Nasal endoscopic surgery is an effective treatment for rhinosinusitis, but there is a lack of further understanding of the regression pattern of symptoms after rhinosinusitis. Previous studies have focused on the findings of physician’s examination findings, such as CT and nasal endoscopy, while neglecting patients’ self-evaluation of symptoms. In this study, we analyzed the regression pattern of each symptom of sinusitis after nasal endoscopic surgery based on the patient’s self-rating of five common symptoms of sinusitis to guide the postoperative follow-up work. Chen Dong, Department of Otolaryngology, Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine
1. Materials and methods
1.1 Clinical data.
From January 2003 to October 2005, there were 187 patients with sinusitis who were seen in the nasal endoscopy outpatient clinic after nasal endoscopy surgery, of whom 94 were male and 93 were female; the youngest was 12 years old, the oldest was 88 years old, and the average was 47.8 years old; 26 were unilateral and 161 were bilateral. According to the “Haikou standard” [1], the diagnosis was 3 cases of type I stage 1, 5 cases of type I stage 2, and 10 cases of type I stage 3; 37 cases of type II stage 1, 74 cases of type II stage 2, 40 cases of type II stage 3; and 18 cases of type III.
1.2 Methods.
Autonomous scoring method: Patients made marks on an unmarked line according to the severity of their symptoms, with a score of 0 at one end indicating no such symptoms and a score of 10 at the other end indicating severity. The severity of the symptom was measured according to the loci marked by the patient. Each patient was given an independent score on five symptoms: (1) facial pain or fullness, (2) headache, (3) nasal obstruction, (4) runny nose, and (5) olfactory disturbance.
Follow-up requirements: weekly for the first 4 weeks after surgery, every 2 weeks thereafter, monthly after 3 months, and follow-up after 6 months as appropriate. In all cases before surgery, the follow-up cases were scored autonomously at 2 weeks, 1 month, 3 months and 6 months after surgery, and the improvement values of symptoms in each postoperative time period were recorded and calculated. Those who insisted on follow-up within six months were classified as the follow-up group with a total of 150 cases, and those who had less than 5 follow-ups within 6 months after surgery (but with postoperative March score) were classified as the control group with a total of 37 cases.
2. Results.
2.1 Symptoms of runny nose, facial pain (distension) and olfactory disturbance turned out to be good, with significant differences in symptom improvement in adjacent time periods (p<0.05), and headache and nasal obstruction symptoms no longer improved significantly from 1 month postoperatively (p>0.05).
Table 1: Regression of mean autonomic scores and test results between adjacent time periods (X±s)
Facial pain or fullness
t-value
p-value
Stridor
t-value
p-value
Olfactory disturbance
t-value
p-value
2 weeks
0.28±0.19
0.51±0.34
0.46±0.43
1 month
1.40±0.66
19.9726
0.0000
0.93±0.63
7.1854
0.0000
0.95±0.69
7.3815
0.0000
March
1.74±0.77
4.1040
0.0001
1.49±0.59
7.9462
0.0000
1.4±0.81
5.1796
0.0000
Half year
2.06±1.12
2.8836
0.0042
1.75±0.71
3.4495
0.0006
2.06±1.23
5.4886
0.0000
Headache
t-value
p-value
Nasal obstruction
t-value
p-value
2 weeks
1.18±0.56
4.69±1.37
1 month
1.71±0.87
6.2738
0.0000
5.53±0.97
6.1287
0.0000
March
1.84±0.62
1.4903
0.1372
5.50±1.07
-0.2544
0.7994
Half year
1.88±0.93
0.4383
0.6615
5.34±1.11
-1.2710
0.2047
2.2 The difference between the two groups of control for symptom improvement values at 3 months postoperatively was significant (p<0.05), except for runny symptoms.
Table 2: Test results of symptom improvement values for the two control groups at 3 months after surgery (X±s)
Facial pain or fullness
Headache
Nasal obstruction
Runny nose
Olfactory disturbance
Follow-up group
(150 cases)
Control group
(37 cases)
Follow-up group
(150 cases)
Control group
(37 cases)
Follow-up group
(150 cases)
Control group
(37 cases)
Follow-up group
(150 cases)
Control group
(37 cases)
Follow-up group
(150 cases)
Control group
(37 cases)
Improvement value
1.74±0.77
1.17±0.71
1.84±0.62
1.03±0.77
5.50±1.07
4.29±1.17
1.49±0.59
1.41±0.71
1.40±0.81
1.04±0.83
t-value
4.0929
6.7669
6.0469
0.7086
2.4096
p-value
0.0001
0.0000
0.0000
0.4795
0.0170
2.3 Recurrence, follow-up group (2/150), control group (7/37), χ2 test was performed and there was a significant difference between the two groups (P<0.05).
Table 3: Comparison of recurrence rate between the two groups (n, %)
Number of cases
Number of recurrences
%
Follow-up group
150
2
1.33
Control group
37
7
18.92
χ2 (Yates correction)=16.3801, P=0.0001
2.4 The presence of budding spores or vesicles in the postoperative cavity is the pathological basis of postoperative recurrence of rhinosinusitis, and we performed χ2 test statistical analysis on the number of cases with budding spores or vesicles in the postoperative cavity in different clinical subtypes.
