鼻炎怎么治？鼻炎与鼻-鼻窦炎的分类、治疗原则及推荐方案
早在1992年，国内就有作者[1]对慢性鼻窦炎、鼻息肉进行了临床分型分期。在此基础上，1995年和1997年又做了进一步修订，形成了海口标准[2]，具体如下：
慢性鼻窦炎的分期
依据病史、内窥镜检查和ＣＴ扫描。
慢性鼻窦炎、鼻息肉的分型、分期(以侧计，前后筛窦分开计)
Ⅰ型 单纯型慢性鼻窦炎(保守治疗无效)
1期：单发鼻窦炎；2期：多发鼻窦炎；3期：全组鼻窦炎。
Ⅱ型 慢性鼻窦炎伴鼻息肉
1期：单发鼻窦炎伴单发性鼻息肉；2期：多发鼻窦炎伴多发性鼻息肉；3期：全组鼻窦炎伴多发性鼻息肉。
Ⅲ型 多发性鼻窦炎或全组鼻窦炎伴多发性、复发性鼻息肉和/或筛窦骨质增生。
疗效评定标准(以鼻内窥镜检查为准)
治愈：症状消失，内窥镜检查窦口开放良好，窦腔粘膜上皮化，无脓性分泌物；
好转：症状明显改善，内窥镜检查见窦腔粘膜部分区域水肿、肥厚或肉芽组织形成，有少量脓性分泌物；
无效：症状无改善，内窥镜检查见术腔粘连，窦口狭窄或闭锁，息肉形成，有脓性分泌物。
随访
近期随访不少于6个月，远期随访一年以上
显然，这一分型分期标准，是为了评定内窥镜鼻窦手术疗效，这一标准除了可以从有无鼻息肉、既往手术史、CT所示病变范围、骨质增生等，初步判定病情严重程度和在某种程度上确定手术范围外，没有反映出和涉及到慢性鼻-鼻窦炎更深层次上的问题，至少制定标准者没有特别强调，执行标准者没有足够重视这些问题。
比如：① 保守治疗无效的标准；② 如何依据鼻腔黏膜炎症状态，给予相应的药物治疗；③ 慢性鼻-鼻窦炎的致病因素与分类问题；④ 鼻炎、鼻窦炎与鼻-鼻窦炎的相互影响和相互转变。
但是，这些问题却直接涉及到了：①CT投照时机与手术适应症和手术范围的准确判定；②鼻腔、鼻窦病变的相关药物和手术治疗原则；③系统整体治疗原则和疗效评定标准；④药物与手术治疗的相互关系；⑤鼻腔与鼻窦手术的相互关系；⑥围手术期与远期治疗的相互关系。
当然，这一标准的优点是：简单明了，易于掌握。而且这一标准为鼻内镜手术在中国的规范开展和迅速推广起到了巨大的推动作用，功不可没。假如这一标准能够站在更高和更全面的角度来系统考虑的话，则需要在原有的基础上，予以补充完善。
1、鼻炎的分类与治疗原则：
鼻炎依据患病时间和炎症状态可以分为：急性鼻炎、亚急性鼻炎、慢性鼻炎；慢性鼻炎依据症状和体征又可分为：单纯性鼻炎、肥厚性鼻炎。另外，鼻炎还包括：变应性鼻炎，干燥性鼻炎，萎缩性鼻炎，等等。变应性鼻炎又包括了血管运动性鼻炎、季节性变应性鼻炎、常年性变应性鼻炎。或者分为：轻度、中重度，间歇性和持续性。当然，还有因为物理刺激，化学刺激，职业性损害，心理因素，等等，很多较为少见的鼻炎类型。如果站在可能性致病因素的角度，鼻炎、鼻-鼻窦炎，又有感染性、变应性、阻塞性，以及其它致病因素引起的各种炎症。
上述炎症，无论是何种致病因素，都可以不同程度的表现为鼻黏膜的慢性充血，苍白水肿，增生肥厚，囊肿样变，息肉样变，等等。都可以认为是黏膜功能出现了异常，以及在此基础上，发生的更为严重的可逆性或/和非可逆性病变。除此之外，与鼻炎有关的还有鼻中隔偏曲、下鼻甲骨增生、泡性中鼻甲、钩突或/和筛泡的解剖异常，等等。少数患者，泡性中鼻甲，钩突或/和筛泡的解剖异常，局限性的单发鼻息肉，未必一定伴有明显的鼻窦炎。
