翼腭窝加压封闭减少鼻内窥镜手术出血的临床研究
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摘要
目的：自20世纪80年代以来，鼻内窥镜手术在全世界已得到广泛应用，是当今公认的治疗慢性鼻窦炎及鼻息肉的首选手术方法，已基本替代了传统手术，其技术日臻完善，给广大患者带来了福音，但它同其他任何手术一样也有并发症，尤其术中出血是影响鼻内窥镜手术质量和预后的重要因素。为减少鼻内窥镜手术出血，人们采取了各种措施，但术中出血仍是困扰耳鼻喉科医生的难题。为进一步减少术中出血，我们采用翼腭窝加压封闭的方法进行研究。
方法：在行功能性鼻内窥镜手术的患者中，选择符合以下条件的65位患者进行观察研究。入选条件：1，年龄在18~50岁的慢性鼻窦炎或慢性鼻窦炎伴鼻息肉患者，双侧鼻腔鼻窦病变范围基本一致；2，手术时行鼻窦开放和/或鼻息肉摘除术，需行鼻中隔矫正术者不计入内；3，术前检查无高血压，糖尿病，风湿病，出血性疾病等全身性疾病，妇女不在月经期。符合入选条件的患者均进行术前常规准备，包括用青霉素或头孢唑啉钠等正规抗炎治疗5～7天，全身和局部应用糖皮质激素，进行鼻窦冠状CT扫描及内窥镜检查，详细了解鼻腔病变情况，制定完善的手术方案。将符合条件且做了术前常规准备的患者进行研究。手术开始前，一侧用1%利多卡因2ml行翼腭窝封闭阻滞神经，作为对照组；一侧用1%利多卡因20ml行翼腭窝加压封闭，作为观察组，比较双侧鼻腔鼻窦手术出血量，以研究翼腭窝加压封闭在减少鼻内窥镜手术出血中的作用。所选
择的病例均采用局部麻醉， Messenklinger术式，从前向后进行手术。其中，鼻息肉患者所实施的手术均为双侧鼻息肉摘除+筛窦开放+钩突切除+上颌窦自然窦口扩大术，必要时可加做蝶窦开放+额隐窝开放+中鼻甲部分切除术；鼻窦炎患者所实施的手术为钩突切除+筛窦开放+上颌窦自然窦口扩大术, 必要时可加做蝶窦开放+额隐窝开放+中鼻甲部分切除术。
结果：经过对65例患者的研究，我们发现翼腭窝加压封闭能有效减少鼻内窥镜手术出血，其中62例的出血量减少。其中，慢性鼻窦炎（1型）患者观察组较对照组出血量平均减少35.9%，鼻息肉（2型）患者平均减少42.1%，复发性鼻息肉（3型）患者平均减少39.9%，总共平均减少40.6%。观察组的平均出血量为68.06±30.93ml,平均手术时间为36.6±8.73m,对照组的平均出血量为114.57±51.44ml,平均手术时间为45.8±8.64m。其中，慢性鼻窦炎（1型）患者观察组出血量为43.36±12.41ml，用时29.07±5.23m，对照组出血量为67.71±19.19ml，用时39±6.36m；鼻息肉（2型）患者观察组的平均出血量为60.24±18.9ml，用时36.72±7.51m，对照组的平均出血量为103.76±20.61ml，用时45.62±7.37m；复发性鼻息肉（3型）患者观察组的平均出血量为113.43±22.76ml，用时43.79±8.68m，对照组的平均出血量为189±53.06ml，用时53.07±8.38m。各型患者的观察组与对照组的出血量与手术时间经统计均有显著性差异（P<0.01）。 65例患者进行翼腭窝加压封闭时未出现并发症。
结论：翼腭窝加压封闭可以减少鼻内窥镜手术出血，效果明显。
Objective: Since 1980’s,fuctional endoscopic sinus surgery (FESS)has been widely applied all over the world, now it is considered the best surgical method to treat chronic sinusitis and nasal polyps. The surgical technique is becoming more and more skillful. As to other operation, there exists complications too. Bleeding during operation is still a very important factor affecting surgical prognosis. In order to reduce blood loss during operation, many methods have been explored. All these methods had reduced blood loss. Nasal bleeding during operation is still a main problem disturbing doctors. In order to further reduce blood loss, petrygopalatine fossa injection with positive pressure was used.
