慢性鼻-鼻窦炎-鼻息肉伴哮喘患者鼻内镜围手术期药物治疗

目的 探讨慢性鼻-鼻窦炎-鼻息肉(CRSwNP)伴支气管哮喘患者鼻内镜围手术期药物治疗原则及效果。方法 收集2010年6月至2013年12月山东大学齐鲁医院耳鼻咽喉科收治的109例CRSwNP伴支气管哮喘患者行鼻内镜手术(ESS)的临床资料。术前均对哮喘进行全面评估, 哮喘完全控制6个月后行ESS手术治疗, 围手术期采用雾化吸入及全身糖皮质激素等药物治疗。结果 围手术期无哮喘急性发作, 仅1例患者术后第2天因口服镇痛剂出现喘息;术后随访1~3年, 采用鼻内镜检查并行ESS临床疗效评估, 病情完全控制者5例(4.59%), 病情部分控制者94例(86.24%), 病情未控制10例(9.17%);仅1例术后13个月因股骨头坏死行手术治疗。结论 全面细致的哮喘病情评估和ESS围手术期药物治疗有利于防止围手术期哮喘发作及控制术后CRSwNP患者鼻息肉复发, 有利于提高手术疗效。     

内镜鼻窦手术围手术期局部糖皮质激素的应用

近年来，内镜鼻窦手术（ESS）的广泛开展和技术的成熟，逐渐取代了传统手术方式而成为外科治疗慢性鼻窦炎鼻息肉的首选方式，并收到了良好的治疗效果。在ESS围手术期包括抗生素、糖皮质激素在内的药物配合治疗对提高治愈率是必不可少的，其中鼻腔局部糖皮质激素的应用占重要组成部分。术前激素应用能减轻鼻窦炎鼻息肉的炎症反应，缩小鼻息肉的体积，从而为手术进行创造有利条件；术后应用能减轻手术造成的水肿，更能预防或延缓鼻息肉的复发。现将近年来有关ESS围手术期，尤其是术后局部糖皮质激素的应用及相关问题的研究进展综述如下。     

加强慢性鼻-鼻窦炎围手术期综合治疗

经鼻内镜鼻窦手术（endoscopic sinus surgery，ESS）本身并不能直接治疗慢性鼻-鼻窦炎（chronic rhinosinusitis，CRS），手术的主要目的是为鼻窦黏膜形态与功能的改善与恢复创造一个结构合理、通气良好、引流通畅的局部环境。围绕着提高手术质量和效果所进行的系列药物治疗和辅助处理的过程，称为围手术期综合治疗。     

慢性鼻窦炎伴鼻息肉与哮喘的相关性机制及治疗策略研究进展

慢性鼻窦炎伴鼻息肉(CRSwNP)和哮喘作为上下呼吸道最具代表性的慢性炎症性疾病，二者在发病过程中常相互并存，临床诊治棘手。目前对CRSwNP和哮喘的相互作用机制尚未阐明。欧洲鼻窦炎鼻息肉诊疗指南(EPOS 2012)对治疗CRSwNP伴或不伴哮喘已给出具体的指导意见，其常规治疗包括鼻用糖皮质激素、生理盐水洗鼻等，并进一步根据CRSwNP的特点、症状严重程度等进行后续的联合治疗。据报道，鼻窦手术和药物治疗CRSwNP对合并支气管哮喘的转归有益。但CRSwNP合并哮喘患者经药物与手术治疗后的疗效判定尚缺乏足够的随机对照试验证据。     

辅舒良在鼻内镜鼻窦手术围手术期的疗效观察

目的 探讨辅舒良在鼻内镜鼻窦手术围手术期的辅助治疗效果.方法 将慢性鼻窦炎、鼻息肉病例随机分为对照组(96例)和观察组(94例).对照组单纯给予常规抗生素、黏液溶解排除剂(吉诺通)等治疗；观察组在对照组的基础上,手术前后给予鼻腔局部皮质类固醇药物(辅舒良)治疗,比较两组疗效.结果 观察组在术中出血量、术后术腔清洁时间、术后术腔上皮化时间及疗效方面都优于对照组,差异均有统计学意义(P＜0.05).结论 辅舒良可以提高和巩固鼻内镜鼻窦手术的疗效.     

