Clinical analysis of 892 cases of endoscopic sinus surgery Deng Xiangkun, Department of Otorhinolaryngology, Sanming Hospital of Integrative Medicine Qiu Zhihong, Wang Jinquan, Deng Xiuyu, Fu Lihua, Department of Otorhinolaryngology, Sanming Hospital of Integrative Medicine Deng Xiangkun – [Abstract] This paper reports the results of 892 cases of endoscopic sinus surgery patients who were followed up for more than six months after surgery. The precautions in nasal endoscopic surgery and the treatment of middle turbinate, the main points of mycosis fungoides are discussed. It was pointed out that the establishment of a strict postoperative nasal endoscopic follow-up medication change system is the key to improve the efficacy. – With the extensive development of nasal endoscopic surgery, the superiority of nasal endoscopic sinus surgery has been fully reflected. 892 cases of nasal endoscopic sinus surgery were performed in our department from April 2000 to February 2007, and 892 cases were followed up with medication changes for six months or more after surgery, and this 892 cases with complete follow-up data are reported as follows:- 1 Data and methods – 1.1 Clinical data- Among 892 patients, 562 cases were male and 330 cases were female, age 8-78 years, duration 2-55 years, chronic sinusitis patients were typed according to the ’97 Haikou standard, including 327 cases of each stage of type I, 397 cases of each stage of type II, and 178 cases of type III. Among them, there were 56 cases of maxillary sinus varices, 23 cases of butterfly sinus varices, 5 cases of frontal sinus varices, 23 cases of maxillary sinus osteoma, 34 cases of septal sinus osteoma, 10 cases of mucous cysts in middle turbinate and frontal septum, and 478 cases of combined nasal septal deviation. All cases were routinely scanned with coronal sinus CT before surgery, and those with severe disease were combined with horizontal scans. – 1.2 Surgical methods- 834 cases were operated under local anesthesia and 58 cases were operated under general anesthesia with tracheal intubation. They were operated under 300 and 700 nasal endoscopes and surveillance systems. The operation was performed according to the Messerklinger procedure, with anterior to posterior excision of the hooked process, opening of the septal vesicles, opening of the middle turbinate substrate, opening of the posterior group of septal sinuses, and opening of the maxillary sinuses by the middle nasal pathway. The frontal sinus and pterygoid sinus were opened as appropriate, and those with concomitant nasal polyps were first removed with a fully automatic cutting suction. For those with vesicular turbinates, middle turbinoplasty is performed, and for those with deviated septum, submucosal correction of the septum is performed at the same time. Tetracycline cortisone ophthalmic ointment is used to apply absorbent hemostatic damask to re-cover the trauma at the end of surgery, and the middle nasal passage is compressed and filled with Vaseline gauze or swelling sponge. For nasal septal surgery, a 1 cm diameter silicone rubber tube was implanted in the postoperative nasal cavity to compress the septum to stop bleeding, and the intraoperative bleeding ranged from 20 ml to 400 ml. – 1.3 Pre-operative medication; post-operative medication change and follow-up- Intravenous antibiotic drip 5-7 days before surgery, oral prednisone (0.5-1mg/kg body weight), 48 hours after surgery, Vaseline gauze or tumescent sponge was removed from the middle nasal passage, and from the third day after surgery, the nasal cavity was removed by suction as appropriate. On the third postoperative day, the clot and absorbent hemostatic damask were removed from the nasal cavity by suction as appropriate, and the nasal cavity was cleaned with saline twice daily. Liquid paraffin or cod liver oil drops were used alternately to contract and lubricate the nasal mucosa 4-5 times a day. The medication was changed endoscopically once a week for one month at discharge, and once every 2 weeks for 2-3 months until epithelialization of the operative cavity, and the medication was reviewed and changed once a month for 3 months to 6 months. – After surgery, corticosteroids should be taken orally for one week, and the cilia promoter Ghirudon should be taken orally until 2-3 months after surgery, and the nasal cavity should be sprayed twice a day until 3-6 months after surgery with Burkner or Reynocort, and the spraying time should be extended as appropriate for combined nasal polyps. For those who are found to have recurrent lesions at the time of follow-up, they should be given timely cleanup remedy according to the situation and the closed sinus opening should be reopened as appropriate. For those who have serious mucosal edema in the maxillary sinus, gentamicin + dexamethasone can be used to eliminate the mucosal edema by intra-mandibular sinus injection as appropriate. – 2 Results- According to the standard of efficacy of endoscopic sinus surgery (’97 Haikou standard) we statistically analyzed a total of 892 cases after six months of follow-up and stopping drug exchange, 759 cases (82.5%) were cured, 133 cases (15%) were improved and 22 cases (2.5%) were invalid. Most by seen in type II stage 3 and type III patients. Complications of surgery were orbital cardboard injury in 27 cases, cerebrospinal fluid nasal leakage in 11 cases, postoperative hemorrhage in 1 case, and sieve roof injury in 6 cases, most of which occurred at the early stage of surgery. – 3 Discussion- Nasal endoscopic sinus surgery is mainly to open the occluded sinus opening and improve its drainage, and the healthy mucosa in the sinus and the inflammatory edematous mucosa that is estimated to recover its function after surgery should be preserved as much as possible during the operation. Because of the important anatomical structures around the septal sinus, adequate opening of the septum is the basic guarantee to prevent the recurrence of polyps and inflammation, and is also the key to perform other sinus surgeries. During surgery, the frontal sinus and pterygoid sinus should be opened to clear the sinus orifice and serious lesions in the sinus. In the past, traditional intranasal septal sinus surgery and nasal polyp removal could only improve the degree of nasal ventilation, but not relieve the symptoms of dizziness and headache. In addition, the preoperative application of antibiotics and corticosteroids is necessary for the smooth operation and the reduction of intraoperative bleeding and complications. Generally, oral corticosteroids are administered 4-5 days before surgery. For hypertensive patients, ensure that the blood pressure is controlled within the normal range. For diabetic patients, blood glucose should be controlled below 10 mmol/L. – Preservation of the middle turbinate is the focus of endoscopic sinus surgery. However, turbinate pneumatization and curve anomalies are the most common anatomical variation of the middle turbinate. Turbinate pneumatization and curve anomalies can completely obstruct the entrance to the middle nasal tract, which is one of the factors predisposing to sinusitis, and the middle turbinate and leptomeninges are the main primary sites of nasal polyps. For hooked turbinates, they should be removed completely so as not to interfere with the drainage of maxillary and frontal sinuses. The treatment of the middle turbinate variant is, for vesicular middle turbinates that interfere with the drainage of the middle nasal tract, to cut the middle turbinate longitudinally and remove the mucosa and bone from its lateral portion. ��- For middle turbinate with abnormal curve, if the mucosa is normal, it is fractured and turned inward. In patients with significant mucosal polypoid changes of the middle turbinate, the polypoid mucosa of the lateral part of the middle turbinate needs to be completely removed, preserving the more normal mucosa of the medial part of the middle turbinate. For patients with polypoid lesions in the medial part of the middle turbinate, the middle turbinate can be removed as appropriate. However, this should be done after septal sinus opening. – For patients with mycosis fungoides, it is necessary to fully open the occluded sinus opening, thoroughly clear the sinus of the mycobacterial masses, and perform sinus cavity flushing, as long as the sinus opening is good, the diseased mucosa will soon recover, and there is no need for systemic application of antifungal drugs. – For frontal sinus blockage and narrow sinus opening, the frontal sinus opening can be probed, and the frontal saphenous fossa can be cleared carefully forwards, inwards or outwards, do not bite backwards to remove the bone, because it is the location of the anterior sieve artery tube, so as not to damage the anterior sieve artery causing haemorrhage. – Postoperative follow-up and medication change under nasal endoscope should be strengthened. Postoperative follow-up medication change is extremely important and should be given high priority. Reasonable postoperative medication, proper postoperative management and regular nasal endoscopic follow-up are the keys to improve the efficacy of surgery. We believe that the postoperative treatment should pay attention to the following aspects ① the first week after surgery to clean up the surgical cavity clot and fibrinous exudate, pay attention to protect the new epithelial mucosa, ② the second week after surgery due to postoperative inflammatory reaction, mucosal edema is obvious, but it is not polyp pre-polyps change, for reversible mucosa, do not need to remove, only clean up the scab to keep the surgical cavity drainage can be smooth. ③ In the third week after surgery, vesicle formation and polyp recurrence begin, and the best way to remove the lesion is by suction with a suction device. For patients with sinusitis combined with nasal polyps, postoperative nasal spray of Berkner or Renolcort is given until six months after surgery. To inhibit the recurrence of polyps. All patients were instructed to insist on nasal rinsing with nasal washers after discharge, and a strict follow-up system was established, and patients were instructed to return to the hospital regularly for endoscopic drug changes, which is a very important measure to improve the efficacy. Long-term follow-up after nasal endoscopy is necessary through clinical observation.