According to the guidelines for the diagnosis and treatment of chronic rhinosinusitis developed by the Chinese Medical Association’s Branch of Otolaryngology-Head and Neck Surgery in Nanchang in 2008, chronic rhinosinusitis is defined as chronic inflammation of the mucous membrane of the nasal cavity and sinuses, with nasal symptoms lasting more than 12 weeks and not completely relieved or even worsened. It is further clinically divided into chronic rhinosinusitis with and without nasal polyps.
Clinical manifestations
(a) Systemic symptoms: The systemic symptoms of chronic rhinosinusitis are not obvious or mild, and there may be dizziness, easy tiredness, mental depression, memory loss, and lack of concentration.
(B) local symptoms.
1. nasal obstruction: nasal obstruction is also common in people with chronic sinusitis, mostly due to chronic inflammation-induced mucosal hypertrophy, turbinate hypertrophy, excessive nasal secretions and or with polyps forming to obstruct ventilation. (with picture)
2. runny nose: pay attention to the nature and amount of runny nose, chronic sinusitis when the secretions are more viscous, yellow or gray, can be lumpy, but also often have a fishy smell. In the case of odontogenic maxillary sinusitis, the pus is more with putrid odor. (with picture)
3. Loss of sense of smell or absence of smell. Inflammatory changes of mucous membrane in the olfactory area, or formation of polyps, or accumulation of purulent secretions in the olfactory fissure are common causes, and the time and severity of the loss of sense of smell should be noted.
4. Head and facial pain: chronic sinusitis headache is not obvious, only local dull pain and stuffy feeling, pain time and location are more fixed;
The main symptoms are nasal obstruction and runny nose, and the secondary symptoms are head and facial swelling and pain, loss of sense of smell or loss.
Diagnosis
Based on two or more of the above mentioned symptoms, one of which must be nasal obstruction and runny nose, as well as nasal polyps and/or purulent discharge from the middle nasal tract and/or edema/mucosal obstruction predominantly in the middle nasal tract as seen on nasal endoscopy;
and/or CT changes/mucosal changes in the sinonasal tract complex/sinus.
(i) Typical symptoms.
Take a detailed history to understand such as the nature of nasal congestion, how much and what color the runny nose is, whether there is any odor, the site of headache, the duration of pain, and the degree and pattern of olfactory loss.
(II) Examination
Routine examination with anterior rhinoscopy and nasal endoscopy may see the following lesions.
Mucopurulent secretions originating from the middle nasal tract and olfactory fissure, congestion and edema of the mucosa of the middle nasal tract, and the degree of swelling or hypertrophy of the turbinates and the presence of local anatomical variation should also be observed.
(C) Imaging examination
CT examination is the most direct and accurate method to diagnose sinusitis, which can show the location and scope of diseased sinuses, anatomical pathogenic factors, and the degree of mucosal lesions in the nasal cavity and sinuses.
【Treatment
(A) Treatment principles.
1. Control the inflammation of the mucous membrane of the nasal cavity and sinuses caused by infection and allergic factors.
2. Improve the ventilation and drainage of the nasal cavity and sinuses.
3. The lesion is light, non-chronic sinusitis and not accompanied by anatomical deformities, the use of drug therapy (including systemic and local drug therapy) can achieve better results; otherwise, a comprehensive treatment means should be taken, including medical and surgical measures.
(II) Treatment options.
1. anti-inflammatory drugs.
1.1 glucocorticoids: nasal spray glucocorticoids, with anti-inflammatory and anti-edema effect, the course of treatment is not less than 12 weeks; systemic glucocorticoids: severe recurrent nasal polyps or perioperative period, oral prednisone can be taken, need to pay attention to the control of complications, pay attention to the observation of adverse reactions.
1.2 Macrolides (14 metacyclic): with anti-inflammatory effect, recommended for long-term oral administration in small doses for not less than 12 weeks.
2. antibacterial drugs: limited to acute attacks only, not as a routine drug for chronic sinusitis.
3. decongestants: not recommended. It can be used for a short period of time for severe nasal congestion, and the course of treatment should not exceed 7 days.
4. Mucus promoter: It can dilute mucus and improve cilia activity, and is recommended
Surgery: It is currently believed that the drainage and ventilation disorders of the sinus opening are the most important mechanism causing sinusitis, and functional endoscopic sinus surgery (functional endoscopic
sinus
FESS surgery is based on the above theory and can be performed under nasal endoscopy and television surveillance to maintain permanent drainage and ventilation of sinus openings and sinuses for the purpose of curing sinusitis. This procedure has become the main surgical modality in the contemporary surgical treatment of chronic sinusitis.
