加速康复外科理念在慢性鼻-鼻窦炎伴鼻息肉手术治疗中的应用

目的 探讨加速康复外科(ERAS)在慢性鼻-鼻窦炎伴鼻息肉(CRSwNP)手术患者围手术期的应用效果。 方法 选取CRSwNP患者136例,随机分为ERAS组70例,对照组66例,两组均接受鼻内镜下鼻息肉切除加鼻窦开放手术,ERAS组患者行术前宣教、围手术期气道评估干预、缩短禁食时间、术中控制性低血压、按时镇痛等一系列优化措施;对照组行传统的围术期处理。比较两组术前肺功能异常可耐受手术率、术后疼痛评分、术后24 h鼻腔出血量、术后住院时间、总住院时间。 结果 ERAS组、对照组术前肺功能异常患者可耐受手术率分别为93.3%、75.0%,两组比较差异无统计学意义(χ2=1.924, P=0.165); ERAS组患者术后鼻部疼痛、鼻塞、头痛、眼部胀痛、流泪、耳闷和睡眠困难的VAS评分均低于对照组(P均<0.001); ERAS组术后24 h内出血量为5.7(3.0,10.3)mL,对照组为7.2(5.0,13.2)mL,两组比较差异无统计学意义(U=-0.913, P=0.361)。平均住院日ERAS组、对照组分别为(4.6±0.8)、(7.5±1.1)d,两组比较差异有统计学意义(t=17.79, P<0.001);术后住院日ERAS组与对照组分别为(2.1±0.5)、(3.8±0.3)d,两组比较差异有统计学意义(t=23.94, P<0.001)。 结论 将ERAS理念贯穿于CRSwNP患者围手术期将有效减轻患者心理和生理的创伤应激反应,缩短住院时间。     

Superantigens and chronic rhinosinusitis: detection of staphylococcal exotoxins in nasal polyps

OBJECTIVE/HYPOTHESIS: The role of infectious agents in the etiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) remains unclear. Recent studies have provided indirect evidence of exposure to staphylococcal exotoxins in the blood and polyp tissue of patients with CRSwNP. These exotoxins have the capacity to act as superantigens, bypassing normal antigen processing and directly stimulating a massive inflammatory response. The objective of the study was to analyze mucus and polyp tissue samples from patients with CRSwNP for the presence of staphylococcal exotoxins. STUDY DESIGN: Prospective study. METHODS: Tissue and mucus samples were obtained from 42 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis and 11 normal control patients. Twenty-nine of 42 patients had chronic rhinosinusitis with bilateral nasal polyposis, 2 had antrochoanal polyps, and 11 had chronic rhinosinusitis without nasal polyps. Eleven patients without chronic rhinosinusitis or polyps served as normal control patients. Specimens were analyzed for the presence of five staphylococcal exotoxins (SEA, SEB, SEC, SED, and toxic shock syndrome toxin type 1 [TSST-1]) using enzyme-linked immunosorbent assay (ELISA). Histological analysis of specimens and mean eosinophil counts were correlated with the presence of toxin. RESULTS: At least one toxin was detected in 14 of 29 patients with bilateral nasal polyposis. Nine of the 14 patients also had positive findings for additional toxins. The dominant histological pattern in the CRSwNP patient group was polypoid mucosa with edema, which was found in both ELISA-positive and ELISA-negative patients. Mean eosinophil counts tended to be higher in ELISA-positive patients with polyps compared with patients without toxin detection. No toxin was detected in the 11 specimens taken from normal control patients. Only 1 of the 13 patients with CRS without polyps had positive ELISA results for toxin. CONCLUSION: The current study demonstrates the presence of superantigen toxins in 14 of 29 patients with CRSwNP, with SEB and TSST-1 being the most common. Further studies are necessary to correlate the presence of toxin with the pathological changes present in polyp tissue.     

