鼻内镜下上颌窦开口的形态学观察

尽管有关上颌窦自然开口的研究已经有100多年历史[1],鼻内镜鼻窦手术中上颌窦自然开口的开放与扩大仍然只是一个笼统的概念,尚未形成一个统一的操作规范.在前期研究中,我们发现自然开口被全面扩大开放的上颌窦,术后黏液纤毛输送系统多数并没有沿着正常的生理途径进行传输[2].     

上颌窦自然开口的超微结构与纤毛分布观察

目的 探讨上颌窦自然开口黏膜在各个方向上超微结构与纤毛分布的异同.方法 ①对1例上颌窦自然开口窦内侧黏膜进行取材,直径为1 cm;②按扫描电镜标本制样程序制样;③使用扫描电镜仪对经制样处理后黏膜的上、下、前和后缘检查.结果 ①在上颌窦自然开口窦内侧的上、下、前、后缘黏膜,扫描电镜下均可见到密集的纤毛细胞,各个方向上各自纤毛的摆动方向一致,但各个方向相互间纤毛的摆动方向不一致;②上颌窦自然开口黏膜的微绒毛细胞数量在四个方向上由多到少的排列顺序:前、上、下、后缘;分泌细胞细胞数量在四个方向上由多到少的排列顺序:上、前、下、后缘.结论 上颌窦自然开口周围纤毛分布密集,但在不同方向上纤毛摆动方向和超微结构不同,提示上颌窦自然开口在各个方向上可能存在着功能差异.     

下鼻道泪后开窗上颌窦手术47例临床分析

目的：探讨经鼻内镜下鼻道泪后开窗处理上颌窦病变的疗效。方法：对47例上颌窦病变的患者,采取在鼻内镜鼻窦手术基础上进行下鼻道泪后开窗,经下鼻道窗和扩大的自然窦口对上颌窦息肉、内翻性乳头状瘤、侵袭性鼻窦真菌病等病变进行清理。结果：47例患者上颌窦腔清洁,上颌窦窦口引流好,黏膜转归良好,中鼻道引流好,无囊泡水肿等黏膜病变。仅2例（4．25％）下鼻道窗口约2个月闭锁,1年后上颌窦腔清洁,无病灶复发。结论：经鼻内镜下鼻道泪后开窗联合扩大的自然窦口完全满足处理上颌窦良性病变的需要,同时保留下鼻道窗可在术后起到机械性重力引流作用,在鼻腔鼻窦黏膜纤毛运输系统功能修复前尤为重要。     

上颌窦中鼻道窦造口术及窦壁成形术（摘要）

经Caldwell-Lue径路行上颌窦前壁环钻术，保留完整骨片。根治性或功能性清除上颌窦及筛窦的病变组织。改变下鼻道开窗为中鼻道窦造口术或自然孔扩大。修补窦前壁并把骨片对合复位，钻孔固定．完成窦壁成形术。术后结果表明．窦口开放率高．窦腔结构正常，复发率低。中鼻道窦口符合窦腔和窦口区纤毛流动方向，有利于生理性引流，窦壁成形修复完整窦腔为鼻窦生理功能提供了解剖生理环境。     

鼻内窥镜术上颌窦自然开口的处理

探讨内窥镜鼻窦手术治疗慢性鼻窦炎，鼻息肉的上颌窦中鼻道开口的重要性及处理方法。方法 配对研究５６例双侧鼻窦炎，鼻息肉患者，比较同一患者术中扩大或不扩大上颌窦自然开口的术后情况。结果 窦口的开放率在不扩大和扩大上颌窦自然开口的术侧中分分别为９２．９％和８０．４％。     