Table 4: Comparison of the number of postoperative cavities with budding spores or vesicles in different clinical staging (n, %)
Fractal stage
Number of cases
Presence of budding spores or vesicles
%
Type I
18
1
5.56
Type II
151
47
31.13
Type III
18
10
55.56
Total
187
58
31.02
χ2 =10.5204 , P = 0.0052
3. Discussion
3.1 The symptoms of rhinosinusitis are diverse, and the current research in China is still limited to the “1997 Haikou’s diagnostic and efficacy assessment criteria” [1], but clinical work has found that it is not complete and scientific enough to be based only on the order. The autonomy score, an evaluation method that focuses on autonomic sensory symptoms, was earlier applied mainly in psychiatric disciplines, and in the beginning of this century foreign scholars [2-4] began to introduce it into the evaluation of symptoms of rhinosinusitis. This scoring method can better reflect patients’ true feelings about the main symptoms of rhinosinusitis, and it appears to be a more reasonable and humane judgment than relying only on the examination results of CT or endoscopy to determine the efficacy of surgery, and at the same time, the digital scoring facilitates scientific statistics.
3.2 In this group study, the most important five symptoms of rhinosinusitis were selected from various symptoms of rhinosinusitis for independent scoring, and the scores of each group were analyzed to understand the regression of symptoms of rhinosinusitis after nasal endoscopic surgery.
Facial pain or fullness was mainly caused by pus accumulation in the sinus cavity, which was often caused by mucosal swelling of the sinus orifice, nasal polyps or anatomical abnormalities, and the improvement of this symptom after nasal endoscopic surgery to remove the lesion was more satisfactory, with a symptom improvement value of 1.74±0.77 at 3 months postoperatively. Further improvement in symptoms reached a value of 2.06±1.12 six months after surgery.
Headache is often caused by pus accumulation or occlusion in the sinus cavity and high deviation of the nasal septum, and most of these symptoms can be improved after nasal endoscopic surgery.
Nasal congestion is the most obvious symptom of rhinosinusitis, as evidenced by the highest preoperative score of 7.81±1.12 in this study. Despite the most pronounced symptoms the surgical results were also the best, with an improvement value of 4.69±1.37 at 2 weeks postoperatively and a peak improvement at 1 month postoperatively. It is noteworthy that there was a mild rebound of symptoms at 3 and 6 months postoperatively, which may be related to scarification of the surgical cavity or compensatory hyperplasia of the nasal mucosa in some cases during this period.
There are many causes of runny nose, which may be related to infection in the sinus cavity, to allergic reactions, or both. sinus endoscopic surgery restores the physiological function of the nasal-sinus cavity by changing the anatomical relationship of the nasal cavity and sinuses, so the surgery itself cannot directly overcome the infection, much less alter the immune mechanisms that cause allergic reactions [5]. francois Lavigne [6] et al. concluded that endoscopic sinus surgery disrupts the anatomy of the septal sinus while exposing the mucosa of the septal sinus to more allergens and is the reason for the lack of significant improvement in runny symptoms in some patients after surgery. In this study, we found that runny symptoms improved at all scoring stages, but not to the same extent as other symptoms. Antibiotics should be administered promptly to reduce the irritation of pus on the sinus cavity mucosa if the symptoms of runny nose appear during the follow-up.
The pathological basis of hyposmia in chronic rhinosinusitis is mainly based on olfactory cell reduction, olfactory epithelial atrophy, and respiratory epithelial metaplasia.With the aggravation of the disease, the olfactory epithelial pathological changes range from mild to severe, and its staging is significantly correlated with olfactory mucosal pathological changes [7], which is a difficult point in the treatment of rhinosinusitis. Our study found that the course of its regression is similar to that of runny symptoms, which may be related to the inability of surgery to directly change its pathological basis, and nasal endoscopic surgery may only have a more direct effect on olfactory hyposmia due to mechanical obstruction of the olfactory region [8].
3.3 Active postoperative follow-up is important for the regression of chronic rhinosinusitis symptoms. In our study, 187 cases were divided into a follow-up group and a control group depending on follow-up, and a comparative analysis of the five symptom improvement values at 3 months after surgery revealed that the statistical differences in the improvement values were significant for all symptoms except for runny nose. The recurrence rate of cases in both groups was also statistically analyzed, X2=20.0348, P<0.001, a statistically significant difference. These studies suggest that suggest that active and reasonable postoperative management and treatment are not only important to improve the efficacy of endoscopic sinus surgery, but also to reduce the recurrence of sinusitis, which is consistent with the views of Eng n Dursun [9] and other scholars. The results of some clinical studies have shown that adrenocorticotropic hormones can make nasal polyps smaller in size or even disappear, and postoperative application can delay or prevent recurrence of polyps [10], but recurrence of severe allergic rhinosinusitis and nasal polyposis is sometimes difficult to control, and two cases of recurrence in the follow-up group of this study were nasal polyposis.
3.4 From 3 weeks to 3 months after nasal endoscopic surgery, mucosal defects around the septal sinus and frontal fossa begin to appear as “demucosalization reactions” such as vesicles or budding spores, which are caused by the exuberant secretion of mucosal glands and budding spores are granulation-like growths on the exposed bone surface. Therefore, the follow-up treatment at this stage is particularly important. In our study, we found that the postoperative cavities with buds and vesicles were mostly found in patients with clinical staging type II or above, which may be related to the fact that the scope of surgery involves more sinus cavities. The use of steroid hormones in the nasal cavity can effectively inhibit the release of vasoactive mediators, reduce the permeability of nasal mucosal vessels, and reduce tissue edema, which can reduce the occurrence of vesicles or buds. This data also reminds us that patients with clinical staging type II or above should be more closely followed and actively treated.
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