鼻内镜手术中病变累及中鼻甲基板水平部的处理

Treatment of lesions of horizontal portion of middle turbinate's basal lamella in endoscopic sinus surgery

目的探讨功能性鼻腔鼻窦手术(FESS)中病变累及中鼻甲基板水平部时,切除(或部分切除)和保留中鼻甲基板水平部与手术疗效的关系。方法采取前瞻性试验设计,选取2014年1月至2017年6月40例病变累及中鼻甲基板水平部的双侧全组慢性鼻-鼻窦炎伴或不伴鼻息肉患者入组。按住院时间顺序分成单双号,单号在鼻内镜手术中切除或部分切除左侧中鼻甲基板水平部,保留右侧中鼻甲基板水平部,双号则刚好相反。术后随访6个月~1年,在术前及术后1、3、6、9、12个月评价VAS评分、Lund-Kennedy内镜黏膜形态评分和术后中鼻甲漂移粘连情况。结果术前及术后1、3、6、9、12个月保留侧和切除侧VAS评分无统计学差异(P>0.05);切除侧Lund-Kennedy内镜黏膜形态评分总得分略低于保留侧(即黏膜状况好于保留侧),但差异无统计学差异(P>0.05)。保留侧中鼻甲漂移粘连发生率略高于切除侧,但差异无统计学意义(P>0.05)。结论如果能够保证中鼻甲支点稳定,切除中鼻甲基板水平部并不一定增加了中鼻甲漂移及粘连的可能性,手术的疗效取决于良好的通畅引流、不可逆病变及骨质畸形的去除、病变气房完全轮廓化及在黏膜上皮化前的及时随访清理。

Objective To investigate the association of surgical effect with resection （ or partial excision） and retention of the involved lesions of horizontal portion of middle turbinate＇s basal lamella （hBL） in functional endoscopic nasal sinus surgery （FESS）. Methods By prospective trial design,40 patients with hBL lesions of bilateral chronic rhinosinusitis with or without nasal polyps were enrolled from January 2014 to June 2017 ,and they were divided into single number group and double number group according to the time of hospital admission. In single number group, it was conducted that left hBL was excised or partially excised, and right hBL was retented in FESS, and the just reversed operation （ excision or partial excision of right hBL and retention of left hBL） was performed in double number group. Scores of visual analogue scale （VAS） ,Lurid-Kennedy endoscopic mucosal morphology and postoperative middle turbinate drift adhesion were evaluated before and 1-,3-,6-,9- and 12- month after operation. Results There was no significant difference in VAS score between resection side and unresected side before and 1-,3-,6-,9- and 12- month after operation. （P 〉 0.05 ）. The total score of Lund-Kennedy endoscopic mucosal morphology in the resection side was slightly lower than that in the reserved side （ namely, the mucosal condition was better in the resection side ）, but there was no statistical difference （ P 〉 0.05 ）. The incidence of drift adhesion of middle turbinate on reserved side was slightly higher than that in resection side, but there was no significant difference （P 〉 0.05 ）. Conclusion If the fulcrum of the middle turbinate is stable, resection of hBL does not inevitably increase the probability of drift and adhesion of the middle turbinate. Good drainage, remove of irreversible lesions and bone malformation, complete contouring of diseased air ceils and timely follow-up and cleanup before mucosal epithelialization play the key roles in the clinic efficacy of surgery.