上颌窦穿刺器下鼻道开口置管引流治疗化脓性上颌窦炎

对230例化脓性上颌窦炎患者，在通畅或扩大上颌窦自然开口的基础上，用上颌窦穿刺器经下鼻道钻入上颌窦。经鼻窦内窥镜检查，对可逆性的窦内粘膜炎症，在拔除上颌窦穿刺器之前，经穿刺器套管放入直径为4mm的塑料管，用于上颌窦引流、冲洗、注药，可一次置管至脓液消失。在拔除置管后，下鼻道可形成窦道，起到了类似下鼻道开窗术的作用。于3～6个月后随访，治愈率为85．7％。表明，此方法具有组织损伤小、操作简便快速、出血少、反应轻，以及病人痛苦小等优点。用之治疗化脓性上颌窦炎，行之有效。     

慢性上颌窦炎鼻内镜下开窗方式的选择与疗效观察

目的观察鼻内镜下上颌窦开放术治疗慢性上颌窦炎,不同开窗方式的选择与疗效分析。方法 56例单侧慢性筛、上颌窦炎伴鼻息肉患者,术前Lund-Mackay CT评分,CT评分=2者纳入研究对象,术中随机分为A组28例、B组28例,分别行中鼻道开窗和中下鼻道联合开窗,以鼻腔鼻窦结局测试-20（sino-nasal outcome test-20,SNOT-20）量表中文版、Lund-Kennedy评分及糖精试验黏液纤毛传输时间（mucociliary transport time,MTT）对比术后疗效,另外,用亚甲蓝染色观察黏液纤毛传输途径。结果术后6个月时,A、B两组SNOT评分、Lund-Kennedy评分及MTT值差异均有统计学意义（P〈0.05）;50例亚甲蓝从上颌窦口下缘流出,5例亚甲蓝从上颌窦口前缘流出。结论①对于慢性上颌窦炎Lund-Mackay CT评分=2的病例,行中、下鼻道联合开窗可取得更好的疗效;②上颌窦口下缘黏膜是黏液纤毛传输的重要途径,对上颌窦的引流起着极为重要的作用。     

鼻内镜手术联合下鼻道开窗治疗慢性上颌窦炎的选择与疗效

目前,功能性内镜鼻窦手术（functiongal endoscopic sinus surgery,FESS）在我国普遍开展,鼻外科学得到了快速发展[1]。对慢性上颌窦炎的治疗多倾向于单纯扩大上颌窦自然口。但笔者临床观察,对上颌窦内黏膜纤毛功能进行监测,纤毛功能丧失者,行下鼻道联合开窗明显优于单纯开放上颔窦自然口,现报道如下。     

上颌窦良性占位性病变手术入路的探讨

目的探讨鼻内镜下多种手术入路治疗上颌窦良性占位性病变的方法及疗效。方法采用鼻内镜下中鼻道扩大上颌窦自然开口术、鼻内镜下中-下鼻道联合上颌窦开窗术、鼻内镜下鼻腔外侧壁切开上颌窦手术、鼻内镜下上颌窦内侧壁切除术、鼻内镜下改良Denker术等多种入路对136例上颌窦良性占位性病变进行手术治疗。结果除2例上颌窦后鼻孔息肉和1例内翻性乳头状瘤复发,经再次手术治疗痊愈外,其他患者均无复发。结论根据上颌窦良性占位性病变的不同临床特点,采用不同手术入路既可有效治愈上颌窦病变,同时可最大限度地减少手术创伤。     

上颌窦Coldwell-Luc手术下鼻道是否造对孔的研究

为了研究下鼻道是否有必要造对孔,作者自1984年以来对38例慢性上颌窦炎患者进行了双侧上颌窦根治术,左侧按Caldwell—Luc法切除上颌窦和下鼻道的粘膜,下鼻道造对孔引流,右侧于一周后切除筛骨的钩突,扩大中鼻道自然开口,上颌窦的粘膜也被切除。两种手术方法以面颊部肿胀,失血量和手术时间为指     

