摘要
选取2015年1月-2019年12月该院收治的FMS患者200例作为研究对象。观察组(n = 100)采用鼻内镜下下鼻道外侧壁长方形开窗术治疗,对照组(n = 100)于鼻内镜下采用泪前隐窝入路治疗。观察两组患者手术时间、术中出血量及并发症发生率等情况。
观察组术中出血量64~100 mL,平均(78.5±8.4)mL,手术时间17~43 min,平均(29.5±5.8)min,术后随访1年,1例术侧空鼻综合征,治愈率为99.0%。对照组术中出血量62~108 mL,平均(81.4±8.5)mL,手术时间18~51 min,平均(32.4±6.5)min,术后随访1年,1例溢泪,1例术侧鼻腔粘连,1例术侧鼻腔狭窄,2例术侧空鼻综合征,治愈率为98.0%。两组患者术中出血量和手术时间比较,差异均有统计学意义(P < 0.05);两组患者并发症发生率比较,差异无统计学意义(P > 0.05)。
真菌性上颌窦炎(fungal maxillary sinusitis,FMS)发病原因很多,但确切病因不明,可能与体内体外环境变化、周围炎症刺激和抗菌药物长期应用等诸多内外因素有关。目前,常采用泪前隐窝入路治疗FMS,但其具有手术时间较长和术中出血量较多的弊端。因此,本研究在常规泪前隐窝入路手术治疗的基础上,采用鼻内镜下下鼻道外侧壁长方形开窗治疗FMS,取得了一定的效果。现报道如下:
选取2015年1月-2019年12月联勤保障部队第九八八医院行鼻内镜下下鼻道外侧壁长方形开窗治疗的FMS患者100例作为观察组,另选鼻内镜下泪前隐窝入
组别 | 性别/例 | 年龄/岁 | |
---|---|---|---|
男 | 女 | ||
观察组(n = 100) | 30 | 70 | 50.4±28.1 |
对照组(n = 100) | 38 | 62 | 51.7±28.4 |
t/ | 1.43 |
0.3 | |
P值 | 0.232 | 0.745 |
注: †为t值
采用鼻内镜下下鼻道外侧壁长方形开窗术。在0°鼻内镜直视下,经中鼻道可见上颌窦自然窦口处有霉菌团块和脓液溢出,以吸引器吸出霉菌团块和脓液,并保留自然窦口。下鼻甲骨折内移,距下鼻甲前缘约1.0~1.5 cm,靠近下鼻道外侧壁上颌窦骨质最薄弱处,注意避开鼻泪管开口,用中号弯钳(18.0 cm)戳穿进入上颌窦内,可见部分霉菌团块及脓液溢出,以吸引器吸出,向前用咬骨钳(厂家:德国STORZ公司,型号:662121)配合反咬钳(厂家:桐庐斯科医疗器械有限公司,型号:69-1035)咬除戳穿处周围残余骨质,用0°动力刀头(厂家:美敦力公司,型号:1884004)吸切残余黏膜,完成上颌窦下鼻道开窗,窗口前后径约为20 mm,上下径约为15 mm,略呈长方形(图

图1 鼻内镜下下鼻道外侧壁模拟切口
Fig.1 Simulated incision of lateralis wall of inferior nasal passage under nasal endoscope

图2 鼻内镜下下鼻道外侧壁略呈长方形切口
Fig.2 Slightly rectangular incision on lateralis wall of inferior nasal passage under nasal endoscope
采用泪前隐窝入路。行全身麻醉,自下鼻甲前缘上方、下鼻甲附着鼻腔的外侧壁,从上往下切开,并切至鼻底处黏膜,刀口呈弧形,切至黏骨膜下,并顺骨面剥离至下鼻甲骨附着的鼻腔外侧壁,剪断下鼻甲附着根部,顺根部剥离下鼻甲及鼻腔外侧壁黏膜至上颌窦窦口前缘,并向后下剥离至鼻泪管开口的周围,使黏膜游离,然后去除下鼻甲附着根部及上颌窦的内侧壁,找到骨性鼻泪管,并去除膜性鼻泪管周围骨
术后随访1年,观察组治愈率为99.0%(99/100),与对照组的治愈率98.0%(98/100)比较,差异无统计学意义(P > 0.05)。见
组别 | 治愈/例 | 复发/例 | 治愈率例(%) |
---|---|---|---|
观察组(n = 100) | 99 | 1 | 99(99.0) |
对照组(n = 100) | 98 | 2 | 98(98.0) |
| 0.34 | ||
P值 | 0.578 |
观察组术中出血量较对照组少,手术时间较对照组短,两组患者比较,差异均有统计学意义(P < 0.05)。见
组别 | 术中出血量/mL | 手术时间/min |
---|---|---|
观察组(n = 100) | 78.5±8.4 | 29.5±5.8 |
对照组(n = 100) | 81.4±8.5 | 32.4±6.5 |
t值 | 2.50 | 3.33 |
P值 | 0.015 | 0.001 |
观察组并发症发生率为1.0%,对照组为5.0%,两组患者比较,差异无统计学意义(P > 0.05)。见
组别 | 溢泪/例 | 术侧鼻腔粘连/例 | 术侧鼻腔狭窄/例 | 空鼻综合征/例 | 总发生率 例(%) |
---|---|---|---|---|---|
观察组(n = 100) | 0 | 0 | 0 | 1 | 1(1.0) |
对照组(n = 100) | 1 | 1 | 1 | 2 | 5(5.0) |
P值 | 0.212 |
注: 采用Fisher确切概率法
解剖上,上颌窦位于鼻腔的两侧,底在上方,尖在下方,如同倒置的不规则锥体。鼻内镜下经中鼻道开口难以窥及其全貌,尤其是上颌窦的前下及内侧
下鼻道开窗,窗口前后径为20 mm;上下径为15 mm,略呈长方形(靠近梨状孔,开窗过程中尽量避开位于下鼻道前端的鼻泪管下口)。在70°镜下,通过翻转70°镜面,可以看到上颌窦内各个窦腔区域,故能顺利处理上颌窦内各个角落的真菌团
FMS所形成的真菌团块往往附着在上颌窦的前下或前内侧壁,与上颌窦内壁黏膜粘连较紧,可形成钙化,单纯冲洗很难完全清除。采用泪前隐窝入路,虽然视野较清晰,但损伤较大,且手术时间长,术后并发症较多。因此,笔者采用鼻内镜下下鼻道外侧壁长方形开窗的方法,将真菌团块从黏膜上分
FMS多在患者较长时间使用激素、抗生素和免疫抑制剂等情况下发生,也与患者有无糖尿病、高血压和冠心病等基础性疾病有关。FMS一般为单侧上颌窦发病,很少波及双侧,且中年女性居多。FMS危害较大,患者多有失眠健忘、哮喘、消化系统功能障碍等情况发生,有时还会出现精神萎靡、易疲劳、头痛及头晕、高热惊厥等症状。故预防FMS时,要做到以下几点:平时讲究鼻腔卫生,可用等渗盐水每天晨起冲洗鼻腔;喜欢游泳者下水时姿势要正确,尽量避免鼻孔浸在水中;擤鼻时方法要得当,尽量不要使鼻涕倒流。
综上所述,鼻内镜下下鼻道外侧壁长方形开窗治疗FMS的效果较佳,能明显缩短手术时间,减少术中出血量,术后不易复
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