Application of Ultrasound-guided Stellate Ganglion Block in Treatment of Allergic Rhinitis
超声引导下星状神经节阻滞治疗过敏性鼻炎的应用

Allergic rhinitis (AR) is an allergic disease with very highly morbidity. [1] The relevant reports showed that [2,3] in recent years, Artemisia plants has been widely seed sowed in various areas of Ordos City in Inner Mongolia due to improvement of the environment, which makes the patients has more chance to exposure and inhalation the Artemisia pollen, and lead to the increase morbidity of AR in the area year by year. Moreover, the Artemisia pollen dissemination season is at months of July to September annually. Therefore, the AR patients were significantly increased and the symptoms were aggravated in that range of period. AR is considered to be unable to radical cure, and the symptoms can only be alleviated by controlling the numbers of morbidity.
过敏性鼻炎 （AR） 是一种发病率非常高的过敏性疾病。[1] 相关报告显示，[2,3] 近年来，由于环境的改善，蒿属植物在内蒙古鄂尔多斯市各地广泛播种，使患者有更多机会接触和吸入蒿属花粉，导致该地区 AR 的发病率逐年增加。此外，艾蒿花粉传播季节为每年 7 月至 9 月。因此，在该期间，AR 患者显著增加，症状加重。AR 被认为无法根治，只有控制发病率才能缓解症状。

The induction of AR is related to gene and environment [4], in which environmental factors play an important role. Nowadays, the indoor and outdoor environment allergen exposure limitation is the most effective primary preventive measure [5]. At present, the most common therapeutic method of AR is by medications although it may cause side effects such as intranasal dryness and heat, epistaxis and arrhythmia [6,7], and it may also raise intraocular pressure and cause glaucoma [8]. Moreover, some patients are allergic to drugs or the effectiveness after the treatment is not ideal. Stellate ganglion block (SGB) has attracted widespread attentions because of its positive effect on inhibiting inflammatory response and improving immune function, and some scholars have achieved good clinical results on the treatment of SGB by blind puncture to treat AR patients [9-11]. However, the anatomical position of SGB is very complex, and the traditional blind spot block is easy to cause accidental injury and severe complications [12].
AR 的诱导与基因和环境有关 [4]，其中环境因素起着重要作用。如今，室内和室外环境过敏原暴露限制是最有效的一级预防措施 [5]。目前，AR 最常见的治疗方法是药物，尽管它可能会引起鼻内干热、鼻出血和心律失常等副作用 [6,7]，它还可能升高眼压并导致青光眼 [8]。此外，一些患者对药物过敏或治疗后效果不理想。星状神经节阻滞 （SGB） 因其对抑制炎症反应和提高免疫功能的积极作用而受到广泛关注，一些学者对盲穿刺治疗 SGB 治疗 AR 患者取得了良好的临床效果 [9-11]。然而，SGB 的解剖位置非常复杂，传统的盲区阻滞容易造成意外伤害和严重并发症 [12]。

At present, with the rapid development of medical imaging, ultrasound-guided SGB has been widely application [13], such as alleviation of pain [14], improvement of postoperative gastrointestinal function [15], anxiety relief of post-traumatic stress disorder [16], and the treatment of refractory ventricular arrhythmia [17]. This study was to demonstrate the effectiveness and safety of ultrasound-guided SGB in the treatment of AR and to provide a safer and convenient method for the clinical treatment of AR.
目前，随着医学影像学的快速发展，超声引导下SGB已得到广泛应用[13]，如缓解疼痛[14]、改善术后胃肠功能[15]、缓解创伤后应激障碍的焦虑[16]、治疗难治性室性心律失常[17]。本研究旨在证明超声引导下 SGB 治疗 AR 的有效性和安全性，并为 AR 的临床治疗提供一种更安全、更便捷的方法。

