鼻睫神经痛的手术治疗体会

目的探讨鼻睫神经痛的临床特征，以提高对该病的诊疗水平。方法对5例鼻睫神经痛患者的临床资料进行回顾性分析。5例患者分别行鼻中隔矫正术，中鼻甲成形术及筛窦切除术治疗。结果术后随访半年，5例患者痊愈。结论鼻睫神经痛的主要表现为与筛、额窦炎相似的头痛，但无流涕；细致的鼻腔检查及鼻窦CT扫描是防止漏诊、误诊的重要手段；恰当的鼻中隔及中鼻甲矫正术及筛窦开放术疗效确切。     

Pott's Puffy Tumor and Epidural Abscess Arising from Pansinusitis

Background

Sinusitis is a common disorder that can result in rare but serious complications including periorbital or orbital cellulitis, intracranial abscess or meningitis, subperiosteal scalp abscess (“Pott's puffy tumor”), osteomyelitis, and cavernous sinus thrombosis.

Case Report

We report a case of a 41-year-old man who presented to our Emergency Department with pansinusitis. He did not obtain recommended follow-up treatment after discharge and 26 days later returned with a persistence of sinusitis, Pott's puffy tumor, and an intracranial abscess caused by Streptococcus intermedius. The patient required multiple otolaryngological and neurosurgical interventions and was treated with long-term antibiotic therapy.

Conclusions

Pott's puffy tumor is a complicated infection that requires intravenous antibiotic and surgical treatment. Diagnosis is made by contrast-enhanced computed tomography scan. Early treatment significantly contributes to favorable outcome and decreases the risk of further complications such as epidural abscess.     

Radiologic imaging in the management of sinusitis

Sinusitis is one of the most common diseases treated by primary care physicians. Uncomplicated sinusitis does not require radiologic imagery. However, when symptoms are recurrent or refractory despite adequate treatment, further diagnostic evaluations may be indicated. Plain radiography has a limited role in the management of sinusitis. Although air-fluid levels and complete opacification of a sinus are more specific for sinusitis, they are only seen in 60 percent of cases. Noncontrast coronal computed tomographic (CT) images can define the nasal anatomy much more precisely. Mucosal thickening, polyps, and other sinus abnormalities can be seen in 40 percent of symptomatic adults; however, clinical correlation is needed to avoid overdiagnosis of sinusitis because of nonspecific CT findings. Use of CT is typically reserved for difficult cases or to define anatomy prior to sinus surgery. Magnetic resonance imaging (MRI) cannot define bony anatomy as well as CT. MRI is only used to differentiate soft-tissue structures, such as in cases of suspected fungal infection or neoplasm. Referral will occasionally be needed in unusual or complicated cases. Immunocompromised persons and smokers are at increased risk for serious sinusitis complications.     

Radiological findings in a rare case of eyelid swelling: Pott's puffy tumor

Pott's puffy tumor (PPT), or osteomyelitis of the frontal bone, is a rare entity especially in adults. PPT is believed to occur as a complication of fronto-ethmoidal sinusitis or trauma to the frontal bone. We present the computed tomography and magnetic resonance imaging findings in such a rare case of Pott's puffy tumor.     

Orbitocranial Complications of Acute Sinusitis in Children

Background

Orbitocranial complications (OCCs) of sinusitis are uncommon but potentially life threatening. OCCs carry high morbidity, mortality, and significant long-term sequelae. Late recognition leads to even worse outcomes.

Objective

To present four case reports showing that aggressive management of complications of sinusitis-like OCC decreases long-term sequelae and mortality in pediatric patients.

Case Reports

Four pediatric patients diagnosed with OCC were treated at our institution from April 2012 to March 2013. Three were boys and one was a girl; ages ranged from 4–14 years. Magnetic resonance imaging and computed tomography were the most useful imaging modalities. All patients received broad-spectrum antibiotics. Additional interventions consisted of endoscopic sinus surgery, subdural empyema drainage, and orbital decompression.

Conclusion

The difficult complications of acute sinusitis in the pediatric age group should be anticipated, recognized early, and aggressively managed to prevent morbidity and a fatal outcome.     

