2012年欧洲鼻窦炎和鼻息肉意见书解读

慢性鼻-鼻窦炎(CRS)和鼻息肉是一组多因素导致、多步骤发生的、具有高度异质性的鼻黏膜炎性病变,尽管过去20年间相关研究取得了巨大进展,但仍有很多重要的诊疗问题没有获得专家学者们的一致认识[1].2007年,由荷兰鼻科专家Fokkens等牵头组织的国际专家组依据循证医学的原则对2005年CRS和鼻息肉的诊疗文件进行了整理和补充,随后在Rhinology杂志以增刊的形式刊发了该立场文件,即2007版的欧洲CRS和鼻息肉意见书(European position paper on rhinosinusitis and nasal polyps 2007,EPOS 2007)[2].该文件随后被翻译成超过15种语言在世界各国出版,提升了CRS和鼻息肉的诊疗水平.     

鼻内镜下治疗79例慢性鼻窦炎鼻息肉的临床观察

慢性鼻窦炎、鼻息肉是耳鼻咽喉科的常见病、多发病，传统的治疗方法是在额镜下手术，光线弱，或采用鼻外手术，损伤重，并且病变切除不彻底。鼻内镜的临床应用，使慢性鼻窦炎、鼻息肉治疗提高到了一个新的水平。我院自2001年6月～2003年6月期间，施行鼻内镜手术治疗79例慢性鼻窦炎、鼻息肉。现总结、分析如下。     

慢性鼻窦炎鼻息肉临床分型分期与疾病分类的标准化

中华医学会耳鼻咽喉科学分会和中华耳鼻咽喉科杂志编辑委员会于1997年在海口制订了“慢性鼻窦炎鼻息肉临床分型分期及内窥镜鼻窦手术疗效评定标准”（简称海口标准）。通过近10年来的临床实践，“海口标准”对规范慢性鼻窦炎、鼻息肉的临床分型，鼻内镜手术疗效的评价，以及在学术交流和临床科研等方面产生了巨大的影响。然而随着医疗卫生信息化的发展，“海口标准”的部分内容已不能完全适应临床工作和医疗卫生信息化的需求。     

飞行人员鼻窦炎鼻息肉的临床诊治和医学鉴定研究

目的：总结飞行人员鼻窦炎鼻息肉的临床诊治和医学鉴定经验。方法：分析飞行人员鼻窦炎鼻息肉资料93份。结果：急性鼻窦炎11例，慢性鼻窦炎鼻息肉82例。慢性鼻窦炎鼻息肉Ⅰ类46例（包括Ⅰa地面有症状39例和Ⅰb体检时发现7例），Ⅱ类36例（地面无症状、飞行中有继发性气压伤，包括Ⅱa继发性鼻窦气压伤14例，Ⅱb继发性耳气压伤13例，Ⅱc继发性鼻窦气压伤＋耳气压伤9例）。慢性鼻窦炎鼻息肉Ⅰ型1期24例，Ⅰ型2期38例，Ⅰ型3期7例；Ⅱ型1期2例，Ⅱ型2期6例，Ⅱ型3期3例；Ⅲ型2例。84例恢复飞行，9例永久停飞。结论：鼻窦炎鼻息肉可直接或因继发性气压伤而危及飞行安全，慢性鼻窦炎鼻息肉伴继发性耳气压伤者是医学停飞的重要原因，患鼻窦炎鼻息肉的飞行人员只有在获得良好治疗效果及耳气压功能和鼻窦气压功能正常的情况下方可恢复飞行。     

解读英国变态反应和临床免疫学会鼻鼻窦炎和鼻息肉诊治指南

2008年初《Clinical and Experimenta Allergy》发表了由英国国立皇家耳鼻咽喉科医院Scadding等9位学者共同完成的“英国变态反应和临床免疫学会鼻鼻窦炎和鼻息肉诊疗指南”。该指南在收集分析相关文献的基础上,参考医学专家的意见,对数据类型和推荐等级分别进行分类和分级,反映了所依赖的数据可靠程度。英国指南短小精悍,省略了基础研究的数据,重点突出临床实用性,主要针对从事变态反应工作的内科医师。     

霉菌性鼻窦炎的误诊及处理

霉菌性鼻窦炎近几年已成为耳鼻咽喉科较为常见疾病,因临床表现各异,患者自觉症状轻重不一,使临床医师较难及时作出正确诊断,容易引起误诊而影响患者的治疗效果.本文通过回顾性分析外院误诊而在我院确诊的15例霉菌性鼻窦炎患者的临床资料,对其误诊原因和选择正确的治疗方法进行探讨.     

