| 摘要: | 研究目的 慢性鼻炎及鼻竇炎是台灣常見的上呼吸道疾病。雖然從一般大眾的觀點而言，慢性鼻炎及鼻竇炎對於病人的生活品質有著負面的影響，但影響程度卻在病人之間有很大的不同，病人感受症狀的嚴重程度也有很大的變異，可簡略分為沒有症狀、症狀輕微、症狀中等以及症狀嚴重四個層級。症狀輕微者，以內科治療是一合理的治療方式。症狀嚴重者或是慢性鼻炎及鼻竇炎歸因於鼻息肉、鼻腔鼻竇腫瘤、黴菌感染或是鼻腔鼻竇解剖構造異常，若內科治療無效，手術治療確實有其必要。功能性鼻竇內視鏡手術已成為治療慢性鼻炎及鼻竇炎手術方法中的主流。然而，對於症狀為中重程度者，功能性鼻竇內視鏡手術的角色為何？很少有文獻針對病人本身主觀認知其慢性鼻炎及鼻竇炎症狀為中重度的族群來分析其預後。本研究目的就是先摒除鼻息肉、鼻腔鼻竇腫瘤、黴菌感染或是鼻腔鼻竇解剖構造異常的情況之下，針對病人自身感受有中重度的慢性鼻炎及鼻竇炎症狀的族群，以病人感受評分、內視鏡及電腦斷層攝影來評估功能性鼻竇內視鏡手術的角色。
研究方法 我們使用視覺類比評分問卷來評估慢性鼻炎及鼻竇炎症狀的嚴重程度。所評估的症狀包括鼻塞、流鼻水/鼻水倒流、頭痛、臉痛及嗅覺損失等五種及整體的不舒適程度。每一症狀評分範圍為零分到十分，零分為沒有症狀，十分為症狀最嚴重。我們選取慢性鼻炎及鼻竇炎症狀為至少有兩項或兩項以上的症狀，其症狀評分大於或等於八分，而且其整體的不舒適程度也必須大於或等於八分的患者視為中重程度患者。前瞻性地蒐集患有中重度慢性鼻炎及鼻竇炎症狀的成年人的資料，並予以分析。這些病患在初診時填寫視覺類比評分問卷，並接受診斷性的鼻內視鏡檢查，依照Lund and Kennedy提出的內視鏡評分系統給予0至20分的評分。病患亦接受鼻竇電腦斷層檢查，並依照Lund-Mackay 評分系統給予0至24分的評分。若病患對於足夠的內科治療無效，則建議病患接受功能性鼻竇內視鏡手術。有接受功能性鼻竇內視鏡手術的病患在至少6個月之後再次填寫視覺類比評分問卷，並接受鼻內視鏡檢查。因個人因素未接受功能性鼻竇內視鏡手術的病患，亦在距離初診至少6個月之後再次填寫視覺類比評分問卷，並接受鼻內視鏡檢查。
研究結果 共有三十二位病患列入本研究，其中有22位男性，10位女性。平均年齡38.2歲（範圍為18至56歲），平均追蹤時間為11.8個月（範圍為7至19個月）。13位病人經由血清特殊免疫球蛋白E檢查，證實具有過敏體質。有18位病人接受功能性鼻竇內視鏡手術。經由統計分析，視覺類比症狀評分與電腦斷層評分二者之間並無相關性(p>0.05)。視覺類比症狀評分與電腦斷層評分在過敏體質的病患與非過敏體質的病患之間，並無統計學上的顯著差別(p>0.05)。也就是說有過敏體質者未必有較嚴重的慢性鼻炎及鼻竇炎症狀，也未必有較嚴重的電腦斷層評分。假設不考慮是否有無過敏體質，比較手術組與非手術組在治療前的電腦斷層評分、治療前後的視覺類比症狀評分與內視鏡評分，發現治療前的三種評分在手術組與非手術組之間並無統計學上的顯著差別(p>0.05)。然而手術組在治療後的視覺類比症狀評分與內視鏡評分明顯低於非手術組(p<0.05)。除此之外，若將過敏體質的因素列入考慮，手術組亦有較佳的治療預後。
研究結論 本研究顯示電腦斷層上的發現與病患主觀認知的症狀嚴重程度，二者之間並無相關性。雖然過敏是一個重要的因素，但本研究發現過敏體質者未必有較嚴重的慢性鼻炎及鼻竇炎症狀，也未必有較嚴重的電腦斷層評分。治療後的視覺類比症狀評分與內視鏡評分，手術組明顯低於非手術組。所以對於具有中重程度的慢性鼻炎及鼻竇炎症狀的病患而言，假設內科治療無效，功能性鼻竇內視鏡手術是一個有效的治療方式。
Objectives Chronic Rhinosinusitis (CRS) is a common upper airway respiratory disease in Taiwan. Although it is clear from a popular standpoint that CRS makes a negative influence on patient’s quality of life, the level of personal influence may vary widely from individual to individual. For patient’s perception, symptom severity can easily be classified as none, mild, moderate and severe. Medical treatment is reasonable to treat patients with mild symptoms of CRS. For patients with severe symptoms of CRS, or CRS is due to nasal polyp, sinonasal tumor, fungal infection or identified sinonasal anatomic variations, surgical intervention is indicated if they have been refractory to medical treatment. FESS has been the main stream of surgical methods to treat CRS for about 20 years. Few literatures offered adequate discussions focusing on the role of FESS for patients with perceived moderate-to-severe symptoms of CRS. The aim of this study was to investigate the role of FESS in moderate-to-severe chronic rhinosinusitis by using subjective symptom score and objective endoscopy and CT scan.