慢性鼻-鼻窦炎术后复发的治疗策略

<正>最近20多年来随着鼻内镜外科(endoscopic sinus surgery,ESS)技术在临床的应用,慢性鼻-鼻窦炎(chronic rhinosinusitis,CRS)的治疗水平获得很大提高。但是由于内镜手术技巧的差异、加之患者鼻-鼻窦局部因素和全身因素等原因,导致一部分病例术后复发[1]。ESS修正性手术主要是针对内镜鼻窦手术或传统手术失败后的再次手术,本文结合     

内镜鼻窦手术中眶内壁陈旧性骨折的处理

目的了解接受内镜鼻窦手术(endoscopy sinus surgery,ESS)的慢性鼻及鼻窦炎伴或不伴鼻息肉(chronic rhinosinusitis with or without nasal polyps,CRSwNP/CRSsNP)患者眶内壁陈旧性骨折的出现情况和存在特点,并讨论ESS过程中眶内壁陈旧性骨折的处理原则。方法回顾分析2006年11月～2010年01月因CRSwNP/CRSsNP接受ESS的一组连续病例中眶内壁陈旧性骨折的出现情况、术前计划和术中所见、术后填塞情况以及术后眶部并发症出现情况等。结果 520例患者中,眶内壁陈旧性骨折出现率2.5%(1 3/520)。鼻窦病变累及范围、眶内容突入情况、额窦引流是否受影响都是决定是否开放受累气房的决定因素。术后近期和远期没有出现眶部并发症。结论眶内壁陈旧性骨折在因CRSwNP/CRSsNP接受ESS的患者中出现并不罕见;作为一个影响ESS疗效的因素,术前应充分评估其对眶内结构、功能和鼻窦引流、特别是额窦引流影响;只要计划充分,在顺利完成手术的前提下,眶内容的损伤程度可以降至最低。     

鼻内镜治疗慢性鼻-鼻窦炎围手术期的临床观察

目的探讨鼻内镜治疗慢性鼻-鼻窦炎围手术期治疗的重要性。方法回顾性分析76例慢性鼻-鼻窦炎患者的临床资料。分为治疗组和对照组,治疗组56例,术前使用鼻腔局部糖皮质激素药物(辅舒良)、黏液溶解排除剂(吉诺通);对照组20例,术前未使用以上药物,比较两组疗效,总结鼻内镜手术围手术期治疗作用。结果 76例患者行鼻内镜手术患者,随访6月~2年,治愈62例,症状改善明显10例,复发4例。治疗组及对照组在术中出血量、术后术腔上皮化时间及疗效方面差异均有统计学意义(P0.05)。结论功能性鼻内镜手术是治疗慢性鼻-鼻窦炎最有效的临床方法之一,围手术期局部使用鼻喷剂、黏液溶解排除剂等处理,可以减少术中出血和缩短术后术腔上皮化时间,患者疗效满意。     

长期小剂量克拉霉素联合鼻用激素治疗慢性鼻-鼻窦炎的初步观察

目的:观察长期小剂量大环内酯类药物联合鼻用糖皮质激素治疗慢性鼻-鼻窦炎(CRS)的疗效.方法:克拉霉素片0.25 g口服,2次/d,2周后改为1次/d;曲安奈德喷雾剂喷鼻,1次/d.不伴鼻息肉的CRS患者26例给药时间12~28周,平均16.62周.伴鼻息肉的CRS患者30例,先在内镜下切除鼻息肉(手术前后用抗生素、激素5~7 d),然后开始药物疗法.给药时间12~33周,平均20.03周.治疗前后采用Lund-Mackey鼻窦CT评分,主观症状自评治疗效果.结果:伴息肉组治疗后鼻窦CT平均得分2.83±1.86,显著低于治疗前(7.20±2.06,t=11.41,P<0.01);不伴息肉组治疗后鼻窦CT平均得分2.43±1.91,显著低于治疗前(6.23±1.88,t=12.86,P<0.01).伴息肉组和不伴息肉组鼻窦CT评分疗效治愈率分别达到43.3%和50.0%.两组的自评疗效与鼻窦CT评分疗效比较无明显差异.结论:长期使用小剂量的克拉霉素联合鼻用糖皮质激素治疗CRS有效.鼻息肉多发和手术处理次数多的患者疗效相对较差.鼻息肉切除和围手术期集中使用大剂量抗生素、糖皮质激素有利于提高伴息肉的CRS患者药物疗法的疗效.     

