鼻窦炎患者鼻窦骨结构变异和鼻窦粘膜异常的CT扫描分析

对109例临床疑为鼻窦炎患者的CT冠状扫描结果进行了分析,鼻窦粘膜异常改变者93例(85.3％),16例粘膜呈正常影像(14.7％),93例鼻窦粘膜异常改变者中,发现鼻窦骨结构变异60例(64.5％)。通过对鼻窦骨结构变异和鼻窦炎情况的观察分析,认为鼻窦骨结构变异可能是鼻窦炎致病因素之一。鼻窦粘膜异常以前组筛窦和上颌窦发生率最高,同时伴有窦口鼻道复合体粘膜异常,支持了鼻窦口引流障碍可以继发鼻窦炎的观点。作者认为采用鼻窦CT冠状扫描对判断鼻窦炎的病因和临床诊断具有重要意义。     

CT扫描对上颌窦骨间隔畸形的诊断价值

目的：探讨ＣＴ扫描对上颌窦骨间隔畸形的诊断价值。方法：对８例经ＣＴ扫描确诊、手术证实的上颌窦骨间隔畸形患者的临床资料进行分析。结果：８例中,垂直冠状分隔者５例,水平分隔者２例,垂直矢状分隔者１例,双侧者３例,单侧者５例。     

Anatomic variations of the paranasal sinuses: CT examination for endoscopic sinus surgery

Chronic rhinosinusitis endoscopic surgery requires an accurate evaluation of diseases and paranasal sinus anatomic variations. This study aims to show the main anatomical variations in the ostiomeatal complex and paranasal sinuses which are usually depicted by computed tomography (CT). CT scans obtained 2 mm thickness in axial and coronal plane from a series of 200 patients with chronic sinusitis were examined to determine the prevalence of anatomic variants. Anatomical variations determined were supraorbital recess in 6%, concha bullosa in 30%, sphenomaxillary plate in 17%, infra-orbital ethmoid cells (Haller's cells) in 6%, spheno-ethmoid cells (Onodi's cells) in 12%, pneumatization of the anterior clinoid process in 6%, carotid artery bulging into the sphenoid sinus in 8%, pneumatization of the uncinate process in 2%, paradoxical curvature of the middle turbinate in 3% and septal deviation in 36%. Level difference between the ethmoid roof and nasal vault was an average of 8 mm in right side and 9.5 mm in left side. Awareness of these different variations will help the rhinologic surgeon in his orientation during endoscopic surgical procedures.     

Paranasal sinus exostoses: Possible correlation with cold temperature nasal irrigation after endoscopic sinus surgery

Exostoses of the external auditory canal (EEAC) are a commonly encountered clinical exam finding; however, exostoses in other locations are vanishingly rare. The postoperative paranasal sinuses are penetrated with cold water solutions, the reputed etiological agent for EEAC, and development of exostoses in this unexpected location may be observed endoscopically. The surprising appearance of these protuberant lesions within the sinuses could be mistaken for more ominous processes, subjecting the patient to biopsy, surgery, or unnecessary medical therapy. The radiologic appearance of exostoses within the paranasal sinuses is herein reported for the first time, and care is taken to distinguish these bony lesions from the osteoneogenesis of chronic inflammation. Laryngoscope, 2013     

Basic surgical techniques and variations of endoscopic sinus surgery

This article gives complete information on the care of the endoscopic sinus surgery patient. Indications and preoperative evaluations necessary for endoscopic sinus surgery are described. The technique of functional endoscopic sinus surgery is covered in detail. Postoperative care and complications are also described. Various procedures for patients with extensive or unusual disease are discussed.     