2.1 Surgical principles: correction of anatomical abnormalities of the nasal cavity; removal of irreversible lesions; preservation of the nasal-sinus mucosa as much as possible; reconstruction of the ventilation and drainage of the nasal cavity and sinuses; creation of a physiological local environment for the benign regression of nasal-sinus inflammation, and finally the recovery of the morphology and function of the nasal-sinus mucosa
2.2 Indications for surgery.
① Obvious anatomical abnormalities affecting the sinus-oral-nasal tract complex or the drainage of each sinus
②Nasal polyps affecting the sinonasal complex or the drainage of the sinuses
③ by drug treatment, unsatisfactory improvement of symptoms
④Cranial, orbital and other complications
2.3
Perioperative treatment: FESS surgery is a functional surgery, so formal drug treatment is very necessary and cannot be replaced by surgery. It includes preoperative use of antibiotics, intranasal local hormones, and short-term systemic hormones. Regular postoperative cavity cleaning should be performed after surgery, and postoperative medication should be treated as above.
[Nursing assessment].
(I) Medical history
Assess whether the patient has a clear history of acute sinusitis attacks, any clear precipitating factors, any specific disease history, family history, etc.
(II) Mental-emotional status
The patient’s awareness of chronic sinusitis, mental and emotional status, personality type, perception and recognition ability, patient’s reaction to current symptoms, perception of their current disease, etc.
(C) Systemic symptoms
The patient’s general physical condition, including temperature, respiration, pulse, mental status, etc., the presence of concomitant systemic complications, and the presence of other diseases requiring medical intervention in the course of an attack. The presence of systemic symptoms of chronic sinusitis
(iv) Local symptoms
Include the severity of nasal obstruction, the nature and amount of runny nose, the degree of loss of smell, and the relationship with nasal obstruction. The location, severity, time pattern and other symptoms of headache.
(E) Auxiliary examination
1. Anterior rhinoscopy and nasal endoscopy: whether there is mucosal hypertrophy, hyperplasia, edema, abnormal secretion from the middle nasal tract or olfactory fissure, and whether there is local anatomical variation.
2. Coronal CT of sinuses: mucosal hypertrophy or hyperplasia of sinuses, sinus effusion, etc.
[Nursing diagnosis
1. change of comfort: general discomfort caused by local or systemic symptoms of sinusitis
2. lack of knowledge: lack of knowledge about the treatment, prevention and prognosis of chronic sinusitis
3. pain: head and facial pain caused by preoperative sinusitis, post-nasal endoscopy due to: (1) trauma caused by nasal surgery, resulting in increased release of inflammatory substances and stimulation of nerve endings causing pain. (2) The pain is aggravated by the pressure of the stuffing on the nasal mucosa causing reactive edema, local ischemia and hypoxia, resulting in increased release of pain-causing substances. Pain often leads to lack of sleep, which is not conducive to wound repair and physical recovery, and even causes painful shock in severe cases.
4. Risk of infection: Due to the poor treatment effect and serious condition, there may be a risk of aggravation of local or even systemic infection or other infections.
5. Excessive body temperature: systemic reaction caused by aggravation of infection
6. Potential complications: risk of intraorbital or intracranial complications.
Nursing objectives
1. To master the knowledge of prevention and self-care of chronic sinusitis.
2. The patient’s discomfort and anxiety are significantly reduced.
3. Sinus inflammation is controlled and ventilation and drainage is improved.
4. Body temperature can be maintained within the normal range, and pain and other discomforts are reduced.
5. No infection and complications occur or signs of complications are detected early and treated promptly.
6. Smooth perioperative period and satisfactory postoperative results
【Nursing measures
1. Psychological care
1.1 Explain the possible causes of chronic sinusitis, the development process, treatment methods and purposes, possible complications and causes, recovery and prevention methods.
1.2 Explain the purpose and significance of sinusitis surgery, surgical methods, possible postoperative discomfort and risk postoperative reactions and discomfort, and precautions.
1.3 Actively deal with the patient’s postoperative discomfort, comfort and encourage the patient, reduce anxiety and cooperate with treatment.
2. Treatment care (see nasal endoscopic surgery care for details)
2.1 Administer systemic and local medication as prescribed by the doctor, observe and record the reaction and changes of the disease after medication.
2.2 Observe postoperative vital signs and perform routine postoperative care. See after for details
2.3 Observe postoperative nasal bleeding and actively treat if necessary
2.4 If nasal medication is needed, instruct local medication and methods such as nasal spray, nasal drops, nasal rinse, etc.
3. Pre-operative routine preparation
3.1 Complete preoperative laboratory tests and imaging examinations to exclude contraindications to surgery.
3.2 Pre-operative medication as instructed
3.3 Pre-operative fasting of food and water for 6-8 hours.
3.4 Pre-operative antibiotic skin test.
3.5 Pre-operative verification of patient information with operating room personnel.
4. Postoperative care routine
4.1 Understand the anesthetic and surgical modality, intraoperative situation, filling, and any other precautions.
4.2 Routine of postoperative care after general anesthesia nasal endoscopy.
①Observe the changes of vital signs, monitor ECG, blood pressure, finger pulse oxygen and give oxygen inhalation for 6 hours each.
② After general anesthesia, lie down with the head on one side, ask the patient to spit out the endocrine secretions and do not swallow them, wake up the patient once in 15-20 minutes, do not make the patient in a drowsy state, so as to spit out the endocrine secretions in time, and observe the secretions in the mouth and observe whether the patient has frequent swallowing movements, if there is more blood in the mouth, observe whether the patient has active bleeding, check whether there is blood clot or blood flowing down the posterior pharyngeal wall, and notify the doctor for treatment in time. Promptly notify the physician for treatment. Observe the blood seepage from the nasal cavity, if there is bloody liquid outflow, wipe it away with tissues in a timely manner, and place the used tissues centrally without throwing them away so as to observe the amount of bleeding.
