Scholarly Journal of
Otolaryngology
DOI: 10.32474/SJO.2022.09.000310

Research Article

ISSN: 2641-1709

Statistical Study of the Effectiveness of EAT Treatment for
Chronic Epipharyngitis
Hirobumi Ito*
Department of ENT, Ito ENT Clinic, Japan*Corresponding Author: Hirobumi Ito, Department of ENT, Ito ENT Clinic, Japan
Received:

Published:

November 07, 2022

November 17, 2022

Abstract
Introduction: However, few studies have compared the outcomes of EAT to those of conventional blind epipharyngeal abrasive
therapy (B-spot therapy).
Subjects and Methods: EAT was performed on 546 patients with chronic epipharyngitis who visited our clinic between August
2018 and August 2019. A retrospective observational study was conducted on 55 of these cases that received a cure decision. As
evaluation indices, the bleeding score and the EAT score were used. Multiple regression analysis was used to see if a prognostic
indicator could be constructed using age, gender, disease duration, gross histology, EAT score, and bleeding score as evaluation
indices.

Results: Chronic epipharyngitis was more prevalent in middle-aged and elderly women, and Mf type was more prevalent in
women. After about 2 months of treatment, the cure case group showed improvement in subjective symptoms, and after about 4
months of treatment, the bleeding findings improved, and a cure decision was made. Multiple regression analysis revealed that the
Mf type had a shorter healing period, and the higher the EAT score at the initial visit, the more treatment sessions were required.
Tissue type and EAT score at the initial visit were thought to be factors influencing healing time.
Discussion: At the initial visit, tissue type and EAT score were beneficial prognostic indicators. It is critical to treat patients
based on changes in the bleeding and EAT scores.

Keywords: Chronic epipharyngitis; bleeding score; EAT score; prognostic indicators; multiple regression analysis
Abbreviations: EAT: Epipharyngeal Abrasive Therapy; NRS: Numerical Rating Scale

Introduction
Horiguchi et al. used blind epipharyngeal abrasive therapy(EAT) (B-spot therapy) for chronic epipharyngitis and reported
that symptoms improved after three months of treatment once or
twice a week [1]. The degree of improvement in subjective symptoms, the degree of improvement in bleeding findings during rubbing, etc. are used to determine treatment effectiveness. However,Copyright © All rights are reserved by Hirobumi Ito.

pain during rubbing varies greatly between individuals, and clear
diagnostic criteria for determining subjective symptoms and bleeding findings have yet to be developed. Currently, it is thought necessary to develop a cure diagnostic standard. Tanaka published astudy on endoscopic epipharyngeal abrasive therapy (EAT) combined with endoscopic diagnosis to improve diagnosis and cure1014

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rates [2]. Although the introduction of endoscopic diagnosis may
have increased the diagnosis rate of chronic epipharyngitis, there
are few reports on the outcomes of EAT treatment [3]. In this study,
bleeding findings were scored as a measure of other findings at
the time of EAT using the Numerical Rating Scale (NRS) EAT questionnaire, and the bleeding score (bleeding score) was defined as ameasure of subjective symptoms at the time of, and the total score
was used as a measure of subjective symptoms at the time of EAT.
The total score was calculated as the EAT score (EAT score). To clarify the cure criteria, the bleeding and EAT scores were used, andthe subjects were divided into three groups: cured cases, noncured
cases, and interrupted cases who withdrew during treatment. The
primary complaint, gender, age, disease duration, gross histologicalfeatures, EAT score, and the bleeding score were calculated, and thecharacteristics of each group were described. The effectiveness of
EAT treatment was also investigated in terms of treatment durationand number of treatments in the cured case group. Furthermore,
multiple regression analysis was performed to determine whether a prognostic indicator could be constructed from the evaluation
items used during the initial examination. This statistical study,
we believe, will be useful in clarifying the pathogenesis of chronic
epipharyngitis and improving the cure rate.

Subjects and Methods

The subjects were 546 patients (136 males, mean age 44.4 ±18.4 years; 410 females, mean age 52.1 ± 15.4 years; male to female
ratio 1:3.0) who visited our clinic between August 2018 and August
2019, diagnosed and treated as chronic epipharyngitis. Patientswere treated and followed up on for up to a year, and their age, gender, chief complaint, disease duration, EAT score, gross histomorphology, and bleeding score were all examined retrospectively ona chart basis using the method described below. Fifty-five patients(10 males, mean age 60.7 ± 16.5 years, 45 females, mean age 59.6
± 15.1 years, male to female ratio 1:4.5) were deemed cured using the criteria outlined below. In the non-core group, there were
314 patients (78 males, mean age 44.5 ± 18.7 years; 236 females,mean age 52.1 ± 14.9 years; male-female ratio 1:3.0) who could not
be judged to be cured during the observation period. There were
177 patients in the group of interrupted cases who withdrew during treatment (48 males, mean age 41.0 ± 16.9 years; 129 females,mean age 49.6 ± 15.7 years, male-female ratio 1:2.7). According toTomiyama’s diagnostic criteria [4], patients with acute nasopharyngitis who had been ill for less than one month were exempted fromthe current study based on the medical history questionnaire. Patients with chronic rhinosinusitis as the primary cause of posteriorrhinorrhea or allergic rhinitis as the primary cause of symptoms as
determined by sinus x-ray examination were also excluded from thestudy. The diagnosis and treatment of chronic epipharyngitis weremade using A band-limited optical endoscope system was used todiagnose and treat chronic epipharyngitis (Pentax EPK-i7000 video processor, VNL11-J10 video scope with a tip outer diameter of

