修正性鼻内镜手术联合中鼻甲切除术综合治疗难治性鼻-鼻窦炎

目的探讨修正性鼻内镜手术联合中鼻甲切除术综合治疗难治性鼻一鼻窦炎的手术效果及应用价值。方法35例难治性鼻一鼻窦炎经CT检查、鼻内窥镜检查、局部用药等规范术前准备,行改良鼻丘径路额窦开放为主修正手术加中鼻甲全部或部分切除,术后凭鼻内镜保健手册进行定期复查,规范随访。26例合并鼻中隔偏曲者其中16例行内镜下传统矫正切除,10例行局限性矫正切除;15例合并变应性鼻炎者对下鼻甲前端、中鼻甲对应鼻中隔等部位黏膜电凝。结果35例患者门诊内镜随诊3～6月以上,治愈11例（31．4％）,黏膜完全上皮化;好转18例（51．4％）,黏膜可以上皮化,但变应性鼻炎发作时,术腔黏膜水肿,经局部处理及药物治疗后可恢复上皮化;无效6例（17．2％）。总有效率82-8％,6例无效均为合并变应性鼻炎及哮喘患者。结论修正性鼻内镜手术联合中鼻甲切除术综合治疗难治性鼻鼻窦炎,疗效较为确切,值得临床推广。     

Long-term postoperative control of eosinophilic chronic rhinosinusitis recurrence by inserting a steroid-eluting,sinus-bioabsorbable device reduces the dosage of oral steroid

Objective

We employed a steroid-eluting, sinus-bioabsorbable device for local treatment after surgery for eosinophilic chronic rhinosinusitis (ECRS). One year later, we investigated its efficacy in suppressing recurrence and reducing the use of oral steroids.

Expression and distribution of glucocorticoid receptor isoforms in eosinophilic chronic rhinosinusitis

Objective

Patients with eosinophilic chronic rhinosinusitis (ECRS) show a high percentage of eosinophilic infiltration in the paranasal sinus mucosa. It is well documented that topical steroids have a beneficial effect in ECRS with nasal polyposis. We investigated mucosal distribution and cellular localization of glucocorticoid receptor (GR) isoform expression in human paranasal sinuses in relation to the clinical characteristics of eosinophilic chronic rhinosinusitis (ECRS) patients.

Methods

Mucosal specimens were obtained from 20 sinusitis patients by endoscopic sinus surgery (ESS). Quantitative fluorescence immunohistochemical analysis was employed to examine the degree of glucocorticoid receptor (GR) isoform expression in sinus mucosa specimens. An RT-PCR procedure was performed to determine the relative quantities of mRNA for the human GRα and GRβ genes.

Results

Patients in the ECRS group showed significant increases in peripheral blood eosinophils as compared to the non-ECRS group (16.98% vs. 2.31%). Positive immunoreactivity of GRβ expression was predominantly found to be positive in inflammatory cells. The absolute number of GRβ-positive cells in the ECRS group was increased in comparison with that in the non-ECRS group. The difference was statistically significant both in the maxillary (179.7 cells/mm² vs. 82.5 cells/mm²) and ethmoid sinus (302.0 cells/mm² vs. 61.5 cells/mm²) mucosa. The GRβ/GRα cell ratio in the ECRS group was elevated when compared with that in the non-ECRS group both in the maxillary and the ethmoid sinus mucosa, with the latter difference being significant.

Conclusions

The presence of high peripheral eosinophilia indicates a high likelihood of ECRS disease. Our results support the association of GRβ expression with ECRS. The expression of GRβ immunoreactivity, an endogenous inhibitor of steroid action previously associated with steroid insensitivity, may be one of major contributing factors in ECRS.     

鼻内镜手术中的中鼻甲的处理

目的探讨鼻内镜手术中的中鼻甲处理技巧和意义。方法回顾性分析收治的80例慢性鼻窦炎、鼻息肉患者随机分为观察组32例（39侧）和对照组48例（54侧）,观察组强调中鼻甲的处理上尽可能保障中鼻甲空间结构和形态上的相对正常;对照组采用传统的Messerklinger术或wigand术式。术后6个月对比两组中鼻甲的稳定性,中鼻道狭窄或粘连的发生情况以及按lund—Kennedy内镜黏膜形态评分系统进行评价。结果两组患者的术前lund—Kennedy内镜黏膜形态评分差异无统计学意义（t=1．659,P〉0．05）,观察组术后6个月Lund—Kennedy评分为（1．89±1．31）分,低于对照组（2．48±1．42）分,两组比较差异具有统计学意义（t=8．1,P〈0．01）。术后观察组中鼻甲结构良好稳定,中鼻甲轻度外移、中鼻道狭窄、中鼻甲与鼻腔外侧壁粘连3种情况的发生率分别为83．2％、4．1％、6．7％,对照组的发生率分别为44．9％、21．6％、10．3％,两组比较差异具有统计学意义（r=10．77,P〈0．01）。结论保障中鼻甲空间结构和形态上的相对正常有助于提高鼻内镜手术疗效,减少术后不良并发症。     

Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis

PURPOSE: To assess objective and quality of life (QOL) outcomes before and after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) and to determine preoperative factors that predict surgical outcome in these patients. METHODS: One hundred nineteen adult patients with CRS and a mean follow-up of 1.4 +/- 0.35 years were evaluated prospectively including the following patient factors: prior sinus surgery, polyps, asthma, acetylsalicylic acid intolerance (ASA), smoking, allergy, depression, and sex. Computed tomography (CT), endoscopy, and QOL assessment was performed. Predictive value of patient factors was determined based on change in endoscopy and QOL scores after ESS. RESULTS: Objective outcomes: preoperative CT scores were significantly worse in patients with polyps, asthma, and ASA, whereas CT score was unaffected by prior sinus surgery, smoking, allergy, depression, and sex. Patients with CRS demonstrated significant improvement on nasal endoscopy after ESS, but preoperative, postoperative, and change in scores were affected by certain patient factors. Endoscopy scores were significantly worse in patients with prior sinus surgery, polyps, asthma, and ASA, but these patients also experienced the greatest improvement in endoscopy scores. Smokers and patients with depression had the least change in endoscopy scores. QOL outcomes: patients with CRS experienced improvement in QOL after ESS. Pre- and postoperative QOL was positively affected by polyps and adversely affected by ASA, depression, and female sex, but these groups still experienced significant improvement in QOL scores. Pre- and postoperative QOL was unaffected by prior sinus surgery, asthma, smoking, and allergies, and all of these groups experienced significant improvement in QOL scores. Factors predictive of outcome: ASA and depression were predictive of worse outcome. Preoperative CT scores approached significance as being predictive of outcome. CONCLUSION: Surgical management of CRS was associated with significant improvement on objective and QOL measures; however, specific patient factors, in particular ASA and depression, predict poorer outcome. Preoperative CT may be a predictor of endoscopic and QOL outcome and deserves further study.     

鼻内镜下中鼻甲功能性部分切除治疗慢性鼻窦炎76例分析

目的 观察鼻内镜手术中鼻甲功能性部分切除对于有中鼻甲病变的慢性鼻窦炎伴鼻息肉患者的疗效。 方法 2014年1月至2017年1月收治的76例慢性鼻窦炎伴鼻息肉患者行功能性鼻内镜手术。依中鼻甲有无病变及是否行中鼻甲切除分为观察组(n=38)与对照组(n=38),观察两组手术时间、疗效、中鼻甲粘连和术后主观症状评分。 结果 观察组手术时间为(50.53±6.25)min、对照组为(58.11±6.09)min,差异有统计学意义(t=5.355, P<0.001);术后随访6个月,两组患者治疗有效率均为100%,其中对照组的治愈率为78.95%(30/38),观察组为81.58%(31/38),差异无统计学意义(P>0.05);术后中鼻甲粘连率(χ2=4.155, P=0.042)和主观症状评分差异有统计学意义(Z=3.68, P=0.031)。 结论 对有中鼻甲病变的慢性鼻窦炎伴鼻息肉患者实施鼻内镜手术时行功能性部分中鼻甲切除,能明显缩短患者手术时间、减少中鼻甲粘连率、改善患者的主观症状。     

慢性鼻窦炎手术方法的探讨

目的：探讨治疗慢性鼻窦炎的手术方法及中鼻甲前端部分切除术在治疗慢性鼻窦炎中的作用。方法：对87例(155侧)慢性鼻窦炎患者，根据其发病原因及病情不同分为3类，采用相应的手术方法进行治疗。结果：第l类43侧，治愈39侧，好转4侧；第2类8l侧，治愈69侧，好转l0侧，无效2侧；第3类3l侧，治愈17侧，好转9侧，无效5侧。总治愈率为80．6％，有效率为95．5％。结论：对慢性鼻窦炎的手术治疗应因病因、病情不同，采用不同的手术方法，中鼻甲前端部分切除术对治疗慢性鼻窦炎具有重要作用。     

New clinical diagnostic criteria for eosinophilic chronic rhinosinusitis

Objective

Chronic rhinosinusitis is a heterogeneous disease. Most cases of chronic rhinosinusitis with nasal polyp(s) (CRSwNP) in Western countries show a strong tendency for recurrence after surgery and pronounced eosinophil infiltration in the nasal polyps. The prevalence of CRSwNP with pronounced eosinophilic inflammation is steadily increasing and is classified as eosinophilic chronic rhinosinusitis (ECRS) in Japan. However, less than 50% of CRSwNP patients in Japan and East Asia show such features. Since the treatment strategy of ECRS differs from that of non-ECRS, clinical diagnostic criteria that distinguish ECRS from non-ECRS are needed.