Materials and methods: 65 patients included in the study， those patients must meet the following conditions:1,Age ranged from eighteen to fifty，there were chronic sinusitis and/or nasal polyps;2, individuals who need nasal septum reconstruction were excluded;3, there is no diseases which affect patients’ blood coagulation function such as hypertension, rheumatic lesion, urophthisis et.Female patients must not in the period of inter- menstrual before operation. All patients received anti- inflammatory therapy for 5 to 7 days with penicillin or cefazolin, intranasal steroids spray. Sinus CT scan and nasal endoscopy were
taken to decide operation procedure in all patients. The operation was performed under local anesthesia. Before operation, 20ml lidocaine was injected to one side’s pterygopalatine fossa, the other side with 2ml. A comparison of bleeding was made between left and right side. The surgical procedures were performed along the guidelines described by Messerklinger . Patients with nasal polyps were operated with uncinate process excision，polypec- tomy, ethmoidotomy, maxillary sinusotomy and uncinate process excision. Chronic sinusitis patients were operated with uncinate process excision , ethmoidotomy, maxillary sinusotomy. When necessary，the following procedures could be added：frontal sinusotomy, sphenoidotomy and partial middle turbinectomy。
Results：A reduction of bleeding was found in sixty-two patients out of sixty-five patients. Blood loss reduction was found in patients with chronic sinusitis by 35.9%， nasal polyps by 42.1%，recurrent nasal polyps by 39.9%,with an average of 40.6%。In the experimental sides, the average blood loss during operation was 68.06±30.93ml, the average operating duration was 36.6±8.73minutes。Among them, in chronic sinusitis patients, the average blood loss was 43.36±12.41ml，the average operating duration was29.07±5.23 minutes; in nasal polyps patients, the average blood loss was 60.24±18.9ml，the average operating duration was 36.72±7.51minutes; in recurrent nasal polyps patients, the average blood loss was 113.43±22.76ml，the average operating duration was 43.79±8.68 minutes; in the contralateral side, the average blood loss during operation was 114.57±
51.44ml, the average operating duration was 45.8±8.64minutes。Among them, in chronic sinusitis patients, the average blood loss was67.71±19.19ml，the average operating duration was 39±6.36minutes; in nasal polyps patients, the average blood loss was 103.76±20.61ml，the average operating duration was 45.62±7.37minutes;in recurrent nasal polyps patients, the average blood loss was 189±53.06ml，the average operating duration was 53.07±8.38minutes.There was statistic significance between two groups in bleeding amount and surgical duration（P<0.01）.There was no complications during pterygopalatine fossa injection with positive pressure.
Conclusion: Pterygopalatine fossa injection with positive pressure could significantly reduce blood loss during operation.
