鼻腔黏膜瓣在额窦磨削手术中的应用

The application of nasal mucosal flaps in frontal drill out procedures

目的回顾性总结额窦磨削手术(DrafⅡb、扩大DrafⅡb和DrafⅢ)中应用鼻腔黏膜瓣的临床随访结果,探讨和归纳不同黏膜瓣的应用适应证及使用黏膜瓣对术后额窦口开放状态的影响。方法收集2013-2019年于北京同仁医院接受内镜下额窦磨削手术的48例患者,根据术中是否使用黏膜瓣进行额窦口重建分为黏膜瓣组(24例,男19例,女5例,年龄19~71岁)和非黏膜瓣组(即对照组,24例,男18例,女6例,年龄21~63岁),利用OsiriX^(■)软件对术后7 d和术后1年额窦引流通道截面积进行测量,并进行Lund-Kennedy评分,分析2组患者预后的差异。采用SPSS 23.0软件进行统计学分析。结果术后随访时间18~102个月。黏膜瓣组术后上皮化时间(2.5±0.9)个月(均值±标准差,后同),对照组术后上皮化时间(3.0±0.7)个月,组间差异有统计学意义(t=1.97,P=0.024)。随访终期黏膜瓣组额窦开放良好者23例(95.8%),狭窄者1例(4.2%),无再手术病例。对照组额窦开放良好者16例(66.7%),狭窄者8例(33.3%),再手术者4例(16.7%)。黏膜瓣组额窦口狭窄率明显低于对照组(χ^(2)=4.92,P=0.027)。黏膜瓣组术后1年额窦口面积缩小(0.87±0.58)cm^(2),对照组额窦口面积缩小(1.54±1.15)cm^(2),组间差异有统计学意义(t=1.72,P=0.046)。2组均无额窦口闭锁病例,无手术并发症。术后两因素重复测量方差分析提示,黏膜瓣组平均Lund-Kennedy评分比对照组低0.78分,即手术方式对Lund-Kennedy评分的影响具有统计学意义(F=5.33,P=0.035)。结论额窦磨削手术中应用黏膜瓣覆盖裸露骨面可减轻黏膜瘢痕及新骨形成,显著降低额窦口狭窄率。

Objective To summarize the follow-up outcomes of frontal drill out procedures(drafⅡb,extended drafⅡb and drafⅢ)using mucosal flaps,and discuss the surgical indications of different mucosal flaps and their potential benefits to the opening of the frontal neo-ostium.Methods A total of 48 patients with chronic rhinosinusitis or frontal mucoceles treated by drafⅡb,extended drafⅡb and drafⅢbetween 2013 and 2019 in Beijing TongRen Hospital were enrolled in this study.Twenty-four patients who were treated with mucosal flaps were considered as mucosal flap group(including 19 males and 5 females,aging from 19 to 71 years),and the other 24 patients who didn′t have neo-ostium reconstruction were considered as control group(including 18 males and 6 females,aging from 21 to 63 years).The frontal neo-ostium crosssectional area was measured with osiriX^(■)7 days and 1 year postoperatively.Lund-Kennedy score(LKS)was also completed to analyze the difference of therapeutic effect between mucosal flap group and control group.SPSS 23.0 software was used for statistical analysis.Results The postoperative follow-up time was 18 to 102 months.The postoperative epithelialization time in the mucosal flap group and the control group was(2.5±0.9)months and(3.0±0.7)months(Mean±SD),respectively,with statistically significant(t=1.97,P=0.024).At the end of follow-up,23 cases(95.8%)had well opened frontal neo-ostium,1 case(4.2%)was re-stenosed,and there was no revision surgery in the mucosal flap group.In the control group,16 cases(66.7%)had well opened frontal neo-ostium,8 cases(33.3%)were re-stenosed,4 cases(16.7%)had revision surgery.The mucosal flap group had much fewer stenosis cases than control group(χ^(2)=4.92,P=0.027).The neo-ostium area in the mucosal flap group and the control group was reduced by(0.87±0.58)cm^(2)and(1.54±1.15)cm^(2)1 year after operation respectively,with statistically significant(t=1.72,P=0.046).There was no case of frontal sinus atresia and no surgical complication in both groups.The two-factor repeated measurement analysis of variance after surgery showed that the average LKS of the mucosal flap group was 0.78 points lower than that of the control group.In other words,the influence of grafting technique on LKS was statistically significant(F=5.33,P=0.035).Conclusions The application of mucosal flaps to cover the denuded bone during frontal drill out procedures can prohibit mucosal scar and new bone formation,and significantly reduce the stenosis rate of frontal neo-ostium.