探讨开放后组筛窦、蝶窦在鼻内镜手术治疗慢性鼻窦炎中的必要性

慢性鼻窦炎、鼻息肉病变往往涉及多个鼻窦，包括额窦、上颌窦、前组筛窦、后组筛窦及蝶窦。近10余年来，鼻内镜外科技术成为治疗慢性鼻窦炎和鼻息肉的重要手段。鼻内镜下纠正鼻腔、鼻窦的解剖异常，恢复和重建鼻腔、鼻窦良好通气和引流是治疗鼻窦炎、鼻息肉的主要目的。我们发现开放后组筛窦、蝶窦与否在鼻内镜手术中治疗鼻窦炎、鼻息肉有着相同的治愈率。     

复发性鼻窦炎鼻息肉的修正性鼻内镜手术治疗

目的 总结修正性鼻内镜手术治疗复发性鼻窦炎鼻息肉的手术体会。方法 采用MesserKlinger技术对84例复发性鼻窦炎鼻息肉病人行筛窦、蝶窦开放，额窦、上颌窦窦口扩大等修正性手术治疗。结果 治愈51例，好转17例，无效16例。治愈率为60．7％，有效率为80．9％，无效率为19．1％。结论 修正性鼻内镜手术是治疗复发性鼻窦炎鼻息肉的有效方法。选择具有定向定位作用的解剖参照点是手术安全的基础；选择恰当的术式、实施精细的操作是手术成功的关键。结构变异、出血、鼻息肉病等因素是手术失败的原因。     

霉菌性鼻窦炎的诊断与治疗

目的 探讨霉菌性鼻窦炎的诊断与治疗方法。方法 对87例经手术病理证实为霉菌性鼻窦炎的临床表现、体征、影像学及手术、病理资料、治疗效果进行总结分析。结果 65例术前经临床表现、结合CT即明确诊断，22例为术后经病理检查才明确诊断，87例均行鼻窦病灶清理术，术后用抗真菌药物冲洗窦腔，全部病例均治愈。结论 该病大多有典型的临床表现，CT有明确的特征性，手术彻底清除病灶，通畅引流，抗真菌药物冲洗窦腔是有效的治疗方法。     

功能性内镜手术前后上颌窦及筛窦粘膜的改良

目的 回顾近年来文献，综述慢性鼻窦炎病人经功能性内镜鼻窦手术前后上颌窦粘膜病变与转归。方法 分析近年有关的文献13篇。结果 慢性鼻窦炎病人经功能性内镜鼻窦手术治疗后病变粘膜均有不同程度恢复。结论 功能性内镜鼻窦手术是治疗慢性鼻窦炎的有效手段。了解手术前后粘膜病变与转归对指导术后治疗与护理大有帮助。     

鼻内镜下鼻窦病变和开口的处理

建立以筛窦为中心的各窦引流通畅,是慢性鼻窦炎鼻内镜下鼻窦开放术的首要内容。鼻窦口开放与否是鼻内镜手术疗效评定的重要依据之一。尽管鼻内镜术后的鼻窦口开放率与许多因素有关,但完善的手术操作仍是影响其开放的重要因素。1993年1月-2003年12月我院共收治鼻源性疾病1893例,所有患者均经鼻内镜检查和鼻窦冠状位CT扫描,其中经鼻内镜手术治疗后病理证实慢性鼻窦炎患者1581例,疗效较好,现报告如下。     

鼻内镜鼻窦手术治疗青少年慢性鼻窦炎临床观察——附43例报告

目的 探讨鼻内镜鼻窦手术治疗青少年慢性鼻窦炎的适应证、并发症及手术疗效。方法 本组43例（78侧）全部采用Messerkling′s术式，视病变范围，鼻腔解剖变异情况切除钩突，摘除息肉。扩大上颌窦自然开口，开放筛窦，酌情开放额窦。同期处理相关病变。结果 43例病人总的治经为86．05％，好转率为9．3％，无效为4．65％，同期成人鼻窦炎鼻肉镜手术治愈率为59．26％，两者相比差异具有非常显著性（P＜0．01），术后并发症主要是术腔粘连。结论 鼻肉镜鼻窦手术治疗青少年慢性鼻窦炎是目前较为理想的治疗方法。     