方法：在行功能性鼻内窥镜手术的患者中，选择符合以下条件的65位患者进行观察研究。入选条件：1，年龄在18~50岁的慢性鼻窦炎或慢性鼻窦炎伴鼻息肉患者，双侧鼻腔鼻窦病变范围基本一致；2，手术时行鼻窦开放和/或鼻息肉摘除术，需行鼻中隔矫正术者不计入内；3，术前检查无高血压，糖尿病，风湿病，出血性疾病等全身性疾病，妇女不在月经期。符合入选条件的患者均进行术前常规准备，包括用青霉素或头孢唑啉钠等正规抗炎治疗5～7天，全身和局部应用糖皮质激素，进行鼻窦冠状CT扫描及内窥镜检查，详细了解鼻腔病变情况，制定完善的手术方案。将符合条件且做了术前常规准备的患者进行研究。手术开始前，一侧用1%利多卡因2ml行翼腭窝封闭阻滞神经，作为对照组；一侧用1%利多卡因20ml行翼腭窝加压封闭，作为观察组，比较双侧鼻腔鼻窦手术出血量，以研究翼腭窝加压封闭在减少鼻内窥镜手术出血中的作用。所选
择的病例均采用局部麻醉， Messenklinger术式，从前向后进行手术。其中，鼻息肉患者所实施的手术均为双侧鼻息肉摘除+筛窦开放+钩突切除+上颌窦自然窦口扩大术，必要时可加做蝶窦开放+额隐窝开放+中鼻甲部分切除术；鼻窦炎患者所实施的手术为钩突切除+筛窦开放+上颌窦自然窦口扩大术, 必要时可加做蝶窦开放+额隐窝开放+中鼻甲部分切除术。
结果：经过对65例患者的研究，我们发现翼腭窝加压封闭能有效减少鼻内窥镜手术出血，其中62例的出血量减少。其中，慢性鼻窦炎（1型）患者观察组较对照组出血量平均减少35.9%，鼻息肉（2型）患者平均减少42.1%，复发性鼻息肉（3型）患者平均减少39.9%，总共平均减少40.6%。观察组的平均出血量为68.06±30.93ml,平均手术时间为36.6±8.73m,对照组的平均出血量为114.57±51.44ml,平均手术时间为45.8±8.64m。其中，慢性鼻窦炎（1型）患者观察组出血量为43.36±12.41ml，用时29.07±5.23m，对照组出血量为67.71±19.19ml，用时39±6.36m；鼻息肉（2型）患者观察组的平均出血量为60.24±18.9ml，用时36.72±7.51m，对照组的平均出血量为103.76±20.61ml，用时45.62±7.37m；复发性鼻息肉（3型）患者观察组的平均出血量为113.43±22.76ml，用时43.79±8.68m，对照组的平均出血量为189±53.06ml，用时53.07±8.38m。各型患者的观察组与对照组的出血量与手术时间经统计均有显著性差异（P<0.01）。 65例患者进行翼腭窝加压封闭时未出现并发症。
结论：翼腭窝加压封闭可以减少鼻内窥镜手术出血，效果明显。
Objective: Since 1980’s,fuctional endoscopic sinus surgery (FESS)has been widely applied all over the world, now it is considered the best surgical method to treat chronic sinusitis and nasal polyps. The surgical technique is becoming more and more skillful. As to other operation, there exists complications too. Bleeding during operation is still a very important factor affecting surgical prognosis. In order to reduce blood loss during operation, many methods have been explored. All these methods had reduced blood loss. Nasal bleeding during operation is still a main problem disturbing doctors. In order to further reduce blood loss, petrygopalatine fossa injection with positive pressure was used.