度普利尤单抗在慢性鼻窦炎伴鼻息肉治疗中的研究进展

慢性鼻窦炎(CRS)是一种常见的鼻窦黏膜炎症性疾病,复杂的发生机制造就了CRS的高度异质性,部分患者无法从目前标准的药物治疗和手术中得到缓解。CRS具有不同的炎症内型和临床表型,慢性鼻窦炎伴鼻息肉(CRSwNP)一直是治疗难点,其症状相对较重还常合并哮喘,易对常规药物和手术的疗效不佳并伴有较高的复发风险。近年来,度普利尤单抗(dupilumab)在成人顽固性CRSwNP中疗效显著,其通过阻断Ⅱ型炎症中关键驱动因子IL-4和IL-13的信号传导,达到治疗作用。目前度普利尤单抗对国人CRSwNP治疗研究尚无报道。本文将对度普利尤单抗治疗CRSwNP的研究进展进行综述,以期为其在CRSwNP中的进一步应用研究提供参考。     

慢性鼻-鼻窦炎伴鼻息肉合并哮喘患者肺功能分析

目的 分析慢性鼻-鼻窦炎伴鼻息肉(CRSwNP)合并哮喘患者肺功能情况。 方法 选取74例经鼻内镜手术(FESS)的CRSwNP合并哮喘患者,分组进行肺功能比较:男49例(男性组),女25例(女性组);吸烟32例(吸烟组),不吸烟42例(非吸烟组);血清特异性IgE阳性者27例(IgE组),阴性者47例(非IgE组);外周血嗜酸粒细胞升高(外周血嗜酸粒细胞绝对值>0.5×10⁹/L)者27例(外周血嗜酸粒细胞升高组),未升高者47例(外周血嗜酸粒细胞非升高组);术后送检鼻息肉组织嗜酸粒细胞升高(嗜酸粒细胞平均>10个/HPF)者31例(组织嗜酸粒细胞升高组),未升高者43例(组织嗜酸粒细胞非升高组)。所有肺功能检测均在具有上岗资质变态反应科专业医师指导下完成,检测数据由德国康讯肺功能仪(PowerCubeBody)采集,肺功能指标包括第1秒用力呼气容积(FEV₁)占预计值的百分比(FEV₁% pre)、FEV₁与用力肺活量(FVC)的比值占预计值的百分比(FEV₁/FVC% pre)、最大通气量(MVV)占预计值的百分比(MVV% pre)、用力呼出50%肺活量时的瞬间呼气流(FEF_50%)、用力呼出75%肺活量时的瞬间呼气流(FEF_75%)及最大呼气中期流量(MMEF)。74例患者评估肺功能下降程度后针对性给予雾化吸入治疗,2~3次/d,沙美特罗替卡松粉吸入剂1吸,2次/d,予孟鲁司特钠 10 mg/d,氯雷他定10 mg/d口服,同时给予盐酸氮卓斯汀鼻喷剂 2次/d+布地奈德鼻喷雾剂 2次/d喷鼻治疗。自入院至术前,患者行药物治疗时间为1~14 d。所有患者术前30 min雾化吸入1次,麻醉前行沙美特罗替卡松粉吸入剂1吸。对术前药物干预后肺功能改善情况进行判定。 结果 74例患者均顺利完成手术。入院时女性组FEF_50%、FEF_75%及MMEF低于男性组(t分别为3.213、2.829、3.644,P分别为0.002 0、0.006 1、0.000 5),吸烟组较非吸烟组、外周血及鼻息肉组织中嗜酸粒细胞升高组均较非升高组FEV₁/FVC% pre下降(t分别为2.032、2.259、2.634,P分别为0.045 8、0.029 2、0.010 3),同时鼻息肉组织嗜酸粒细胞升高组较非升高组MVV% pre降低(t=2.453, P=0.0166)。经术前规范药物干预后,患者肺功能指标FEV₁%pre、FEV₁/FVC% pre、MVV% pre、FEF_50%、FEF_75%及MMEF均较入院时改善(t分别为6.640、6.071、8.166、5.554、6.137、4.256, P均为0.000 0)。 结论 CRSwNP合并哮喘患者中,女性较男性更易伴发小气道功能障碍;吸烟、外周血及鼻息肉组织嗜酸粒细胞升高亦可影响肺功能;规范的术前药物干预可有效改善CRSwNP合并哮喘患者的肺功能,减少围术期哮喘急性发作风险,有助于手术顺利实施。     