因此，无论鼻炎是否伴有鼻窦炎，初次就诊，首先应该依据病史和鼻腔所见，在原有鼻炎分类的基础上，站在另外一个角度，对其进行重新分类和分期，具体如下：
① 功能异常性鼻炎：即主要以鼻腔黏膜功能异常为主的鼻炎。此时，鼻腔黏膜可以表现为：充血肿胀，苍白水肿，增生肥厚，等等。
② 形态异常性鼻炎：即主要以鼻中隔偏曲、中鼻甲骨增生、泡性改变和下鼻甲骨增生，以及钩突、筛泡等形态发育异常为主的鼻炎。
③ 功能形态异常性鼻炎：上述两种情况同时存在。
因此，鼻炎从另外一个角度来看，又可以分为：功能异常和解剖异常两大类。两种异常可以单独存在，也可以混合存在。所不同的是，这种混合存在的形式，常可以表现为以一种异常为主，另一种异常为辅。其中，长期的形态异常，是引发或/和加重功能异常的一个重要因素。反之，长期的功能异常，也可以产生和加重形态异常。同时，功能异常引起的鼻塞，在形态异常的基础上，更易加重和难以恢复，从而最终导致一系列的病理生理和组织形态的改变。各种病毒、细菌、真菌、变应原，以及其它致病因素，也是导致或/和加重功能异常的又一重要原因。
依据这一分类标准，应该遵循的治疗原则为：功能异常，以药物治疗和自身修复为主，形态异常，以手术治疗为主，功能和形态异常同时存在，则从药物和手术治疗两个方面入手，实现药物和手术治疗的协调统一。片面使用一种方法，既是错误的做法，也是现在临床经常见到的一种情况。而在实际工作中，更多遇到的是功能和形态异常往往同时存在。
2、鼻炎炎症状态分期与治疗原则：
如前所述，依据病史和前鼻镜下所见鼻腔黏膜炎症状态，可以将慢性鼻炎划分为
① 慢性鼻炎急性发作期：有长期炎症病史，近期症状明显加重，鼻腔黏膜充血肿胀明显，多呈鲜红色。类似急性鼻炎。
② 慢性炎症迁延期：有长期炎症病史，症状持续存在，近期无明显加重或减轻，鼻腔黏膜充血肿胀明显，多呈暗红色。
③ 慢性炎症好转期：有长期炎症病史，症状明显改善，鼻腔黏膜呈浅红色，甚至接近正常黏膜色泽。
依据这一分期标准，以及鼻炎、鼻-鼻窦炎之间的相互转换，互为影响的关系，应该遵循的治疗原则为：
① 药物治疗：依据病史和鼻腔黏膜炎症状态，依据可能的致病因素，给予充分的综合药物治疗，使其尽量恢复至慢性炎症好转期。
当然，某些病例在接受了较长期的综合药物治疗后，鼻腔炎症并无明显改善。此时，应该参照EPOS为基层医疗系统提供的成人ARS（急性鼻-鼻窦炎）循证性处理方案和为ENT专科医师提供的成人ARS循证性处理方案 酌情选择下一步治疗方案。
② CT检查：在慢性炎症好转期或鼻炎长期无改善的情况下，实施CT检查。
③ 手术治疗：根据鼻腔形态异常与功能异常的情况，确定鼻腔手术范围和术式。
假如CT检查发现伴有鼻窦病变，则根据鼻窦病变范围，确定鼻窦手术范围和术式。由于鼻腔、鼻窦病变往往同时存在、相互影响、互为加重，手术应该遵循“系统全面考虑、一期完善处理”的手术原则，注重鼻腔与鼻窦手术的协调统一。