霉菌性鼻窦炎的诊治体会

目的探讨霉菌性鼻窦炎的临床特点及诊治方法.方法回顾分析1999至2003年48例霉菌性鼻窦炎的临床资料.结果48例中霉菌球性鼻窦炎44例,变态反应性霉菌性鼻窦炎(AFS)2例,急性暴发型侵袭性霉菌性鼻窦炎(AFFS)2例;12例行改良上颌窦根治术,36例行鼻内镜手术;2例AFFS死亡1例,1例存活,右眼视力丧失,余46例临床症状消失,术腔上皮化良好,引流通畅,随访3个月无复发.结论霉菌性鼻窦炎以霉菌球型最为常见.侵袭性霉菌性鼻窦炎病情危重,预后差,临床应予以足够的重视.鼻窦CT是早期诊断的有效方法.手术彻底清除病窦内病变组织,建立通畅的长期引流通道是治疗的关键.     

真菌性鼻窦炎CT的非特征性表现

目的：回顾分析真菌性鼻窦炎患者术前CT,提出非特征性的临床表现,以提高术前诊断的准确性。方法：术后病理诊断为真菌性鼻窦炎患者CT176例,术前均行鼻窦CT检查及鼻内镜检查。所有患者均经鼻内镜下鼻窦开放术,术中清理窦内病变并经病理检查证实为真菌感染。其中单纯蝶窦35例,单纯上颌窦84例,筛窦上颌窦49例,全组鼻窦3例,筛窦蝶窦5例。观察以上各组术前CT除病变钙化特征以外的非特征性表现。结果：本组患者共176例179侧,其中单侧173例,双侧3例（全组鼻窦感染）。CT的非特征性改变包括：窦内病变密度均匀增高,窦内病变密度不均匀增高,受累鼻窦内侧壁可有骨质吸收。病理证实179侧中,单纯蝶窦组CT病变钙化27侧,CT病变非特征性改变8侧,其中窦内均匀密度增高5侧,不均匀密度增高3侧;单纯上颌窦组病变钙化72侧,病变非特征性改变12侧,其中窦内均匀密度增高8侧,不均匀密度增高4侧,伴有骨质吸收5侧;筛窦上颌窦组病变钙化36侧,病变非特征性改变13侧,其中窦内均匀密度增高9侧,不均匀密度增高4侧,伴有骨质吸收6侧;全组鼻窦组病变钙化6侧;筛窦蝶窦组病变钙化5例。窦内病变钙化达81.56％。结论：窦内病变的钙化被视为真菌性鼻窦炎CT的特征性表现,但在临床工作中可观察到部分真菌性鼻窦炎术前CT的非特征性改变。当缺乏CT的特征性表现时,仅通过CT尚不能作出真菌性鼻窦炎的术前诊断,需其他检查手段来做鉴别诊断,甚至需经手术探查后的病理诊断来确诊。     

功能性内镜手术前后上颌窦及筛窦粘膜的改变

目的回顾近年来文献,综述慢性鼻窦炎病人经功能性内镜鼻窦手术前后上颌窦及筛窦粘膜病变与转归.方法分析近年有关的文献13篇.结果慢性鼻窦炎病人经功能性内镜鼻窦手术治疗后病变粘膜均有不同程度恢复.结论功能性内镜鼻窦手术是治疗慢性鼻窦炎的有效手段,了解手术前后粘膜病变与转归对指导术后治疗与护理大有帮助.     