内镜鼻窦手术后随访及雷诺考特喷鼻的疗效观察

目的 :探讨慢性鼻窦炎、鼻息肉内镜鼻窦术后随访的时间和糖皮质激素鼻内用药的效果。方法 :对 30例鼻窦炎、鼻息肉患者行内镜鼻窦手术 ,术后定期随访 ,行内镜下术腔护理、鼻窦冲洗和糖皮质激素雷诺考特鼻内局部应用 ,观察临床疗效。结果 :术后 3个月 ,2 5例鼻腔、鼻窦已干燥、上皮化 ;术后 6个月 ,2 8例鼻腔、鼻窦已干燥、上皮化 ,鼻塞、头痛均消失。 4例伴变应性鼻炎者 ,鼻腔有少许分泌物 ;10例嗅觉障碍者中 3例无改善。结论 :内镜鼻窦手术后的鼻内镜随访、术腔护理及糖皮质激素鼻内应用 ,在慢性鼻窦炎、鼻息肉的治疗过程中起着同样重要的作用。     

Differential effects of postoperative oral corticosteroid on eosinophilic vs. non-eosinophilic CRSwNP subtypes

Purpose

The efficacy of postoperative oral corticosteroids on surgical outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) patients following endoscopic sinus surgery (ESS) remains controversial. This study evaluated the potential benefits of postoperative oral corticosteroids on surgical outcomes in CRSwNP patients and investigated the differential effects on eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (NECRSwNP).

Seeking an optimal dose of preoperative corticosteroids in chronic rhinosinusitis with nasal polyposis: A randomized controlled trial

BackgroundPreoperative corticosteroids have been shown to improve surgical visibility and intraoperative blood loss for chronic rhinosinusitis with nasal polyposis (CRSwNP) patients undergoing endoscopic sinus surgery (ESS). However, there is no consensus on the optimal dosing regimen.MethodsA randomized, controlled trial was conducted to compare low, medium, and high dose corticosteroids prior to ESS. Patients with CRSwNP refractory to medical management were randomized to low (N = 8), medium (N = 10), or high (N = 5) dosing regimens of corticosteroids prior to ESS. Baseline disease severity was measured with the 22-item Sino-nasal Outcome Test and Lund-Mackay scores. Modified Lund-Kennedy endoscopic scores (MLKES) were measured at baseline and after corticosteroid treatment. Intraoperative parameters were measured including Boezaart surgical visibility score, intraoperative blood loss, and operative time.ResultsMedium dose corticosteroids demonstrated a superior surgical visibility score to low dose and comparable results to high dose, but these results were not significant (p = 0.33). No significant difference was observed between groups for total blood loss (p = 0.15), operative time (p = 0.87), or change in MLKES (p = 0.27).ConclusionsCurrent recommendations include the use of preoperative corticosteroids in patients with CRSwNP undergoing ESS, but there is no consensus on dose or duration. We did not find a statistically significant difference in surgical field visibility, intraoperative blood loss, or operative time between different dosing regimens. Further studies are needed to evaluate the efficacy of a low-dose preoperative regimen with the goal of reducing cumulative patient exposure to systemic corticosteroids.     

慢性鼻-鼻窦炎伴鼻息肉患者鼻内镜术后症状与病理学指标相关分析

目的：评估病理学指标对预测慢性鼻-鼻窦炎伴鼻息肉患者鼻内镜术后疗效的价值。方法：通过对53例接受鼻内镜手术1年以上的慢性鼻-鼻窦炎伴鼻息肉患者的临床症状问卷调查,阅读这些患者的手术标本病理切片,统计相关病理指标,统计学分析慢性鼻-鼻窦炎伴鼻息肉患者接受鼻内镜术后的主要症状及其与病理学指标之间的联系。结果：慢性鼻-鼻窦炎伴鼻息肉患者接受鼻内镜手术后最主要的症状有鼻塞、流脓涕、流清涕或打喷嚏,其中杯状细胞与打喷嚏、流脓涕症状,病理性腺体形成与头昏症状,组织水肿程度与后鼻滴漏症状相关（P〈0.05）。结论：病理学指标有助于预测慢性鼻-鼻窦炎伴鼻息肉患者鼻内镜术后疗效。     

Relationship between positive bacterial culture in maxillary sinus and surgical outcomes in chronic rhinosinusitis with nasal polyps

Objectives

There are many studies on clinical prognosis following endoscopic sinus surgery (ESS) for the treatment of chronic rhinosinusitis with nasal polyp (CRSwNP). However, there are no independent reports on bacterial infection as a factor that influences surgical outcomes. We investigated the association between bacterial infection and surgical outcomes following ESS.

Methods

This retrospective review of medical records was performed on 71 patients with CRSwNP that was refractory to medical treatment and who were diagnosed between July 2007 and June 2012. The extent of the polyps and the Lund–Mackay CT score (L–M score) were preoperatively evaluated in all the patients. For this analysis, patients were classified into three groups (normal flora, culture-positive, and culture-negative) according to their intraoperative bacterial culture results. We compared the objective endoscopic findings between these groups at 6-months postsurgery.