Preoperative CT scanning for endoscopic sinus surgery: a rational approach

Recent research on inflammatory sinus disease has implicated a central role for the ethmoid labyrinth, which may influence changes in the maxillary and frontal sinuses. CT can provide excellent definition of the paranasal sinuses and particularly the ethmoids, which is a prerequisite for endoscopic surgery. We describe a prospective series of 110 coronal CT scans performed on patients with a clinical diagnosis of sinusitis who had undergone diagnostic nasal endoscopies and medical treatment prior to surgery. 86% of the scans showed abnormal mucosal thickening. The ethmoids were affected in 73% and the maxillary sinus in 64%. Pneumatization of the middle turbinate was a common variant and when present was associated with anterior ethmoid disease in 60% of patients. Anterior ethmoid inflammatory changes were demonstrable in 95% of patients with maxillary sinus disease. Direct coronal CT can readily demonstrate disease in the infundibulum, frontal recess and posterior ethmoids in the same orientation confronting the endoscopist, and helps in the planning of ethmoidal surgery. Following surgery the sinuses can be directly inspected in outpatients which reduces the need for any further plain radiographs. It is important that the diagnosis of sinusitis is not based on CT findings alone as isolated areas of mucosal thickening are common in the normal population.     

Preoperative CT scanning for endoscopic sinus surgery: a rational approach.

Recent research on inflammatory sinus disease has implicated a central role for the ethmoid labyrinth, which may influence changes in the maxillary and frontal sinuses. CT can provide excellent definition of the paranasal sinuses and particularly the ethmoids, which is a prerequisite for endoscopic surgery. We describe a prospective series of 110 coronal CT scans performed on patients with a clinical diagnosis of sinusitis who had undergone diagnostic nasal endoscopies and medical treatment prior to surgery. 86% of the scans showed abnormal mucosal thickening. The ethmoids were affected in 73% and the maxillary sinus in 64%. Pneumatization of the middle turbinate was a common variant and when present was associated with anterior ethmoid disease in 60% of patients. Anterior ethmoid inflammatory changes were demonstrable in 95% of patients with maxillary sinus disease. Direct coronal CT can readily demonstrate disease in the infundibulum, frontal recess and posterior ethmoids in the same orientation confronting the endoscopist, and helps in the planning of ethmoidal surgery. Following surgery the sinuses can be directly inspected in outpatients which reduces the need for any further plain radiographs. It is important that the diagnosis of sinusitis is not based on CT findings alone as isolated areas of mucosal thickening are common in the normal population.     

鼻内镜鼻窦手术中鼻腔鼻窦解剖变异与慢性鼻窦炎的关系

目的 探讨鼻内镜鼻窦手术中鼻腔鼻窦解剖变异与慢性鼻窦炎的关系。 方法 选取慢性鼻窦炎患者206例,根据是否患有慢性鼻窦炎分为观察组85例与对照组121例。记录两组患者是否存在鼻中隔偏曲、泡状中鼻甲、下鼻甲及鼻丘气房肥大、中鼻甲反向偏曲及钩突气化等鼻腔鼻窦解剖变异现象。 结果 观察组鼻中隔偏曲、下鼻甲及鼻丘气房肥大、泡状中鼻甲发生率均显著高于对照组(P<0.05),而中鼻甲反向偏曲及钩突气化发生率比较无显著差异(P>0.05)。两组鼻中隔偏曲均以高位偏曲为主,但观察组鼻中隔高位偏曲发生率显著高于对照组(P<0.05)。 结论 鼻中隔偏曲、泡状中鼻甲、鼻丘气房及下鼻甲肥大均为慢性鼻窦炎发展中的重要结构变异,与慢性鼻窦炎的发生密切相关。     

Paranasal sinus mucosal regeneration: the effect of topical retinoic acid

BACKGROUND: Paranasal sinus mucosa may suffer morphological and functional alterations as a result of surgical trauma. Mucosal stripping typically yields regenerated mucosa characterized by fibrosis, inflammatory infiltrate, and dysmorphic or absent cilia. The aim of this study was to determine the effect of topical retinoic acid (vitamin A) on regeneration of paranasal sinus mucosa. METHODS: Both maxillary sinuses of 12 New Zealand white rabbits were surgically opened and stripped of mucosa. Six rabbits received 0.01% topical retinoic acid gel treatment to the stripped left maxillary sinus (low concentration group). The remaining six rabbits received 0.025% topical retinoic acid gel to the stripped left maxillary sinus (high concentration group). The stripped right maxillary sinus of all 12 rabbits served as the operated, untreated control to reflect the normal healing process. Six other animals served as unoperated controls. The sinus mucosa was examined by light microscopy after 14 days. RESULTS: Untreated regenerated mucosa showed expected changes of submucosal gland loss, basal lamina and lamina propria fibrosis, cellular atypia, and loss of cilia. Topical retinoic acid treatment appeared to result in better mucosal regeneration marked by less cellular atypia and fibrosis. Although the regenerated mucosa was still grossly abnormal, the degree of ciliary loss and cellular derangement was reduced. The lower-concentration retinoic acid group had more favorable morphology than the higher-concentration retinoic acid group, and both were improved when compared with no treatment. CONCLUSIONS: In a rabbit model, topical vitamin A in the form of retinoic acid gel appears to enhance regeneration of ciliated paranasal sinus mucosa. This preliminary study suggests that topical retinoids may have applicability in promoting sinus wound healing.     

