Intranasal acupuncture 2023

Inspired by Liu et al 2023.[1]

INA – intranasal acupuncture
PAR – persistent allergic rhinitis
WM – western medicine (in this case – nasal steroid and antihistamine)
VAS – visual analogue scale
RQLQ – rhinoconjunctivitis quality of life questionnaire

key to acroyms

I first came across INA when a consultant ENT surgeon (a rhinologist) who had trained with the BMAS mentioned to me that he thought the point LI20 was more effective when he placed the needles from inside the nasal vestibule rather than through the skin just lateral to the ala nasi. He justified doing it with the phrase “Well I’m in there anyway” (…as a rhinologist).

I figured that despite a couple of stints in ENT, I was definitely not a rhinologist, and since the flora of the nasal vestibule often includes Staph aureus, I would stick to the more conventional route.

The second time I came across INA was at a conference in Japan. I was chairing a session on acupuncture for headache. As chair I presented first and then went on to demonstrate TrP needling for myofascial headache. Our subject was a male student who looked a bit like a young Buddhist monk. I apologised for what I was about to do and kept the dry needling to a minimum. All the remaining speakers were from different East Asian countries, and they all seemed to be competing with each other to see who could perform the most outrageous needling techniques. The speaker who followed me started the whole process by performing periosteal stimulation to the inferior turbinate of the poor student.

Anyway, this paper uses two points in the lateral wall of each nasal cavity – Neiyingxiang and Biqiu, which lie just above the inferior turbinate and middle turbinate respectively. The needles were inserted to a depth of 20mm and retained for 20 minutes every other day for 2 weeks. This treatment was compared with 2 weeks of nasal steroid and antihistamine, and the patients were followed up at 6 weeks. The trial was set in the ENT department of a hospital in Beijing and the needles were inserted during nasal endoscopy. 75mm needles were inserted into the mucosa parallel to the inferior and middle turbinates.

120 patients with persistent allergic rhinitis were randomised in a 2:1 ratio leaving 75 in the INA group and 38 in the WM group. So, 5 immediately dropped out from the INA group and 2 from the WM group. The INA group reduced to 70 at 2 weeks and 60 at 6 weeks, making a 25% dropout rate in total. The WM group was 35 at 2 weeks and 30 at 6 weeks, which was also a 25% dropout. On this basis, it is hard to argue that the INA was putting the patients off in any way.

The primary outcome was a VAS score for nasal symptoms. RQLQ was also measured as a secondary outcome. The results showed significant differences between groups after the first treatment and at 6 weeks follow-up, but absolutely no differences at 2 weeks (after the complete treatment course). INA was better initially, and WM was better at 6 weeks, although the clinical significance of the difference at follow-up is difficult to judge since it was only just over 3mm on a 100mm scale.

The bottom line is that INA has a much faster onset of action but requires ENT expertise and is clinically, but not statistically, non-inferior at 6 weeks. I cannot see this catching on in the West, but keen ENT clinicians with endoscopes might just consider a combination of INA at the initial assessment followed by a course of nasal steroids.

References

1          Liu L-L, Gong Z, Tang L, et al. A novel and alternative therapy for persistent allergic rhinitis via intranasal acupuncture: a randomized controlled trial. Eur Arch Otorhinolaryngol Published Online First: 9 January 2023. doi:10.1007/s00405-022-07793-x