背景:对于药物治疗或保守手术难以治疗的过敏性鼻炎(AR)患者,内镜下神经切除术有望提供良好的治疗缓解。然而,其利益的证据基础仍有争议。在这项研究中,我们进行了系统评价和荟萃分析,以阐明各种形式的翼系神经切除术在难治性AR中的治疗作用.
方法:系统评价和荟萃分析指南的首选报告项目被用来对主要研究进行系统评价,这些研究报告了内窥镜翼管神经切除术(EVN)和翼管分支神经切除术的原始患者数据。其中包括选择性翼管神经切除术(SVN)和后鼻神经切除术(PNN)。主要结果是患者报告的结果指标(PROMs),包括鼻结膜炎生活质量问卷(RQLQ)和视觉模拟量表(VAS),评估鼻腔症状严重程度和患者生活质量的改善情况。手术并发症的发生率和其他客观结果被认为是次要结果。
结果:本综述包括24项临床研究,涉及1677例难治性AR患者,其中6项研究的510例患者合并慢性鼻-鼻窦炎伴鼻息肉(CRSwNP),1项研究的95例患者合并哮喘.几乎所有接受vidianp的患者的术后PROM均明显优于术前(RQLQ:标准化平均差异[SMD]=2.66,95%置信区间[CI]=2.40-2.92,p<0.001;VAS:SMD=5.15,95%CI=4.29-6.02,p<0.001)或vidian-分支神经切除术(N中的RQLQ:SMD=3.34,PN总体上优于保守治疗组。以18个月为分界点,对随访期进行了亚组分析,结果表明,与术前相比,长期和短期术后患者的症状均大大减少。这两个手术,SVN和PNN,归因于vidian分支神经切除术的并发症非常少。然而,EVN更容易引起干眼和腭麻木,无其他严重并发症。在AR和CRSwNP患者中,视距或选择性视距神经切除术联合功能性内窥镜鼻窦手术(FESS)比常规FESS更有效(RQLQ:SMD=2.17,95%CI=1.66-2.69,p<0.001;VAS:SMD=6.42,95%CI=4.78-8.06,p<0.001)。对于同时患有AR和哮喘的患者,SVN与咽支切除是一种潜在的治疗选择。
结论:EVN和vidian分支神经切除术(包括SVN和PNN)是有效的治疗方法,但是前者有更高的并发症风险。此外,FESS的vidian分支神经切除术对混合性CRSwNP患者有益。SVN是AR和哮喘并存患者的潜在治疗方法。
BACKGROUND: Endoscopic vidian neurectomy is expected to provide good therapeutic relief in patients with allergic rhinitis (AR) being refractory to medication therapy or conservative surgery. However, the evidence bases for its benefit remain debatable. In this study, we conducted a systematic review and meta-analysis to clarify the therapeutic role of various forms of vidian neurectomy in refractory AR.
METHODS: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct a systematic review of primary studies that reported original patient data for endoscopic vidian neurectomy (EVN) and vidian-branch neurectomy, which includes selective vidian neurectomy (SVN) and posterior nasal neurectomy (
PNN). The primary outcome was patient-reported outcome measures (PROMs), including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Visual Analog Scale (VAS), to assess an improvement in nasal symptom severity and quality of patient\'s life. The incidence of surgical complications and other objective outcomes were considered secondary outcomes.
RESULTS: This review included 24 clinical studies involving 1677 patients with refractory AR, of which 510 patients in six studies had combined chronic rhinosinusitis with nasal polyps (CRSwNP) and 95 patients in one study had combined asthma. Postoperative PROMs were significantly better than preoperatively in almost all patients who underwent vidianp (RQLQ: standardized mean difference [SMD] = 2.66, 95% confidence interval [CI] = 2.40-2.92, p < 0.001; VAS: SMD = 5.15, 95% CI = 4.29-6.02, p < 0.001) or vidian-branch neurectomy (RQLQ in
PNN: SMD = 3.29, 95% CI = 2.45-4.13, p < 0.001; VAS in
PNN: SMD = 4.38, 95% CI = 3.41-5.34, p < 0.001), and were generally better than in the conservative treatment group. Dividing with 18 months as the cutoff point, a subgroup analysis of the follow-up period was conducted, and the results showed that both long-term and short-term postoperative patients had considerably reduced symptoms compared to the preoperative period. The two surgical procedures, SVN and
PNN, attributed to vidian-branch neurectomy have extremely few complications. However, EVN is more likely to cause dry eyes and palatal numbness, with no other serious complications. In patients with AR and CRSwNP, vidian or selective vidian neurectomy combined with functional endoscopic sinus surgery (FESS) is more effective than conventional FESS (RQLQ: SMD = 2.17, 95% CI = 1.66-2.69, p < 0.001; VAS: SMD = 6.42, 95% CI = 4.78-8.06, p < 0.001). For patients who have both AR and asthma, SVN with pharyngeal branch excision is a potential treatment option.
CONCLUSIONS: EVN and vidian-branch neurectomy (including SVN and
PNN) are effective treatments, but the former has a higher risk of complications. Additionally, vidian-branch neurectomy with FESS is beneficial for patients with mixed CRSwNP. SVN is a potential approach for patients with coexisting AR and asthma.