Reevaluation of maxillary sinus surgery: experimental study in rabbits

Functional endoscopic sinus surgery concentrates primarily on the removal of ostiomeatal complex disease. When required, maxillary sinus ostioplasty is performed. However, surgical widening of a sinus ostium is contrary to common precepts. A study therefore was performed to reevaluate the effects of antrostomies and of intrasinus mucosal removal. Widening of the natural ostium, a separate antrostomy at some distance from the ostium, or radical mucosal removal was performed on 30 rabbits. Fifteen sinuses were used as controls. After 6 to 8 weeks the status of the sinus mucosa and mucociliary clearance was studied. The study confirmed that mucociliary clearance continued toward the natural ostium following inferior antrostomy. Following widening of the natural ostium, mucociliary clearance through the ostium redeveloped in 11 of 18 sinuses but was typically imperfect. There were no cases of ostial closure; however, the incidence of infection was significantly higher in all three experimental groups than in the control group.     

鼻内镜下上颌窦良性病变的手术治疗

目的:探讨鼻内镜下上颌窦良性病变的手术切除方法.方法:41例上颌窦息肉、囊肿、曲菌病、内翻性乳头状瘤等良性病变,分别采用3种不同的手术方式清除病灶,其中30例经扩大的上颌窭自然开121径路;4例经鼻内中、下鼻道双径路;7例经扩大的上颌窦自然开口及鼻腔外侧壁切除双径路.结果:术后随访6个月以上,治愈39例,2例复发,治愈率95.1%.结论:鼻内镜下经鼻腔采用3种不同的手术径路切除上颌窦良性病变,疗效肯定,创伤小,值得临床推广.     

The influence of the size of the maxillary sinus ostium on the nasal and sinus nitric oxide levels

BACKGROUND: Nitric oxide (NO) is produced in significant quantities in the nasal sinuses and is thought to have a beneficial effect on the mucociliary transport of the sinuses and nose and to have significant antibacterial properties that contribute to the health of the sinuses. Recently, the concept of "mini-functional endoscopic sinus surgery" has been introduced where the uncinate is removed without enlargement of the maxillary ostium. Although no scientific evidence has been published, enlargement of the ostium is thought to possibly disrupt the mucociliary pathway and decrease the concentration of NO in the nose and sinuses. The aim of this study was to establish the effect of enlargement of the maxillary ostium on sinus and nasal NO. METHODS: Twenty-nine patients who were post-endoscopic sinus surgery were included with 52 who were maxillary sinus ostia cannulated. There were 22 large maxillary sinus ostia and 30 small ostia. Smoking, allergy status, and topical steroid use were recorded. NO levels were measured in the nose and maxillary sinus after decongestion with patients mouth breathing and breath holding. RESULTS: This study shows that enlargement of the maxillary sinus ostium above its normal size (20 mm2) produces a significant decrease in both the maxillary sinus and the nasal cavity NO levels. In addition, the size of the ostium showed a significant correlation to the sinus NO level. Use of topical nasal steroid sprays and topical decongestants were shown to effect NO levels in the sinuses and nasal cavity. The lowered levels of NO were found irrespective of the technique of measurement of the NO. CONCLUSIONS: The effect of this lowered NO level on the susceptibility of the maxillary sinuses to recurrent infection is yet to be determined.     