Anatomy for endoscopic sinus surgery

An understanding of the anatomy of the paranasal sinuses is essential for successful endoscopic sinus surgery. The anatomy of the sinuses is carefully described and illustrated.     

Image-guidance for endoscopic sinus surgery

Objectives/Hypothesis: Image‐guided surgery (IGS) is a critical tool. However, its clinical validity remains controversial. A review of indications and a consensus based on literature are presented. Methods: Literature review. Results: Traditional indications remain valid. Novel applications have emerged, and the reliability of IGS has been consistently endorsed. Although evidence is based on scattered reports and expert opinions, the use of IGS in approved instances is regarded as the state of the art. Conclusions: IGS is reliable, and a scientific validation of outcomes would entail unethical strategies. An expanding spectrum of indications is anticipated, although IGS does not replace proper training.     

Cost analysis of computer-aided endoscopic sinus surgery

Functional endoscopic sinus surgery' (FESS) is a common otolaryngologic procedure, with over 250,000 operations performed annually. Computerized surgical navigation systems are available to assist the rhinologic surgeon in the complex dissection required for FESS. Our objective was to determine whether this system provided quantifiable benefits in FESS. We retrospectively reviewed 203 patients with chronic sinusitis who underwent endoscopic sinus surgery, and divided them into two groups based on whether or not computerized surgical navigation was used. There was no statistically significant difference between the two groups in terms of surgery duration, extent of surgery, percent of complementary procedures, percent of supplementary procedures, complexity of surgery, and percent revision surgery. Computer-assisted surgery (CAS) was 6.7% more expensive than sinus surgery without computerized surgical navigation (p = 0.01). However, the intangible benefits of CAS may outweigh the added expense. (American     

大环内酯类药物治疗内镜鼻窦手术后黏膜迁延性炎性反应的临床观察

目的 观察小剂量服用大环内酯类药物对内镜鼻窦手术后鼻窦黏膜长期迁延性炎性反应患者治疗的临床效果。方法 病例来源于2004-2006年中山大学附属第一医院耳鼻咽喉科医院首次经内镜鼻窦手术治疗后2年以上、长期迁延性鼻窦炎性反应、疗效评估未愈的慢性鼻窦炎患者13例。治疗方案采用克拉霉素250 mg/d,连续口服超12 ～ 28周,同时保留原有基本治疗（鼻用糖皮质激素、黏液促排剂、鼻腔盥洗）。在治疗结束时与结束后3、6个月采用症状视觉模拟量表和内镜黏膜形态评估（Lund-Kennedy评分法）对临床疗效进行主客观综合评价。以SPSS 16.0统计软件进行t检验或非参数检验。结果 13例患者中1例经20周治疗无效中断治疗,其他12例均达到预定的停药标准。全部患者停药时间分别为：12周4例,16周2例,20周5例,24周1例,28周1例。综合评价结果：非常好6例,好4例,比较好2例,不好1例。治疗前后症状视觉模拟量表及内镜Lund-Kennedy评分（中位数[25分位数;75分位数]）分别为8.00[7.50;8.50]与1.00[0.25;1.00];7.00[6.50;8.00]与1.00[0.00;1.00],治疗前后差异均有统计学意义(Z分别为-3.201、-3.194,P均＜0.01)。停药后3～6个月未发现鼻窦炎复发。13例患者未发生药物不良反应,肝肾功能均未受到影响。结论 小剂量（250 mg/d）、长期（12 ～28周）使用大环内酯类药物治疗内镜鼻窦手术后顽固的持续性迁延性炎性反应临床疗效显著、稳定。大环内酯类药物临床安全性和患者耐受性较好。     