慢性鼻窦炎伴鼻息肉复发手术时的组织病理学及外周血特征变化

目的:探讨慢性鼻窦炎伴鼻息肉（CRSwNP）患者复发手术时的组织病理学及外周血特征变化趋势。方法:回顾性分析1999年2月至2019年4月于北京协和医院连续2次接受内镜鼻窦手术的41例CRSwNP患者的临床资料,其中男性25例,女性16例,年龄前次手术时为（40.7±13.6）岁（ xˉ±s,下同）,复发手...     

JESREC score and mucosal eosinophilia can predict endotypes of chronic rhinosinusitis with nasal polyps

Objective

Recently, JESREC score and mucosal eosinophil count have been used to diagnose eosinophilic chronic rhinosinusitis (ECRS) in Japan. However, it remains unknown whether the subtypes of CRS diagnosed by these criteria have different endotypes. In the present study, we investigated whether JESREC score and mucosal eosinophil count were appropriate for classification of CRS subgroups into endotypes.

嗜酸性粒细胞与慢性鼻-鼻窦炎伴鼻息肉的相关性研究进展

慢性鼻窦炎（chronic rhinosinusitis,CRS）是鼻腔黏膜和鼻窦黏膜的慢性炎性疾病,根据有无鼻息肉可分为慢性鼻-鼻窦炎伴鼻息肉（chronic rhinosinusitis with nasal polyps,CRSwNP）和慢性鼻-鼻窦炎（chronic rhinosinusitis without nasal polyps,CRSsNP）。鼻息肉组织常见有嗜酸性粒细胞(eosinophils,EOS) 浸润增多,根据嗜酸性粒细胞的浸润程度可将CRSwNP分为两个亚型：嗜酸粒细胞型慢性鼻窦炎伴鼻息肉(eosinophilic chronic rhinosinusitis with nasal polyps, ECRSwNP)和非嗜酸粒细胞型慢性鼻窦炎伴鼻息肉 (nonesinophilc chronic rhinosinusitis with nasal polyps,nonECRSwNP);将慢性鼻窦炎分为：嗜酸粒细胞型慢性鼻窦炎（eosinophilic chronic rhinosinusitis, ECRS)和非嗜酸粒细胞型慢性鼻窦炎(non eosinophilic,NECRS)。嗜酸性粒细胞在鼻息肉形成、发展机制中的作用多年来一直备受学者们关注。随着研究的不断深入,嗜酸性粒细胞在鼻窦炎鼻息肉炎症趋化、息肉形成、分型和预后中的作用得到越来越多的重视。     

Real-world characterisation of patients with chronic rhinosinusitis with nasal polyps with and without surgery in England

Objectives

To characterise the real-world burden of chronic rhinosinusitis with nasal polyps (CRSwNP) in the UK, stratified by number of surgeries.

Design

Retrospective cohort study.

Setting

UK Clinical Practice Research Datalink Aurum database with Hospital Episodes Statistics linkage (2007–2019).

Participants

Adults ≥18 years of age with a first NP diagnosis (index) and 365 days of baseline and ≥180 days of follow-up data. Follow-up continued until disenrollment, death or end of data collection.

Main Outcome Measures

Primary: primary care physician prescribed CRSwNP-related treatments, and all-cause healthcare resource utilisation (HCRU) in 90 days post-index, stratified by surgeries during follow-up. Secondary: rate of surgery and CRSwNP point prevalence. Baseline patient demographics, clinical characteristics and comorbidities were also assessed.

Results

Of the 33 107 patients included, 23.5% and 2.2% had ≥1 and ≥2 surgeries during follow-up, respectively (mean follow-up: 5.3 years). Patients with more surgeries (≥2/≥1/0) during follow-up were more likely to be male (67.3%/69.0%/58.0%), have asthma (37.8%/28.2%/20.2%) and have baseline blood eosinophil counts ≥300 cells/μL (68.5%/66.0%/51.5%). During the first 90-days post-index as surgery number increased, the proportion of patients using oral corticosteroids (25.8%/20.7%/14.2%) and mean (SD) number of all-cause healthcare visits (5.9 [4.2]/5.4 [4.0]/4.9 [4.2]) increased. Time between surgeries was shorter among patients with more surgeries. CRSwNP prevalence on 31 December 2018 was 476 cases per 100 000 persons.

