| Objective: Chronic rhinosinusitis (CRS) is a common health problem in the department of ear nose and throat.A quarter of the Otolanrygology therapies are about CRS. About ten million people suffered from CRS in china, every year. The etiology and clinical classification of CRS have no consensus. There are investigations demonstrating that the etiologies of CRS include infectious agents,nasal anotomic abnormalities,primary or secondum functional disturbance of mucociliary clearance and allergic mechanisms, and so on. The pathogenesis of CRS is multifactorial and there is a complex interaction among those factors. With the development of Nasal Endoscopic Technique, functional endoscopic sinus surgery (FESS) has become the principal therapeutic tool for the CRS. At present, our cure rate is above 80%, which is near to the western country's. However, about 15%~20% of the patients get inefficacy or relapse. Nowadays, most of scholars consider that pathological changes degree of the CRS,allergic factors and history of sinus operation are the significant factors that impact prognosis of operation. In this study, we observed the differences between infectious CRS and allergic CRS in the recovery of histomorphology and mucociliary clearance function of nasal mucosa after FESS, in order to provide new thinkings about clinical classification,rational administration and improving cure rate.Methods: Nasal endoscopic,light microscope,electron microscope and saccharin test were used to observe the differences between infectious CRS and allergic CRS in recovery of histomorphology and mucociliary clearance function of nasal mucosa after FESS. (1) According to preoperative examinations, patients with CRS were divided into 3 groups: infectious group,allergic group and mixed group. 40 subjects were chosen randomly from infectious group. 20 subjects were chosen randomly from allergic group. All the patients were diagnosed as CRS with at least 2 sinuses involved besides of the patients who were caused by fungous infection,primarily mucosal cilia structure and unctional disturbance,cystic fibrosis,granulocytosis anallergic rhinitis,general immunity disease,the recurrence after FESS, et al. 20 healthy volunteers received the saccharin test as normal controls. Uncinate process mucosas were gotten from 3 deviated nasal septum patients caused by trauma as normal controls for light microscope and electron microscope. (2) Groups and treatments: Infectious group was randmonly divided into 2 groups (A, B), each group was consist of 20 subjects. Allergic group with 20 subjects was the third group (C). Patients of groups A and C received combined treatment including nasal lavaging, anti-infection, consperging topical intranasal glucocorticosteroid, mucolytic agent, after FESS; patients of group B only received treatment including nasal lavaging and anti-infection after FESS; all the patients received periodic rechecking. (3) Nasal endoscopic observation: Changing dressings periodically and recording the time of epithelization. (4) Making specimen for light microscope and observation: Biopsy of ethmoid mucosa were performed at the time of 4 weekes later and epithelization after FESS. The light microscope was used to observe pathology changings of the ethmoid mucosa. The results were analyzed as semiquantitative ranked data. (5) Making specimen for electron microscopy and observation: 3 subjects were selected randomly from each group to be observed after epithelization.S3500-N SEM and T7500 TEM were used to observe the ultrastructures of mucosa and cilia. (6) Saccharin test was used to test the mucociliary clearance of middle meatus. (7) SAS8.0 was used to analyse all the data. Quantitative data were expressed as ( x±s). P value <0.05 was considered significant.Results: (1) Nasal endoscopy: Time of epithelization:Group A (57.75±12.62) d, Group B (58.10±11.38) d, Group C (84.00±14.72)d. Group A was shorter than Group C (P<0.05). There was no significant difference between Group A and Group B (P>0.05). (2) Light microscopy: The mucosa of normal control group appeared that the epithelia were pseudostratified ciliated columnar epithelium, cilia were in good order, there were no edema and glands hyperplasy, but a few of inflammatory cells in submucosa. At the time of 4 weeks postoperation, we observed the hyperplasy of goblet cells and glands, interstitial edema and inflammatory cells infiltration in all the groups. Furthermore, the pathological changes of Group C were significantly different from Group A (P<0.05) and there was no significant difference between Group A and Group B (P>0.05). After epithelizating, the results of comparison among the 3 groups were the same to that after 4 weeks. With the epithelization of nasal sinus, the pathological changes were obviously improved except hyperplasy of submucosa glands in all the 3 goups. In addition, we observed that there was not any obvious change of inflammatory cells infiltration in Group C (P>0.05). (3) Electron microscope observation: TEM: The epithelia of normal controls were pseudostratified ciliated columnar epithelium, there were goblet cells among them, the cell-cell junction was tight, and there were abundant mitochondria, the cross sections of cilia appeared as the structures of"9+2". The epithelia of infectious group A and B were pseudostratified ciliated columnar epithelium, the structures of"9+2"was observed, the mitochondria were less than normal control group and edematus slightly. The majority of inflammatory cells were neutrophilic granulocytes and mononuclear macrophages. The epithelia of allergic group C were pseudostratified ciliated columnar epithelium too, in which eosinophile granulocytes were more than neutrophilic granulocytes and mast cells degranulated. Cilia were edematus and central microtubule was absence or monomicrotubule. Mitochondria were rare and edematus, mitochondrial cristae fused with membrane. SEM: The cilia of normal control groups were thick and in good order. The areas of cilia and absent cilia appeared alternately in infectious groups A and B. The cilia were bare and most of them were microvilli in allergic group C. (4) MTR: Normal group: (5.96±0.66) mm/ min, Group A: (4.10±0.53) mm/min, Group B: (3.94±0.44) mm/ min, Group C: (2.26±0.32) mm/min. Although the nasal sinus had been epithelialized, the MTR of groups A,B and C were slower than the normal group's (P<0.05), it was slower in group C than in Group A (P<0.05). There was no significant difference between Group A and Group B (P>0.05).Conclusion: (1) The time of the recovery of nasal mucosa function after FESS was different in CRS of different etiopathogenisis. (2) Allergic factors are important to the effect of FESS. (3) Dealing with CRS caused by infection, nasal lavaging and anti-infection after FESS are enough. (4) The patho-changes of mitochondria in patients with CRS were serious especially in patients with allergic CRS, energy misture such as ATP may be helperful for improving oedema of mucosa and MTR. (5) Although epithelizated, it needs even longer time for mucosa to recover its physiological functions. |
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