Ⅲ型慢性鼻窦炎鼻息肉综合治疗方法的探讨

目的：探讨Ⅲ型慢性鼻窦炎鼻息肉有效的综合治疗方法。方法：57例Ⅲ型慢性鼻窦炎鼻息肉（均有一次以上鼻腔鼻窦手术史），其中21例筛窦骨质明显增生，窦腔融合，15例（24侧）为上颌窦根治术后复发，采用Messerkinger法彻底开放筛窦，充分扩大自然孔，术后用内镜电离子技术处理术腔水肿样肉芽组织及早期息肉与逐步处理上颌窦病变组织，冲洗窦腔，控制感染等综合治疗方法的随访观察。结果：大部分病例术后6－9个月症状明显改善，鼻腔，中鼻道，筛窦腔均已上皮化，12例（18例）上颌窦腔充分扩大且上皮化，3例（4侧）1年后除上颌窦前下壁少许粘膜水肿外均上皮化，全部病例均随访1年－1年半，治愈36例（63．2％），结论：Ⅲ型慢性鼻窦炎鼻息肉鼻内镜手术只是治疗的重要一环，内镜电离子技术是术后处理早期病变和上颌窦内病变促进上皮化的有效方法，术中充分扩大自然孔，开放筛窦和术后有效的抗感染是重要环节。     

Functional Endoscopic Sinus Surgery and 109 Mycetomas of Paranasal Sinuses

Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.     

高分辨率CT在窦口-鼻道复合体的临床应用价值

目的通过高分辨率CT(HRCT)对慢性鼻窦炎患者窦口-鼻道复合体(OMC)的影像分析,探讨其在功能性鼻内镜手术(FESS)的应用价值.方法收集12～54岁患者30例,常规冠状位HRCT扫描和横断面扫描,并采用适宜的窗技术观察.结果HRCT能直接显示慢性鼻窦炎病变的范围、程度以及OMC的阻塞部位;且能清晰显示解剖变异,骨质改变.结论HRCT对FESS有肯定的指导价值.     

Primary and secondary fungal infections of the paranasal sinuses: clinical features and treatment outcomes

CONCLUSION: In a retrospective study of 239 cases of fungal sinusitis, noninvasive paranasal sinus aspergillosis was most common and successfully treated by endoscopic sinus surgery (ESS) with postoperative sinus irrigation. For the treatment of fungal sinusitis, ESS with or without antifungal agents and control of predisposing factors for secondary cases are recommended. OBJECTIVE: The aim of this study was to investigate the clinical characteristics of fungal sinusitis and evaluate the treatment outcomes of primary and secondary fungal infections of the paranasal sinuses. MATERIALS AND METHODS: Two hundred thirty-nine cases of fungal infection of the paranasal sinuses seen between January 1997 and December 2006 were retrospectively analyzed by reviewing their medical records. There were 200 cases of primary fungal infection and 39 cases of secondary fungal infection. RESULTS: The symptoms of chronic rhinosinusitis such as nasal obstruction, purulent rhinorrhea, and postnasal drip were commonly present in both primary and secondary infections, and the sphenoid sinus was commonly involved in secondary infection. The radiological findings in fungal sinusitis included haziness, calcification, and bone destruction of the involved sinuses. CT scans in 80% of the primary and 69% of the secondary cases revealed calcific densities in a paranasal soft tissue mass. Twenty-eight of 38 cases which had MR showed decreased signal intensities on T1-weighted images and markedly reduced signal intensities surrounded by bright signal on T2-weighted images. In secondary cases, the most common concomitant disease was diabetes mellitus. All patients received surgery including biopsy, ESS, and Caldwell-Luc's operation. Mucosal hypertrophy with fungus ball, which was the most common finding in both types, was found in 124 cases (62%) with primary and in 26 cases (67%) with secondary cases, and aspergillosis was most common, followed by unidentifiable colony, and mucormycosis. Eleven cases received amphotericin-B postoperatively. Two hundred thirty-eight cases showed no recurrence during the mean follow-up period of 11 months.     