例3：某病人，间歇性鼻塞伴头闷胀痛12年，鼻内镜术后10年，术前、术后没有接受系统药物治疗，术后仍间歇性鼻塞伴右侧头闷胀痛。CT检查示：①右侧钩突已切除，上颌窦开放良好，说明既往确实接受过鼻内镜手术，符合其主诉。②右侧额窦密度增高，局部骨质完整，说明前期手术包括鼻丘气房在内的额筛隐窝没有同期处理。③鼻中隔右偏，前期手术没有同期处理。④双侧下鼻甲肿大，骨质增生明显，左侧中鼻甲可见泡性改变（见图五）。
显然这一病例既没有遵循药物与手术治疗的协调统一，也没有遵循鼻腔与鼻窦手术的协调统一。令人担忧的是，类似情况至今在临床依然时有发生，并未引起普遍的足够重视。
3、慢性鼻-鼻窦炎分类与治疗原则
依据术前鼻腔和术中鼻-鼻窦黏膜病变情况，参照CT检查，可以将慢性鼻-鼻窦炎分类为：
①感染性鼻-鼻窦炎：鼻-鼻窦内可见脓性分泌物。真菌性鼻-鼻窦炎也是感染性鼻-鼻窦炎的一种特殊类型：鼻窦内可见干酪样物，CT可见鼻窦高密度灶中有钙化斑。
②阻塞性鼻-鼻窦炎：鼻息肉、组织水肿和/或解剖异常伴窦内粘稠潴留物。
③变应性鼻-鼻窦炎：有变应性鼻炎症状和鼻窦密度增高。
④感染阻塞性鼻-鼻窦炎：鼻息肉、组织水肿和解剖异常伴鼻-鼻窦脓性分泌物。
⑤感染变应性鼻-鼻窦炎：有变应性鼻炎症状和鼻窦密度增高，同时伴有黏膜充血，脓性分泌物等。
⑥变应阻塞性鼻-鼻窦炎：有变应性鼻炎症状和鼻窦密度增高，同时伴有鼻息肉、组织水肿和/或解剖异常，以及窦内粘稠潴留物。
⑦感染变应阻塞性鼻-鼻窦炎：有变应性鼻炎症状和鼻窦密度增高，同时伴有鼻息肉、组织水肿和/或解剖异常，以及脓性分泌物。
参见慢性鼻-鼻窦炎分类示意图：
需要注意的是：
1、即便是被诊断为感染性炎症，也只是说明以感染因素为主，不能排除其它多种致病因素的共同参与，而这种以感染性因素为主的炎症，也会随着各种致病和治疗因素的此消彼长，转变成为以其它炎症为主的新的炎症形式。当然，如果自身抵抗力和修复能力超过了致病因素的作用，或者在恰当的药物和手术治疗的帮助下，相关症状会逐步减轻或/和痊愈。同样，阻塞性、变应性炎症，等等，也存在同样问题。
2、感染性炎症，不仅包含了病毒性，真菌性和细菌性感染，而且，细菌性感染还包含了特异性和非特异性细菌性感染，以及需氧菌和厌氧菌感染。其中，非特异性细菌性感染的合理性治疗，还涉及到了生物膜形成和耐药性问题，以及抗生素的合理有效使用和长期与间歇性治疗等问题。此类相关性问题，EPOS文件中都有详细阐述，只是2008年在南昌制定的CPOS，本着“由繁入简”的原则，未能涉及到而已。所以，笔者认为，应该让人们首先详细阅读EPOS，而后再本着“由浅入深，深入浅出”的原则，最终实现CPOS的“由繁入简”。
3、阻塞性鼻-鼻窦炎，包含有鼻腔的解剖异常，如：鼻中隔，中、下鼻甲，黏膜的病理性改变，如：黏膜水肿，增生肥厚，息肉样变，鼻窦的解剖异常，如：窦口鼻道复合体区域的以筛泡为中心的局部解剖异常等。而阻塞性的完善治疗包含了两个主要方面：一是鼻内镜手术的精细微创，二是鼻鼻窦手术的协同处理。