Methods

A total of 124 patients with CRSwNP patients who underwent endonasal sinus surgery were classified as ECRS or non-ECRS according to their clinical characteristics and the clinical features of the two groups were compared. Computed tomography (CT) images of the sinuses were graded according to the Lund-Mackay system. We also graded CT images of the olfactory cleft. Blood examination findings, sinus CT images and asthma complications were analyzed by multivariate logistic regression. Clinical findings that were significantly different between ECRS and non-ECRS were analyzed by receiver operating characteristic curves to determine optimal predictors of ECRS.

Results

Blood eosinophilia, asthma complications and CT image scores were significantly different between ECRS and non-ECRS. In particular, increased blood eosinophil percentage and CT image scores for the posterior ethmoid and the olfactory cleft showed good accuracy as predictors of ECRS. A combination of the cut-off values for three predictors (increased blood eosinophil percentage above the normal range, olfactory cleft score ≥1 and posterior ethmoid score ≥1) indicated high accurate diagnostic ability (sensitivity, 84.6%; specificity, 92.3%).

Conclusion

A set of three clinical findings can differentiate ECRS from non-ECRS with high accuracy, even when these findings are assessed in regular outpatient clinics.     

892例慢性鼻－鼻窦炎患者内镜鼻窦手术围手术期临床分析

目的 探讨内镜鼻窦手术围手术期处理原则及注意事项。方法 分析892例内镜鼻窦手术患者术后随访及手术1年后治疗效果。 结果 根据慢性鼻－鼻窦炎诊断和治疗指南2008年南昌标准,以手术后1年为近期疗效评估时间,采用Lund-Kennedy评分法进行鼻内镜检查量化评估,892例中治愈759例（82.5%）,好转133例（15%）,无效22例（2.5%）,均为慢性鼻－鼻窦炎伴有鼻息肉的患者。手术并发症为眶纸板损伤27例,脑脊液鼻漏11例,术后大出血1例,筛顶损伤6例,多数并发症发生于手术后初期。 结论 认真的围手术期治疗、建立术后严格的鼻内镜随访换药制度是防止手术并发症、提高手术疗效的关键。     

鼻腔冲洗在慢性鼻窦炎鼻内镜术后治疗中的应用研究

慢性鼻窦炎（CRS）是鼻窦黏膜的慢性炎症性疾病,其病因学及病理生理机制复杂。随着基础和临床研究不断深入,其诊断、治疗策略逐渐向个体化和精准化方向发展。手术治疗是CRS整体治疗的重要组成部分。鼻内镜手术因其功能性和微创性成为目前CRS首选的外科治疗手段,但是术后鼻腔、鼻窦黏膜仍处于炎症环境中,若处理不当会影响手术疗效。临床研究证实,鼻内镜手术后行鼻腔冲洗可改善症状,促进术腔恢复。本文将从冲洗液、冲洗方法、冲洗工具等方面进行综述,为鼻腔冲洗临床应用提供参考。     

Doyle silicone splint insertion: endoscopy-assisted versus nasal speculum assisted

IntroductionSeptoplasty and endoscopic sinus surgery are very often concurrently performed operations in otolaryngology practice. The most common complication of endoscopic sinus surgery is lateralization of the middle turbinate. In our practice intranasal stenting is done routinely with Doyle silicone splints.ObjectiveRetrospectively, we aimed to review the postoperative period and to document efficacy of endoscopy-assisted Doyle silicone splint application on prevention of middle turbinate lateralization.MethodsPatients who had failed medical therapy and who underwent elective primary endoscopic sinus surgery for chronic rhinosinusitis with septal deviation requiring septoplasty were included to the study. Doyle silicone splints were inserted to all patients at the end of the operation with nasal speculum or with endoscopic assistance. Groups were compared for position of the middle turbinate at the end of the postoperative first month regarding lateralization and for pain score recorded on the second postoperative day.ResultsIn the Doyle silicone splints applied with nasal speculum group, there were 46 patients with a total of 80 operated sides. In the endoscopy assisted group, there were 54 patients with a total of 88 operated sides. At the 1 month follow-up, the mean of middle turbinate position scores was 1.62 in the speculum-assisted group and 1.80 in the endoscopy-assisted group, the difference between two groups was found to be statistically significant. Mean of postoperative second day pain scores were worse in patients with the Doyle silicone splints applied with endoscopic assistance. This difference was found statistically significant.ConclusionIn our study, after concomitant endoscopic sinus surgery and septoplasty, less middle turbinate lateralization was observed when the Doyle silicone splints were inserted with endoscopic guidance. The surgical techniques or methods of sinus packing as well as nasal packing may have an impact on middle turbinate lateralization after concurrent septoplasty and endoscopic sinus surgery.     