鼻炎汤在变应性鼻窦炎鼻息肉术后应用观察

慢性鼻窦炎、鼻息肉为耳鼻咽喉科常见病，目前治疗是以手术为主的综合治疗。以变应性为主要病因的鼻窦炎鼻息肉占慢性鼻窦炎鼻息肉的很大一部分。功能性鼻内镜下鼻窦炎、鼻息肉手术，目的在于清除病灶，改善鼻腔、鼻窦的通气引流；手术是治疗慢性鼻窦炎、鼻息肉的关键部分，而围手术期的治疗及术后的后续治疗，与鼻窦炎、鼻息肉术后的疗效及预后有密切关系；     

传统手术后复发性鼻窦炎鼻息肉的鼻内镜修正术

由于鼻腔鼻窦解剖结构的复杂性和鼻息肉本身具有易复发的特性,使得鼻窦炎鼻息肉术后复发成为困扰鼻科临床医师的难题.Kenndey等(1985)报道用鼻内镜手术治疗慢性鼻窦炎鼻息肉,治愈率可达80%,其复发率仍达20%.而许多基层医院因限于条件还未装备鼻内镜,因此还有大量的基层医院仍在以传统手术治疗鼻窦炎、鼻息肉.这些患者或因手术时限于条件为避免严重并发症的发生导致手术不彻底,或因患者不能按时随访清理而导致复发,复发率远远高于20%.我们从2002年1月～2003年12月开始采用鼻内镜修正术治疗传统手术后复发性鼻窦炎鼻息肉,取得了较好疗效,现选取资料完整、定期随访的75例报告如下.     

金黄色葡萄球菌在变应性鼻炎和慢性鼻窦炎伴鼻息肉中的研究进展

金黄色葡萄球菌（金葡菌）定植与变应性鼻炎（AR）和慢性鼻窦炎伴鼻息肉（CRSwNP）的加重及预后密切相关。本文详细阐述了金葡菌造成AR及CRSwNP难以控制的机制,同时概括性描述了金葡菌在AR和CRSwNP患者的局部定植情况及对血清炎症的影响。     

国际著名鼻科专家Wytske J.Fokkens教授访谈录

Wytske J.Fokkens荷兰阿姆斯特丹医学中心教授,耳鼻咽喉科主任。1986～1992年接受耳鼻咽喉科专科医师培训,1991年发表博士学位论文《变应性鼻炎的发病机制:侧重于探讨郎罕斯细胞的作用》,1992～2002年耳鼻咽喉科医师和鼻科专科医师,1994～2002年担任鹿特丹依拉斯姆医学中心鼻黏膜研究组组长。学术团体主要任职:WHO变应性鼻炎及其对哮喘的影响(ARIA)工作组常委;美国变态反应、哮喘和免疫学会(AAAAI)非变应性鼻炎工作组成员;荷兰耳鼻咽喉科学会变态反应和免疫学组主任;欧洲变态反应和临床免疫学会(EAACI)鼻窦炎鼻息肉诊断(EPOS)工作组主任、非变应性鼻炎诊断和治疗工作组成员;欧洲鼻科学会常务委员;Allergy杂志副主编;Acta Oto-Laryngologica国际编委,全球变态反应和哮喘研究欧洲协作网(GA2LEN)阿姆斯特丹医学中心代表。     

European Position Paper on Rhinosinusitis and Nasal Polyps 2012

The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007.The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps and chronic rhinosinusitis with nasal polyps are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed.     

