Clinical Efficacy of Endoscopic for Chronic Sinusitis Sinus Surgery Naoki Otsuki and Kazuo Kumoi (Himeji National Hospital) Yasuji Teramoto (Takatsuki
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1 Clinical Efficacy of Endoscopic for Chronic Sinusitis Sinus Surgery Naoki Otsuki and Kazuo Kumoi (Himeji National Hospital) Yasuji Teramoto (Takatsuki Hospital) Functional endoscopic sinus surgery (FESS) is the surgical treatment of choice in chronic sinusitis for many physicians. We evaluated subjective and objective improvement in patients undergoing first-time FESS over a 5-year period. Eighty-seven patients were followed for mean of 11 months (range 3 months to 45 months). A retrospective analysis was performed using the patient's medical records. Outcomes analyzed included pre- and postoperative clinical symptoms (nasal obstruction, nasal discharge, postnasal discharge, headache, olfactory disturbance), preoperative computed tomographic (CT) findings and postoperative endoscopic findings of maxillary and ethmoid sinuses. The most common presenting complaint was nasal obstruction, followed by nasal discharge and olfactory disturbance. Clinical symptoms improved in 94% of the patients subjectively. However, the cure rate of olfactory disturbance and postnasal discharge was below 70%. In the objective endoscopic findings, 87% of patients obtained a good outcome. Residual or recurrent polyposis was noted in 12 (13%) of the 87 patients. Four patients with persistent symptoms underwent revision FESS. The extent of disease on CT was classified into four groups according to Kennedy's staging system. Patients with severe disease (stage III-IV) had a worse outcome than patients with mild/moderate disease (stage I-II) but this difference was not significant. Seventeen patients with allergic rhinitis and/or asthma had a worse objective outcome than patients without allergic rhinitis and asthma but this difference was not significant. There was no significant difference in subjective outcome between patients with and without allergic rhinitis and/or asthma. The finding in this study suggest that factors affecting outcome after FESS included the CT stage of disease, allergic rhinitis and asthma, but that FESS improved in terms of subjective symptoms in patients with severe disease and with allergic rhinitis and asthma. Key words: chronic sinusitis, functional endoscopic sinus surgery (FESS), postoperative evaluation
