兩種鼻腔沖洗方法在功能性鼻竇內(nèi)鏡手術(shù)后的效果比較

李國(guó)賢 郭永康 齊佳

杭州市蕭山區(qū)第一人民醫(yī)院耳鼻喉科，浙江杭州311200

兩種鼻腔沖洗方法在功能性鼻竇內(nèi)鏡手術(shù)后的效果比較

李國(guó)賢 郭永康 齊佳

杭州市蕭山區(qū)第一人民醫(yī)院耳鼻喉科，浙江杭州311200

目的觀察并比較兩種鼻腔沖洗方法在功能性鼻竇內(nèi)鏡手術(shù)后的應(yīng)用效果。方法選擇2012年4月～2014年4月于杭州市蕭山區(qū)第一人民醫(yī)院耳鼻喉科行鼻竇內(nèi)鏡下手術(shù)治療的慢性鼻竇炎患者132例，所有患者均給予鼻內(nèi)鏡下Messerklinger術(shù)。采用隨機(jī)數(shù)字表法將其分為對(duì)照組和觀察組，每組各66例。術(shù)后給予兩組不同的沖洗液，對(duì)照組為0.9%氯化鈉溶液。觀察組為0.9%氯化鈉溶液200 mL混合慶大霉素16萬(wàn)U+α-糜蛋白酶8000 U+地塞米松10 mg。所有患者均隨訪超過3個(gè)月，觀察比較兩組患者的治療效果。結(jié)果觀察組治愈41例，治愈率為62.12%，對(duì)照組治愈29例，治愈率為43.94%，觀察組治愈率明顯高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(χ2= 24.842，P＜0.05)。觀察組總有效率為95.45%，對(duì)照組總有效率為89.39%，觀察組治療總有效率明顯高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(χ2=12.782，P＜0.05)。結(jié)論功能性鼻竇內(nèi)鏡手術(shù)治療慢性鼻竇炎后給予鼻腔沖洗能有效控制并發(fā)癥的發(fā)生，安全性高，患者易于耐受且操作簡(jiǎn)便。慶大霉素、α-糜蛋白酶和地塞米松的氯化鈉溶液沖洗效果優(yōu)于單純氯化鈉溶液沖洗，值得臨床推廣。

鼻腔沖洗;功能性鼻竇內(nèi)鏡手術(shù);慢性鼻竇炎;慶大霉素;地塞米松

臨床上慢性鼻竇炎的主要表現(xiàn)是鼻塞、流膿涕以及頭痛等，程度較重時(shí)可累及鼻眶和鼻顱，甚至可威脅到患者生命安全。病因?qū)W檢測(cè)結(jié)果表明需氧菌是導(dǎo)致該疾病發(fā)生的重要病原菌，且以條件致病菌如表皮葡萄球菌等占據(jù)了大多數(shù)。目前針對(duì)慢性鼻竇炎的治療中，鼻內(nèi)鏡手術(shù)是首選的治療手段，但從臨床上的觀察結(jié)果看來，手術(shù)治療對(duì)發(fā)生在鼻竇黏膜上的炎性反應(yīng)控制效果不理想。而這種炎性反應(yīng)能否徹底清除在很大程度上影響了手術(shù)的效果，清除不徹底則很容易導(dǎo)致癥狀的反復(fù)和遷延。為減少術(shù)后復(fù)發(fā)率，獲得滿意的治療效果，常用的方法包括藥物治療、行鼻腔沖洗等。筆者在功能性鼻竇內(nèi)鏡手術(shù)后的采用了兩種不同沖洗方法，并將效果進(jìn)行比較，現(xiàn)將相關(guān)情況報(bào)道如下:

1 資料與方法

1.1 一般資料

選擇2012年4月～2014年4月于杭州市蕭山區(qū)第一人民醫(yī)院耳鼻喉科(以下簡(jiǎn)稱“我院”)行鼻竇內(nèi)鏡下手術(shù)治療的慢性鼻竇炎患者132例，所有患者術(shù)前均行CT檢查明確診斷。分型標(biāo)準(zhǔn):Ⅰ型，單純型慢性鼻竇炎(保守治療無效);Ⅱ型，慢性鼻竇炎伴鼻息肉;Ⅲ型，多發(fā)性鼻竇炎或全組鼻竇炎伴多發(fā)性、復(fù)發(fā)性鼻息肉和(或)篩竇骨質(zhì)增生。采用隨機(jī)數(shù)字表法將所選患者隨機(jī)分為對(duì)照組和觀察組。觀察組66例，其中男41例，女25例;年齡21～68歲，平均(39.4± 10.9)歲;Ⅰ型32例，Ⅱ型26例，Ⅲ型8例。對(duì)照組66例，其中男48例，女18例;年齡19～70歲，平均(35.8± 11.6)歲;Ⅰ型35例，Ⅱ型25例，Ⅲ型6例。兩組患者的性別比例、平均年齡以及分型分期等資料比較差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，具有可比性。