鼻内镜加鼻外进路手术治疗慢性额窦炎37例围术期护理体会

目的:探讨鼻内镜加鼻外进路手术治疗慢性额窦炎的效果及护理方法。方法:将123例慢性额窦炎患者随机分为3组,传统根治术组41例,行传统根治手术治疗;功能性鼻内镜手术组45例,行功能性鼻内镜手术(FESS)治疗;鼻内镜加鼻外进路手术组37例,行常规鼻内镜手术切除筛房病变,经面部弧形小切口根治额窦内病变,同时上下联合扩大鼻额管,并给予精心围术期护理。结果:鼻内镜加鼻外进路手术组术后疗效与其他两组比较均有显著性差异(P<0.01),该组患者术后10d内均痊愈出院,未出现严重并发症,随访6个月~4年无1例复发。结论:鼻内镜加鼻外进路手术治疗慢性额窦炎,损伤小,可缩短术后治疗时间,加之精心的围术期护理,可减少并发症的发生,促进患者康复。     

Comparison of Sinus X-rays with Computed Tomography Scans in Acute Sinusitis

Objective: To determine the sensitivity and specificity of sinus x-rays of patients clinically diagnosed as having acute sinusitis. Methods: Thirty consecutive adult, nonpregnant emergency department (ED) patients clinically diagnosed as having acute sinusitis and meeting study criteria were entered into the study. Sinus x-rays were obtained immediately after study entry and sinus computed tomography (CT) scans were done within 72 hours. Radiologic criteria for sinusitis were defined as more than 3 mm of mucoperiosteal thickening (MPT), an air/fluid (A/F) level, or opacification. All films were read in a blinded fashion [CT scans by two radiologists and plain films by two emergency medicine (EM) staff members and the same radiologists]. A third radiologist interpreted CT scans when the initial radiologists disagreed. Results: Sinus CT scans were obtained for 29 of 30 patients. Radiologists interpreted 28 of 29 CT scans identically, with 21 being positive for sinusitis. Sensitivity and specificity of x-rays were 57% and 88%, 62% and 88%, 67% and 75%, and 48% and 100% for the two radiologists and the two EM physicians, respectively. Four ethmoid, five frontal, and five sphenoid sinuses were opacified or had A/F levels on CT scan. No ethmoid, frontal, or sphenoid sinus was interpreted as being opacified or having an A/F level on plain film. Sensitivity and specificity of maxillary sinus opacification or A/F level on x-ray were 70% and 100%, 70% and 100%, 70% and 96%, and 70% and 96% for the two radiologists and the two EM physicians, respectively. Mean concordances (kappa) of x-ray and CT scan interpretations for the four reviewers were 0.34 (range, 0.30–0.39) for the diagnosis of sinusitis and 0.77 (range, 0.74–0.79) for maxillary sinus opacification or A/F level. Conclusion: Sinus x-rays are less sensitive than sinus CT scans for demonstration of radiographic changes consistent with acute sinusitis. Sinus plain films may not be reliable enough to assist with clinical decision making. If severity of patient illness requires diagnostic certainty, more sensitive imaging studies, such as CT scans of the sinuses, should be considered.     

鼻内镜手术治疗真菌性鼻-鼻窦炎的围术期护理

目的探讨鼻内镜手术治疗真菌性鼻-鼻窦炎围术期的护理方法。方法选择行鼻内镜手术治疗的96例真菌性鼻-鼻窦炎患者,不同类型的鼻窦炎患者采取个性化的护理措施,总结护理方法。结果96例真菌性鼻-鼻窦炎患者中,真菌球型鼻-鼻窦炎76例,变态反应真菌性鼻-鼻窦炎12例,急性暴发性真菌性鼻-鼻窦炎2例,慢性侵袭性真菌性鼻-鼻窦炎6例,所有患者随访1～8年,无一例出现护理并发症。结论对于不同类型的真菌性鼻-鼻窦炎,需根据患者的具体情况做好围术期护理,以减少术后并发症及复发的可能。     

Unique Case of “Post‐Lumbar Puncture Headache”

Lumbar puncture (LP) is associated with complications that include post‐LP orthostatic headache, local bleeding, and subdural hematoma. We report a unique case of a spontaneous frontal epidural hematoma following a therapeutic lumbar puncture in a patient with a history of idiopathic intracranial hypertension. This case highlights the importance of symptomatology in patients following LPs by revealing a rare intracranial presentation that would be devastating if not discovered promptly and appropriately managed.     

Subdural empyema and epidural abscess: recent experience in a community hospital

We treated 31 cases of localized central nervous system infection over a seven-year period in our community hospital. The causes included brain abscess in 18 cases (58%); cranial subdural empyema (CSE) in six cases (20%); spinal epidural abscess (SEA) in four cases (13%); cranial epidural abscess (CEA) in two cases (6%); and spinal subdural empyema (SSE) in one case (3%). Both CSE and CEA were often caused by sinusitis and manifested by fever, headache, altered sensorium, and focal neurologic signs. Treatment consisted of drainage by burr holes or craniotomy followed by long-term administration of parenteral antibiotics. Though all patients with CSE and CEA survived, half had severe residual neurologic deficits. Both SEA and SSE were manifested by fever, spinal pain, and loss of motor function, and both were treated by laminectomy drainage and antibiotic administration. One patient died and three of the other four had residual neurologic deficits or back pain. Diagnosis of CSE and CEA was facilitated by CT scanning, while clinical examination, CT scanning, and myelography were useful in diagnosing SEA; SSE was not suspected preoperatively.     

