鼻内镜术后上颌窦异常引流与黏膜炎症状态

Correlation between mucosa inflammation and abnormal drainaging state of maxillary sinus after endoscopic sinus surgery

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实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搬痕形成,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。

Objective This study is aimed to observe the natural draining state of maxillary sinus, to search for the key draining location （KDL） in the natural ostium, to investigate the relation between maxillary sinus draining and sinus inflammation, and to guide the treatment of maxillary sinus opening in endoscopic sinus surgery （ESS）. Methods Methylene blue was used as tracer agent in this study. Fifteen cases with or without light maxillary sinus inflammation （ without any treatment） were selected to observe the natural draining state and the key draining location in maxillary sinus fontanel. Eighty-nine cases with chronic rhinosinusitis, but without nasal polyp, were selected, of which the maxillary sinus mucosa restored well 6 months after ESS, to observe the draining state and modes in maxillary sinus. All patients were followed up for 12 months to evaluate the inflammation state of mucosa, and to analyze the relations between the draining mode and mucosa inflammation. Results The KDL for maxillary sinus was located in the posterior-inferior portion of the natural ostium, close to the attachment of caudal end of the uncinate process. The draining flowed along it from maxillary sinus to nasopharynx. After conventional transnasal endoscopic operation, 15 cases showed relatively normal drainage, others displayed abnomal state and mode,including reverse draining （maxillary sinus-ethmoid sinus）, multiphase draining （outflow from front, back and lower wall of natural ostium）, draining failure （ with cilia transporting function of maxillary epithelium mucosae） , cistern like change （ maxillary sinus and ethmoid sinus formed one operation cavity, secretion accumulated in maxillary sinus ） and mucosa disfunction （loss of cilia transporting function of maxillary epithelium mucosae）. Inflammation was observed in 33.7% of the patients 12 months after ESS, especially in those with mucosa disfunction, draining failure and reverse draining. Conclusions The KDL for maxillary sinus may be located in the posterior-inferior portion of the natural ostium, close to the attachment of caudal end of the uncinate process, and the drainage mode is not affected by gravity and posture. The KDL lesion after ESS results in abnormal draining of maxillary sinus, and excessively large maxillary sinus opening may aggravate mucosa inflammation of maxillary sinus. The abnormal draining state and mode may be related with the incidence of mucosa inflammation after operation. Preserving caudal end of uncinate process and avoiding injury of KDL would be beneficial to the restoration of mucosa and lessen the incidence of inflammation recurrence.