Shikani Alan H, Chahine Karim A, Alqudah Mohannad A
Department of Otolaryngology-Head and Neck Surgery, Union Memorial Hospital, 201 East University Pkwy., Baltimore, MD 21218, USA.
Ear Nose Throat J. 2014 Apr-May;93(4-5):E48-54.
The management of refractory chronic rhinosinusitis (CRS) after endoscopic sinus surgery is complex and challenging. We conducted a prospective clinical pilot study to evaluate the effectiveness of a rhinotopic protocol for the treatment of refractory CRS. Our study population was made up of 20 patients--8 men and 12 women, aged 31 to 76 years (mean: 50.1)--who were treated in our tertiary care rhinology fellowship training program. The rhinotopic protocol consisted of twice-daily saline rinses, each of which was followed by the administration of a nebulized corticosteroid and then a nebulized antibiotic. This regimen was administered for 6 weeks. Thereafter, patients underwent a once-weekly endoscopic sinus debridement followed by topical intrasinus installation of a corticosteroid and antibiotic. The duration of follow-up was 24 weeks, and thus the total study duration was 30 weeks. Treatment outcomes were based on Lund-Kennedy symptom scores and Lund-Kennedy endoscopic appearance scores. We found a 56% improvement in the mean symptom score after 3 weeks of therapy and 77% after 6 weeks. Subsequent follow-up revealed 90% improvement 4 weeks following the completion of therapy and 95% at 8 weeks post-therapy. Thereafter, we saw a small decrease in improvement: 73% at 16 weeks of follow-up and 65% at 24 weeks. Analysis of endoscopic appearance scores revealed a 55% improvement at 3 weeks of therapy and 84% at 6 weeks. The same general pattern emerged during follow-up, with 94% improvement 4 weeks after the cessation of therapy, 96% at 8 weeks, 76% at 16 weeks, and 75% at 24 weeks. Sinus cultures performed 4 weeks after the cessation of therapy found no growth in 13 patients (65%), normal respiratory flora in 5 patients (25%), a persistent pathogen in 1 patient (5%), and the emergence of a new pathogen in another (5%). Analysis of symptom scores and endoscopic appearance scores revealed that the rhinotopic protocol resulted in statistically significant improvement (p < 0.001) throughout the treatment period and follow-up period, although the improvement gradually declined over time. We therefore conclude that a rhinotopic protocol can be an effective treatment for refractory CRS.
内镜鼻窦手术后难治性慢性鼻窦炎（CRS）的管理复杂且具有挑战性。我们进行了一项前瞻性临床试点研究，以评估鼻局部治疗方案对难治性CRS的治疗效果。我们的研究对象包括20名患者，其中8名男性和12名女性，年龄在31至76岁之间（平均50.1岁），他们均在我们的三级医疗鼻科学 fellowship 培训项目中接受治疗。鼻局部治疗方案包括每日两次用生理盐水冲洗，每次冲洗后给予雾化皮质类固醇，然后给予雾化抗生素。该方案持续6周。此后，患者每周接受一次内镜鼻窦清创术，随后在鼻窦内局部应用皮质类固醇和抗生素。随访时间为24周，因此总研究时长为30周。治疗结果基于Lund-Kennedy症状评分和Lund-Kennedy内镜表现评分。我们发现治疗3周后平均症状评分改善了56%，6周后改善了77%。后续随访显示，治疗结束后4周改善率为90%，治疗后8周为95%。此后，改善率略有下降：随访16周时为73%，24周时为65%。内镜表现评分分析显示，治疗3周时改善率为55%，6周时为84%。随访期间出现了相同的总体模式，治疗停止后4周改善率为94%，8周时为96%，16周时为76%，24周时为75%。治疗停止后4周进行的鼻窦培养显示，13名患者（65%）无细菌生长，5名患者（25%）有正常呼吸道菌群，1名患者（5%）有持续病原体，另1名患者（5%）出现了新的病原体。症状评分和内镜表现评分分析显示，尽管改善率随时间逐渐下降，但鼻局部治疗方案在整个治疗期和随访期均导致了具有统计学意义的改善（p < 0.001）。因此，我们得出结论，鼻局部治疗方案可以作为难治性CRS的有效治疗方法。
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