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3.5 mm). The endoscopic diagnosis was made using Tanaka’s diagnostic criteria [2] during the initial examination and EAT was
performed. Nasal abrasion with Rutze swabs soaked in 1% zincchloride solution was used for EAT, followed by oral abrasion with
Zermach pharyngeal crimp cotton swabs. The hemorrhage findings
were assessed two-dimensionally in terms of the extent of the EATcaused hemorrhage area. The nasopharynx was divided into four
regions, with the center being the central fossa of the pharyngeal
tonsil. If the bleeding was discovered in three or four regions, it wasscored as severe bleeding (3 points), if the bleeding was discovered in two or more regions, it was scored as moderate bleeding (2points), if the bleeding was discovered in one region, it was scoredas mild bleeding (1 point), and if the bleeding was not discovered
even after rubbing, it was scored as no bleeding. No bleeding wasscored as 0 if there was no bleeding or barely blotting. The scoreobtained was used as the bleeding score. Bleeding scores were assessed at the initial examination and at approximately one-monthintervals during treatment [5].

Subjective symptoms were assessed using the EAT questionnaire in conjunction with the NRS. This questionnaire assessedboth local and general symptoms of chronic epipharyngitis. The
following symptoms were considered: posterior rhinorrhea (posterior rhinorrhea, etc.), nasopharyngeal irritation (abnormality,
headache, stiff shoulders, etc.), nasal symptoms (rhinorrhea, nasal
obstruction, nasal irritation, etc.), Eustachian tube symptoms (otorrhea, tinnitus, etc.), dizziness-related symptoms, voice-related
symptoms (hoarseness, voice disorder, etc.), laryngeal irritation
symptoms (cough, sore throat, etc.), sleep apnea-related symptoms
on a 6-point NRS scale (snoring The 10 gastrointestinal symptoms(gastric acid reflux, lethargy, etc.) and autonomic nervous system
symptoms (chronic fatigue, depression, etc.) were scored. The
following scores were used: 0 for no subjective symptoms, 1 forslightly or rarely bothering, 2 for a little or sometimes bothering,
3 for always bothering, 4 for fairly or almost always bothering but
tolerable, and 5 for very bothering and intolerable. The EAT score
was calculated by adding the scores from each group, yielding amaximum score of 50 points and a minimum of 0 points. The EATscore was assessed during the initial visit and at approximately
one-month intervals between treatments [5].
The time when both subjective symptoms and objective conclusions improved, i.e., when the bleeding score reached 0 and the EATscore was 10 or less, a defined cure. In terms of the gross histology
of chronic epipharyngitis, Mogi classified it into Mycoplasma pneumoniae type (Mp type) and Mycoplasma fermentans type (Mf type)
to Mycoplasma infection. Mycoplasma pneumoniae type (Mp type)
and Mycoplasma fermentans type (Mf type) are the two histologicaltypes [6]. In this study, we used Mogidate’s criteria to divide thegross histology into two histological types for evaluation: Mp type
and Mf type. Other gross histological features include canopy type,which is distinguished by edema and swelling of the mucosa near

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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the canopy, and Tornwaldt type, which is distinguished by crust formation and adhesion, as well as mucosal swelling primarily aroundthe site of Tornwaldt cyst development. Although the pathogenesis

Copyrights @ Hirobumi Itoof these types differs from that of the Mf and Mp types, they were
included in this study as subtypes of the Mf type (Figure 1).