③ One hour after general anesthesia can be pillow, six hours after shaking the head of the bed, take a semi-recumbent position.
④ 4 hours of general anesthesia can enter a small amount of warm and cool boiled water, drink water before taking a side position with a small amount of water to rinse the mouth in order to clean the residual blood and secretions in the mouth, six hours later can eat warm and cool semi-liquid food, such as thin rice, milk, egg custard and other soft foods that are easy to digest and easy to chew. Do not eat hot and spicy hard foods such as mutton and dog meat and chili mustard.
4.3 Postoperative care routine for nasal endoscopy.
①Take a semi-recumbent position after local anesthesia, and eat and drink after two hours, and the rest of observation and care is the same as after general anesthesia.
② Encourage patients to drink more water after surgery, because the nasal cavity is stuffed, the patient breathes through the mouth, the mouth does not have the effect of heating and humidifying the air, so there will be discomfort symptoms of oral dryness and sore throat, a small amount of water can relieve the discomfort symptoms, the ward can place a humidifier to humidify the air in the ward. Nebulized inhalation therapy is feasible for patients with severe pharyngeal discomfort in general anesthesia intubation.
③ Postoperative monitoring of temperature changes, inform patients that there may be mild fever after surgery, not more than 38.5 ℃ is the absorption of heat after surgery, is a normal phenomenon, do not be nervous, can drink more water, generally about three days body temperature will return to normal.
④Ice packs on the forehead for six hours to reduce local blood flow to reduce postoperative bleeding, while nasal filling after nasal surgery causes head pain and discomfort, ice pack ice packs can reduce discomfort.
⑤ On the day of surgery, due to long-term bed fasting and surgical stimulation, patients are prone to transient shock symptoms, so on the day of surgery, patients are advised not to get out of bed and urinate and defecate in bed.
(6) Try to rest in a semi-recumbent position after surgery to help reduce blood flow to the head and face and reduce bleeding. When moving, do not exert force on the head and neck. Do not force or lower your head for a long time to avoid postoperative bleeding. Do not cough and sneeze with force. Ask the patient to relax the body as much as possible if he/she feels like sneezing and coughing, breathe deeply or tongue against the gums of the upper jaw, and if he/she sneezes continuously and incessantly, tell the medical staff in time and give anti-allergy medication to relieve the symptoms. To prevent nasal bleeding caused by excessive force.
(7) Start moderate activity on the first day after surgery and eat laxative foods rich in coarse fiber to prevent constipation and reduce the possibility of bleeding caused by straining to defecate.
(8) Keep the oral cavity clean after surgery, and rinse before and after meals with stomatitis.
The postoperative nasal stuffing is an important measure to stop bleeding after surgery. Therefore, the patient should not withdraw the nasal stuffing by himself, and he should be informed that there will be a small amount of blood leakage after nasal surgery and nasal secretion mixed with blood will flow out through the nose or mouth, which will increase when sitting up or moving around, so wipe it off gently with tissue or spit it out through the mouth. At the same time, the nasal stuffing may compress the nerve around the nasal cavity or cause discomfort such as headache and toothache, which can be relieved slowly after the nasal stuffing is extracted. Patients should be asked to eat and drink before extraction of nasal stuffing to prevent deficiency when extracting the stuffing.
After the nasal stuffing is extracted, the nasal cavity should be rinsed twice a day after the nasal endoscopic review. Instruct the method of nasal drip and rinsing that
Post-nasal endoscopic pain care routine.
1. Explain to the patient and family members that nasal filling can cause different degrees of nasal distension, frontal pain, lacrimation and headache, which are normal, and explain the causes of pain and the necessity of filling.
2. Apply cold compresses to the nose to constrict blood vessels, reduce local edema, lower the sensitivity of nerve endings and make the pain less.
3. Give intravenous glucocorticosteroids in time as prescribed by the doctor to suppress the inflammatory response and reduce local edema and pain. Pay attention to the possibility of hormonal complications.
4. Use pain relievers and sedatives as prescribed by the doctor if necessary.
Health education]
1 Teach patients the correct methods of nasal rinsing, nasal spray use, nose blowing, etc.
2 Prevent colds and flu, enhance physical fitness, appropriate physical exercise, and avoid the stimulation of adverse external environment.
3 Correct bad living habits and quit smoking. Avoid overexertion, improve living and working environment, keep air circulation and appropriate temperature and humidity.
4 Patients can wash their hair and take a bath after one to two weeks after nasal surgery, but pay attention to not lowering your head and exerting yourself for too long when washing your hair, it is better to use the method of tilting your head to wash your hair, and the temperature of the water for bathing and washing your hair should not be too hot.
5 Follow the instructions of medication, review the outpatient clinic as scheduled, and seek medical advice if there is any change in condition.