Impact of endoscopic sinus surgery on otologic symptoms associated with chronic rhinosinusitis

ObjectiveTo evaluate improvements in otologic symptoms after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS), and identify differences in symptoms, if any, between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyposis.Material and methodsThis is a prospective multi-center observational cohort study. Adults with medically recalcitrant CRS who elected ESS were enrolled in a prospective, multi-center, observational cohort study between March, 2011 and October, 2014. Preoperative evaluation of subjects included assessment of clinical characteristics, measures of disease severity, and quality of life evaluation using the 22-item SinoNasal Outcome Test (SNOT-22). Postoperative improvement in otologic symptoms (ear fullness, dizziness, ear pain) scores were evaluated and compared between CRSwNP and CRSsNP subgroups.ResultsThree hundred and ninety-five study patients completed both preoperative and postoperative evaluations, with an average follow-up of 13.9 months after ESS. The prevalence of patients reporting at least one otologic symptom preoperatively (87%) significantly decreased after ESS (63%, P < 0.001). Significant postoperative improvement across all otologic scores was also reported (P < 0.001). Relative mean improvement in otologic symptom severity was similar for both CRSwNP and CRSsNP, except patients with CRSwNP reported significantly greater postoperative improvement in ear fullness compared to CRSsNP (54% vs. 41%, P = 0.039). A total of 61%, 44%, and 43% of patients reported experiencing improvement in “ear fullness”, “dizziness” and “ear pain”, respectively.ConclusionSinus surgery significantly improves otologic symptoms associated with CRS. CRSwNP patients reported slightly greater relief of ear fullness than CRSsNP patients following ESS.     

内窥镜鼻窦手术中不同中鼻甲处理方法对鼻气道阻力的影响

目的 :研究内窥镜鼻窦手术中不同中鼻甲处理方法对鼻气道阻力及主观鼻气流感觉的影响。方法 :采用主动前鼻测压法及视觉类比法对 32例 (侧 )中鼻甲完全切除患者、37例 (侧 )中鼻甲部分切除患者及 34例(侧 )中鼻甲完全保留患者内窥镜鼻窦手术前后鼻气道阻力和主观症状评分进行了研究。结果 :术后三组患者鼻气道阻力和主观症状评分均较术前明显下降 (P <0 .0 1) ,三组间鼻气道阻力及主观症状评分的差异均无显著性意义 (P >0 .0 5 )。结论 :中鼻甲不同处理方法对鼻气道阻力及主观鼻气流感觉无显著影响     

鼻内镜手术治疗慢性鼻-鼻窦炎575例疗效分析

目的探讨鼻内镜下鼻窦手术治疗慢性鼻-鼻窦炎（CRS）的疗效。方法对575例CRS患者按照海口标准分型,其中I型204例,Ⅱ型281例,Ⅲ型90例。术前进行围手术期处理,采用鼻内镜手术,术后进行综合治疗,随访6个月以上,根据海口疗效标准进行评估。结果Ⅰ型治愈率为92．6％（189／204）,Ⅱ型治愈率为73．0％（205／281）,Ⅲ型治愈率为53．3％（48／90）,3型之间比较治愈率有统计学意义（P〈0．05）。术后眶纸样板损伤11例,鼻腔粘连76例,术中大出血5例,进行相应处理后全部治愈。结论术前病情评估、准确的临床分型和围手术期及术后综合治疗,是提高治愈率的重要因素。     

Quality of life after endoscopic sinus surgery in refractory pediatric chronic rhinosinusitis

ObjectiveThe present study aims to evaluate the role of Endoscopic Sinus Surgery (ESS) in refractory pediatric Chronic Rhinosinusitis (CRS) and to assess the change in quality of life after ESS.Materials and MethodsThis prospective interventional study included 35 children (aged between 6 and 12 years) of refractory CRS, not responding to 4 weeks of maximal medical therapy attending the pediatric ENT clinic of a tertiary referral centre. Study period was from November 2013 to March 2016. This patient pool underwent Non Contrast Computed Tomography scan (NCCT) paranasal sinuses and diagnostic nasal endoscopy and those fulfilling the requisite inclusion criteria underwent Endoscopic sinus surgery. Global assessment of Rhinosinusitis Symptom severity score and SN-5 quality of life score of the patients was assessed preoperatively and 1 year after the surgery.Results91.4% children showed an improvement in the total symptom score with a statistically significant (p value < 0.001) reduction in the mean total score postoperatively. Similarly 91.4% of the children showed an improvement in their quality of life with a statistically significant (p value < 0.001) difference seen in the average SN-5 scores after ESS. No major complications were encountered in any of the cases.ConclusionESS is a safe and effective surgical management for children with CRS refractory to maximal medical therapy leading to an improvement in their quality of life.