内镜鼻窦手术治疗慢性鼻-鼻窦炎临床结局的主客观评估

Subjective and objective clinical outcome assessment on chronic rhinosinusitis following endoscopic sinus surgery

目的评估内镜鼻窦手术治疗慢性鼻．鼻窦炎的主客观临床结局并构建临床实用性的主客观结局评估体系。方法通过前瞻性队列研究，对120例慢性鼻-鼻窦炎患者术前和术后12个月的临床结局进行视觉模拟量表（visual analog scale，VAS）、医学结局研究简表36项（medical outcome study short-form 36-items，SF-36）和鼻腔鼻窦结局测试20条（sino-nasal outcome test-20，SNOT-20）等症状与生存质量的主观评估，以及内镜下黏膜形态、纤毛功能与组织病理学等客观评估。数据统计采用t检验、Х^2检验和Spearman相关分析处理手术前后主客观结局的变化及其相互关系。结果①术后12个月，VAS、SF-36和SNOT-20整体评分较术前明显改善（P〈0．01），其中85．96％、77．19％和83．33％的个体三项主观指标评分分别较术前改善，同时改善的比例为72．28％；手术前后各个时期，三种主观指标评分均具相关性（P值均〈0．01），其中SNOT-20兼性作用最大。②术后12个月，内镜下黏膜形态、纤毛功能和组织病理学整体评分较术前明显改善（P值均〈0．05），其中86．84％、86．81％和75．57％的个体三种客观指标评分分别较术前改善，同时改善的比例为71．85％；手术前后各个时期，三种客观指标评分均具相关性（P值均〈0．05），其中内镜下黏膜形态兼性作用最大。③SNOT-20与内镜下黏膜形态同时评估显示：术后12个月74．56％的患者主客观评分升降结局一致，而25．44％的患者主客观结局不一致，其中伴发鼻息肉患者更容易出现这种差异性（P〈0．05）。④手术前后不同时期，SNOT-20与内镜下黏膜形态评分均无相关性（P〉0．05），但前10位条目总分与内镜下黏膜形态评分具有相关性（0．18≤r≤0．42，P〈0．05），而后10位条目总分与之不相关（P〉0．05）。结论①内镜鼻窦手术可有效改善慢性鼻-鼻窦炎患者术后的症状、生存质量、内镜下黏膜形态、纤毛功能及组织状态等临床结局；②构建以SNOT-20和内镜下黏膜形态评估为主体的主客观结局评估体系，简约可靠，合理有效，具有临床实用性。

Objective To assess the subjective and objective outcomes of chronic rhinosinusitis （CRS） following endoscopic sinus surgery （ESS） and establish an assessment system of outcome with ease of application clinically. Methods A prospective cohort study was conducted to survey and assess the outcomes of 120 consecutive CRS patients undergoing endoscopic sinus surgery at 12 months after operation. The subjective and objective measures comprised symptom by visual analog scale （ VAS ）, health-related quality of life by medical outcome study short-form 36-items （SF-36） and sino-nasal outcome test-20 （SNOT-20） scales, endoscopic appearance, mucociliary function, and histological findings. The differences of subjective and objective assessments before and after operation were compared by t-test and Chi-Square test and the correlations between the parameters above were analyzed by Spearman correlation analysis. Results At 12 months after operatiion, the patients＇ total scores by VAS, SF-36 and SNOT-20 scales improved significantly beyond the preoperative survey （ P 〈 0. 01 ） ; there were 85.96% , 77. 19% and 83.33% patients with the scores respectively superior to that of preoperation, of which 72. 28% subjects benefited simultaneously from these parameters; and a significant correlation was observed among them before and after operation （P 〈 0. 01 ） where SNOT-20 showed a more compatibility than the other two. At 12 months after operatiion, the patients＇ total scores of endoscopic appearance, mucociliary function, and histological findings significantly improved beyond the preoperative evaluation （ P 〈 0. 05 ） ; there were 86. 84% , 86. 81% and 75. 57% patients with the scores respectively superior to that of preoperation, of which 71.85% subjects benefited simultaneously from these parameters; and a significant correlation was observed among them before and after operation （ P 〈 0. 05 ） where endoscopic appearance showed a more compatibility than the other two. At 12 months after operatiion, 74.56% patients showed an accordant improving or worsening outcome evaluated by SNOT-20 and endoscopic appearance, while 25.44% ones represented inverse endings, of which patients with comorbidity of nasal polyps more easily demonstrated this tendency significantly （ P 〈 0. 05 ）. No significant correlation existed between the scores of SNOT-20 and endoscopic appearances both in preoperation and in postoperation （ P 〉 0. 05 ）, but the total scores of the anterior 10-item, excluding the posterior 10-item, of SNOT-20 inventory was found significantly correlated with the quantitative appearances on nasal endoscopy throughout （ 0. 18 ≤ r ≤ 0. 42, P 〈 0. 05 ）. Conclusions Administration of ESS can effectively improve the outcomes of CRS patients including symptom, healthrelated quality of life, endoscopic appearance, mucociliary function, and histological findings. A subjectively and objectively measured assessment system with terseness, trustiness, reasonableness, and effectiveness and with ease of application clinically is established on the basis of SNOT-20 and endoscopic appearance evaluation for outcome research.