Effect of Obstructive Sleep Apnea on Immunity in Cases of Chronic Rhinosinusitis With Nasal Polyps

Objectives.Chronic rhinosinusitis with nasal polyps (CRSwNP) is a more severe inflammatory form of CRS that often coexists with obstructive sleep apnea (OSA). However, little is known about the relationship between OSA and the immune profile in patients with CRSwNP. We aimed to investigate the immune profile of patients with CRSwNP according to OSA severity.Methods.This study included 63 patients with CRSwNP and nine control subjects. Protein levels of inflammatory mediators were determined using multiplex immunoassays. All patients underwent standard polysomnography.Results.In patients with eosinophilic CRSwNP (ECRSwNP), interleukin (IL)-6 and chemokine [C-X-C motif] ligand (CXCL)-1 (type 1 immune-related markers) were upregulated in cases of moderate-to-severe OSA. Additionally, IL-4, IL-13, C-C motif chemokine (CCL)-11, CCL-24 (type 2 immune-related markers), and IL-17A (a type 3 immune-related marker) were present at elevated levels in patients with moderate-to-severe OSA. Although there were no significant differences in type 1, 2, or 3 immune-related markers among patients with non-eosinophilic CRSwNP (NECRSwNP) according to the severity of OSA, transforming growth factor-beta expression was higher in those with moderate-to-severe OSA. Furthermore, in ECRSwNP with moderate-to-severe OSA, associations were detected between serum markers and some upregulated inflammatory markers.Conclusion.OSA may increase the heterogeneity of the immune profile (types 1, 2, and 3) in patients with ECRSwNP, but not in those with NECRSwNP.     

Benign Nasal Polyps Causing Bone Destruction in the Nasal Cavity and Paranasal Sinuses

Benign nasal polyposis, when extensive, can cause bone displacement and destruction within the nasal cavity and paranasal sinuses. Consequently it may be difficult to distinguish this entity from a malignant neoplasm.     

Nasal Obstruction and Palate-Tongue Position on Sleep-Disordered Breathing

Objectives

We wanted to evaluate whether the presence of nasal obstruction makes a change on the association between the modified Mallampati score and the severity of sleep-disordered breathing (SDB) and the sleep quality.

Methods

Polysomnography (PSG), the modified Mallampati score (MMS), the body-mass index, and a questionnaire about nasal obstruction were acquired from 275 suspected SDB patients. The subjects were divided into two groups according to the presence of nasal obstruction. The clinical differences between the two groups were evaluated and the associations between the MMS and PSG variables in each group were also assessed.

Results

Significant correlations were found between the MMS and many PSG variables, including the apnea-hypopnea index, the arousal index and the proportion of deep sleep, for the patients with nasal obstruction, although this was not valid for the total patients or the patients without nasal obstruction.

Conclusion

The severity of SDB and the quality of sleep are well correlated with the MMS, and especially for the patients with nasal obstruction. The MMS can give more valuable information about the severity of SDB when combined with simple questions about nasal obstruction.     

Nasal Obstruction and Sleep-disordered Breathing: The Effect of Supine Body Position on Nasal Measurements in Snorers

Objective --Nasal obstruction is considered to be a potential etiological factor in sleep-disordered breathing. However, a significant correlation between nasal measurements and obstructive sleep apnea has not been demonstrated so far. The aim of this study was to investigate the relationships between nasal resistance, nasal volumes and selected sleep parameters using nasal measurements performed in both seated and supine positions. We also investigated whether snoring patients in our clinical sample showed increased positional or decongestive nasal mucosal changes. Material and Methods --Forty-one snoring men on a waiting list for correction of nasal obstruction underwent polysomnography, anterior rhinomanometry and acoustic rhinometry. Nineteen non-snoring control subjects were also recruited. Nasal measurements were performed in a seated position, after lying down in a supine position and, after decongestion of nasal mucosa, in a seated position again. Results --In the overall patient group, nasal volume at a distance 2-4 cm from the nares in the supine position correlated inversely with apnea-hypopnea index (AHI) ( r = &#109 0.32, p <0.05) and oxygen desaturation index (ODI) ( r = &#109 0.49, p <0.05). In the non-obese patients, total nasal resistance measured in a supine position correlated with AHI ( r =0.50, p <0.05) and ODI ( r =0.58, p <0.05) and supine nasal volumes were also inversely correlated with ODI. No significant correlations were found between baseline nasal measurements performed in a seated position and sleep parameters. Postural or decongestive changes in nasal measurements were not increased in snoring patients compared with control subjects. Conclusion --The relationship found between nasal measurements and sleep parameters suggests that nasal obstruction does augment airway collapse.