Figure 1: Tissue type classification, photo a; Mf type, photo b; Mp type, photo c; canopy type, photo d; Tornwaldt type.
First, basic statistics for the chief complaint, sex, age, disease
duration, tissue type, EAT score at the initial visit, and bleedingscore at the initial visit were obtained for each case group to better understand the pathogenesis of chronic epipharyngitis. The
healed and unhealed case groups were compared using Fisher’s direct establishment test and unpaired t-test. The healed case group
was then divided into two tissue types, and basic statistics werecomputed. Unpaired t-tests were used to compare age, disease duration, and EAT scores between tissue types. The age was further
subdivided into three groups: under 40 years, 40–60 years, and 60
years or older. The disease time was stratified into three categories:
1 month to 4 months, 4 months to 1 year, and 1 year or more. The
first bleeding score was divided into four categories: 0–3 points.
Next, the efficacy of EAT treatment in the cured case group was assessed in terms of treatment duration and number of treatments
until the EAT score was 10 or less, the bleeding score was 0, andthe EAT score was 10 or less and the bleeding score was 0 or less(at the cure determination time). First, Spearman’s rank correlation coefficient for treatment duration and number of treatments
was calculated. The duration and number of treatments were thensubjected to repeated measures of ANOVA (rm-ANOVA). Multiple
comparisons were conducted using the Bonferroni method.
The frequency of treatment in the cured case group was thenexamined. Patients who visited the clinic more than twice a week
were classified as high-frequency, patients who visited once a week
were classified as intermediate-frequency, and patients who visitedthe clinic more than 2 weeks apart were classified as low-frequency. For each frequency group, a one-way analysis of variance (one-way ANOVA) was performed on the number of visits and the lengthof time between visits. Multiple comparisons were performed using
the Bonferroni method. Next, multiple regression analysis was performed to develop a prognostic indicator using the duration andnumber of visits until the patient was deemed cured as the objective variables. Based on the information available at the time of thefirst visit, gender, age, disease duration, tissue type, EAT score at thefirst visit, and bleeding score at the first visit were used as explanatory variables. Gender and tissue type were dummy variables on
the nominal scale. Gender was set to 0 for males and 1 for females.
The tissue type was set to 0 for Mp and 1 for Mf. Age was divided
into three categories: under 40 years, 40–60 years, and 60 years
and older. The duration of the disease was divided into three categories: 1 month to less than 4 months, 4 months to less than 1 year,
and more than 1 year. Multiple regression analysis was performedon all variables because there were no explanatory variables withstrong correlations in the correlation matrix table.
The healed case group was then subjected to Cox proportional
hazards regression analysis to investigate the effect of predictive
indicators related to the length of hospital visits preceding the healing decision. The analysis utilized gender, age group, disease duration, tissue type, EAT score at the initial visit, and bleeding scoreat the initial visit as covariates, using the healing decision as theevent. Kaplan-Meier curves were generated and analyzed to show
the length of hospital visits until the cure. Kaplan-Meier curves
were also generated and compared for each tissue type. The statistical software EZR version 2.6-2 was used for the analysis. A risk
rate of less than 5% was outlined as statistically significant. This

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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was a retrospective observational study that used existing data, nothuman samples. The study followed the Helsinki Declaration, andall patients provided oral and written informed consent. We tookcare to protect the subjects’ confidentiality when handling data andother materials related to the study, we did not include any information that could identify the subjects when publishing the study’s
results. The Ethics Committee approved the conduct of this study.
(Approval No. 20200625006 by the Ethics Committee of the Chiba
Prefecture Health Physicians Association).

Results

The most common initial complaint in all 546 patients wasposterior rhinorrhea (45.2%), followed by a sense of abnormality(14.1%), sore throat (7.5%), hoarseness (7.5%), and cough (4.2%).
Additionally, dizziness, tinnitus, otorrhea, stiff shoulders, headache,and general malaise were reported. The gender distribution of all
patients’ ages revealed that women were older than men at thetime of consultation. The Mf type had a higher average age at presentation than the Mp type (Figure 2). Among the 55 patients in the
cured group, the most common subjective symptoms were posterior rhinorrhea (43.3%), abnormality (14.9%), sore throat (7.1%),
nasal obstruction (5.8%), hoarseness (5.8%), headache (3.7%), andcough (3.4%). The distribution of chief complaints followed thesame pattern as the overall case group. Tissue types exhibited thesame distribution pattern as the overall case group. There were no
significant differences in gender, age, duration of illness, EAT scoreat the initial visit, or bleeding score at the initial visit between the
cured and non-healed groups, but Mf type was significantly morecommon in the cured group. When comparing ages by tissue type,the cured group had significantly older Mf and Mp types (Table 1).

Table 1: Patient background of the cured and noncured case groups.
All Cases (n=546)

Healed Cases(n=55)

Non-Healing Cases(n=314)

Discontinued Cases(n=177)

P -value Healing Cases _ vs _ Non-Healing
Cases

Sex
male

female

136
410

10

78

45

236

48

Age

129

a

0.946

b

mean

50.2 ± 16.5

59.8 ± 15.2

52.2 ± 16.2

mean

42.7 ± 75.7

45.6 ± 76.5

46.6 ± 78.7

34.9 ± 69.7

0.55

b

organization type
Mp type

303

17

178

108

0

a

0

b

69

0

0.802

b

range
range
male

14 - 90

1 - 48098

29 - 85

1 - 360
5

14 - 84

Disease Duration

1 - 4805947.3 ± 16.4

0.391

14 - 90

1 - 48034age39.2 ± 15.1

52.0 ± 15.3

40.0 ± 16.1

35.8 ± 12.2

age

45.9 ± 14.7

50.3 ± 16.9

45.6 ± 14.6

44.2 ± 14.6

FemaleMf type
male

205
243
38

12
38
5

119
138
19

74
14

1

a

a

age

58.1 ± 19.4

69.4 ± 13.6

58.3 ± 19.8

55.3 ± 19.8

0

b

age

58.3 ±13.5

63.0 ± 13.1

57.7 ± 13.0

EAT score at first visit

56.9 ± 14.4

0bmean ± sd

19.5 ± 8.7

17.0 ± 8.7

19.1 ± 8.2

Initial bleeding score21.2 ± 9.2

0.084

b

mean ± sd

2.62 ± 0.64

2.65 ± 0.58

2.65 ± 0.61

2.57 ± 0.70

0.985

b

female

205

33

117

55

Data display: mean ± SD; range (min-max).
P -value: a: Fisher’s exact test; b: unpaired t test
Mp type: Mycoplasma pneumoniae type; Mf type: Mycoplasma fermentans type.