Epidural administration of morphine for control of cancer pain: long-term efficacy and complications

The long-term analgesic effects and the complications of epidural narcotic analgesia (ENA) were investigated in 40 cancer patients in whom systemic narcotic therapy failed to relieve pain or caused unacceptable side effects. In 32 patients, an externally fixated polyamide epidural catheter was used ("external group"), and in 8 patients, a polyurethane epidural catheter was tunneled and connected to a subcutaneous access port ("internal group"). The average duration of catheter treatment was 80.9 days (range 9-533 days). Twenty-five patients were treated as outpatients, and 15 remained hospitalized. Initially, all patients had significant or complete pain relief from 10 mg morphine/day, but the daily epidural morphine requirement showed a threefold increase during the first 3 weeks. During ENA, other methods of pain relief (radiotherapy, chemotherapy, surgery, epidural administration of local anesthetics, and nerve blocks) were necessary in 14 patients. Pharmacological side effects were of minor importance, with transient pruritus being the main subjective complaint. In the "external" group, 31 catheter replacements were necessary, mostly due to backflow of injected morphine outside the catheter. In two patients of the internal group, neurological complications occurred, but these disappeared spontaneously after removal of the system. They were presumably due to epidural fibrosis with compression of the spinal cord. Further technical improvements are necessary for the easier use and higher safety of the catheter technique.     

Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis.

Neurology. 2002;59:1450-1453.
Trigeminal pain processing was studied in 14 patients with unilateral migraine attacks and 14 age- and sex-matched patients with comparable unilateral headache from frontal sinusitis. Using a nociception-specific blink reflex method (nBR), a facilitation of nBR responses predominantly on the headache side was observed in migraine, but not in sinusitis. The facilitation of trigeminal nociception may be specific for migraine rather than a consequence of peripheral pain such as frontal sinusitis.
Comment: Here we have evidence for the central hyperexcitability of migraine, not found in the previously cited article by Boska et al. SJT     

鼻内镜下上颌窦窦口开放联合下鼻道开窗入路手术治疗真菌性鼻窦炎的有效性和安全性

目的探讨鼻内镜下上颌窦窦口开放联合下鼻道开窗入路手术治疗真菌性鼻窦炎的有效性和安全性。方法选取2013年9月至2018年8月于我院行手术治疗的真菌性鼻窦炎患者146例,依患者意愿分为对照组(n=69)和研究组(n=77),分别行鼻内镜下上颌窦窦口开放术和鼻内镜下上颌窦窦口开放联合下鼻道开窗入路术治疗,随访3个月。比较两组手术前及随访结束后的鼻内镜评分、生存质量、术后并发症发生情况。结果随访结束后,两组患者的鼻内镜评分和生存质量评分均明显低于手术前,且研究组低于对照组(P<0.05)。两组患者术后并发症总发生率比较,差异无统计学意义(P>0.05)。结论鼻内镜下上颌窦窦口开放联合下鼻道开窗入路术治疗真菌性鼻窦炎可改善患者的临床症状,提高其生存质量,且并发症少。     

鼻内窥镜下鼻窦鼻息肉手术60例疗效观察

目的 观察鼻内窥镜下鼻窦鼻息肉手术治疗的效果.方法 对60例(107侧)慢性鼻窦炎鼻息肉患者行鼻内窥镜下手术,术后随访1年.结果 治愈39例(65.0%),好转16例(26.7%),无效5例(8.3%).总有效率91.7%.术后并发症主要为鼻腔粘连.结论 鼻内窥镜下鼻窦鼻息肉手术治疗具有良好的疗效,术中正确处理中、下鼻甲及鼻中隔,术后定期随访可提高治愈率,减少并发症.     