Sixty patients participated in the treatment of AR with ultrasound-guided SGB in our hospital from July to September of 2021, and all the patients were at the onset of AR, and did not receive antihistamine or hormone treatment before block treatment. The patients included 32 males and 28 females, with the disease course of 2-25 (8.93 ± 5.73) years, and the age of 19-60 (34.62 ± 10.98) years old. The study was approved by the hospital ethics committee and the informed consent was signed by all patients.
2021 年 7 月至 9 月在我院接受超声引导下 SGB 治疗 AR 的 60 例患者，所有患者均处于 AR 发作期，阻滞治疗前未接受抗组胺药或激素治疗。患者包括男性 32 例，女性 28 例，病程为 2-25 岁 （8.93 ± 5.73） 岁，年龄 19-60 岁 （34.62 ± 10.98） 岁。该研究得到了医院伦理委员会的批准，所有患者都签署了知情同意书。

As inclusion considerations, the clinical presentation and diagnosis of allergic rhinitis were consistent with the results of skin prick test or serum protein biomarkers IgE detection. Clinical symptoms included 2 or more symptoms such as sneezing, clear nasal discharge, nasal congestion and nasal itching, which can be accompanied by ocular symptoms such as itchy eyes and conjunctival congestion. Physical signs included nasal mucosa pale, edema, nasal cavity watery secretion, as well as skin prick test (SPT), serum protein biomarkers IgE positive.
作为纳入考虑因素，过敏性鼻炎的临床表现和诊断与皮肤点刺试验或血清蛋白生物标志物 IgE 检测结果一致。临床症状包括打喷嚏、清流鼻涕、鼻塞和鼻痒等 2 种或以上症状，可伴有眼睛发痒、结膜充血等眼部症状。体征包括鼻粘膜苍白、水肿、鼻腔水样分泌物，以及皮肤点刺试验 （SPT）、血清蛋白生物标志物 IgE 阳性。

Inclusion criteria for patients with diagnosed allergic rhinitis included 18-65 years old, no history of neck trauma, no swelling or infection at the puncture site, normal coagulation function, and no history of local anesthetic allergy.
诊断为过敏性鼻炎患者的纳入标准包括 18-65 岁，无颈部外伤史，穿刺部位无肿胀或感染，凝血功能正常，无局部麻醉药过敏史。

Patients with mental illness, serious diseases such as heart, lung, liver, brain, kidney, etc., pregnancy and no intention of cooperating with study were excluded.
排除患有精神疾病、心、肺、肝、脑、肾等严重疾病、怀孕且无意配合研究的患者。

Ultrasonic diagnostic apparatus (Prosound F75, ALOKA, Japan) with linear array high-frequency probe (probe frequency of 6-13 MHz) were used in this study. Nerve block instruments included one single use sterile puncture needle (22G) (0.7 × 90 mm), one 5 ml syringe, 5 ml lidocaine (5 ml: 0.1 g) + 10 mg triamcinolone acetonide acetate (0.5 ml: 20 mg) mixed liquor.
本研究使用带有线性阵列高频探头（探头频率为 6-13 MHz）的超声诊断仪 （Prosound F75， ALOKA， Japan）。神经阻滞器械包括一根一次性使用无菌穿刺针 （22G） （0.7 × 90 mm）、一个 5 ml 注射器、5 ml 利多卡因（5 ml：0.1 g）+ 10 mg 醋酸曲安奈德（0.5 ml：20 mg）混合液。

The patient took the supine position with the neck padded with a thin pillow and the head backward slightly to the contralateral side with, the neck muscles relaxed. The doctor was located on the right side of the patient, place the probe with sterile cover on the neck after routine disinfection. In the study, obtain a transverse axial view of the neck at the C6-7 level. After the carotid artery, internal jugular vein, long neck muscle and prevertebral fascia were identified, the needle was vertically inserted from the outside of the probe, and the whole process of the needle tract and the tip of the needle was presented, passing through the anterior scalene muscle to the position behind the carotid sheath and the stellate ganglion at the front of the longus colli muscles. Then, after air-free, no blood and no cerebrospinal fluid were pumped back, the correct position was confirmed, 5 ml lidocaine and triamcinolone acetate mixed liquor were injected, and the needle hole was pressed after the injection to prevent the formation of hematoma. See Figure 1 for details.
患者采取仰卧位，颈部垫有薄枕头，头部略微向后向对侧，颈部肌肉放松。医生位于患者的右侧，常规消毒后将带有无菌罩的探头放在脖子上。在研究中，获得 C6-7 水平颈部的横向轴向视图。确定颈动脉、颈内静脉、颈长肌和椎前筋膜后，从探头外侧垂直插入针头，呈现针道和针尖的全过程，穿过斜角肌到达颈动脉鞘后方位置和长骨肌前部的星状神经节。然后，无气后，无血液、无脑脊液泵回，确认正确位置，注射利多卡因和醋酸曲安奈德混合液 5 ml，注射后按压针孔，防止血肿的形成。有关详细信息，请参见图 1。

