A prospective study of the effect of functional endoscopic sinus surgery on the recovery of olfactory function in patients with chronic rhinosinusitis with nasal polyposis
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摘要: 目的 探讨功能性内镜鼻窦手术(functional endoscopic sinus surgery，FESS)对慢性鼻窦炎伴鼻息肉(chronic rhinosinusitis with nasal polyps，CRSwNP)患者嗅觉功能障碍的具体疗效，同时为嗅觉的预后评估以及嗅觉事件相关电位(olfactory event-related potentials，oERPs)在临床上评估嗅觉皮层的可塑性变化提供参考。方法 以2021年10月-2022年10月招募在我科行FESS九步法标准化治疗的45例CRSwNP患者为研究对象，分为嗜酸性CRSwNP患者22例，非嗜酸性CRSwNP患者23例，术前进行VAS嗅觉障碍评分(VAS-olfactory dysfunction，VAS-OD)、SNOT-22嗅觉评分、Sniffin' Sticks测试以及oERPs的采集、处理。术后3个月随访，均再次进行术前评估的所有项目。结果 所有CRSwNP患者术后VAS-OD、SNOT-22嗅觉评分均明显低于术前[F(1，43)=357.429，P < 0.001；F(1，43)=185.657，P < 0.001]，Sniffin' Sticks测试T、D、I及TDI总分均明显高于术前[F(1，43)=126.302，P < 0.001；F(1，43)=311.301，P < 0.001；F(1，43)=131.401，P < 0.001；F(1，43)=295.885，P < 0.001]；ECRS组VAS-OD及SNOT-22嗅觉评分的下降幅度均小于nECRS组[F(1，43)=4.825，P=0.033；F(1，43)=9.916，P=0.003]，T、D评分及TDI总分的提高幅度均明显小于nECRS组[F(1，43)=6.719，P=0.013；F(1，43)=4.890，P=0.032；F(1，43)=4.469，P=0.040]；术前外周血(eosinophil-to-lymphocyte ratio，ELR)与术后SNOT-22嗅觉评分及其变化幅度均成正相关(r=0.455，P=0.002；r=-0.414，P=0.005)，与术后T、TDI评分及各自的变化幅度均呈负相关(r=-0.431，P=0.003；r=-0.385，P=0.009；r=-0.383，P=0.010；r=-0.316，P=0.035)；所有CRSwNP患者术后P3的潜伏期显著短于术前[F(1，14)=24.840，P < 0.001]，而波幅却无显著的手术效应[F(1，14)=0.000，P=0.995]。结论 FESS能够显著改善CRSwNP患者的嗅觉功能，同时嗅觉皮层可能发生了可塑性的变化。另外，术前外周血嗜酸粒细胞水平对术后嗅觉改善具有一定预测作用。Abstract: Objective To investigate the efficacy of functional endoscopic sinus surgery(FESS) in the treatment of olfactory dysfunction in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), at the same time, it provides an evidence for the prognosis evaluation of olfaction and the clinical application of oERPs to evaluate the plasticity of olfaction cortex.Methods From October 2021 to October 2022, 45 patients with CRSwNP who underwent FESS nine-step standardized treatment in our department were recruited as the research subjects, divided into 22 patients with eosinophilic CRSwNP(ECRS)and 23 patients with non-eosinophilic CRSwNP(nECRS). VAS-olfactory dysfunction (VAS-OD) score, SNOT-22 olfactory score, Sniffin' Sticks test and oERPs collection and processing were performed before the operation. All items were evaluated again 3 months after the operation.Results VAS-OD and SNOT-22 olfactory score were significantly lower in all CRSwNP patients after the operation than those before the operation[F(1, 43)=357.429, P < 0.001; F(1, 43)=185.657, P < 0.001], the scores of T, D, I and TDI scores in Sniffin' Sticks test were significantly higher than those before the operation[F(1, 43)=126.302, P < 0.001; F(1, 43)=311.301, P < 0.001; F(1, 43)=131.401, P < 0.001; F(1, 43)=295.885, P < 