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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Figure 2: Graph of the age distribution of overall gender and organization type.
For within-group comparison, the cured case group was divided into two tissue types, Mp type, and Mf type. There were no
statistically significant differences in disease duration, EAT score at
the first visit, or bleeding score at the first visit, but female Mf typepatients were significantly older (Table 2). Spearman’s rank correlation coefficients were calculated for the EAT score and bleedingscore based on treatment duration and number of treatments. The
test results revealed no significant difference in treatment duration(p = 0.415) and no correlation (r = 0.112). The number of treatments was significant at p < 0.001 with a correlation coefficient of r
= 0.441, denoting that the EAT and bleeding scores varied with thenumber of treatments. Table 3 displays the findings of an analysisof the treatment duration and the number of treatments required
until the EAT score was 10 or less, the bleeding score was 0, and the
EAT score was 10 or less and the bleeding score was 0 or less (atthe time of cure determination) in the cured case group. The EATscore improved the fastest during treatment, followed by the bleeding score and then the time of cure. The treatment period differedsignificantly between groups, according to rm-ANOVA. The numberof treatments was lowest until the EAT score improved, then the
bleeding score, and finally at the time of healing. The rm-ANOVA
revealed a significant difference between the EAT and bleedingscores, and between the EAT score and time of cure (Table 3).

Table 2: Patient background comparison by tissue type in the cured case group.
Mp type (n=17)

Mf type (n=38)

P-value

Organization TypeMale

5

Female12Male52.0±15.3

FemaleAge50.3±16.9

5

0.255

a

69.4±13.6

0.094

b

0.033

a

33
63.0±13.1

Age Category
<40

5

60≤

6

40-60
Mean ±SD

Range (min-max)

6
Disease Duration

40.9±64.7
1-240

Disease Duration Category

1424
47.7±82.0

0.767

b

1.000

a

1.0-360

6

14

12<

6

13

5

b

0

<4

4-12

0.011

11

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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EAT score at first visit
Mean±SD16.8±9.0

Range (min-max)

0-41

Initial Bleeding Category

17.4±8.0

0.841

b

0.521

a

0.900

b

9.0-41.0

0

0

0

2

3

10

2.82± 0.39

2.58±0.64

1

0

3

3

14

Mean ±SD

Data display: mean ± SD; range (min-max).
P -value: a: Fisher’s exact test; b: unpaired t test.

25

Table 3: Comparison of treatment duration and number of treatments until EAT score alone is cured, bleeding score alone is cured,and both EAT score, and bleeding score are cured.
①EAT Score②Bleeding Score③Healing Judgement

2.1±1.6

3.8±2.4

4.2±2.4

Duration of Treatment
Number of Treatment

11.4±12.6

Duration of Treatment (month± SD)

17.6±10.4

number of Treatments (times ±SD)

The frequency of treatment was examined in the cured casegroup. With cure as the outcome, the Kaplan-Meier curves werecreated and compared. The high-frequency group received treatment more frequently, followed by the intermediate-frequency
group, and finally the low- frequency group (Figure 3). On the frequency of visits until cure and the duration of visits until cure, aone-way ANOVA was performed. Multiple comparisons revealed
that patients who received treatment twice a week healed faster,
but there was no discernible difference between the intermediate-frequency group (once a week) and the low-frequency group(once every two weeks or more). The frequency of visits differedsignificantly between the high-frequency, intermediate-frequency,
and low-frequency groups. The more frequent the visits, the fasterthe healing time (Figure 4). Multiple regression analysis was done
to investigate the factors influencing the duration of clinic visits.
There were no explanatory variables found to be significantly related to healing time, and all VIFs were less than 10.0, indicating that

P-value① Vs ②① Vs ③② Vs ③

0.00

0.00

0.03

19.6±10.4

0.00

rm-ANOVA (Bonferroni).

0.00

0.10

multicollinearity was not an issue. When the explanatory variables
were entered and analyzed stepwise, a significant association for
the tissue type item was discovered. The analysis predicted that the
Mf type would heal more quickly. However, the adjusted coefficientof determination for degrees of freedom was 0.059, which was low,
and the model was deemed unfit (Table 4). At the time of the initial
visit, a multiple regression analysis was performed on the factors
influencing the number of hospital visits to cure in a group of cured
cases. There were no explanatory variables that were significantly
related to the number of hospital visits to cure, and all VIFs wereless than 10.0, indicating that multicollinearity was not an issue.
No explanatory variable was found to be significantly related to
the number of hospital visits. The analysis revealed that the EATscore at the first visit was related to the number of hospital visits. A
higher initial EAT score was expected to be associated with a higher
number of hospital visits (Table 5).

