Chronic sinusitis is a chronic inflammation of the mucous membrane of the nasal cavity and sinuses, with nasal symptoms lasting more than 12 weeks without complete relief or even worsening.
Clinical classification
1.Chronic rhinosinusitis (without nasal polyps) Jinmei Xue, Department of Otolaryngology, Second Hospital of Shanxi Medical University
2.Chronic rhinosinusitis (with nasal polyps)
Note: The mechanism of occurrence of nasal polyps is still unclear, and studies have shown that nasal polyps have their own relatively independent characteristics. Therefore, the classification of this guideline
classification does not imply that there is an inevitable causal relationship between chronic rhinosinusitis and nasal polyps in terms of developmental stages.
Diagnosis
I. Symptoms
1. Primary symptoms: nasal congestion, mucous, purulent nasal discharge.
2.Secondary symptoms: head and face swelling and pain, reduced or lost sense of smell.
The diagnosis is based on the above two or more related symptoms, among which nasal congestion, mucous and purulent nasal discharge must be one of the main symptoms.
Examination
1. Nasal examination: mucopurulent secretions from the middle nasal tract and olfactory fissure, congestion and edema of the mucosa of the middle nasal tract or the presence of nasal polyps.
2. Imaging examination: CT scan shows sinus-oral nasal tract complex or nasal tract mucosal lesions.
III. Determination of disease severity
According to the visual analogue scale (VAS), the condition is classified as mild 0~3, moderate 3~7 and severe 7~10. See Figure 1.
Drug treatment
The following categories of drugs are commonly used clinically.
I. Anti-inflammatory drugs
1. Glucocorticoids.
① intranasal local glucocorticoids: with anti-inflammatory and anti-edema effects, the course of treatment is not less than 12 weeks;
The recommended dose is 0.5 mg/(kg・d), taken once a day in the morning on an empty stomach for 5-10 d, up to 14 d. The contraindications to the use of systemic glucocorticoids should be noted, and the possible adverse reactions should be closely observed during the administration. Systemic or intranasal injection of glucocorticoids is not recommended.
2. Macrolides (14-ring): They have anti-inflammatory effects and are recommended to be taken in small doses (1/2 of the conventional antibacterial dose) for a long time.
Oral, the course of treatment is not less than 12 weeks.
Second, antibacterial drugs
Penicillin, cephalosporins, sulfonamides, macrolides, fluoroquinolones sensitive drugs for chronic rhinosinusitis
Acute exacerbations, regular doses, duration of treatment not exceeding 2 weeks. Topical antibiotics in the nasal sinuses are not recommended.
III. Decongestants
Not recommended. Short-term use (<7d) for severe nasal congestion.
Mucus promoter
Can dilute mucus and improve cilia activity, recommended.
V. Systemic antihistamines
For patients with symptoms of allergic reactions, second-generation or new antihistamines can be taken orally.
Chinese medicine
Some herbal medicines are effective in improving the symptoms of chronic rhinosinusitis and should be selected according to the principle of dialectical treatment.
Seven, saline or hypertonic saline (2%-3%)
Surgical treatment
I. Indications for surgery
Chronic rhinosinusitis can be treated surgically if one of the following conditions is present.
1.Significant anatomical abnormalities affecting the sinus-oral nasal tract complex or the drainage of each sinus.
2. Nasal polyps affecting the sinonasal complex or the drainage of the sinuses.
3.Insatisfactory improvement of symptoms by drug treatment.
4.The appearance of cranial and orbital complications.
II. Perioperative treatment
The perioperative treatment is centered on surgery, and in principle, it should include a series of medication from 1 week before surgery to 3-6 months after surgery
In principle, it should include a series of medication strategies and treatment principles from 1 week before surgery to 3-6 months after surgery. At present, there is no uniform standard for perioperative management of nasal endoscopic surgery, and no rigid rule is made for the time being. The recommended treatment plan is as follows.
1. Pre-operative medication: routine application of antibacterial drugs, intranasal local and/or systemic glucocorticoids, mucus pro-discharge agents, etc.
Duration of postoperative local treatment: regular postoperative cavity cleaning and follow-up treatment interval after 1 to 2 weeks according to the recovery of the operative cavity for 3 to 6 months.
3. The postoperative drug treatment is based on the same principles as the above-mentioned drug treatment for chronic rhinosinusitis, with anti-inflammatory response medication for not less than 12 weeks.
Assessment of efficacy
I. Assessment methods
1.Subjective assessment: VAS is recommended for quantitative assessment of symptoms.
2, objective assessment: quantitative assessment of nasal endoscopy was performed using the Lund-Kennedy scale [7] (Figure 1); quantitative assessment of sinus CT scan results was performed using the Lund-Mackay scale (Figure 2).
Scoring criteria.
①Sinus: 0=no abnormality, 1=partial turbidity, 2=all turbidity;
(ii) Sinus-oral nasal tract complex: 0 = no obstruction, 1 = obstruction;
③0 to 12 per side, total score 0 to 24
Figure 2 Quantitative assessment table of sinus CT scan results
3. If quality of life assessment is performed: the Chinese version of the sino-nasal outcome test-20 (SNOT-20), a special scale for sinusitis, is recommended [8]; if necessary, it can be combined with the universal scale – -medical outcome study shortform 36items health survey (SF-36, applicable to clinical research).
II. Timing of assessment
1.The assessment time for the immediate efficacy of drug treatment is 3 months, and the assessment time for the long-term efficacy is 1 year.
2.The assessment time for the immediate efficacy of surgical treatment is 1 year, and the assessment time for the long-term efficacy is 3 years.
If the patient has recently suffered from acute upper respiratory tract infection, it is recommended to postpone the evaluation until 2 weeks after the symptoms have completely disappeared.