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Figure 1 图 1Ultrasound-guided stellate ganglion block. (A) Before drug injection, the common carotid artery (CCA), internal jugular vein (IJV), sternocleidomastoid (SCM) and longus colli muscles (LCM) were located by ultrasound; (B) After drug injection, the ultrasound showed the puncture needle (arrow) and the pooled injection fluid.
超声引导下的星状神经节阻滞。（A） 药物注射前，超声定位颈总动脉 （CCA）、颈内静脉 （IJV）、胸锁乳突肌 （SCM） 和长链肌 （LCM）;（B） 药物注射后，超声显示穿刺针（箭头）和混合注射液。

All the patients performed SGB for 1 side/d, with alternating bilateral. Two days for both sides of SGB were used as a treatment course. The effect was evaluated one month after the treatment. All SGB operations were completed by a chief physician with 20 years of intervention ultrasound experience.
所有患者均进行 1 侧/d 的 SGB，交替双侧。SGB 两侧均使用 2 天作为疗程。治疗后 1 个月评估效果。所有 SGB 手术均由具有 20 年介入超声经验的主任医师完成。

The occurrence of Horner syndrome means successful block [18], which means that the miosis on the block side, but the response to light was normal, conjunctival hyperemia, enophthalmos, upper eyelid ptosis, facial flushing, hypohidrosis or anhidrosis, etc.
Horner综合征的发生是指阻滞成功[18]，即阻滞侧的瞳孔缩小，但对光的反应正常，结膜充血，眼球内陷，上眼睑下垂，面部潮红，少汗症或无汗症等。

Efficacy evaluation was used in three types, including:
疗效评价分为三种类型，包括：

1. Obvious effect (symptoms such as sneezing, runny nose, nasal itching, and nasal congestion disappear),
1.效果明显（打喷嚏、流鼻涕、鼻痒、鼻塞等症状消失），

2. Effective (The above symptoms occur occasionally, but have improved significantly),
2. 有效（上述症状偶尔出现，但已明显改善），

3. No effect (The above symptoms have no obvious change or aggravation).
3.无效果（以上症状无明显变化或加重）。

The Standard of clinical symptom score was classified as follows:
临床症状评分标准分类如下：

Sneeze score: 1 point: continuity 3-9 times/per time; 2 points: continuity 10-14 times/per time; 3 points: continuity more than 15 times/per time.
打喷嚏评分：1分：连续性3-9次/次;2分：连续性 10-14 次/次;3 分：连续性超过 15 次/每次。

Nasal secretion score: 1 point: nose-blowing ≤ 4 times/d; 2 points: nose-blowing 5-9 times/d; 3 points: nose-blowing ≥ 10 times/d.
鼻分泌物评分：1 分：擤鼻涕 ≤ 4 次/d;2 分：擤鼻涕 5-9 次/d;3 分：擤鼻涕≥ 10 次/d。

Itchy nose score: 1 point: intersectionality nasal itching; 2 points: formicans stupor when nose itching; 3 points: unbearable formicans stupor when nose itching.
鼻子发痒评分： 1 分： 交叉性 鼻痒;2 分：鼻痒时福尔米康人昏迷;3 分：无法忍受的福尔米卡人在鼻子发痒时昏迷。

Nasal congestion score: 1 point: nasal obstruction during active inhalation; 2 points: intersectionality or interactive nasal obstruction; 3 points: severe nasal obstruction and requires mouth breathing.
鼻塞评分：1 分：主动吸气时鼻塞;2 分：交叉性或交互性鼻塞;3 分：严重鼻塞，需要张口呼吸。

