Scholarly Journal of
Otolaryngology
DOI: 10.32474/SJO.2022.08.000300

Research Article

ISSN: 2641-1709

Effect of Epipharyngeal Abrasive Therapy on Long COVID
with Chronic Epipharyngitis
Hirobumi Ito*
Department of ENT, Ito ENT Clinic, Japan*Corresponding Author: Hirobumi Ito, Ito ENT Clinic, 4-13-3 Yatsuya Headquarters Building 3rd Floor, Maebarahigashi, Funabashi
City, Chiba Prefecture 274-0824, Japan
Received:

Published:

September 06, 2022

September 16, 2022

Abstract
Introduction: Currently, there is no established treatment for Long COVID (LC), but epipharyngeal abrasive therapy (EAT)
has been reported to be useful in cases of complicated chronic epipharyngitis. In this study, we performed EAT on LC patients withchronic epipharyngitis and investigated the effects of EAT on subjective symptoms, examination findings, and autonomic nervous
system function.
Methods: Epipharyngeal abrasive therapy (EAT) was performed on 31 patients with Long COVID with chronic epipharyngitis.
We recorded changes in subjective symptoms using the EAT score and changes in bleeding during abrasion using the bleeding score.
Heart rate variability analysis was performed before and after treatment to assess autonomic function.

Results: Bleeding and EAT scores improved significantly over time (p < 0.01), but the autonomic function test did not show any
significant improvement. Noting that, the EAT score improved earlier than the bleeding score did.
Conclusions: Assuming that the improvement in autonomic function would take time, we consider EAT to be a useful treatment
for patients with LC who have chronic epipharyngitis.

Keywords: long COVID; EAT; EAT score; bleeding score; heart rate variability analysis

Abbreviations: PVFS: Post Viral Fatigue Syndrome; LC: long COVID; ME/CFS: Myalgic Encephalomyelitis/Chronic Fatigue
Syndrome; EAT: Epipharyngeal Abrasive Therapy

Introduction
Post viral fatigue syndrome (PVFS) is a long-standing syndromein which patients suffer from the following conditions: low-grade
fever, headache, weakness, impaired thinking, and neuropsychiatric
symptoms such as depression [1]. Particular signs, including
respiratory distress, malaise, olfactory and taste disturbance, hairloss, headache, and poor concentration, may persist for several
months or longer after COVID-19 infection; such manifestations arereported as long COVID (LC) [2]. LC can cause a variety of prolonged
symptoms not only in the respiratory tract but also in cranial nerves
and other areas [3]. Myalgic encephalomyelitis/chronic fatigue

Copyright © All rights are reserved by Hirobumi Ito.

syndrome (ME/CFS), a condition based on the modulation of thenervous, endocrine, and immune systems, is a brain dysfunction
caused by various cytokines induced by viral reactivation andchronic infection [4]. Its pathogenesis is believed to be related togenetic and environmental factors, including physical and mental
distress [5].

Outbreaks of ME/CFS have historically, occurred after viraldiseases epidemics; thus, it is feared that an increase in COVID-19
might result in a rise in the occurrence of ME/CFS in the future [6].
Epipharyngeal abrasive therapy (EAT) is generally used to cure939

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Volume 8 - Issue 5chronic epipharyngitis [7], which is common in LC. In this context,
many studies have reported the effectiveness of EAT as a treatment
for LC [8,9]. Moreover, EAT has been reported to be effective intreating ME/CFS [10]. Therefore, it may be worthwhile to preventthe onset of ME/CFS through the application of EAT in patientswith LC with chronic epipharyngitis. Until now, there has been
no established treatment for LC. In this study, we performed EAT
on patients with LC with chronic epipharyngitis and investigatedthe effects of EAT on subjective symptoms, objective findings, andautonomic function tests. Because of persistent COVID-19 infection
worldwide, the number of LC cases is expected to continue toincrease. Therefore, we believe there is an urgent need to elucidate
the pathogenesis of LC and establish effective evaluation andtreatment methods.