1.2 方法

所有患者均給予鼻內(nèi)鏡下Messerklinger術(shù)式，術(shù)后膨脹海綿填塞止血，常規(guī)給予預(yù)防感染治療。鼻腔填塞物取出后第2天開始行鼻腔沖洗。沖洗時(shí)囑患者張口平均呼吸，沖洗液由一側(cè)鼻孔進(jìn)入，對(duì)鼻腔和鼻咽部進(jìn)行沖洗，由另一側(cè)鼻孔流出，雙側(cè)鼻孔按順序進(jìn)行沖洗，行沖洗前大約30 min予復(fù)方薄荷液(上海坤弘醫(yī)療，批號(hào):140105)進(jìn)行滴鼻。對(duì)照組沖洗液為0.9%氯化鈉溶液。觀察組沖洗液為0.9%氯化鈉溶液200 mL混合16萬(wàn)U慶大霉素(容生制藥有限公司，批號(hào):140218)+α-糜蛋白酶8000 U(華潤(rùn)雙鶴藥業(yè)股份有限公司，批號(hào):140221)+10 mg地塞米松(金耀藥業(yè)有限公司，批號(hào):140125)。兩組患者術(shù)后1周內(nèi)均沖洗2次/d，1周后改為1次/d，沖洗2個(gè)月，隨訪時(shí)間3～12個(gè)月，患者門診復(fù)診隨訪。

1.3 療效指標(biāo)

參考1997年海口會(huì)議中關(guān)于鼻內(nèi)鏡手術(shù)的相關(guān)評(píng)估標(biāo)準(zhǔn):治愈:患者自覺癥狀完全消失，復(fù)查見竇口開放情況較好，竇腔中未查見膿性分泌物，黏膜上皮化程度好;好轉(zhuǎn):患者自覺癥狀明顯改善，復(fù)查見竇腔內(nèi)可有較少量的膿性分泌物，竇腔黏膜中部分區(qū)域仍存在水腫或肉芽組織等情況;無效:患者自覺癥狀無明顯改善，復(fù)查見竇口發(fā)生明顯狹窄甚至閉塞，竇腔內(nèi)大量膿性分泌物，明顯息肉?？傆行?(治愈例數(shù)+有效例數(shù))/總例數(shù)×100%。

1.4 統(tǒng)計(jì)學(xué)方法

采用SPSS 18.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析，計(jì)量資料數(shù)據(jù)用均數(shù)±標(biāo)準(zhǔn)差(±s)表示，兩組間比較采用t檢驗(yàn);計(jì)數(shù)資料用率表示，組間比較采用χ2檢驗(yàn)，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

隨訪結(jié)果顯示，觀察組治愈率明顯高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(χ2=24.842，P＜0.05)。觀察組中的治療總有效率明顯高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(χ2=12.782，P＜0.05)。見表1。

3 討論

近些年來功能性鼻竇內(nèi)鏡手術(shù)在我國(guó)基層醫(yī)院開展日益廣泛，尤其在治療慢性鼻竇炎和鼻息肉等方面，與傳統(tǒng)術(shù)式比較，鼻內(nèi)鏡術(shù)式有更為明顯的優(yōu)勢(shì)，不但能達(dá)到傳統(tǒng)術(shù)式的治療效果，同時(shí)手術(shù)過程中術(shù)野更加清晰、對(duì)患者造成的創(chuàng)傷更小［1-4］。功能性鼻竇內(nèi)鏡術(shù)式的主要目的在于盡可能減小對(duì)鼻腔正常結(jié)構(gòu)的破壞，最大可能保留鼻腔的正常功能［5-7］，以此為前提下通過手術(shù)改變?cè)械囊骱屯馇闆r［8-11］。但在本術(shù)式開展初期，并發(fā)癥的發(fā)生率較高，一項(xiàng)美國(guó)的統(tǒng)計(jì)結(jié)果顯示發(fā)生率為7%～25%［12］，隨著技術(shù)和設(shè)備的逐步改進(jìn)，并發(fā)癥的發(fā)生情況有了明顯改善，目前的臨床統(tǒng)計(jì)結(jié)果為5%～6%［13-18］。由于術(shù)中手術(shù)器械對(duì)黏膜造成的不可避免的損傷，術(shù)后出現(xiàn)纖維素性滲出并形成大量的血癡［19-22］。術(shù)后為止血而采用鼻腔填充的方法亦會(huì)使得局部黏膜因血供不足而發(fā)生糜爛或腫脹，若不及時(shí)進(jìn)行清理則可能引起術(shù)腔發(fā)生粘連、竇口被封閉甚至鼻竇炎的復(fù)發(fā)等［23-25］。過去只能在并發(fā)癥發(fā)生后再次利用鼻內(nèi)鏡對(duì)術(shù)腔進(jìn)行清理［26-28］，且控制效果并不理想。后來逐漸采用鼻腔沖洗的方法來預(yù)防并發(fā)癥的發(fā)生［29-32］，并取得了較為理想的效果。目前的研究認(rèn)為鼻腔沖洗的機(jī)制主要包括以下幾個(gè)方面:①增強(qiáng)了術(shù)腔黏膜表面纖毛的功能［33-35］;②明顯減輕黏膜的水腫程度［36-39］;③物理的清潔作用［40-41］。