鼻内镜术后上颌窦异常引流与黏膜炎症状态

目的观察上颌窦自然引流状态及引流的关键部位，探讨鼻内镜术后上颌窦的引流与窦腔炎症的关系，为鼻内镜手术上颌窦自然窦口的处理提供参考。方法用美蓝作为示踪剂，观察15例上颌窦无明显炎症或炎症较轻受检者上颌窦自然引流状态及引流的关键部位。另选择89例慢性鼻窦炎不伴鼻息肉患者鼻内镜术后6个月，且上颌窦黏膜恢复良好的患者，观察其上颌窦引流状态及方式，并继续随访至12个月，内镜下评估黏膜的炎症情况，分析鼻内镜术后上颌窦引流方式与黏膜炎症状态的关系。结果上颌窦自然窦口引流的关键部位在自然窦口的后下，近钩突尾端的附着处。引流物出上颌窦向后下走行，最终流向鼻咽部。传统鼻内镜手术后，引流方式相对正常者15例，占16．9％；74例（83．1％）患者上颌窦的引流状态及引流方式发生了明显改变。其中包括反向引流6例、多相引流31例、引流不能20例、“蓄水池”样改变9例以及黏膜失用8例。术后12个月33．7％的患者再次发生炎症反应，以黏膜失用炎症的发生率（100％）最高，其次是引流不能及反向引流（各占50％）。结论上颌窦自然窦口的后下近钩突尾端附着处是上颌窦引流的关键部位；鼻内镜术后，上颌窦自然引流关键部位的损伤甚至瘢痕形成，可以导致上颌窦的异常引流，过度开放上颌窦窦口，有可能加重上颌窦黏膜的损伤；上颌窦的异常引流状态及方式与黏膜炎症的发生率密切相关。     

The location of maxillary sinus ostium and its clinical application

The endoscopic sinus surgeons must have a detailed knowledge of inconsistent location of maxillary sinus openings in any interventional maxillary sinus surgeries as it relates to the orbital floor, ethmoid infundibulum and the nasolacrimal duct. Forty cadaver head and neck specimens had been cut sagittally through the nose, such that the lateral nasal wall had been preserved. The findings were documented with an emphasis on location of the maxillary sinus openings. In the present study maxillary sinus ostium opened more commonly into posterior third of the hiatus semilunaris. Accessory maxillary ostium was another variation seen in nearly three-fourths of the cases which opened into membranous meatus inferior to the uncinate process.     

Extended Middle Meatal Antrostomy: The Treatment of Circular Flow

Intranasal surgery has changed significantly over the years. The inferior meatal antrostomy has lost favor to the more physiologic middle meatal antrostomy which includes the natural ostium. Difficult-to-cure patients may exhibit mucous stasis due to circular flow between ostomies. Kennedy described circular flow in both the experimental model and the clinical arena. We have enlarged his definition of circular flow to include the flow of mucus from the natural ostium or a surgically created ostium to any accessory ostium, either natural or surgically created. We present the extended middle meatal antrostomy, a technique which prevents circular flow and allows the mucociliary system to provide for physiologic drainage of the maxillary sinus. This technique is demonstrated in this report to be safe and effective in the treatment of chronic maxillary sinusitis. Laryngoscope, 106:1214-1217, 1996     

Role of the maxillary sinus as a resonant cavity]

Patients with a paranasal disorder often manifest voice change. Yet, computer simulation of these nasal sounds is difficult using a nasal tract model without any branching cavity. In other words, acoustic property of the nasal tract is influenced by a coupling with the paranasal sinuses. If the transfer function of the sinus acts as a Helmholtz resonator, the resonance frequency, or "zero" point, of the sinus would be present on the acoustic spectrum of the nasal cavity. This study was designed to prove the validity of this hypothesis. The sweep tone was given from the subjects' epipharyngeal space. The tone passed through their nasal space and radiated from the anterior nostrils. In 13 cases without nasal or paranasal disorders, the tones obtained at the nostrils were analyzed with Fast Fourier Transformation (FFT) and were compared between two conditions of the ostia of the maxillary sinuses, obstructed and opened with epinephrine. The resonance frequencies of the maxillary sinuses ranged from 1 to 2 kHz and varied considerably among individuals. This variation may be due to a difference in the maxillary sinus volume and in the diameter and length of the natural maxillary ostium. In past reports, in which the resonance frequency of the sinus was measured using a compound model or computed simulation, the maxillary sinus resonated below 1 kHz. In these reports the ostium of the maxillary sinus was regarded as a straight pipe. However, the examination of 29 cadavers revealed that the radius of the ostium differs according to its depth. The radius in the depth halfway from the edge was narrower than that of the edge. The way of evaluating a shape of the ostium is different between the present and the past studies, thus possibly resulted in discrepancy of the resonance frequency.