Materials and Methods

Patients with COVID-19 infection confirmed via polymerase
chain reaction testing, complaining of abnormal nasopharyngeal
sensation and posterior rhinorrhea, after at least 1 month of illness
onset, were referred to our hospital for examination between May
and September 2021. These patients were diagnosed with LC
with residual symptoms of autonomic neuropathy such as fatigue,
breathlessness, and light headedness. A total of 31 patients were
included (14 males, 40.6 ± 7.6 years old, mean duration of disease
3.4 ± 2.8 months; 17 females, 39.6 ± 11.9 years old, mean durationof disease 3.2 ± 2.6 months). We identified 29 patients (13 males
and 16 females) with chronic epipharyngitis according to Tanaka’s

Copyrights @ Hirobumi Itodiagnostic criteria [11]. We evaluated these patients using the EAT
questionnaire and hemorrhage findings during abrasion. We also
evaluated 10 patients (3 males, 46.3 ± 10.5 years old, mean disease
duration 5.0 ± 1.4 months; 7 females, 34.8 ± 14.1 years old, meandisease duration 2.7 ± 2.4 months) for autonomic function at the
beginning of and during the treatment period.
We diagnosed and treated chronic epipharyngitis using aband-limited optical endoscope system (Pentax EPK-i7000 video
processor, VNL11-J10 video scope with a 3.5-mm outer-diameter
tip). We treated EAT via nasal abrasion using a Lutze cotton swab
moistened with 1% zinc chloride solution, followed by oral abrasion
with a Zermach pharyngeal crimp (Figure 1). We evaluated thepatients’ subjective symptoms using the EAT questionnaire basedon the numerical rating scale (NRS; Table 1). This questionnaire
assesses local and general symptoms related to chronic
epipharyngitis as follows: posterior rhinorrhea, nasopharyngeal
irritation (abnormal pharynx, headache, stiff neck, etc.), nasalrelated symptoms (rhinorrhea, nasal obstruction, nasal irritation,etc.), Eustachian tube–related symptoms (otal obstruction, tinnitus,etc.), dizziness, voice-related symptoms (hoarseness, voice disorder,etc.), laryngeal irritation (cough, sore throat, etc.), and sleep apnea.
We rated the following 10 items on a 6-point NRS scale: snoring,insomnia, daytime somnolence, gastrointestinal symptoms (acidreflux, heartburn, lethargy, etc.), and autonomic nervous system
symptoms (fatigue, chronic fatigue, depression, etc.). The following
scores were assigned to each item:

Figure 1: EAT treated by nasal abrasion with a Lutze swab soaked in 1% zinc chloride solution followed by oral abrasion
with a Zermac pharyngeal crimp.
Table 1: Evaluation of subjective symptoms using the EAT questionnaire scored on a 6-point NRS scale. NRS: numerical rating scale.
EAT Questionnaire

Severity of Symptoms

Q1: Postnasal drip symptoms (postnasal drip, rhinorrhea, etc.)

Q2: Epipharyngeal irritation symptoms (irritated throat, headache, stiff neck, etc.)
Q3: Nose-related symptoms (rhinorrhea, nasal congestion, nasal irritation, etc.)

Q4: Eustachian tube-related symptoms (aural fullness, hearing loss, tinnitus, etc.)
Q5: Vertigo-related symptoms (dizziness, light-headedness, etc.)

Q6: Voice-related symptoms (hoarseness, voice disturbances, etc.)

Q7: Laryngeal irritation symptoms (cough, sore throat, laryngeal discomfort, etc.)

Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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Volume 8 - Issue 5

Copyrights @ Hirobumi Ito

Q8: Sleep apnea related symptoms (snoring, insomnia, daytime somnolence, etc.)
Q9: Gastrointestinal symptoms (acid reflux, heartburn, heavy stomach, etc.)

Q10: Autonomic symptoms (fatigue, chronic fatigue, brain fog, depressive symptoms, etc.)

Numerical Rating Scale (NRS)

Total Score

0: Condition without subjective symptoms
1: Slightly/rarely concerned
2: A little/sometimes worrying
3: always sorry
4: Quite/almost bothers me, but I can put up with it
5: I’m so worried I can’t stand it.
a)

0 = no subjective symptoms,c)

2 = sometimes bothering,

b)
d)
e)
f)

1 = slightly bothering,
3 = always bothering,

4 = fairly bothering but tolerable, and

5 = extremely bothering and intolerable.

We computed the EAT score by summing the scores ofeach group with a range of 0–50 points. We defined the time ofsubjective symptom improvement as when the symptoms become
absent or slightly bothersome (i.e., when the EAT score reached ≤10 points). Using endoscopic observation as an objective finding,we evaluated bleeding from the epipharyngeal mucosa at the timeof abrasion. In general, bleeding is evaluated based on the degree ofblood adherence to a cotton swab, but this method is not objective
due to different adopted techniques and skills [11]. For this reason,
quantitative evaluation of the degree of bleeding is considered
to be difficult [12]. However, in this study, we evaluated the area
spread of the bleeding site caused by abrasion in two dimensions.
The epipharynx was subdivided into four (left, right, upper, andlower) centered with the central fossa of the pharyngeal tonsil.
The bleeding score (0–3 points) was calculated from the obtained
bleeding findings, with 3 points for severe bleeding, 2 points formoderate bleeding, 1 point for mild bleeding, and 0 points forno bleeding or barely blotting (Figure 2). We defined the time of
improvement of other sensory findings as when the bleeding score
improved to 0 (Figure 2).