Results

Bacteria were cultured in 55 of the 71 patients (77%). Of these, 43 patients (61%) demonstrated endoscopic improvement at the 6-month follow-up examination. The preoperative L–M score and polyp grade demonstrated no significant statistical differences in terms of surgical outcome, but the cure rate was statistically higher in culture-negative patients in comparison with normal flora and culture-positive patients (87.5% vs. 46.2% vs. 54.8, respectively).

Conclusion

Intraoperative culture results can be a prognostic factor for the clinical outcomes of ESS in CRSwNP patients. Hence, the intraoperative culturing of pathologic secretions and the postoperative administration of susceptible antibiotics could improve surgical results.     

Efficacy of buffered hypertonic seawater in different phenotypes of chronic rhinosinusitis with nasal polyps after endoscopic sinus surgery: a randomized double-blind study

PurposeNasal douching is commonly used as a postoperative management strategy for chronic rhinosinusitis with nasal polyps (CRSwNP). Few studies to date have compared the effectiveness of nasal douching in CRSwNP phenotypes after endoscopic sinus surgery (ESS). We evaluated the efficacy of seawater types in eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (nonECRSwNP) after ESS.MethodsPatients with bilateral CRSwNP who had undergone ESS were blindly randomized to receive buffered hypertonic seawater (BHS) (n = 48) or physiological seawater (PS) (n = 45). CRSwNP patients were stratified by phenotypes (ECRSwNP and nonECRSwNP) retrospectively according to whether tissue eosinophils exceeded 10%. Follow-up evaluations were conducted at 2, 8, 16, and 24 weeks after surgery. Evaluations included the 22-item Sino-Nasal Outcome Test (SNOT-22), visual analog scale (VAS), Lund-Kennedy endoscopic score (LKES), saccharine clearance time (SCT), and adverse events.ResultsAll of the patients experienced significant improvements in SNOT-22 scores, VAS scores, and LKES over time. BHS resulted in better improvement of LEKS and SCT relative to PS at 8 weeks postoperatively. Mucosal edema formation was significantly reduced with less crusting among HBS recipients at 8 weeks. After stratification, only patients in the nonECRSwNP + BHS subgroup showed a significant improvement in LEKS and SCT at 8 weeks postoperatively. Side effect profiles were not significantly different among the groups.ConclusionsBHS has a better inhibitory effect on mucosal edema and crusting during the early postoperative care period of CRSwNP. Among all of the patients, nonECRSwNP patients showed a significant improvement in LEKS and SCT at 8 weeks.     

Effects of intranasal steroid treatment on the presence of biofilms in non-allergic patients with chronic rhinosinusitis with nasal polyposis

Microbial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP). Intranasal application of corticosteroids (INCS) is a reliable option in the management of CRSwNP. INCS medication has been suspected to influence the presence and thickness of microbial biofilms and inflammatory cell patterns in CRSwNP. Two series of identical nasal polyps obtained from non-allergic patients with CRSwNP (n = 56), who underwent endoscopic sinus surgery (ESS), were processed to hematoxylin–eosin (H.E.) and Gram staining, respectively. Patients were recruited into three groups. Group A (n = 21) consisted of patients with continuous preoperative INCS treatment. In group B (n = 17), patients were never treated by INCS, while in group C (n = 18) INCS medication was stopped at least 6 months before ESS. Biofilm positivity varied from 76.4 to 88.8 % in different subject groups. These values and average thickness of biofilms did not reach statistically significant levels (Mann–Whitney’s U probe, p > 0.05) in different patient groups. In contrast, microscopic pattern and numbers of predominant inflammatory cell populations displayed obvious differences according to INCS treatment (Mann–Whitney’s U probe, p < 0.001). According to these observations, INCS treatment does not affect the presence and thickness of microbial biofilms in CRSwNP. In contrast, it has significant effects on the pattern of inflammatory cells infiltrating the subepithelial layer, which might result in beneficially altered extracellular matrix production and cytokine release.     

Endoscopic sinus surgery for rhinocerebral mucormycosis

Rhinocerebral mucormycosis is a fulminant, often fatal, disease. Aggressive surgical debridement has been considered an important part of treatment. Traditionally, an external or transantral approach has been the classic method. Recently, endoscopic sinus surgery (ESS) has been tried on several occasions to reach the goal of radical resection. Since 1991, ESS has been used to treat 9 rhinocerebral mucormycosis patients in our department. Among them, ESS was the only surgical procedure in six patients. The other three patients were treated by ESS combined with a transantral procedure. As a result, eight patients (88.9%) have survived the disease. One patient died 5 days after ESS because of an internal carotid artery occlusion. We conclude that ESS can be used to treat rhinocerebral mucormycosis alone or in combination with the traditional surgical procedures. It has the advantage of less operative morbidity and greater operative accuracy.     