0.001]; The decrease of VAS-OD and SNOT-22 olfactory score in the ECRS group was smaller than that in the nECRS group[F(1, 43)=4.825, P=0.033; F(1, 43)=9.916, P=0.003], T, D and TDI scores were significantly lower in nECRS group than those in nECRS group[F(1, 43)=6.719, P=0.013; F(1, 43)=4.890, P=0.032; F(1, 43)=4.469, P=0.040]; There was a positive correlation between preoperative eosinophil-to-lymphocyte ratio(ELR) and SNOT-22 olfactory score and how much it changes(r=0.455, P=0.002; r=-0.414, P=0.005), a negative correlation between T, TDI score and how much they change respectively(r=-0.431, P=0.003; r=-0.385, P=0.009; r=-0.383, P=0.010; r=-0.316, P=0.035). The latency of P3 was significantly shorter after operation than that before operation in all CRSwNP patients[F(1, 14)=24.840, P < 0.001], however, the amplitude has no significant surgical effect.Conclusion FESS could significantly improve the olfactory function of CRSwNP patients, while changes in plasticity may occur in the olfactory cortex. In addition, the preoperative peripheral blood eosinophil granulocyte level can predict the postoperative olfactory improvement.
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表 1 ECRS与nECRS组患者的基线资料比较
例(%) 项目 CRSwNP
(n＝45)ECRS组
(n＝22)nECRS组
(n＝23)P 年龄/岁 40.7±9.2 38.9±8.9 42.4±9.3 0.201 性别 0.457 男 31(68.9) 14(63.6) 17(73.9) 女 14(31.1) 8(36.4) 6(26.1) 吸烟史 15(33.3) 6(27.3) 9(39.1) 0.399 饮酒史 19(42.2) 9(40.9) 9(39.1) 0.862 哮喘史 14(31.1) 8(36.4) 6(26.1) 0.457 
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表 2 ECRS和nECRS组患者自我报告嗅觉功能比较
CRSwNP(n＝45) ECRS组(n＝22) nECRS组(n＝23) F P VAS-OD 4.825 0.033 术前 9.22±0.95 9.41±0.80 9.04±1.07 术后 2.62±2.311)2) 3.59±2.24 1.70±2.03 SNOT-22嗅觉评分 9.916 0.003 术前 4.22±0.79 4.23±0.75 4.22±0.85 术后 1.49±1.271)2) 2.14±1.28 0.87±0.92 注：F，手术与组别的交互效应；1)手术效应，P < 0.05；2)组别效应，P < 0.05。
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表 3 ECRS和nECRS组患者Sniffin' Sticks测试评分的比较
X±S Sniffin' Sticks CRSwNP(n＝45) ECRS组(n＝22) nECRS组(n＝23) F P T评分 6.719 0.013 术前 1.38±1.15 1.13±0.59 1.62±1.48 术后 5.77±2.83 4.49±2.34 7.00±2.75 D评分 4.890 0.032 术前 3.69±1.66 3.64±1.47 3.74±1.86 术后 10.96±2.44 10.09±2.81 12.04±2.01 I评分 0.148 0.702 术前 4.51±3.13 3.50±1.95 5.48±3.74 术后 10.49±2.86 9.27±2.45 11.65±2.79 TDI评分 4.469 0.040 术前 9.62±4.94 8.35±3.20 10.84±5.99 术后 27.22±6.66 24.00±6.32 30.87±5.81
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表 4 oERPs中P3特征的三因素重复测量方差分析
变异来源 P3 潜伏期 波幅 F P F P 气味 odor(O) 0.052 0.823 0.479 0.500 电极 electrode(E) 0.647 0.532 0.748 0.482 手术 surgery(S) 24.840 ＜0.001 ＜0.001 0.995 O×E 0.974 0.390 0.974 0.390 O×S 1.823 0.198 6.482 0.023 E×S 2.128 0.138 2.065 0.146 O×E×S 0.368 0.695 1.497 0.241
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