Figure 2: Nasopharynx divided into four regions (left, right, upper, and lower) centering on the central fossa of thepharyngeal tonsil. The area of hemorrhage caused by EAT is evaluated two-dimensionally.
We performed autonomic function tests via heart rate variability
analysis of autonomic reflexes induced by orthostatic stress using
KIRITSU MEIJIN software for analysis (Crosswell Inc.). We evaluatedthe autonomic function for the following six items: high frequency(HF), low frequency (LF)/HF ratio (L/H), ⊿L/H, coefficient ofvariation on the R-R interval (CVRR), ⊿CVRR, and Kiritsu Master(KM) score [13]. Although heart rate is affected by respiration andcirculation, periodic fluctuations occur in the electrocardiogram R-R
interval. These fluctuations are divided into two components basedon frequency analysis: HF (0.15–0.40 Hz) and LF (0.04–0.15 Hz).
The HF component mainly reflects parasympathetic function andis used as an indicator of parasympathetic stress resilience whenseated or at rest. Because the LF component reflects sympathetic

and parasympathetic functions, L/H is used as an index of thedegree of tension in the sympathetic nervous system, whereas⊿L/H (increase in L/H compared with sitting and standing) is used
as an index of the stress detection power of the sympathetic reflexes(sympathetic switching power). The autonomic activity measured
with CVRR is an aggregate of the components of frequency analysis
results (HF, LF, etc.) and is used as an index of the sum of autonomic
activities. ⊿ CVRR (increase in CVRR compared between sitting
and standing) is used as an index of stress reactivity of autonomic
nerve activity. Using the measured values of these five items, we
calculated the KM score and used it as an evaluation index of total
autonomic function.

Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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Sch J Oto

Volume 8 - Issue 5

We evaluated the EAT and bleeding scores at the time of theinitial examination and at intervals of approximately 1 month
between treatment periods. Changes in each score were analyzed
statistically using repeated measures (rm) analysis of variance(ANOVA). Of the 29 patients treated, we evaluated the durationand number of treatments for 24 patients; 5 patients dropped
out of the study after the first treatment. The EAT score improvedin 13 patients, hemorrhage score improved in 15 patients, andboth scores improved in 11 patients. We used one-way ANOVA tocompare the following three groups: improvement in EAT score,
improvement in bleeding score, and improvement in both EAT andbleeding scores. In addition, we performed multiple comparisonsusing the Bonferroni method. We evaluated the five autonomic
function assessment items and the KM score at the beginning of
the EAT treatment and at least 1 month after. A paired t test wasused to analyze the results. We performed statistical analyses using
the statistical analysis software EZR version 2.6-2. Significancewas considered at p < 0.05. We conducted the retrospective
observational study, based on existing medical record information,in accordance with the Declaration of Helsinki. All subjects provided
verbal and written informed consent. Neither new samples nor
data were added to the analysis.

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Results
Table 2 presents the main complaints of the 31 LC patients,
which were chronic fatigue (n = 13), olfactory dysfunction (n = 7),
nasal obstruction (n = 2), posterior rhinorrhea (n = 2), headache(n = 2), sore throat (n = 1), abnormal sensation (n = 1), cough (n= 1), and respiratory distress (n = 1). Of the 31 LC patients who
underwent EAT, 29 (93.5%) had chronic epipharyngitis (Table 2).
Figure 3 shows the results of EAT scores by rm-ANOVA; we detectedsignificant decreases in the EAT score between the first visit andthe first evaluation and between the first visit and the second
evaluation (p < 0.01). The mean EAT score, which was 14.9 at thefirst visit, improved to 11.3 at the second evaluation and to 9.3 at
the third evaluation, which is considered as slightly worrisome(Figure 3). Figure 4 displays the results of the rm-ANOVA analysisof the bleeding score. We detected significant decreases in bleedingscore between the first visit and the first evaluation, between thefirst visit and the second evaluation, and between the first visit andthe third evaluation (p < 0.01). The mean bleeding score was 2.1 at
the first visit and improved to 1.0 at the first evaluation, to 0.6 at thesecond evaluation, and to almost no bleeding at the third evaluation
for the total cases (Figure 4). The trend of improvement in bleedingscore tended to be steeper than that of the EAT score.