Conclusion

A small proportion of patients in the UK required multiple surgeries for CRSwNP and this was associated with increasing comorbidity burden, baseline blood eosinophil counts, CRSwNP-related treatment and HCRU use.     

Role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps

Background/Objective: The pathophysiological and prognostic role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps (CRSwNP) emerging from recent studies was investigated.

Material and Methods: The main available evidence and largely-recent publications were critically analyzed.

Results: Several authors reported a direct association between blood eosinophilia and CRSwNP recurrence rates. In some large series, a direct association between recurrent CRSwNP and blood basophil values emerged too. CRSwNP patients’ blood eosinophil and basophil values were strongly related. It was also found that preoperative neutrophil-to-lymphocyte, eosinophil-to-lymphocyte, and basophil-to-lymphocyte ratios were significantly higher in patients who experienced a disease relapse than in those who did not. In histologically-confirmed eosinophilic-type CRSwNP treated with endoscopic sinus surgery, mean blood eosinophil values dropped significantly from before to after the surgical procedure.

Conclusions/Significance: CRSwNP endotypes have different inflammatory profiles reflected in the relative proportions of different types of blood cells. The available data support the theory that blood eosinophil and basophil levels should be included in the routine preoperative work-up of CRSwNP patients in order to give patients accurate prognostic information, adopt rational follow-up protocols after surgery, and provide dedicated postoperative medical treatments.     

伴和不伴鼻息肉的慢性鼻-鼻窦炎患者筛窦的细菌学研究

目的:比较伴和不伴鼻息肉的慢性鼻-鼻窦炎患者及正常对照患者前筛黏膜标本的细菌学特征.方法:在鼻内镜手术中获取前筛黏膜标本,进行需氧和厌氧培养.结果:送检前筛黏膜标本119例,经需氧和厌氧组织匀浆半定量细菌培养,104例标本细菌培养为阳性(细菌培养总阳性率为87.4%);其中慢性鼻-鼻窦炎不伴鼻息肉组(CRSNP-组)、慢性鼻-鼻窦炎伴鼻息肉组(CRSNP+组)、正常对照组需氧或兼性厌氧细菌培养阳性率分别为86.5%、85.7%、90.0%,3组比较差异无统计学意义(P>0.05).3组患者的黏膜标本以需氧菌和厌氧菌混合感染为主,混合感染率分别为CRSNP-组78.4%、CRSNP+组81.0%、对照组85.0%,差异无统计学意义(P>0.05).3组最常见需氧菌株为凝固酶阴性葡萄球菌、棒状杆菌属细菌,比较差异均无统计学意义(均P>0.05).厌氧菌培养阳性率3组分别为78.4%、76.2%、77.5%,差异无统计学意义(P>0.05);最常见厌氧菌株为丙酸杆菌属细菌、消化链球菌属细菌,差异均无统计学意义(均P>0.05).结论:CRSNP-组和CRSNP+组及对照组患者前筛黏膜标本的细菌学特征无明显差异,细菌感染并非是慢性鼻-鼻窦炎发生鼻息肉这一机制中的惟一因素.     