Materials and methods: 65 patients included in the study， those patients must meet the following conditions:1,Age ranged from eighteen to fifty，there were chronic sinusitis and/or nasal polyps;2, individuals who need nasal septum reconstruction were excluded;3, there is no diseases which affect patients’ blood coagulation function such as hypertension, rheumatic lesion, urophthisis et.Female patients must not in the period of inter- menstrual before operation. All patients received anti- inflammatory therapy for 5 to 7 days with penicillin or cefazolin, intranasal steroids spray. Sinus CT scan and nasal endoscopy were
taken to decide operation procedure in all patients. The operation was performed under local anesthesia. Before operation, 20ml lidocaine was injected to one side’s pterygopalatine fossa, the other side with 2ml. A comparison of bleeding was made between left and right side. The surgical procedures were performed along the guidelines described by Messerklinger . Patients with nasal polyps were operated with uncinate process excision，polypec- tomy, ethmoidotomy, maxillary sinusotomy and uncinate process excision. Chronic sinusitis patients were operated with uncinate process excision , ethmoidotomy, maxillary sinusotomy. When necessary，the following procedures could be added：frontal sinusotomy, sphenoidotomy and partial middle turbinectomy。
Results：A reduction of bleeding was found in sixty-two patients out of sixty-five patients. Blood loss reduction was found in patients with chronic sinusitis by 35.9%， nasal polyps by 42.1%，recurrent nasal polyps by 39.9%,with an average of 40.6%。In the experimental sides, the average blood loss during operation was 68.06±30.93ml, the average operating duration was 36.6±8.73minutes。Among them, in chronic sinusitis patients, the average blood loss was 43.36±12.41ml，the average operating duration was29.07±5.23 minutes; in nasal polyps patients, the average blood loss was 60.24±18.9ml，the average operating duration was 36.72±7.51minutes; in recurrent nasal polyps patients, the average blood loss was 113.43±22.76ml，the average operating duration was 43.79±8.68 minutes; in the contralateral side, the average blood loss during operation was 114.57±
51.44ml, the average operating duration was 45.8±8.64minutes。Among them, in chronic sinusitis patients, the average blood loss was67.71±19.19ml，the average operating duration was 39±6.36minutes; in nasal polyps patients, the average blood loss was 103.76±20.61ml，the average operating duration was 45.62±7.37minutes;in recurrent nasal polyps patients, the average blood loss was 189±53.06ml，the average operating duration was 53.07±8.38minutes.There was statistic significance between two groups in bleeding amount and surgical duration（P<0.01）.There was no complications during pterygopalatine fossa injection with positive pressure.
Conclusion: Pterygopalatine fossa injection with positive pressure could significantly reduce blood loss during operation.
引文
Messerklinger W. Back ground and evolution of endoscop-ic sinus surgery .ENTJ1994,73(7):449～450
Kennedy,Dw. Functional endoscopic sinus surgery. Techni-que；ArchOtolaryngol,1985;111(9):643～649
Kennedy,DW. Functional endoscopic Sinus Surgery: Theory and diagnositic evaluation.ArchOtolaryngo , 1985; 111(9): 576～582
Kennedy,DW. Functional endoscopic Sinus Surgery: Theory and diagnositic evaluation.ArchOtolaryngo , 1985; 111(9): 576～582
Stankiewicz, JA. Complications of endoscopic sinus surgery. OtolaryngolClinNorAm,1989,22:749
李源，许庚。鼻内窥镜手术并发症探讨。中华耳鼻咽喉科杂志，1998，33(3)：142～145
吴昌竹，孙树岩，于博。内镜鼻窦手术并发症及相关因素分析。沈阳部队医药，2002,15(3):238～239
孙树岩。内窥镜鼻窦手术中并发症的总结。中华耳鼻咽喉科杂志，2001,36(5):335～337
Padrnos, RE. A method for control of posterior nasal hemorr hage,Arch-Otolaryngol. 1968 Feb; 87(2): 181～183
慢性鼻窦炎鼻息肉临床分型分期及内窥镜鼻窦手术疗效评定标准。中华耳鼻咽喉科杂志。1998，33（S：S）：83
Senior, BA, Kennedy, DW, Tanabodee, J. et al. Long-term results of functional endoscopic sinus surgery.