SPSS 23.0 software was adopted for data analysis. The measurement data conforming to the normal distribution were expressed by means ± standard deviation. The paired t-test was used for the comparison within the group and the counting data were expressed by rate or percentage. The P < 0.05 showed that the difference was statistically significant.
采用 SPSS 23.0 软件进行数据分析。符合正态分布的测量数据用标准差表示±。采用配对 t 检验进行组内比较，计数数据用比率或百分比表示。P < 0.05 表明差异有统计学意义。

As results, a total of 120 punctures for SGB were performed on 60 patients, and 95% of the patients developed Horner syndrome immediately after puncture as an indicator for effectiveness of SGB. Ten patients presented with hoarseness5 patients with pharyngeal foreign body sensation, 1 patient with vomiting, and 1 patient with dizziness All symptoms resolved spontaneously within half an hour after a quiet rest. There were no serious complications occurred.
结果，共对 60 例患者进行了 120 次 SGB 穿刺，95% 的患者在穿刺后立即出现 Horner 综合征作为 SGB 有效性的指标。10 例患者表现为声音嘶哑 5 例咽部异物感，1 例患者出现呕吐，1 例患者出现头晕 所有症状在安静休息后半小时内自发消退。未发生严重并发症。

Under the guidance of ultrasound, the overall effective rate of SGB in the treatment of AR reached 96.7%, and only 2 patients had no improvement in postoperative symptoms. After treatment, the scores of clinical symptoms such as sneezing, runny nose, nasal itching and nasal congestion were remarkable lower than those before treatment with statistically significant differences (P < 0.05). The details are shown in Table 1.
在超声引导下，SGB 治疗 AR 的总体有效率达到 96.7%，仅 2 例患者术后症状无改善。治疗后，打喷嚏、流鼻涕、鼻痒、鼻塞等临床症状评分均显著低于治疗前，差异有统计学意义（P < 0.05）。详细信息如表 1 所示。

In this study, a total of 120 punctures were performed on 60 patients with AR. The 95% of the patients shown Horner syndrome within 2 minutes after the puncture while the symptoms began to improve one hour after surgery. From the perspective of pathogenesis, AR is the mainly type I allergy. When susceptible individuals are exposed to allergens, it is mainly mediated by IgE which activates inflammatory cells and releases allergic mediators such as histamine, serotonin, and leukotriene, causing allergic reaction in tissues immediately. Substance P induces histamine release by the stimulation of the nasal mucosa [19]. Histamine locally produced in the nasal secretions of AR patients can damage the epithelium in vitro, promote the influx of immune cells into the nasal mucosa, leading to persistently worsening of allergic reactions [20]. SGB can regulate autonomic dysfunction, improve blood circulation in the nasal mucosa, dilate the blood vessels of the nasal mucosa, and accelerate the removal of histamine chemicals released during allergies. And it also can reduce the excitability of sympathetic nerve, blocking the hypothalamus-sympathetic nerve-adrenal axis, the domination of glands, the bronchoconstriction, and pain-transmitting nerve fibers under its control, and relatively increase the excitability of nasal mucosal parasympathetic nerves. It inhibits the release of catecholamines and substance P, reduces the allergic reaction of the nasal mucosa, which regulates the excessive activation of the immune system, with a good resistance anti-inflammatory effect [21-23].
在这项研究中，共对 60 名 AR 患者进行了 120 次穿刺。95% 的患者在穿刺后 2 分钟内出现 Horner 综合征，而症状在手术后 1 小时开始改善。从发病机制来看，AR 是主要的 I 型过敏。当易感个体暴露于过敏原时，它主要由 IgE 介导，IgE 激活炎症细胞并释放组胺、血清素和白三烯等过敏介质，立即在组织中引起过敏反应。P 物质通过刺激鼻粘膜诱导组胺释放 [19]。AR 患者鼻腔分泌物中局部产生的组胺可在体外破坏上皮，促进免疫细胞流入鼻粘膜，导致过敏反应持续恶化 [20]。SGB 可以调节自主神经功能障碍，改善鼻粘膜血液循环，扩张鼻粘膜血管，加速清除过敏时释放的组胺化学物质。并且还可以降低交感神经的兴奋性，阻断其控制下的下丘脑-交感神经-肾上腺轴、腺体的支配、支气管收缩和疼痛传递神经纤维，相对增加鼻粘膜副交感神经的兴奋性。它抑制儿茶酚胺和P物质的释放，减少鼻粘膜的过敏反应，调节免疫系统的过度激活，具有良好的抵抗性抗炎作用[21-23]。

