诊室内镜清创联合仰卧头低位布地奈德灌注治疗术后难治性慢性鼻窦炎伴鼻息肉：一项回顾性队列研究

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中文摘要

背景： 难治性慢性鼻窦炎伴鼻息肉（CRSwNP）在充分的内镜鼻窦手术和指南导向的术后治疗后仍可能未得到控制。手术后的窦腔内阻塞性水肿或息肉样组织可能限制局部糖皮质激素的进入并延迟黏膜恢复。我们评估了一种强化门诊策略——针对性的诊室内镜清创后行仰卧头低位布地奈德灌注——是否与更早记录的术后腔上皮化相关。
方法： 这项单中心回顾性队列纳入2020年1月至2025年1月期间接受治疗的102例成人患者，并依据EPOS 2020难治性标准重新评估。52例患者接受强化策略，50例接受常规布地奈德鼻喷雾剂；两组均接受相同的7天口服甲泼尼龙疗程。主要终点为12周时记录的术后腔上皮化。次要终点包括8周上皮化、首次记录上皮化的时间、症状和Lund-Kennedy评分改善、与12周上皮化的探索性校正关联，以及记录中记载的不良事件。由于强化策略包含多个同时实施的组成部分，本研究评估的是整体策略，而非单个组成部分。
结果： 第8周时记录到上皮化的患者中，强化策略组为43/52例（82.69%），常规策略组为20/50例（40.00%）（P < 0.001）。12周时记录到上皮化的患者分别为46/52例（88.46%）和32/50例（64.00%）（风险差为24.46个百分点；95% CI，8.57-40.35；风险比1.38；95% CI，1.10-1.74；P = 0.004）。首次记录上皮化的中位时间分别为4周和12周（log-rank P < 0.001）。经Holm校正的比较显示，强化策略在症状和内镜评分改善方面更优。在探索性Firth回归中，强化策略仍与12周上皮化相关（校正OR，5.58；95% CI，1.87-16.68；P = 0.002）。未记录到严重不良事件，但安全性评估为回顾性且不完整。
结论： 在术后难治性CRSwNP成人患者中，与常规布地奈德鼻喷雾剂相比，强化门诊策略与更早且更频繁记录的术后腔上皮化相关。这些发现表明的是策略层面的关联，并未分离出各组成部分的效应，也未确立比较安全性。12周终点反映的是早期记录的上皮化，并未确立持久疾病控制或预防复发。需要随访至少12个月的前瞻性组分对照或析因研究。

英文摘要

BACKGROUND: Difficult-to-treat chronic rhinosinusitis with nasal polyps (CRSwNP) may remain uncontrolled after adequate endoscopic sinus surgery and guideline-directed postoperative therapy. Obstructive edematous or polypoid tissue in the operated sinus cavity may limit topical corticosteroid access and delay mucosal recovery. We evaluated whether an intensified outpatient strategy-targeted in-office endoscopic debridement followed by supine head-hanging budesonide instillation-was associated with earlier recorded postoperative cavity epithelialization.
METHODS: This single-center retrospective cohort included 102 adults treated from January 2020 to January 2025 and reassessed against EPOS 2020 difficult-to-treat criteria. Fifty-two patients received the intensified strategy, and 50 received conventional budesonide nasal spray; both groups received the same 7-day oral methylprednisolone course. The primary endpoint was recorded postoperative cavity epithelialization at 12 weeks. Secondary endpoints included 8-week epithelialization, time to first recorded epithelialization, symptom and Lund-Kennedy score improvement, exploratory adjusted association with 12-week epithelialization, and adverse events documented in records. Because the intensified strategy comprised multiple co-delivered components, the study evaluated the overall strategy, not individual components.
RESULTS: Epithelialization by week 8 was recorded in 43/52 (82.69%) intensified-strategy patients and 20/50 (40.00%) conventional-strategy patients (P < 0.001). Twelve-week epithelialization was recorded in 46/52 (88.46%) and 32/50 (64.00%) patients, respectively (risk difference, 24.46 percentage points; 95% CI, 8.57-40.35; risk ratio, 1.38; 95% CI, 1.10-1.74; P = 0.004). Median time to first recorded epithelialization was 4 versus 12 weeks (log-rank P < 0.001). Holm-adjusted comparisons favored the intensified strategy for symptom and endoscopic score improvements. In exploratory Firth regression, the intensified strategy remained associated with 12-week epithelialization (adjusted OR, 5.58; 95% CI, 1.87-16.68; P = 0.002). Serious adverse events were not documented, but safety assessment was retrospective and incomplete.
CONCLUSION: In adults with postoperative difficult-to-treat CRSwNP, the intensified outpatient strategy was associated with earlier and more frequent recorded postoperative cavity epithelialization than conventional budesonide nasal spray. These findings indicate a strategy-level association and do not isolate component effects or establish comparative safety. The 12-week endpoint reflects early recorded epithelialization and does not establish durable disease control or recurrence prevention. Prospective component-controlled or factorial studies with follow-up of at least 12 months are needed.