Vasovagal Reactions and Other Complications of Cervical vs. Lumbar Translaminar Epidural Steroid Injections

Objective:   To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections.
Background:   Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported.
Methods:   Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications.
Results:   The incidence of vasovagal reaction was 7 points more common ( P  < 0.001, 95% confidence interval 0.04–0.12) in the cervical group (8%) than in the lumbar group (1%). This correlates to an additional vasovagal reaction for every 14 patients who were treated with cervical injection in comparison with those treated with lumbar injection.
Discussion:   The risk of vasovagal reaction is significantly higher for cervical translaminar epidural steroid injections than for lumbar injections. The risk of vasovagal reaction remained higher for cervical injection even when adjusting for differences between the two populations. The higher rate of cervical vasovagal reactions may result from a combination of anxiety, the prone position with neck flexed, head drapes, and stimulus from a neck procedure.
Conclusion:   Increased vigilance for patients undergoing translaminar cervical epidural steroid injections may be warranted. Clinicians may choose to consider these results when counseling patients regarding risk and the need for conscious sedation during the procedure.     

认知护理干预应用于鼻窦炎手术患者对改善其生活质量及并发症的效果

目的 探究鼻窦炎手术患者接受认知护理干预对改善生活质量及减少术后并发症的效果.方法 选择我院2014年10至2015年10月期间收治的鼻窦炎手术患者96例,随机分为两组各48例.对照组行常规护理,观察组行认知护理干预.对比两组患者术后并发症发生率、住院时间、护理满意度及生活质量情况.结果 观察组患者的总并发症发生率低于对照组,差异有统计学意义(P<0.05);观察组患者的住院时间短于对照组,护理满意度评分高于对照组,差异有统计学意义(P<0.05);观察组患者各生活质量评分均高于对照组,差异有统计学意义(P<0.05).结论 对鼻窦炎手术患者给予认知护理干预可明显降低其术后并发症发生率,缩短住院时间,提高患者对护理的满意度,且能显著改善患者的术后生活质量,值得临床推广应用.     

CT观察中鼻甲气化及其与慢性前组鼻窦炎的关系

目的 探讨中鼻甲气化的CT表现、诊断标准及分类,评价中鼻甲气化与慢性前组鼻窦炎的关系。 方法 回顾性分析248侧中鼻甲气化的CT图像,观察冠状位图像中鼻甲气化表现特征,尝试界定中鼻甲垂直部气化标准及垂直部高位与低位气化的标准。分析中鼻甲气化与慢性前组鼻窦炎的关系。 结果 不同类型中鼻甲气化具有不同的CT表现。鼻窦炎与无鼻窦炎者的中鼻甲气化数量差异有统计学意义。不同中鼻甲气化类型之间慢性额窦炎的数量差异无统计学意义,慢性前组筛窦炎及上颌窦炎的数量差异有统计学意义。鼻窦炎程度积分与中鼻甲垂直部低位气化的大小之间无相关性。 结论 鼻窦冠状位CT对于中鼻甲气化观察分析有重要价值。中鼻甲气化很可能是慢性前组鼻窦炎的潜在危险因素,而且不同气化类型引起鼻窦炎的危险性不尽相同。     

鼻内镜下真菌性上颌窦炎的术式选择及疗效评估

目的鼻内镜下采用3种不同入路手术治疗真菌性上颌窦炎并对其临床疗效进行观察,为临床个体化治疗真菌性上颌窦炎提供参考。方法以该院2016年1月-2017年12月收治的84例非侵袭性真菌性上颌窦炎的手术患者作为研究对象,术前常规行鼻内镜检查和鼻窦CT检查,根据病变的部位范围选择手术方式,将患者分为3组:A组30例,行鼻腔外侧壁保留黏膜瓣的下鼻道入路;B组20例,行上颌窦自然口入路手术;C组34例,行联合入路手术。结果 84例患者均治愈,血涕、面部胀痛、头痛或鼻腔异味症状逐步消失,鼻内镜复查见术腔愈合好,上皮化良好,各鼻道无异常分泌物,术腔病变无残留,无鼻腔粘连、前鼻孔狭窄、鼻泪管损伤或其他并发症。术后6个月复查鼻窦CT无病变残留,下鼻道黏膜瓣愈合良好。结论术前根据病变部位及范围选择手术方式个体化治疗真菌性上颌窦炎,能充分暴露上颌窦窦腔,有效清除病变,避免损伤鼻腔鼻窦的正常结构,达到既微创又能彻底清除病灶的目的。     

Sphenoid sinusitis, a cause of debilitating headache

We present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics. Despite an aggressive evaluation in the emergency department, the correct diagnosis and appropriate treatment were delayed. Recognition of sphenoid sinusitis, the complications associated with it, and the need for aggressive management are addressed.     

Nosocomial maxillary sinusitis during mechanical ventilation: A prospective comparison of orotracheal versus the nasotracheal route for intubation

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n=53) or nasotracheal (n=58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral;p<0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p<0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.