慢性鼻-鼻窦炎鼻息肉内镜术后糖皮质激素对鼻黏膜重塑的影响

目的探讨慢性鼻-鼻窦炎鼻息肉（chronic rhinosinusitis with nasal polypsis，CRSwNP）内镜术后糖皮质激素对鼻黏膜重塑的影响。方法30例CRSwNP患者行鼻内镜手术切除的鼻腔病变黏膜组织作为术前组；术后将患者平均分为两组：激素组（术后应用糖皮质激素丙酸氟替卡松喷剂，200μg／d）和对照组（术后未应用丙酸氟替卡松及其他糖皮质激素）。术后第1、3个月复查时取其前筛区黏膜标本。另取6例行鼻中隔矫正术患者的钩突处黏膜作为正常对照。采用HE染色观察鼻黏膜上皮损伤（脱落）情况；以免疫组化方法观察鼻黏膜中转化生长因子-β1（transforming growth factor．β1，TGF．β1）和胶原Ⅲ的表达。结果术前组鼻黏膜标本可见90％（27／30）的上皮损伤为3期，10％（3／30）为2期；87％（26／30）的鼻黏膜标本可见TGF-β1阳性细胞，胶原Ⅲ阳性基底膜厚度〉20μm者占97％（29／30）。术后第1个月时，对照组和激素组鼻黏膜形态及免疫组化TGF-β1和胶原Ⅲ的表达无明显差异。术后第3个月时，对照组53％（8／15）的上皮损伤为3期，33％（5／15）为2期，14％（2／15）为1期；激素组93％（14／15）为0期，7％（1／15）为1期，两组比较差异有统计学意义（Uc=4．481，P〈0．05）。免疫组化显示对照组TGF-β1阳性炎性细胞数量明显高于激素组（t=2．32，P〈0．05），对照组胶原Ⅲ阳性基底膜厚度〉20μm者10例（67％），与激素组（4例，27％）相比差异有统计学意义（P〈0．05）。结论CRSwNP内镜术后鼻腔黏膜发生组织重塑，术后及时恰当地应用糖皮质激素对抑制重塑，预防复发十分重要；术后随访不应少于3个月或更长。

Effects of glucocorticoid on tissue remodeling of nasal mucosa of chronic rhinosinusitis with nasal polypsis after endoscopic surgery

OBJECTIVE: To evaluate the effects of glucocorticoid on tissue remodeling of nasal mucosa from patients with chronic rhinosinusitis with nasal polypsis (CRSwNP) after endoscopic surgery. METHODS: Nasal mucosa obtained from 30 cases of CRSwNP during nasal endoscopic surgery were considered as preoperation group. These patients were equally divided into two groups after surgery, ie. glucocorticoid group and contrast group. Uncinate process mucosa samples from 6 patients during septoplasty were considered as normal control group. Epithelial damage and expressions of transforming growth factor-beta1 (TGF-beta1) and collagen III were studied by light microscopy and immunohistochemistry. RESULTS: In nasal mucosa samples of preoperation group, epithelial damage showed 90% (27/30) of stage 3 and 10% (3/30) of stage 2; TGF-beta1 positive cells and collagen III positive basement membrane with more than 20 microm were seen in 87% (26/30) and 97% (29/30) of samples, respectively. No significant difference was observed in morphology of nasal mucosa and expressions of TGF-beta1 and collagen III between glucocorticoid group and contrast group at 1th month after surgery. At 3th month after surgery, epithelial damage displayed 53% (8/15) of stage 3, 33% (5/15) of stage 2 and 14% (2/15) of stage 1 in contrast group; however, 93% (14/15) of stage 0 and 7% (1/15) of stage 1 in glucocorticoid group. The difference of epithelial damage between two groups was significant (Uc = 4.481, P < 0.05). The amount of TGF-beta1 positive cell was markedly higher in contrast group than in glucocorticoid group (t = 2.32, P < 0.05). The thickness of basement membrane was above 20 microm in 67% of contrast group (10 cases) and 27% of glucocorticoid group (4 cases); the difference between the two groups was significant (P < 0.05). CONCLUSIONS: Tissue remodeling is present in nasal mucosa of CRSwNP after endoscopic surgery. Early and appropriate administration of glucocorticoid plays an important role in inhibition of tissue remodeling and prevention of relapse. Postoperative follow-up should not be less than 3 month.