Up to the day of follow-up, the statistical effective rate reached 96.7%, indicating that ultrasound-guided SGB is very effective in relieving symptoms of AR, which is related to the following advantages of ganglion block under ultrasound guidance. Ultrasound can directly observe the tissue structures, reduce the confusion caused by anatomical variation among individuals, then locate the position of the stellate ganglion and inject drugs into the prevertebral fascia and the long neck muscle more accurately, improving the success rate of the ganglion block. In addition, the depth of the needle can also be adjusted while monitoring the drug diffusion, so that the drug can diffuse to the stellate ganglion to the greatest extent. In this study, less amount of local anesthetic was used without affecting the blocking effect, which is consistent with the results of relevant studies [24].
截至随访当天，统计有效率达到 96.7%，说明超声引导下 SGB 对缓解 AR 症状非常有效，这与超声引导下神经节阻滞的以下优点有关。超声可以直接观察组织结构，减少个体之间因解剖变异而造成的混乱，然后更准确地定位星状神经节的位置，并将药物注射到椎前筋膜和长颈肌中，提高神经节阻滞的成功率。此外，还可以在监测药物扩散的同时调整针头的深度，使药物最大限度地扩散到星状神经节。在这项研究中，在不影响阻滞效果的情况下，使用了较少的局部麻醉剂，这与相关研究的结果一致 [24]。

Studies have shown that ultrasound-guided regional nerve block is known as the safest nerve block method [25]. Traditional blind spot block may create severe complications, such as retropharyngeal hematoma [26], pneumothorax, epidural block, subdural block, subarachnoid block and convulsion, which may cause life-threatening if it is not handled in time. Moreover, the visualization operation under ultrasound guidance can greatly reduce the complications of SGB [27]. In the study, 10 patients developed transient hoarseness, which may be caused by the drug diffusion to temporarily block the recurrent laryngeal nerve near the esophagus; 5 patients showed globus pharyngeus, which may be related to obesity with brevicollis so that the probe may over compress the neck; vomiting was found in 1 patient and dizziness in 1 patient, which may be related to a small amount of local anesthetic into the blood. Those symptoms could be improved by careful action during operation, and were relieved automatically after a quiet rest for half an hour. The complications of the disease under ultrasound-guided SGB were few and minor, which are due to a numbers of neurovascular tissues and vital organs around the stellate ganglion. However, real-time ultrasound can precisely distinguish bone structures, muscle tissues (longus neck muscle), vascular tissues (superior thyroid artery, lumbar arteriovenous, cervical arteriovenous) and soft tissue structures (thyroid and esophagus). Under the guidance of high-frequency ultrasound probe, the whole process of needle insertion can be observed in real time, which can effectively reduce the occurrence of puncture injury of the surrounding structure, and convenience the operator to adjust the needle insertion angle at any time according to the position of the needle tip, so as to reduces the risk of injection into the vascular sheath, epidural and intramuscular. Moreover, ultrasound guidance can directly surveillance the diffusion of the drugs, observe the diffusion range of the drugs, and reduce the level of local anesthetics [28].
研究表明，超声引导下的区域神经阻滞被认为是最安全的神经阻滞方法 [25]。传统的盲点阻滞可能会产生严重的并发症，如咽后血肿[26]、气胸、硬膜外阻滞、硬膜下阻滞、蛛网膜下腔阻滞和抽搐，如果不及时处理，可能会危及生命。此外，在超声引导下的可视化操作可以大大减少 SGB 的并发症 [27]。在这项研究中，10 例患者出现短暂性声音嘶哑，这可能是由于药物扩散暂时阻断食管附近的喉返神经引起的;5 例患者表现为咽癔球症，这可能与肥胖伴短颈有关，因此探头可能过度压迫颈部;1 例患者出现呕吐，1 例患者出现头晕，这可能与少量局部麻醉剂进入血液有关。这些症状可以通过手术中的小心动作得到改善，并在安静休息半小时后自动缓解。超声引导下 SGB 下疾病的并发症很少且轻微，这是由于星状神经节周围有许多神经血管组织和重要器官。然而，实时超声可以精确区分骨骼结构、肌肉组织（长颈肌）、血管组织（甲状腺上动脉、腰动静脉、颈动静脉）和软组织结构（甲状腺和食管）。 在高频超声探头的引导下，可实时观察进针全过程，可有效减少周围结构穿刺伤的发生，方便操作者根据针尖位置随时调整进针角度，从而降低注射到血管鞘的风险， 硬膜外和肌肉注射。此外，超声引导可以直接监测药物的扩散，观察药物的扩散范围，降低局麻药的水平 [28]。