Table 4: Factors Influencing the Length of Hospital Visits to Cure in a Group of Cured Cases.
Variables

B

SE

β

t

P-valueintercept

5.787

2.026

0.000

2.856

0.006

-0.1930.554-0.3490.729

Sex-0.984

During the Disease-0.038Organization TypeAge

EAT Score at the first visit

Bleeding Score at first visit-1.1840.042-0.1210.887-0.157-1.1100.406-0.013-0.093

0.804
0.040
0.617

-0.226-0.052-1.473

0.149

1.041

-0.029-0.196

VIF

0.273

1.095

0.926

1.092

1.292

0.147

1.235

0.303

1.117

0.845

1.194

Variables

B

SE

t

P-valve

Intercept

5.235

0.574

9.113

0.000

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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Organization Type-1.4460.691-2.0920.043

Model Summary
Multiple R-squared

0.076

F-value

4.376

Adjusted R-squared

0.059

Degrees of Freedom

53

Multivariate Model: Significant Variables are entered using a stepwise method

B: partial regression coefficient; SE: Standard Error; β:standard partial regression coefficient; VIF: Variance Inflation Factor
Table 5: Factors Influencing the Number of Hospital Visits to Cure in a Group of Cured Cases.
Variables

B

SE

β

t

P-valueintercept

9.817

10.968

0.000

0.895

0.375

2.850

2.999

0.950

0.347

Sex

-0.237

During the Disease-0.960EAT Score at the first visit

0.309

Organization Type
Age

Bleeding Score at first visit-3.7894.799-0.007-0.0492.196-0.063-0.437

0.208

1.417

4.352
0.218

1.580

3.338

-0.1370.147-0.871

0.072

0.473

VIF

0.961

1.095

0.664

1.092

1.292

0.388

1.235

0.163

1.117

0.638

1.194

Variables

B

SE

t

P-valve

Intercept

14.296

3.799

3.763

0.000

Organization Type

0.313

0.200

1.508

0.120

Model Summary
Multiple R-squared

0.045

F-value

2.497

Adjusted R-squared
Degrees of Freedom

Multivariate Model: Significant Variables are entered using a stepwise method

0.027
53

B: partial regression coefficient; SE: Standard Error; β:standard partial regression coefficient; VIF: Variance Inflation Factor.

Figure 3: Kaplan-Meier curve to cure by frequency of visit (thick line: high-frequency group, thin line: medium frequency group,
dotted line: low-frequency group).

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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Figure 4: Frequency of visits comparison graph: length of visits, number of visits.
The Cox proportional hazards regression analysis was used toinvestigate the effect of predictive indicators on the number of hospital visits required to cure the group of cured cases. Gender, agegroup, disease duration, tissue type, EAT score at the first visit, andbleeding score at the first visit were used as covariates in the analysis, with cure as the event. The findings revealed an increase in sex,
age group, disease duration, tissue type, and bleeding score at theinitial visit all increased the hazard ratio, except an increase in the
EAT score at the initial visit, which decreased the hazard ratio. In
other words, having a higher EAT score at the first visit was associated with a longer healing time, whereas being female, older, having
a longer disease duration, having a Mf type tissue type, and having ahigher bleeding score at the first visit were associated with a fasterhealing time. There were no variables that independently affectedhealing time as a result of narrowing by P value in the multivariate model with forced entry, but Mf type tended to heal more easily
and a high EAT score tended to make it harder to heal (Table 6). A
Kaplan-Meier curve was created to depict the number of hospital
visits required to make a cure decision, with cure as the outcome.
For cured patients, the median survival time (MST, mean time tocure) for a 50% cure rate was 4 months. The average number ofvisits required to achieve a 50% cure rate was 16. The cumulative
cure rate rises rapidly in the early stages of treatment before stabilizing after 5 months. The MST for the two tissue types, Mp type,
and Mf type, was 5 months for the Mp type and 3 months for theMf type, according to the Kaplan- Meier curve. The Mf type healed
faster than the Mp type (Figure 5).

Figure 4: Frequency of visits comparison graph: length of visits, number of visits.

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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Table 6: Cox proportional hazards regression analysis of the impact of predictive indicators on the length of hospital visits leading
to a cure decision.
Hazard Ratio

95% of CT

P-value

Organization Type

1.54

0.75

to

3.11

0.23

During the Disease

1.13

0.79

to

1.63

0.51

Sex

Age

EAT Score at the first visit

Bleeding Score at first visit

1.50
1.16
0.98
1.18

0.64
0.75
0.95
0.71

to
to
to
to

3.52
1.80
1.01
1.99

0.35
0.51
0.25
0.52

Figure 5: Kaplan-Meier curve showing the length of hospital visits to cure with cure as the outcome.