Figure 3: EAT score improvement with treatment.

Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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Figure 4: Bleeding score improvement with treatment.
Table 2: Characteristics of the 31 LC cases.
Characteristics of Patients: Long COVID 31 Cases
Age

Mean Age
Mean Age

Mean Disease Duration

SD: Standard Deviation

Range

Sex

Mean (SD)n (%)

Mean (SD)
Mean (SD)Using one-way ANOVA, we analyzed the duration and numberof treatments among the three groups (Table 3) and detected nosignificant difference; the numbers of treatments required to
improve the EAT and the bleeding scores were almost the same
(16.4 ± 9.2 to 16.5 ± 11.5). With regard to the duration of treatment,
the EAT score improved faster than the bleeding score did (1.8 ±1.1 to 2.6 ± 1.7). Nevertheless, both scores required more time
(3.1 ± 2.0) and frequency (19.3 ± 11.0) to improve. The results
suggest that the improvement in subjective symptoms precedesthat of objective findings. Of the 29 patients, 10 patients underwent
autonomic function tests (Figure 5). The main complaints werechronic fatigue (n= 4), olfactory dysfunction (n= 3), sore throat (n

Years
Years
Years

months

17-57

Male

40.1 (10.1)

14 (45.2)

40.6 (7.6)
3.4 (2.8)

Female17 (54.8)

39.6 (11.9)
3.2 (2.6)= 1), headache (n = 1), and dyspnea (n = 1). The average durationof treatment until the second examination was 1.5 ± 0.5 months,
while the average number of treatments was 11.0 ± 5.6 times.
No significant differences were detected at any of the endpoints.
However, the sum of autonomic activity CVRR, sympathetic activity
L/H, and sympathetic switching power ⊿L/H showed an increasing
trend, whereas parasympathetic activity HF and stress reactivityof autonomic activity ⊿CVRR showed a decreasing trend. The KM
score increased; the mean score was 5.45 for the first visit, which
improved to 5.9 at the second visit. Consequently, autonomic
function tends to improve with EAT.

Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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Figure 5: Comparison of the autonomic function in 10 cases.
Table 3: Statistical comparison of the three groups. Comparison of the duration and number of treatments in the three groups. The
frequency of treatment was almost the same for the improvement in the EAT and bleeding scores. With regard to treatment duration,
the EAT score improved earlier. Both scores took time and number of times to improve.
Comparison of the treatment duration and number of treatments
EAT Score
duration of treatment
number of treatment

Monthstimes

1.8 (1.1)

16.4 (9.2)

Bleeding Score
2.6 (1.7)

16.5 (11.5)

Mean: Standard Deviation; one-way ANOVA: Bonferroni; NS: Not Significant

Discussion
PVFS is considered to be one of the causes of ME/CFS thatmanifests as symptoms of autonomic dysfunction [6]. Because LC isalso considered to be a form of PVFS [1], the prevalence of ME/CFS
caused by COVID-19 infection is expected to increase in the future. In
this study, we performed EAT on patients with LC who had chronic
epipharyngitis, analyzed its therapeutic effect, and discussed its
mechanism of action. The examined patients had mean disease
duration of 3.5 ± 2.5 months before their visit. The groups of cases
included in this study were considered to be primarily infectedwith the delta strains of COVID, which, as compared with the alphastrains, tend to cause less olfactory and taste disturbance and more
symptoms such as fatigue, brain fog, poor concentration, and poor
memory [14]. Even after recovery from COVID-19 infection, 61% of

EAT Score and Bleeding Score

One-way ANOVA

3.1 (2.0)

NS

19.3 (11.0)

NS

patients are reported to have persistent symptoms after an averageof 6 months [15]. It is expected that further cases of LC are likely
to develop ME/CFS. COVID-19 infects vascular endothelial cells via
angiotensin-converting enzyme 2, causing thrombosis and vascular
injuries and resulting in dysfunction of various organs [16,17]. The
sequelae, such as shortness of breath and dyspnea after pneumonia,
are caused by organic damage of the lungs, but various neurologic
symptoms are also observed, even in mild cases of COVID-19.
The neuropathic manifestations of LC are thought to be caused
by a combination of factors, including direct damage to the cerebral
vascular endothelial cells and the possibility of neurodegenerative
disease–like changes due to immune dysregulation after infection.
In this study, all LC cases were mild with no required hospitalizationor other treatment but with high complication rate of chronic

Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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epipharyngitis (93.5%), which is thought to induce excretionof cerebral metabolites, resulting in autonomic neuropathy andbrain dysfunction [18]. The improvement in LC cases by EAT may
be attributed to improvement in the cerebral microcirculation by
EAT’s action of scraping and phlebotomy of the pathological mucosaof the nasopharynx and to the improvement in brain function by
its autonomic nerve–stimulating action. Ohno reported an overall
improvement rate of 86.8% and a 60.3% increase in local findings inpatients with common chronic nasopharyngitis after ≥ 10 sessions
of EAT once or twice per week [19]. Alternatively, Mogitate et al.
reported that EAT performed at least once per week for 12 weeks
resulted in improvement in urinary protein and urinary occult
blood [20]. Analysis of the treatment courses of EAT and bleedingscores showed a gradual improvement in subjective symptoms but
an improvement of the objective findings at an early stage. This
results shows that subjective symptoms, such as autonomic andbrain dysfunction, require more time to improve, whereas otherfindings such as nasopharyngeal mucosa and lymphatic congestion
by EAT begin to improve in the early stage of treatment. Finally,
we found that about 20 treatments over 3 months were required
to improve both subjective symptoms and objective findings. Longterm treatment is considered necessary to improve autonomic andbrain dysfunction [21].
In the present study, we performed a comparative evaluationof autonomic function after nearly 11 treatment sessions overa period of about 1.5 months, with no significant differences.
Comparison between the hemorrhage and EAT scores suggeststhat the evaluation was performed while the patient had not
yet improved in terms of other sensory findings and subjective
symptoms. Harada reported that nasopharyngeal stimulation
calmed the autonomic symptoms and normalized the vasomotorreflexes [22]. In this study, we observed changes in autonomic
function with no significant differences. However, autonomic andsympathetic nerve and reflex activities showed an increasing trend,
whereas parasympathetic nerve and autonomic reflex activities
showed a suppressing trend. In other words, sympathetic function
was improved by EAT, and patients were able to respond normallyto stimuli, whereas parasympathetic activity was suppressed with
the improvement of chronic epipharyngitis. Using the KM score,
which can evaluate overall autonomic function, six patients showeda tendency to improve, whereas four did not. This might be due tothe differences in severity of illness and individual differences inautonomic response patterns.

In this study, we did not conduct a comparison with a control
group of LC patients who did not receive EAT. However, considering
the unclear spontaneous cure rate of LC and that some LC patients
continue to have symptoms for more than 6 months with no clear
effective treatment for LC, it is highly worthwhile to actively try
EAT, which can be performed both safely and noninvasively, forpatients with LC who have chronic epipharyngitis. Preventing
infections with techniques such as nasal gargling is the mostimportant factor in avoiding LC. Until now, there has been no
established procedure to prevent or treat the sequelae of LC, but

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the results of this study suggest that EAT may be useful for patientswith chronic epipharyngitis who have LC. LC, which is associatedwith medical, social, and economic issues, requires an urgent
solution for prevention and treatment. One problem of EAT is thehigh dropout rate; in this study, 5 of 29 patients (17.2%) stopped
coming to the hospital after their first EAT treatment. Based on
their estimated age range, many adult patients wanted to return towork as soon as possible, even if they were not completely cured,and treatment and evaluation were therefore incomplete. Although
the treatment’s rate of continual improvement is considered to bea further issue, the evaluation method of EAT for LC cases and theduration and frequency of treatment shown in this study may be
useful for maintaining and promoting the willingness of LC patients
to continue their outpatient treatment.

Conclusion

In this study, we investigated the feasibility of EAT treatment
in patients with LC who had chronic epipharyngitis by evaluating
a questionnaire, bleeding findings during rubbing, and autonomic
function tests. The use of EAT significantly improved the bleeding
and interview scores in LC patients with chronic epipharyngitis
but did not significantly improve autonomic function tests, whichis thought to take more time. EAT is considered to be a usefultreatment for patients with LC who have chronic epipharyngitis.

Acknowledgements

There are no conflicts of interest to disclose in this paper. I
would like to express my sincere gratitude to Dr. Manabu Mogitate,
Director of Mogitate Otorhinolaryngology, for his guidance on EAT.

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Citation: Hirobumi Ito. Effect of Epipharyngeal Abrasive Therapy on Long COVID with Chronic Epipharyngitis. Sch J Oto. 8(5)-2022. SJO.
MS.ID.000300. DOI: 10.32474/SJO.2022.08.000300

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