In this study, there were 3 cases without development of Horner syndrome after injection, but their postoperative curative effect was significant, which Horner syndrome may be not a sign of SGB block success, as some investigator had different opinion on the criteria for defining block success [29]. Yamazaki and others used the perfusion index measured by pulse oximeter as a marker to evaluate the success of SGB [30]. In this study, there were 2 patients with no improvement in post-operation, which may be related to the level of the block. Studies have shown that compared with the block at the level of the C7 vertebral body [31], the block at the level of the C6 vertebral body leads to the sympathetic nerve blocks of the head and neck were more successful. In these 2 cases, the block plane was too low and the drug did not diffuse sufficiently to the stellate ganglia, leading to the unsuccessful results.
在本研究中，有 3 例注射后未发生 Horner 综合征，但术后疗效显著，Horner 综合征可能不是 SGB 阻滞成功的标志，因为一些研究者对阻滞成功的定义标准有不同的看法 [29]。Yamazaki 等人使用脉搏血氧仪测量的灌注指数作为指标来评估 SGB 的成功 [30]。在本研究中，有 2 例患者术后无改善，这可能与阻滞水平有关。研究表明，与 C7 椎体水平阻滞相比 [31]，C6 椎体水平阻滞导致头颈部交感神经阻滞更成功。在这 2 例中，阻滞平面太低，药物没有充分扩散到星状神经节，导致结果不成功。

It should be point it out that ultrasound-guided SGB has high requirements on the operator, and physicians need to have exquisite manipulations and a lot of clinical experience to ensure the safety of the operation and reduce the occurrence of complications, which is crucial to the success of ultrasound-guided SGB. Due to the particularity of the environment in the region, the onset time of AR is relatively short, and the postoperative follow-up time is short in this study, thus, the long-term follow-up is required. Also, this study lacked a control group and the size of sample is relatively small, so the subjects will be expanded for further studies in the future. Although the stellate ganglion can be accurately localized under ultrasound guidance and the dosage of local anesthetics can be reduced, future study needs to explore how to use visual operations to implement SGB more accurately and safely for this technique.
需要指出的是，超声引导下 SGB 对操作者要求很高，医生需要有精湛的操作和大量的临床经验，才能保证手术安全，减少并发症的发生，这对于超声引导下 SGB 的成功至关重要。由于该地区环境的特殊性，AR 的发病时间相对较短，且术后随访时间较短，因此需要长期随访。此外，这项研究缺乏对照组，样本量相对较小，因此将扩大受试者以供将来进一步研究。虽然在超声引导下可以准确定位星状神经节，并且可以减少局部麻醉剂的剂量，但未来的研究需要探索如何使用视觉操作更准确、更安全地实施该技术的 SGB。

In conclusion, ultrasound-guided SGB for treatment of AR patients has incomparable superiority with many advantages of accurate, noninvasive and visualization, especially for obesity, short neck and deformity that are difficult to puncture. The efficacy of ultrasound-guided SGB in the treatment of AR significantly improve the quality of life of patients, so it is worth for wide application in clinical practice
综上所述，超声引导下 SGB 治疗 AR 患者具有无可比拟的优越性，具有准确、无创、可视化等优点，尤其适用于肥胖、短颈和难以穿刺的畸形。超声引导下 SGB 治疗 AR 的疗效显著改善了患者的生活质量，因此值得在临床实践中得到广泛应用

This work was supported by Inner Mongolia Autonomous Region Natural Science Foundation (No. 2020MS08176).
这项工作得到了内蒙古自治区自然科学基金（No. 2020MS08176）的支持。