Discussion
Chronic epipharyngitis has been linked to several diseases andmanifests itself in a variety of ways [1,6-8]. Tanaka that EAT canbe used to diagnose chronic epipharyngitis [2], but the criteria for
determining a cure are still unclear. Ohno reported the cure rate
based on EAT findings and the relative improvement of symptoms[3]. We performed a statistical analysis of the therapeutic effect of
EAT in this study by defining the cure judgment based on the absolute improvement of subjective symptoms and bleeding findings
at the time of abrasion by EAT and clarifying the judgment criteria.
We also investigated the feasibility of developing a prognostic indicator using the initial examination evaluation items. We believethat this research will help to clarify the pathogenesis of chronic
epipharyngitis and improve EAT cure rate. The average age of allchronic epipharyngitis patients who visited our hospital was 50.2
years, with a male to female ratio of 1:3. Ohno reported that the
average age of chronic epipharyngitis cases was 42.9 years, with amale to female ratio of 1:3, with a female bias [9]. Ohno reported
that 41.1% of patients had posterior rhinorrhea, 17.8% had abnormal pharyngeal sensations, and 8.2% had a sore throat. The chiefcomplaint and average age of patients with chronic epipharyngitis who visited our clinic for the first time were nearly identical tothose reported by Ohno. Therefore, the findings of this study may

represent the fundamental statistics of chronic epipharyngitis cases seen in general otolaryngology clinics.

First, there is a discussion of the subjective symptom evaluation method used in this study. Tomiyama described a scoring
system-based evaluation method for acute nasopharyngitis [4].
The degree of difficulty in daily living, sore throat, and fever werescored on a three-point scale of 0 to 2 points, and nasopharyngeal examination findings, such as redness and swelling of the nasopharyngeal mucosa and a thick plug of the nasopharynx, werescored on a three-point scale of 0 to 2. The study employed a NRS,
Numeric Scale. In this study, the NRS was used as a 6-point EAT
score to assess subjective symptoms caused by chronic epipharyngitis. Based on the incidence of subjective symptoms of chronic
epipharyngitis, the EAT questionnaire used was designed to createa scale to quantitatively evaluate changes in subjective symptoms
over time; inter-rater reproducibility of the NRS is said to be low,
but intra-rater reproducibility is high in the same examinee [10].
The NRS may be useful as a self-assessment tool in determining thetime course of symptoms. Because the visual analog scale (VAS) is
influenced by psychogenic factors and responses tend to be concentrated in the middle [11], the NRS was used as an evaluation
method in this study.
Ohno rated subjective symptoms on a 4-point scale before andCitation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
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after treatment. The degree of improvement of findings such as
redness, swelling, and posterior rhinorrhea of the nasopharyngeal
mucosa based on imaging records was graded on a 5-point scale(marked improvement, improvement, slight improvement, unchanged, and worsening). EAT was done once or twice a week, andevaluations were done after about 10 treatments. As a result, hereported a 79.5% improvement rate for the chief complaint and an
87.7% improvement rate for the local findings [3]. Ohno reported
each case’s relative improvement rate, whereas this study reported
each case’s absolute improvement rate. The cure criterion in thisstudy is a relatively simple method with the advantage of being able
to confirm that symptoms and findings have improved on the spot.
Horiguchi reported that the pain of EAT and local bleeding is crucial
in the diagnosis of chronic
epipharyngitis, but the bleeding findings and pain vary greatly from person to person, making determining the degree of inflammation difficult [1]. Saito compared changes in local pain andbleeding findings to those of nasopharyngeal mucosal epithelial
cell smear findings after B- spot therapy and discovered that thedegree of epithelial cell detachment in the nasopharynx shifted, indicating a close relationship with the local inflammatory state. He
reported that if the inflammation is reduced with abrasion therapy,
the detached mucosa regenerates quickly, within two weeks, andregenerates as normal mucosa in about one month at the latest[12]. Ide reported that pain from abrasion and epithelial cell detachment are parallel, but the degree of inflammation is not [13].
From the preceding, the degree of pain may reflect the degree of
exfoliation and nerve stimulation, but not necessarily the degree of
inflammation. For these reasons, we did not use pain as an evaluation method for the degree of inflammation in this study, but rather
subjective symptoms and hemorrhage findings during rubbing as
evaluation criteria for local inflammation.

Tanaka proposed EAT, and this method allows for observation and recording of the nasopharyngeal canopy and lateral wallwith moving and still images, which is insufficient in Horiguchi’s
blind EAT, and treatment can be performed under direct observation. This is expected to boost the healing rate. However, because
EAT is associated with a higher frequency of severe hemorrhage
than conventional methods, the treatment period may be extended. Bleeding findings were used as an evaluation method for othersensory findings in this study. Horiguchi et al. reported that blind
EAT (B-spot therapy) should be continued once or twice a week forabout 3 months [1], and the results obtained in this study showedthat when EAT was continued once a week in the cured case group,
subjective symptoms improved after the first 2 months of treatment and after about 4 months of treatment. The bleeding findings
improved after about 4 months of treatment, and the cure was determined after that, which was longer than that reported by Horiguchi et al. This could be because EAT allows for abrasion treatment to be performed on the inflammatory sites that remain in theconventional method, which takes longer for the mucosa to normalize and regenerate than the conventional method, thus prolonging