基于加速康复外科理念的围手术期气道管理对阿司匹林耐受不良三联征患者术前肺功能改善的疗效分析

目的探讨基于加速康复外科(enhanced recovery after surgery,ERAS)理念的围手术期气道管理对阿司匹林耐受不良三联征(aspirin intolerance triad,AIT)患者术前肺功能改善的作用。方法回顾性分析2018年1月至2019年12月就诊于烟台毓璜顶医院耳鼻咽喉头颈外科,拟行功能性鼻内镜鼻窦手术治疗的30例AIT患者(即AIT组),其中男13例,女17例,年龄29~75岁。以及用随机数表法选取同一时间段收治的慢性鼻窦炎伴鼻息肉(CRSwNP)且不合并下气道疾病的患者172例(即CRSwNP组),其中男105例,女67例,年龄17~83岁。比较2组患者的临床资料,并以支气管舒张试验后第一秒用力呼气容积占预计值百分比(FEV₁占预计值%)<80%定义为存在手术高风险,针对术前肺功能异常存在手术风险者给予评估及规范化药物干预,观察干预后2组患者术前肺功能及是否耐受全麻手术。采用SPSS 22.0软件进行统计学分析。结果 AIT组患者入院时各项主要肺功能指标[FEV₁占预计值%、第一秒用力呼气容积与用力肺活量比值占预计值百分比(FEV₁/FVC占预计值%)、用力呼出50%肺活量时呼气流量占预计值百分比(FEF50占预计值%)、用力呼出75%肺活量时呼气流量占预计值百分比(FEF75占预计值%)、最大呼气中段流量占预计值百分比(MMEF占预计值%)]较CRSwNP组均明显降低,差异均有统计学意义(t值分别为10.882、10.506、9.141、10.182、9.099,P值均<0.001)。AIT组入院时肺功能存在手术高风险者占86.7%(26/30),明显高于CRSwNP组(11.6%,20/172),差异有统计学意义(χ²=81.788,P<0.05);支气管舒张试验后AIT组26例患者FEV₁占预计值%均<80%,2组中肺功能存在手术高风险者经过个体化药物干预3 d后,AIT组肺功能达到手术标准的人数占57.7%(15/26),明显低于CRSwNP组90.0%(18/20),差异有统计学意义(χ²=4.335,P<0.05);6 d后,AIT组达到标准的人数占92.3%(24/26),CRSwNP组均达到标准,2组差异无统计学意义(P>0.05)。术前2组FEV₁占预计值%较入院时均改善,差异有统计学意义[AIT组(90.00±6.32)%比(64.79±13.60)%,t=10.110;CRSwNP组(91.65±11.86)%比(76.40±9.35)%,t=9.346;P值均<0.05],同时FEV₁/FVC占预计值%及小气道功能指标FEF50占预计值%、FEF75占预计值%、MMEF占预计值%经雾化干预后均得到改善,差异均有统计学意义(P值均<0.05)。所有肺功能达标的2组患者手术均顺利完成,术中及术后未有气道不良事件发生。结论 AIT患者入院时肺功能差,存在围手术期气道高风险,基于ERAS理念的规范化气道管理可使其肺功能达到耐受手术的标准,降低围手术期气道不良事件的发生。     

慢性鼻窦炎鼻内镜手术中额筛区骨瘤的处理

目的了解因慢性鼻一鼻窦炎伴／不伴鼻息肉（chronic rhinosinusitis with or without nasal pol-yps,CRSwNP／CRSsNP）接受ESS的患者中骨瘤的发病情况、分布特点,讨论其术中处理原则。方法回顾分析2006年11月～2010年1月因cRswNP／cRssNP接受ESS的520例患者中26例患者合并骨瘤的发病情况、术中处理及术后并发症。结果额筛区骨瘤发病率5％（26／520）,其中位于额窦和前组筛窦23例;位于后组筛窦3例。骨瘤同时累及颅底7例,累及眶内壁4例。术中经鼻内镜下完整切除骨瘤20例,经鼻内镜下部分切除2例,未处理7例。均未出现眶部、颅内并发症。结论因CRSwNP／CRSsNP接受ESS的患者中骨瘤并不少见。以单个骨瘤为主、症状不典型且不易与鼻窦炎区分,常在CT检查时发现;额窦和前组筛窦远远多于后组筛窦。大多数骨瘤可以经鼻内镜下完整切除,在保证充分引流前提下可采用经鼻内镜下部分切除或暂不处理。