行鼻腔沖洗是一種安全性較高、操作極為簡(jiǎn)單、副作用極少的方法［42-44］，常見的不良反應(yīng)主要是患者自覺鼻腔內(nèi)沖洗后出現(xiàn)燒灼感、癢感等［15，45-46］，以及沖洗過程中沖洗液自鼻竇中流出時(shí)的不適感等［8］。目前對(duì)沖洗液的選擇在臨床上尚未達(dá)成共識(shí)，其中應(yīng)用較多的是0.9%氯化鈉溶液，因?yàn)檫@種濃度的沖洗液比較適合鼻黏膜的生理情況，沖洗過程中幾乎對(duì)鼻黏膜不會(huì)造成任何刺激［46］，故本資料中對(duì)照組亦采用了該種沖洗液。觀察組在氯化鈉溶液中加入了慶大霉素、α-糜蛋白酶以及地塞米松，因?yàn)閱渭兊穆然c溶液并不具有消炎消腫的作用，對(duì)于術(shù)后術(shù)腔發(fā)生水腫的情況并不能很好地緩解，這樣術(shù)后出現(xiàn)囊泡、肉芽組織以及術(shù)腔粘連等并發(fā)癥的風(fēng)險(xiǎn)較大。慶大霉素是臨床應(yīng)用較多的一類氨基糖苷類廣譜抗生素，該藥物對(duì)于銅綠假單胞菌、金黃色葡萄球菌等導(dǎo)致慢性鼻竇炎發(fā)生的相對(duì)常見的病原菌的敏感性較強(qiáng)［46］。α-糜蛋白酶的作用則主要是對(duì)膿性分泌物進(jìn)行稀釋，避免竇口發(fā)生堵塞而引流不暢。地塞米松一方面能有效緩解術(shù)后術(shù)腔黏膜的水腫程度，另一方面對(duì)息肉的生長(zhǎng)亦有明顯的抑制作用。從本研究的隨訪結(jié)果可以看出，觀察組中治愈41例，治愈率為62.12%，對(duì)照組中治愈29例，治愈率為43.94%，觀察組治愈率明顯高于對(duì)照組(χ2=24.842，P＜0.05)。觀察組總有效率為95.45%，對(duì)照組總有效率為89.39%，觀察組治療總有效率明顯高于對(duì)照組(χ2=12.782，P＜0.05)。

綜上所述，功能性鼻竇內(nèi)鏡手術(shù)治療慢性鼻竇炎后給予鼻腔沖洗能有效控制并發(fā)癥的發(fā)生，安全性高，患者易于耐受且操作簡(jiǎn)便。慶大霉素、α-糜蛋白酶和地塞米松的氯化鈉溶液沖洗效果優(yōu)于單純氯化鈉溶液沖洗效果，值得臨床推廣。

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Effects comparison of two methods of nasal irrigation after functional endoscopic sinus surgery

LI GuoxianGUO YongkangQI JiaDepartment of E.N.T.，the First People’s Hospital of Xiaoshan District in Hangzhou City，Zhejiang Province，Hangzhou 311200，China

Objective To compare the effects of two methods of nasal douche applied after functional endoscopic sinus surgery.Methods 132 cases of patients with chronic nasosinusitis had functional endoscopic sinus surgery in E.N.T. Department of the First People’s Hospital of Xiaoshan District in Hangzhou City from April 2012 to April 2014 were selected，all the patients were given Messerklinger surgery under endoscopic sinus，and they were divided into two groups by random number table，control group and observation group，with 66 cases in each groups.Patients in the two groups were given different postoperative rinses，patients of the control group were given 0.9%sodium chloride solution，while patients in the observation group were given 0.9%sodium chloride solution combined with 160 000 U gentamicin，8000 U α-chymotrypsin and 10 mg dexamethasone.All the patients were followed up more than 3 months，and the therapeutic effects of two groups were observed and compared.Results 41 cases in observation group were healed，cure rate was 62.12%，and 29 cases in control group were healed，cure rate was 43.94%，the cure rate in observation group was higher than that in the control group，the difference was statistically significant(χ2=24.842，P＜0.05).The total effective rate in the observation group was 95.45%，while 89.39%in the control group，and the total effective rate in the observation group was higher than that in the control group，the difference was statistically significant(χ2=12.782，P＜0.05).Conclusion It is effective to control complication by giving nasal douche after functional endoscopic sinus surgery，safe，tolerant and easy.The effect of sodium chloride solution combined with gentamicin，α-chymotrypsin and dexamethasone is better than that of sodium chloride solution alone.It is worthy of clinical promotion.

Nasal douche；Functional endoscopic sinus surgery；Chronic nasosinusitis；Gentamicin；Dexamethasone

R765.4

A

1673-7210(2015)02(c)-0048-04

2014-10-09本文編輯:任念)