Copyrights @ Hirobumi Ito

the improvement of bleeding findings. The degree of bleeding at theinitial visit did not differ significantly between the healed and nonhealed case groups. The possibility of healing is thought to be higher when the tissue is thoroughly abraded and bled during the initial
treatment, but cases with less bleeding may not have sufficiently
abraded the inflammatory site, i.e., the inflammatory site may haveremained, or the tissue changes due to strong inflammation wereso severe that the patient did not bleed much due to severe circulatory disturbance. Because of the high degree of circulatory disturbance caused by the strong tissue changes caused by the strong
inflammation, the patient may not have bled much. Therefore, theseverity of the lesion may not have been determined solely basedon the bleeding findings at the initial visit. Because the bleedingscore at the initial visit and the change in bleeding findings after thestart of EAT (after the second EAT) may differ in what is evaluated,
it was thought that the cure rate of chronic epipharyngitis could
be improved by continuing with treatment while referring to improvement in subjective symptoms rather than focusing solely on
the bleeding findings.
Because it was discovered that the cured case group was distinguished by histological type,age, and gender, the histological type was investigated. Tissue
types were categorized according to Mogidate’s classification. Mogi
defined mycoplasmal infection’s basic pathogenesis as systemic microvasculitis and neuritis, and its relationship to chronic epipharyngitis. He reported that differences in the external histology of thenasopharynx are signs of local infection and circulatory disturbances of venous and lymphatic return [14]. All of the examined cases
and the non-healed cases tended toward the Mp type, whereas thehealed cases tended toward the Mf type. The Mp type was morecommon in males, while the Mf type was more common in females.
Mp type was more common in younger patients, whereas Mf typewas more common in middle-aged and elderly patients. Mp typepredominates in younger male patients, Mf type predominates in
middle-aged female patients, and Mf type predominates in healed
cases. Mf type patients have thinner mucosa, which can lead to submucosal vascular injury and hemorrhage. A comparison of the twogroups, however, revealed no difference in the amount of bleeding
between the Mp and Mf types. There is a type of chronic epipharyngitis known as the Thornwald type, in which crusts tend to adhere
primarily to the pharyngeal central fossa [15]. The Tornwald type isthought to be caused by secretory gland hyperfunction [16] in thelocal mucosa near the central fossa of the pharynx, or by secretion
accumulation due to secretory gland obstruction or local infection.
There is also a canalicular type which has significant mucosal edema and swelling near the nasopharyngeal canal. This type is basedon the circulatory disturbance caused by cerebrospinal fluid congestion in the cerebral basal region and can be caused by impaired
drainage of the nasopharyngeal venous and lymphatic systems orincreased excretion due to increased fluid movement from the local
capillaries to the interstitium, resulting in interstitial edema [17].
It is possible that the Tornwald and canalicular types have distinct

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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pathogenesis mechanisms and will need to be studied separately
in the future.

When the efficacy of EAT was investigated, it was discoveredthat the treatment duration and frequency did not differ significantly from that of conventional blind epipharyngeal abrasive therapy. When we examined whether the EAT score and bleeding score,
the existing assessment indexes, tended to correlate with the duration of treatment or the number of treatments, we discovered thatthey did. The results revealed that increasing the number of treatment sessions leads to improvements in subjective symptoms andobjective findings rather than extending the treatment duration toreach a cure decision. Because a longer treatment period is expected to increase the number of treatments, there is a possibility ofearly improvement even if the treatment period is short. Therefore,
we conducted a frequency analysis to investigate the frequency oftreatment. The frequency analysis revealed that patients who weretreated twice a week or more frequently in the early stages of treatment were more likely to be cured. It was thought that with a treatment frequency of once a week or less, the treatment period could
not be shortened and that the only way to shorten the treatment period was to increase the number of treatment sessions. This implies
that increasing the frequency of treatment in the early stages, i.e.,high-frequency treatment in the early stages will result in a shorter
treatment period.

Next, we investigated the possibility of developing a predictive index based on findings at the initial visit, and the results of
Kaplan-Meier curves and multiple regression analysis revealed that
Mf type patients tended to heal faster and that the higher the EATscore at the initial visit (the stronger the subjective symptoms), themore frequent the number of hospital visits. A Cox proportional
hazards regression analysis using the healing decision as the event
revealed that a higher EAT score at the initial visit tended to result in delayed healing, whereas being female, being older, having
a longer disease duration, having a Mf type tissue type, and having
a higher bleeding score at the initial visit tended to result in fasterhealing. According to basic statistics, middle-aged and older women with Mf type and large bleeding tended to heal quickly, whereas
younger men with Mf type and strong subjective symptoms tended
to heal less easily. Treatment based on tissue type and EAT score at
the time of initial diagnosis may be beneficial in improving the curerate. Furthermore, it is thought necessary to increase the number ofhospital visits (increase the number of EAT procedures) in the earlystages of treatment to improve subjective symptoms as early on.

Chronic epipharyngitis has been linked to a variety of pathogenesis mechanisms and symptoms. There are no standardized
diagnostic criteria or treatment evaluation methods for chronic
epipharyngitis currently. Although the information obtained fromthe basic statistic data obtained in this study has limitations, thepredictive indices used are methods for which information is readily available and relatively easy to evaluate. With the understandingthat the EAT and bleeding scores do not accurately assess subjective

Copyrights @ Hirobumi Itosymptoms or other findings, it is important to use the basic statistic as a reference to understand the pathophysiology of the disease
and to determine a treatment strategy for the patient. The current
study was conducted in the hope that providing predictive indiceswould benefit patients. The current study was a retrospective observational study, and no chronic epipharyngitis cases without EAT
were used as controls. A prospective cohort study is considerednecessary for future validation.