CT检查在真菌性鼻窦炎术前诊断的意义

目的 探讨CT检查在真菌性鼻窦炎术前诊断中的意义。方法 对67例真菌性鼻窦炎患者CT改变、临床表现和术中所见进行回顾性对比分析。结果 CT表现为：鼻窦充填密度不均软组织影29例,术前明确诊断为真菌性鼻窦炎12例;窦内充填软组织影伴散在不规则钙化灶34例,术前均明确诊断为真菌性鼻窦炎;上颌窦内壁吸收破坏21例,术前明确诊断为真菌性鼻窦炎14例：筛顶骨壁吸收破坏2例,术前均明确诊断为真菌性鼻窦炎：上颌窦骨壁出现增生硬化19例,术前明确诊断为真菌性鼻窦炎14例。67例中CT诊断鼻窦炎症60例,其中46例术前临床初诊为真菌性鼻窦炎,7例为上颔窦／筛窦肿物或占位性变。结论 窦腔内散在斑块状钙化的软组织充填是真菌性鼻窦炎CT诊断的主要征象,其它的CT表现常会导致术前误诊。虽然真菌性鼻窦炎的确诊有赖于病理学检查,但CT在其诊断中仍具有重要参考价值,并且是显示鼻窦解剖结构和病变范围的较好方法。     

Nitric oxide: a new concept in chronic sinusitis pathogenesis

PURPOSE: Exhaled NO is produced mainly in paranasal sinuses and nasal mucosa. Nasal NO has been suggested to have a variety of effects in nasal cavity. Decreased exhaled NO is found in chronic sinusitis, and NO metabolite levels are increased in animal models of chronic sinusitis, suggesting a role for them in sinusitis pathogenesis. There was no data available on human NO metabolite level. MATERIALS AND METHODS: We lavaged maxillary sinuses in a control and 2 patient groups. The control group was patients who underwent functional endoscopic sinus surgery (FESS) due to any other reason than chronic sinusitis. The patient groups had chronic rhinosinusitis with and without polyposis who underwent FESS. Maxillary sinuses were lavaged during FESS, and NO metabolites (nitrate and nitrite) were lavaged in the lavage fluid. RESULTS: Nitric oxide metabolite levels (mean +/- SEM) were 8.085 +/- 1.43 mumol/L in healthy maxillary sinus lavage fluid and 18.04 +/- 3.51 and 16.78 +/- 2.91 mumol/L in chronic rhinosinusitis with and without polyposis, respectively. Lavage fluid of sinuses with chronic sinusitis had elevated levels of NO metabolites, which were significantly higher than the control group. The difference between the chronic sinusitis with and without polyposis groups was not significant. CONCLUSIONS: Nitric oxide metabolites were significantly higher in maxillary sinuses of patients with chronic sinusitis. Elevated levels of NO and NO metabolites in sinusitis might damage healthy sinus epithelium. NO metabolites may have an important role in sinusitis pathogenesis.     

Nasal and paranasal sinus anomalies in children with chronic sinusitis

Functional endoscopic sinus surgery (FESS) is being advocated to treat children with chronic sinusitis. The surgeon performing FESS needs an intimate understanding of the anatomy to adequately treat disease and avoid complications. One hundred thirty-six patients who had endoscopic sinus surgery were reviewed. Preoperative direct coronal computed tomography scans were available for review in 114 patients. Several nasal and paranasal sinus anomalies were uncovered during this evaluation. The most common was hypoplasia of the maxillary sinuses. All hypoplastic maxillary sinuses had diseased mucosa. Eleven patients were found to have a laterally deviated uncinate process and abnormal anatomy of the maxillary ostia. Other anomalies such as concha bullosa, Haller's cells, and paradoxic curvature of the middle turbinate were found, and their respective frequencies in this population were determined.     