基于随机森林与人工神经网络慢性鼻窦炎伴鼻息肉诊断模型的构建与分析

目的 慢性鼻窦炎伴鼻息肉(CRSwNP)是一个全球性的健康问题,现有的诊断技术存在一定局限性,因此有必要开发新的诊断模型来补充现有的诊断方法。方法 利用CRSwNP患者(GSE23552、GSE36830)的公开基因表达数据来识别潜在的差异基因,应用随机森林算法和人工神经网络进一步筛选特异性基因,建立CRSwNP的早期诊断模型。结果 共发现78个上调基因和25个下调基因,随机森林算法筛选了4个特异性基因(HPGDS、IL1RL1、FMO3、DOK3),人工神经网络构建出基于上述基因的预测模型,该模型具有良好的预测效果(AUC=0.986),独立数据集GSE194282进一步验证了其准确性(AUC=0.888)。结论 采用机器学习方法建立了一个基于基因表达水平的预测模型,该模型可以预测早期CRSwNP,有助于早期诊断和改善临床决策。     

患者术前临床特征对嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉的预测价值

目的 探讨患者的术前临床特征对嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉(ECRSwNP)的预测价值,并构建用于临床实践的诺模图。方法 选取2019年9月—2020年9月就诊于新乡医学院第一附属医院并行功能性鼻内镜手术治疗的慢性鼻窦炎伴鼻息肉(CRSwNP)患者97例,根据术后病理结果嗜酸性粒细胞(EOS)浸润程度将其分为ECRSwNP组和非嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉(nonECRSwNP)组,收集并比较两组患者的临床特征资料,采用单因素及多因素二元Logistic回归分析筛选对ECRSwNP有预测价值的术前特征资料,并构建用于临床实践的诺模图。采用SPSS 26.0和R语言软件4.1.2对数据进行分析。结果 两组患者在是否合并哮喘史、外周血嗜酸性粒细胞(EOS)计数、外周血嗜碱性粒细胞(Baso)计数、日本难治性嗜酸性慢性鼻窦炎流行病学调查(JESREC)评分、上颌窦评分、前后组筛窦评分、CT总分、E/M(筛窦与上颌窦的Lund-Mackay评分比值)上差异具有统计学意义(P<0.05)。单因素及多因素二元Logistic回归分析并构建的诺模图显示,基于哮喘史、外周血EOS、外周血...     

先天免疫分子Toll-Like-Receptor-9在慢性鼻窦炎鼻息肉发病机制中的作用探讨

目的:检测先天免疫分子Toll-Like-Receptor-9(TLR-9)蛋白在鼻息肉黏膜上皮细胞中的存在及表达,以期探讨其在鼻息肉发病中的作用及功能.方法:取鼻窦内镜下摘除的鼻息肉标本10例(鼻息肉组),鼻中隔偏曲和鼻外伤等手术切除的下鼻甲标本10例作对照组,消化法行原代细胞培养,流式细胞仪双抗纯化上皮细胞和检测上皮细胞中TLR-9蛋白含量.结果:①消化法培养人鼻黏膜原代细胞中上皮占98%;②鼻息肉组和对照组上皮细胞均有TLR-9表达,但鼻息肉组的TLR-9表达(11%～15%)显著低于对照组(49%～60%).结论:TLR-9存在于正常和鼻息肉的黏膜上皮中,但鼻息肉组水平下降,推测先天免疫分子TLR-9可以在鼻息肉发病机制中起作用.     

慢性鼻窦炎伴或不伴鼻息肉患者血清嗜酸粒细胞阳离子蛋白水平的比较

目的 比较慢性鼻窦炎伴有鼻息肉（CRSwNP）和不伴鼻息肉（CRSsNP）患者中血清嗜酸粒细胞阳离子蛋白（ECP）水平的差异。方法 采用ImmunoCAP100E系统,检测99例CRSwNP患者和59例CRSsNP患者的血清ECP水平,并与健康对照组84例比较。结果 三组间血清ECP水平的差异有统计学意义（P＜0.05）,其中CRSwNP组明显高于健康对照组（P＜0.01）,尤其是中-重度患者与健康对照组比较血清ECP水平显著升高（P＜0.01）。但CRSwNP组与CRSsNP组比较,差异无统计学意义（P＞0.05）;两组轻度与中-重度患者之间分别进行比较,差异均无统计学意义（P＞0.05）。结论 嗜酸粒细胞性炎症反应在慢性鼻窦炎伴或不伴鼻息肉的发病中可能均发挥了作用,但疾病的严重程度与炎性指标ECP的血清浓度之间未见明显相关性,有待进一步探讨。