Conclusion

Chronic epipharyngitis is more common in middle-aged and elderly women, and the Mf type is also more common in women. In
the healed case group, subjective symptoms improved after approximately two months of treatment with continuous weekly abrasion
therapy, and bleeding findings improved after approximately fourmonths of treatment, and the patient was determined to be cured.
Increasing the number of treatment sessions rather than extending
the treatment period leads to improvements in subjective symptoms and objective findings to reach a cure decision. To improve thecure rate, it was considered effective to provide treatment more frequently than twice a week in the early stages of treatment. Multiple
regression analysis revealed that the Mf type had a shorter healing
period, and the higher the EAT score at the initial visit, the more frequently treatment was administered. Tissue type and EAT score at
the initial visit were thought to be factors influencing healing time.

Acknowledgements

We would like to express our sincere gratitude to Dr. Manabu
Mogitate, Director of Mogitate Otorhinolaryngology, for his guidance and great advice during his busy schedule.

Appendix

The abstract of this paper was presented at the 33rd Annual
Meeting of the Japanese Society of Oral and Maxillofacial Surgery. I
have no conflicts of interest to disclose regarding this paper.

References

1. Horiguchi S (1966) Systemic diseases and otorhinolaryngology, withspecial reference to nasopharyngitis. Nihon Jibiinkoka Gakkai Kaiho(Supplement 1): 1-78.

2. Tanaka A (2018) Studies on band-limited light endoscopic diagnosis andendoscopic epipharyngeal abrasive therapy in chronic epipharyngitis.
Stomato-Pharyngology 31(1): 57- 67.
3. Ohno Y (2021) Classification of severity of chronic epipharyngitis andefficacy of epipharyngeal abrasive therapy. Stomato-Pharyngology
34(2): 163-172.
4. Tomiyama M (2016) Treatment course of adult patients with severe
acute nasopharyngitis treated with garenoxacin -A study using a scoring
system - Nihon Jibiinkoka Gakkai Kaiho 62: 92-100.

5. Ito H (2022) Effect of epipharyngeal abrasive therapy on long COVID
with chronic epipharyngitis. Sch J Oto 8(5): 939-946.

6. Mogitate M (2018) Chronic epipharyngitis and mycoplasma infection,
Effect of Epipharyngeal Abrasive Therapy (EAT: Epipharyngeal Abrasive
Therapy). Nihon Jibiinkoka Gakkai Kaiho 121(4): 575-576.

Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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7. Hotta O, Nagano C (2018) Consideration of various conditions suggested
being associated with chronic epipharyngitis and epipharyngeal
abrasive therapy. Stomato-Pharyngeal 31(1): 69-75.

8. Mogitate M (2022) Epipharyngeal abrasive therapy for patients withimmunoglobulin A nephropathy: a retrospective study. Sch J Oto 8(3):874-881.
9. Ohno Y (2019) Effectiveness of epipharyngeal abrasive therapy forchronic epipharyngitis. Stomato-Pharyngology 32(19): 33-39.
10. David L, Kihara M. Kaji M, Kihara M (2016) Translation theories andapplications of medical measurement scales: from validity and reliability
to G-theory and item response theory. Medical Science International,
Tokyo, Japan.

11. Yamagiwa M, Sakakura Y (1994) Intensity of abnormal pharyngeal
sensation evaluated by Visual Analogue Scale (VAS) and its influencing
factors. Nihon Jibiinkoka Gakkai Kaiho 97: 67-74.
12. Saito Y (1963) Clinical and cytological studies on the healing process ofnasopharyngitis. Nihon Jibiinkoka Gakkai Kaiho 66(6): 814-828.

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13. Ide Y (1964) Smear cytological picture of nasopharyngitis, with specialreference to the relationship between the pain to the touch and theepithelial picture of the hairline. Nihon Jibiinkoka Gakkai Kaiho 67(2):153-158.
14. Mogitate M, Matuda K (2017) A study on the clinical significance of
mycoplasma lipid antigen-antibody assay in patients with chronic
epipharyngitis. Stomato-Pharyngology 30(3): 444.
15. Tasaka Y (1994) Nasopharyngeal cysts. Nihon Jibiinkoka Gakkai Kaiho
40: 109-113.

16. Valstar MH, de Bakker BS, Steenbakkers RJHM, de Jong KH Smit LA, Klein
Nulent TJW, et al. (2020) The tubarial salivary glands: a potential neworgan at risk. Radiother Oncol 154: 292-298.

17. Uebaba K (2017) A study on the mechanism of action of stabbing
therapy Part 1: “Venous circulatory system hub hypothesis” and “venous
congestive pain hypothesis”. Eastern Med 33(1): 63-77.

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Citation: Hirobumi Ito*. Statistical Study of the Effectiveness of EAT Treatment for Chronic Epipharyngitis. Sch J Oto. 9(3)-2022. SJO.
MS.ID.000311. DOI: 10.32474/SJO.2022.09.000311

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