Laryngoscope,1998 Feb; 108(2): 151～157
韩德民，周兵，刘华超等。1000例鼻窦内窥镜手术疗效分析。中华耳鼻咽喉科杂志。1996；31（6）：358～361
Lazar, RH, Youni, RT, Long, TE. Functional endonasal sinus surgery in adults and children. Laryngoscope. 1993, Jan, 103(1 Pt 1): 1～5
尹金淑，彭洪，汪学勇等。 鼻窦炎患者术前治疗对减少鼻内窥镜手术中出血的影响。中华医学杂志，2001，81（16）：1014
Nass,RL，Holliday,RA，Reede, DL. Diagnosis of surgical sinusitis using nasal endoscopy and computerized tomography.Laryngoscope, 1989.Nov, 99(11): 1158～1160
Vining,EM, Yanagisawa,K,Yanagisawa, E.The importance of preoperative nasal endoscopy in patients with sinonasal disease,Laryngoscope, 1993 May; 103 (5): 512～519
Sonkens,JW, Harnsberger,HR, Blanch,GM et al. The impact of screening sinus CT on the planning of functional endoscop ic sinus surgery. Otolaryngol-Head-Neck-Surg., 1991, Dec. 105 (6): 802~813
Kaluskar, K，Patil, NP，Sharkey, AN.The role of CT in functional endoscopic sinus surgery. Rhinology. 1993, Jun,31(2): 49～52
Gitelman PD,et al.Comparision of functional endoscopic Sinus surgery under local and general inesthesia.Ann O-tol Rhinol Laryngol. 1993, 102(4): 291
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Kennedy,Dw. Functional endoscopic sinus surgery. Techni-que；ArchOtolaryngol,1985;111(9):643～649
Kennedy,DW. Functional endoscopic Sinus Surgery: Theory and diagnositic evaluation.ArchOtolaryngo , 1985; 111(9): 576～582
Kennedy,DW. Functional endoscopic Sinus Surgery: Theory and diagnositic evaluation.ArchOtolaryngo , 1985; 111(9): 576～582
Stankiewicz, JA. Complications of endoscopic sinus surgery. OtolaryngolClinNorAm,1989,22:749
李源，许庚。鼻内窥镜手术并发症探讨。中华耳鼻咽喉科杂志，1998，33(3)：142～145
吴昌竹，孙树岩，于博。内镜鼻窦手术并发症及相关因素分析。沈阳部队医药，2002,15(3):238～239
孙树岩。内窥镜鼻窦手术中并发症的总结。中华耳鼻咽喉科杂志，2001,36(5):335～337
Padrnos, RE. A method for control of posterior nasal hemorr hage,Arch-Otolaryngol. 1968 Feb; 87(2): 181～183
慢性鼻窦炎鼻息肉临床分型分期及内窥镜鼻窦手术疗效评定标准。中华耳鼻咽喉科杂志。1998，33（S：S）：83
Senior, BA, Kennedy, DW, Tanabodee, J. et al. Long-term results of functional endoscopic sinus surgery.
Laryngoscope,1998 Feb; 108(2): 151～157
韩德民，周兵，刘华超等。1000例鼻窦内窥镜手术疗效分析。中华耳鼻咽喉科杂志。1996；31（6）：358～361
Lazar, RH, Youni, RT, Long, TE. Functional endonasal sinus surgery in adults and children. Laryngoscope. 1993, Jan, 103(1 Pt 1): 1～5
尹金淑，彭洪，汪学勇等。 鼻窦炎患者术前治疗对减少鼻内窥镜手术中出血的影响。中华医学杂志，2001，81（16）：1014
Nass,RL，Holliday,RA，Reede, DL. Diagnosis of surgical sinusitis using nasal endoscopy and computerized tomography.Laryngoscope, 1989.Nov, 99(11): 1158～1160
Vining,EM, Yanagisawa,K,Yanagisawa, E.The importance of preoperative nasal endoscopy in patients with sinonasal disease,Laryngoscope, 1993 May; 103 (5): 512～519
Sonkens,JW, Harnsberger,HR, Blanch,GM et al. The impact of screening sinus CT on the planning of functional endoscop ic sinus surgery. Otolaryngol-Head-Neck-Surg., 1991, Dec. 105 (6): 802~813
Kaluskar, K，Patil, NP，Sharkey, AN.The role of CT in functional endoscopic sinus surgery. Rhinology. 1993, Jun,31(2): 49～52
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