitive to ampicillin, oxacillin, cefazolin;

3) immunodiagnostic methods (table 6).

Secondary immune deficiency was revealed for the T-cell link and the neutrophilic granulocyte system, disimmunoglobulinemia with a normal level of IgE and an increased level of cationic protein of eosinophils.

5) a cytological examination of smears and swabs from the nasal cavity revealed the presence of neutrophils;

6) olfactometry - a two-way reduction in smell;

7) radiography of the paranasal sinuses - parietal thickening of the mucous membrane of the right maxillary sinus, rounded formation in the alveolar bay on the right.

Diagnosed with persistent allergic rhinitis of moderate severity, sensitization to allergens dog dandruff. Cyst of the right maxillary sinus.

The patient was treated according to the scheme:

Stage I: polyoxidonium 12 mg, 1 tablet 2 times a day - 10 days according to the scheme: 1, 2, 4, 6, 8, 11, 14, 17, 20, 23 days.

Stage II (from the fifth day from the appointment of polyoxidonium):

- ampicillin 1.0 intramuscularly per day - 10 days;

- Dolphin rinse your nose 2 times a day - 10 days;

Stage III (the day after the end of the course of antibacterial and elimination therapy):

- Maksilak 1 capsule per day with meals - 20 days;

- polyvalent bacteriophage of 5 drops in each half of the nose 3 times a day - 14 days.

At the end of the course of treatment, nasal breathing and smell were completely restored, rhinorrhea and paroxysmal sneezing disappeared.

The parameters of the immune status are within normal values. Upon discharge from the clinic, the level of cationic protein of eosinophils is significantly lower than before treatment. When observing for 6 months, there was no relapse of symptoms, the cyst of the right maxillary sinus resolved, feeling good (table 7).

The presented values before and at the end of the treatment course differ significantly, according to the level of activity of CD cells, immunoglobulins, immunoregulatory index and cationic protein of eosinophils, the differences are significant among themselves, P <0.05

Claims (1)

A method of treating patients with allergic rhinitis with a disturbed microbial landscape of the nasal mucosa, consisting in conservative therapy, characterized by its three-stage implementation: at the first stage, an immunomodulator of polyoxidonium is prescribed in tablet form, 12 mg 2 times a day, orally for 10 days according to scheme 1, 2, 4, 6, 8, 11, 14, 17, 20, 23 days, in accordance with the changes in the immune system available to patients; at the second stage, from the fifth day from taking polyoxidonium, on the basis of a bacteriological study, taking into account the sensitivity, antibiotic therapy and elimination therapy with dolphin are administered 2 times a day for 10 days; on the third, after the end of the course of antibacterial and elimination therapy, a maxillac synbiotic is prescribed orally 1 capsule per day for 20 days and a polyvalent bacteriophage 5 drops in each half of the nose 3 times a day - 14 days.