Instruments and equipment for endoscopic sinus surgery

It is the fiberoptic endoscope and its related hardware that distinguish endoscopic sinus surgery from previous techniques. Lens angles of 0, 25, and 70 degrees, comprising a representative telescope set, accommodate virtually any endoscopic sinus procedure, diagnostic or therapeutic, with unsurpassed visualization. Each telescope may be fitted with an optional suction-irrigation adaptor, a highly controversial accessory among endoscopic surgeons. The clinical situation often dictates the optimal combination of equipment, anesthesia, and technique; surgeon's preference is equally influential. Mastery of conventional operative techniques combined with thorough endoscopic skills is essential for consistent, effective, and safe surgical performance.     

Long-term outcome analysis of endoscopic sinus surgery for chronic sinusitis

BACKGROUND: The purpose of this study was to determine long-term subjective outcome of endoscopic sinus surgery (ESS) for chronic sinusitis (CS) and to evaluate prognostic indicators for surgical treatment failure. METHODS: This is a prospective study of patients who underwent ESS for CS. Symptom assessment was performed using a visual analog scale at a pretreatment interview and then at regular intervals post-ESS for up to a 3-year period. The indicators for symptom scoring were nasal obstruction, facial pain, postnasal drip, anterior discharge, and anosmia/hyposmia. RESULTS: Data analysis indicates that ESS improves symptom scoring early on, but the effects begin to dissipate over time. Anosmia/hyposmia is the most severe symptom overall for all patient subgroups and recurs to a greater degree 3 years postoperatively in Samter's Triad sufferers (p = 0.006), asthmatic patients (p = 0.002), and those with a worse CT scan at presentation (p = 0.04). In addition, Triad sufferers who complain of nasal obstruction and anterior nasal discharge have a significant recurrence of their symptoms postoperatively (p = 0.04 and 0.001, respectively). CONCLUSION: Individuals must be warned that ESS may not be a long-term solution for CS because of its chronic nature. Patients are relieved of their symptoms initially; however, these tend to recur over a 3-year period. Samter's Triad is the strongest determinant of long-term treatment failure. Asthma also is a determinant of treatment failure, which lends credence to the notion of combined airway disease. Allergy was not a strong determinant of treatment failure in our study.     

鼻内镜鼻腔鼻窦手术临床分析

目的探讨鼻内窥镜下鼻腔鼻窦手术临床效果及术后处理。方法鼻内镜下进行各种鼻腔鼻窦手术并术后随访的方法将鼻内镜手术治疗过的各类鼻腔、鼻窦疾病患者,给予定期鼻内镜检查、局部处理、鼻腔冲洗以及合理用药等。结果术后患者临床症状改善明显,均达到临床治愈,鼻窦炎鼻息肉术后复发6例,1例慢性肥厚性鼻炎病例术后出现鼻腔粘连,2例上颌窦炎术后复发,按时随访的患者术后症状改善明显,复发机会减少。结论鼻内镜术后大部分临床症状改善明显,均达到临床治愈,术后随访及术腔处理将鼻内镜手术的疗效提高,减少复发,减轻患者不适感。     

Telemedicine: teleproctored endoscopic sinus surgery

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.     

Platelet gel for endoscopic sinus surgery

OBJECTIVES: New techniques are being utilized to improve outcomes for endoscopic sinus surgery, including newer forms of packing. Platelet gel is an innovative technique that holds many advantages, including comfort, hemostasis, and growth factors that may improve wound healing. This report discusses the theoretical advantages of this packing material and describes the initial results in a cohort of patients who underwent endoscopic sinus surgery. METHODS: A cohort of patients who underwent endoscopic sinus surgery were interviewed and evaluated after the placement of platelet gel. A quality of life study was also administered for further understanding. RESULTS: None of the patients in the study had postoperative epistaxis that required additional packing, and there were no instances of synechia formation or exuberant granulation tissue. Although not statistically significant because of a small population, the quality of life scores did show improvement over the control group. CONCLUSIONS: Platelet gel used as a packing material after endoscopic sinus surgery offers efficient hemostatic properties, as well as growth factors that can advance the healing process. The quality of life of the patient may be improved by the use of platelet gel packing.