免疫组织化学法在鼻窦真菌球诊断中的价值

OBJECTIVE: To study the pathogens of fungus balls in paranasal sinuses and establish an immunohistochemical test by which the main opportunistic fungi could be identified. METHODS: Twenty-five patients with fungal balls were treated by surgical removal of the fungus ball in the infected sinuses. The pathogenic fungi on the specimens were identified by means of routine PAS and immunohistochemical staining methods, and the sensitivity of the two methods were compared. RESULTS: The most commonly infected sinus was the maxillary sinus, followed by sphenoid sinus. Pathogens of fungal balls were found to be aspergillus (92%, 23/25) and candida 2 cases (8%). Aspergillus and candida albicans in infected sinuses could be specifically identified by immunostainning. There was no statistically significant differences of sensitivity between immunostainning and PAS stain. CONCLUSIONS: The main pathogen of the fungus ball was aspergillus. Immunostainning was a rapid and reliable method to identify fungi in infected tissues of paranasal sinuses. It should be widely used in the diagnosis of fungal sinusitis.     

鼻内镜在诊治鼻腔鼻窦真菌病中的应用

目的：评价鼻内镜技术在鼻腔鼻窦真菌病的诊断和治疗中的应用价值。方法：对54例非变态反应性真菌性鼻窦炎患者应鼻内镜技术诊断与治疗的经验进行总结。结果：全部患者均获治愈，随访1-5年未见复发。结论：在本病的诊断与治疗中，应用鼻内镜技术可减轻患者的侵损性操作，并缩短诊治时间，避免或减少复发。鼻内镜技是诊断治疗鼻腔鼻窦真菌病较为理想的方法。     

免疫组织化学法在鼻窦真菌球诊断中的价值

目的　研究鼻窦真菌球的主要致病菌种 ,探索组织切片中快速鉴定主要条件致病真菌的组织病理学方法。方法　 2 5例鼻窦真菌球患者接受鼻窦病变清除术 ,对其组织病理标本分别进行了碘酸雪夫染色 (paraaminosalicylic ,PAS)和免疫组织化学染色 ,并比较两种方法的敏感性。 结果鼻窦真菌球以上颌窦发病率最高 ,其次是蝶窦。致病真菌检测 :曲霉菌感染 2 3例 (92 % ) ,白色念珠菌感染2例 (8% )。鼠抗曲霉单克隆抗体、兔抗白色念珠菌多克隆抗体可以分别鉴定组织中的曲霉菌和白色念珠菌。免疫组化和PAS染色的敏感性差异无显著性 (χ2 =0 2 72 ,P >0 0 5 )。结论鼻窦真菌球感染以曲霉菌属多见 ,免疫组化技术具有抗原特异性强、诊断快速的特点 ,为确定鼻窦组织的真菌感染以及鉴定真菌菌属提供了新的可靠方法     

鼻窦胆固醇肉芽肿24例

目的探讨鼻窦胆固醇肉芽肿患者的病因、发病机理以及治疗方法。方法回顾性总结分析1996年3月至2003年3月经手术和病理证实的24例鼻窦胆固醇肉芽肿患者的临床资料。结果24例患者中，术前诊断为慢性鼻窦炎10例，鼻窦黏液囊肿8例，鼻息肉或出血坏死性鼻息肉5例，考虑可能为胆固醇肉芽肿者仅l例。主要症状有鼻塞(20／24)、鼻漏(18／24)、嗅觉减退(10／24)、头痛(7／24)、眼眶痛(5／24)、复视(2／24)等。鼻窦CT及MRI提示为慢性鼻窦炎、鼻窦囊肿以及鼻息肉和(或)黏膜息肉样变。所有病例均因保守治疗无效而采取外科手术治疗，即鼻内镜术或Caldwell-Luc术，仅l例行鼻侧切开术。23例手术效果良好，随访1年以上无复发；仅l例Caldwell-Luc术后2年复发，再次行鼻内镜术，术后3年未复发。结论鼻窦胆固醇肉芽肿的病因主要有三：含气腔通气受阻、引流障碍、含气腔出血。鼻窦胆固醇肉芽肿似乎与鼻窦慢性炎性疾病关系密切，尤其是鼻窦黏液囊肿。术式的选择应根据病变范围和程度来决定，其原则是彻底清除病变，保持鼻窦通畅引流。