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3 耳鼻 臨床 95: 7 内視 鏡 下鼻 内手 術 び改 善 を 得 た 症例 の割 合 を他 覚所 見 の改 善率 と した. 721 痛 お よび頭 重 感 が それ ぞれ85例(97. 37例 (42.5%), 57例( CTに お け る重 症 度 と術 後 の改 善 率 との 関係 %), KennedyのCTに で認 め られ た. 各 症 状 別 に治 癒 率 をみ る と, 術 前 にそ れ お ける 重 症 度 分 類 の 各群 につ い て術 23修可 (26,4%), 7%), 11修可 (12. 6%) 後 の 自覚 症状 お よび他 覚所 見 の 改善 率 を 求 め 比較 検 討 し ぞ れ の症 状 を訴 え た症 例 の うち, 鼻 閉93, 0%, た. 重 感84. 6%, 鼻 漏75. 4%, 4. ア レル ギ ー 性 鼻 炎, 気 管 支 喘 息 と重 症度 お よび改 善 率 との 関 係 嗅 覚 障 害63. 2%, %で 症 状 が 消失 して お り, 嗅 覚障 害, 後 鼻 漏 の 治 癒 率 が あ っ た(図1). 治 癒 に至 らず, 術 後 に症 状 の 残 存 した 症 (以下, 合 併 群)と ア レル ギ ー 性 鼻 炎 お よび 気 管 支 喘 息 を 例 は40例 合 併 しな い 症 例(以 下, 非 合 併 群)と でCTに 例, 後 鼻 漏8例, お ける 重 で, 残 存 した症 状 は 嗅 覚 障害14例, 鼻 閉6例, 症度, 術 後 の 自覚 症状 お よび他 覚所 見 の 改善 率 を 比較 し 他 覚所 見 の改 善 率 は87. 4%で, た. が34例, 5. 再 手 術 例 の経 過 につ い て で あ っ た. 一 方, 軽 度 病 変 が 残 存 した もの 高 度 病 変 が 残 存 ま た は 再 発 した もの が11例 で 3. CTに お け る重 症 度 と術 後 の 改 善 率 との 関 係 (以下, 再 手 術 例)に つ い て再 手 術 後 の成 績 を検 討 し た. CTに お け る 重 症 度 別 の 自 覚 症 状 の 全 般 改 善 率 は, stage lで100%, 結 頭 痛2例 鼻 漏12 あ っ た. 初 回手 術 後 の 経 過 が 不 良 の た め 再 手 術 を 行 っ た 症 例 IVで87. 果 お ける 重症 度 分類 stage IIで93. 3%, stage IIIで92. 1%, stage 5%で あ った(図2上). 軽 症 群 と重 症 群 とで 自覚 症 状 の 全 般改 善 率 を 比べ る と軽 症 群 で は95. 1%, stage I力弐11修可,stage II力弐30例, stage IIIが38例, stage IVが8例 後 鼻 漏60. 9 低 か っ た. ま た, 全 症 例 にお け る全 般 改 善 率 は93. 1%で ア レル ギ ー 性 鼻 炎 ま た は 気 管 支 喘 息 を 合 併 す る 症 例 1. CTに 頭 痛 頭 で あ っ た. stage Iお よびstage IIを 軽 症 群, stage 重症群 で は91. 3%で 各 群 間 に有 意 差 は認 め られ な か っ た. ま た, 他 覚所 見 の 改善 率 は, stage Iで100%, stage IIで93. 3 IIIおよびstage IVを 重 症 群 とす る とそ れ ぞ れ41例, 46例 で %, 重 症 群 は 全 体 の52. 9%を 占 め てい た. 2下). 軽 症 群 と重 症 群 とで他 覚所 見 の改 善 率 を比 較 す る 2. 術 後 の 自覚症 状 お よび他 覚所 見 の改 善 率 stage IIIで84. 2%, stage IVで62. 5%で あ った(図 と軽 症 群 で は95. 1%, 重 症 群 で は80. 4%で あ り重 症 群 で 術 前 の 自覚 症 状 は鼻 閉, 鼻 漏, 後 鼻 漏, 嗅 覚 障 害, 頭 自覚 症状 の全 般改 善 率 症状別治癒率 stage I (N=11) 鼻 閉 (N=85) stage II (N=30) 鼻漏 (N=57) 治癒 stage III (N=38) 後鼻漏 (N=23; stagen (N=S) 嗅覚障害 (N=37) 治 癒 頭 痛 頭重感 (N=11; 非治癒 自覚 症 状 の全 般 改 善率 不変 他 覚所 見 の改 善 率 stage I (N=11) stageii (N=30) 著明改善 stageiii 全症例 (N=87) (N=38) stagen 経 過不良 (N=8) 図1 自覚症状 の改善率 図2 CT重 症度分類 と治療成績
4 722 大 月 直 樹, 他2名 耳鼻臨床 95: 7 自覚 症 状 の全 般 改 善 率 非合 併群 非合 併群 (N=70) 治癒 合併 群 stage 不変 (N=17) 合併群 stage I II stageiii stageiv 他覚 所 見 の改 善 率 非合 併群 図4 合 併 症 とCTに お け る重 症 度 分 類 (N=70) 著 明改善 合 併群 (N=17) 改 善 率 は 合 併 群 で は70. 6%, 非 合 併 群 で は91, 4%で あ っ 経過不 良 た(図3下). 自覚 症 状 の全 般 改 善 率, 他 覚所 見 の改 善 率 と も に各 群 間 に統 計 学 的 に有 意 差 は 認 め られ な か っ た 図3 が, 合 併 群 で は 非 合 併 群 と比 較 して改 善 率 が低 い傾 向 に 合併症 と治療 成績 あ った. 特 に他 覚 所 見 の 改 善 率 は 合併 群 に お い て不 良 で あ っ た. ま た両 群 でCTに お け る 重症 度 を 分 類 す る と, 改 善 率 が低 い傾 向 に あ っ た が, 統 計 学 的 に有 意 差 は認 め 合 併 群 で はstage Iが2例, stage IIが5例, られ なか った. 例, stage IVが3例 4. ア レル ギ ー性 鼻 炎, 気 管 支 喘 息 の合 併 と重 症 度 お よ び改 善 率 との 関係 合 併 群 は17例 で あ った. 一 方, 非 合 併 群 で はstage Iが9例, stage IIが25例, stage IIIが31例, stage IVが5例 で あ った(図4). 