Materials and Methods We used Visual Analogue Score (VAS) Questionnaire to evaluate CRS symptoms status. Symptoms include nasal obstruction, rhinorrhea / postnasal drip, headache, facial pain and olfactory disturbance and overall discomfort. Each symptom was scored on a scale from 0 to 10 which 0 presented no symptom and 10 presented the most severe symptom. According to the VAS questionnaire, patients with equal to or over 8 scales in at least two symptom items and overall discomfort scales also equal to or over 8 scales were included into our study. They were regarded as having moderate-to-severe symptoms of CRS. Patients with nasal polyp, sinonasal tumor, fungal sinusitis or sinonasal anatomic variations were excluded. Analysis of prospectively collected data was performed. These patients filled the VAS Questionnaire in the initial visit. Diagnostic nasal endoscopy was performed and given a score from 0 to 20 according to the scoring system proposed by Lund and Kennedy. Sinus CT scan were assessed and given a score from 0 to 24 according to the Lund-Mackay staging system. Functional endoscopic sinus surgery (FESS) was suggested if patient was refractory to maximal medical treatment. Patients who have undergone FESS filled VAS Questionnaire and were assessed with nasal endoscopy at least 6 months postoperatively. Those without FESS due to personal reasons also filled VAS Questionnaire and were assessed with nasal endoscope at least 6 months after initial visit.
Results Thirty two patients were included in this study. There were 22 males and 10 females. The mean patient age was 38.2 years (range, 18-56 years). Mean follow-up period was 11.8 months (range, 7-19 months). Thirteen patients were allergen positive proved by specific IgE antibody in serum. Eighteen patients underwent FESS. After statistical analysis, the endoscopic findings correlate with the subjective symptom severity (p<0.05). Moreover, there was excellent correlation between the endoscope score and CT score (p<0.001). In contrast, there was no significant correlation between VAS score and CT score (p>0.05). There was also no statistically significant difference in VAS score and CT score between atopic and non-atopic group in the pre-treatment period (p>0.05). There was no statistically significant difference between surgical and non-surgical group in the three parameters in the pre-treatment period (p>0.05). However, the VAS score, endoscopy score had more marked reduction in surgical group than non-surgical group in the post-treatment period
(p<0.05).
Conclusions This study demonstrated that findings on the CT scan do not correlate with the severity of nasal symptoms. Although atopy constitute is an important factor, there was no significant difference between atopic and non-atopic CRS patients on VAS symptom score and CT score in the pre-treatment period. The VAS score, endoscopy score had significantly marked reduction in surgical group than non-surgical group. For patients with moderate-to-severe symptoms of CRS, if they have been refractory to adequate medical treatment, FESS is an effective treatment method. |
