26例变应性真菌性鼻-鼻窦炎临床分析

Presentation and management of allergic fungal rhinosinusitis

目的:分析变应性真菌性鼻-鼻窦炎(AFRS)的临床特点及以鼻内镜手术为主的综合治疗的作用。方法:对26例AFRS患者术前常规进行鼻窦CT扫描,血清总IgE及特异性IgE检测,术中取窦内分泌物及受累鼻窦黏膜行真菌学及组织病理学检查。26例患者均行鼻内镜手术,术前及术后配合抗生素、皮质类固醇激素和局部抗真菌药鼻腔冲洗治疗。术后随访至少1年。结果:26例患者中有21例伴变应性疾病史,临床表现无特异性,鼻窦CT多表现为受累鼻窦腔内中间呈斑片状或条索状高密度影,在软组织窗表现更为典型,部分患者窦腔扩大、窦壁变薄甚至骨质吸收;血清总IgE阳性22例,真菌SIgE阳性20例。窦内分泌物涂片均可见真菌菌丝,真菌培养阳性14例,以曲霉菌多见。分泌物及黏膜苏木精-伊红染色可见大量嗜酸细胞浸润,8例分泌物内可见Charcot-leyden结晶。术后1年有19例术腔黏膜完全上皮化,其余7例有不同程度的黏膜肿胀、息肉样变或黏脓性分泌物。结论:AFRS诊断主要依据病史、鼻窦CT扫描、组织病理学、真菌学和免疫学检测。鼻内镜手术结合全身和(或)局部激素以及局部抗真菌药鼻腔冲洗是治疗AFRS的有效手段。

Objective：To assess the presentation of allergic fungal rhinosinusitis （AFRS） and describe the line of management in our setup. Method： Twenty-six cases of AFRS from October 2002 to June 2006 were retrospectively analyzed for the study in Department of Otorhinolaryngology Head and Neck Surgery, Peking University First Hospital. Laboratory findings （especially total serum IgE level and special serum IgE level） and computed tomography were noted preoperation. Surgical specimens were sent for mycology and histopatbologic analysis. The management included endoscopic sinus debridement, adequate sinus aeration, pre- and post-operative use of ster- oids and saline irrigations with antifungal drugs. Result：Nasal obstruction and hyposmia were the commonest presentations. In 21（80.8 %） of 26 patients, AFRS was fund to be associated with allergic diseases. CT scan showed serpiginous or patchy increased attenuation within the completely opacified sinuses on reconstructed soft tissue window. Some of the involved sinuses had bone erosion and expansion. 84.6% （22/26） patients had elevated total IgE levels ,76.9% （20/26） had positive for sIgE levels to fungal allergen. Fungal smear were positive for all 26 patients. But only 14 surgical specimens were positive for fungal cultures. The most common causative agent was Aspergillus. The involved mucosa and allergic mucin with H ＆ E staining contained clusters or sheets of degenerating eosinophils. Charcot Leyden crystals was found in 8 surgical specimens. The follow up after a year, the mucosa recoverred epithelization in 19 patients. Conclusion： The diagnosis of AFRS required to depend on history, CT scanning, histopathology, mycologic and immunologic monitoring. Comprehensive treatment with endoscopic sinus surgery, steroids and saline irrigations with antifungal drugs is effective method.