合 併 群 で は重 症 群 が58. 8%を 両 者 を合 併 す る症 例 に有 意 差 は認 め られ な か っ た. しか し, 気 管 支 喘息 の合 が2例 で あ っ た. 気 管 支 喘 息 合 併 例 の うち1例 は アス ピ 併 した6例 で は5例(83. リン喘 息 症 例 で あ った. 合 併群 に お け る 自覚 症状 は鼻 閉, 群 に比 べ 重 症 群 の 割 合 が 高 か っ た. 鼻 漏, 後 鼻 漏, 嗅 覚 障 害, 頭 痛 お よび 頭 重 感 が そ れ ぞ れ 16例 (94.1%), (23.5%), 12例 7例(41. (70. 6%), 2%)で 8例 (47.1%), 4例 3%)が 重症 群 で あ り, 非 合 併 5. 再 手 術 例 の経 過 につ いて 再 手 術 例 の 概 要 を表3に 示 す. 再 手 術 の 施 行 時 期 は初 認 め られ た. 症 状 別 の治 癒 率 は 嗅覚 障害, 後 鼻 漏 が そ れ ぞ れ37. 5%, 占め て い た の に対 し, 非合 併群 で は51. 4%で あ り両群 間 に統 計 学的 で, ア レル ギー 性 鼻 炎 の み の 症 例 が11 例, 気 管 支 喘 息 のみ の症 例 が4例, stage IIIが %で 不 良 回手 術 よ り6ヵ 月 か ら1年2ヵ た. CTに 月 で 平 均11. 8ヵ 月 で あ っ お ける 重症 度 は4例 中3例 が重 症 群 で あ った. で あ っ た. 自覚 症 状 の全 般 改 善 率 を合 併 群 と非 合 併 群 と ア レル ギ ー 性 鼻 炎, 気 管 支 喘 息 の 合 併 が そ れ ぞ れ1例 認 で比 較 す る と, 合 併 群 で は88. 2%で あ っ た の に対 し非 合 め られ た. 再 手術 に よ り 自覚症 状 で は1例 が 治 癒 とな り, 併 群 で は94. 3%で あ った(図3上). 3例 が 改善 とな っ た. ま た, 他 覚 所 見 で は2例 一 方, 他 覚 所 見 の 表3 (注)初 回術後 の他 覚所見 は全例経過不良 再手術例 の概要 が著 明改
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6 1) Kennedy DW: Prognostic factor, outcomes and staging in ethmoid sinus surgery. Laryngoscope 102: 1-18, ) Kennedy DW: Functional endoscopic sinus surgery. Arch Otolaryngol 111: , ) Levine HL: Functional endoscopic sinus surgery; evaluation, surgery, and follow-up of 250 patients. Laryngoscope 100: 79 ti 84, ) Rice DH: Endoscopic sinus surgery; results at 2-year follow up. Otolaryngol Head Neck Surg 101: , ) Friedman M, Caldarelli DD, Venkatesan TK, et al.: Endoscopic sinus surgery with partial middle turbinate resection; effect on olfaction. Laryngoscope 106: , ) Delank KW and Stoll W: Olfactory function after functional endoscopic sinus surgery for chronic sinusitis. Rhinology , ) Salvin RG, Cannon RE, Friedman WH, et al.: Sinusitis and bronchial asthma. J Allergy Clin Immunol 66: , ) Ikeda K, Tanno N, Tamura G, et al.: Endoscopic sinus surgery improves pulmonary function in patients with asthma associated with chronic sinusitis. Ann Otol Rhinol Laryngol 108: , ) Senior BA, Kennedy DW, Tanabodee J, et al.: Long-term impact of functional endoscopic sinus surgery on asthma. Otolaryngol Head Neck Surg 121: 66-68, ) King JM, Caldarelli DD and Pigato JB: A review of revision functional endoscopic sinus surgery. Laryngoscope 104: , ) Chu CT, Lebowitz RA and Jacobs JB: An analysis of sites of disease in revision endoscopic sinus surgery. Am J Rhinol , 1997.
耳展 長 32:6 舩 宏 隆,他 表2 症状 の改 善率 と臨床 病型 表3 レ線 的改 善率 と臨床 病 型 M.N. 14歳 臨 床 症型:浮 腫茸 状 型 手 術 法:両 前篩 骨 洞 開放 術 両 下鼻 道 開 窓術 治療 効 果:両 側著 明改 善 2年 術 前 術 後 症 例1 40 (550) 上 顎 洞 開 窓 術(小 児) 耳展 32:6 M.H. 13歳 臨床 病 型1浮 腫
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