4、变应性鼻-鼻窦炎，随着工业化进程和环境污染的加剧，此类疾病呈逐年递增趋势，在临床
治疗原则：术前依据鼻腔黏膜炎症转归情况，术后依据鼻-鼻窦黏膜炎症转归情况，确定用药种类、时间和用量。其中：①用药时间，应依据病情转归情况而定；②药物用量，应依据病情严重程度而定；③用药种类，应依据可能致病因素而定。
要想做到这一切，应该：①要求病人定期复诊；②对慢性炎症的炎症状态进行分期；③对慢性鼻-鼻窦炎进行分类，以指导具体的药物治疗。显然，既往不仅缺乏对药物治疗重要性的认识，更缺乏富有针对性的药物治疗原则[3]。
参考方案如下：
感染类 炎症迁延期和急性发作期，给予先锋类、喹诺酮类或依据药物敏感试验选择有效抗生素，同时辅以相关中成药（如：辛芩颗粒、中联鼻炎片、鼻渊舒，等等）。炎症好转期口服罗红霉素150mg bid或克拉霉素250mg bid。鼻腔喷用类固醇激素，每鼻孔2喷qd或bid。炎症加重时，依据病情，重复治疗，至炎症好转后再改用口服罗红霉素或克拉霉素和鼻腔喷用类固醇激素。
潴留类 尤其是鼻息肉患者，给予口服强地松20mg～30mg/d，晨空腹顿服，术前5天，术后10天，同时口服罗红霉素150mg bid或克拉霉素250mg bid，鼻腔喷用类固醇激素，每鼻孔2喷 qd或bid。
感染潴留类 上述药物同时使用。
真菌性鼻-鼻窦炎 主要是引流通畅、冲洗和对症处理。同时注意其它致病因素的治疗。
变应性鼻-鼻窦炎 主要是口服抗组织胺类药物加局部类固醇激素治疗。
4、治疗阶段的划分和综合药物治疗
① 术前治疗阶段：是整个慢性鼻-鼻窦炎治疗的基础，具有以一当十的作用，十分重要。如前所述，这一阶段主要是通过对鼻炎炎症分期和分类的判断，给予正确的综合药物治疗。
② 手术治疗阶段：是慢性鼻-鼻窦炎整个治疗过程中的点睛之笔。亦如前述，要注意鼻腔与鼻窦手术的协调统一，在确保恰当而合理的矫正鼻腔、鼻窦解剖异常和清除不可逆病变，满足鼻-鼻窦引流通畅的同时，依据微创外科理念，以较小的鼻腔、鼻窦损伤和恰当的鼻窦开窗大小，获得疾病的顺利转归。
③ 术后治疗阶段：是一个艰苦而又漫长的过程，也是一个考验技术与耐心的阶段。需要通过尽可能完善和更加持久的综合药物治疗，尽量消除和避免炎症的迁延存在。实现围手术期与远期治疗的协调统一。
上述整个治疗过程中的3个阶段可以概括为6个字：“药物+手术+药物”。
其中，术后治疗阶段又包括了：两个方面和三个分期。
两个方面：内镜随访，药物治疗。
三个分期：创面修复期，结构恢复期，功能恢复期。
创面修复期：术后15-25天，创面被修复阶段。
创面修复期抗生素、局部激素、鼻腔冲洗等治疗应该持续，尤其是感染性鼻-鼻窦炎，抗生素的大量使用，仍是必要的。术后加强术腔冲洗，可以避免或/和减少内镜下清理。
在此基础上，第一次镜下随访应该在术后7-10天，不可超过2周，主要是清理鼻腔内结痂和窦内血性分泌物，防止术腔粘连和窦口狭窄闭锁。
第二次随访应该在20-25天，不可超过4周，主要是检查有无术腔粘连和窦口狭窄闭锁，如有发生，可及时补救。
感染潴留性鼻-鼻窦炎可以给予适量的口服激素，有学者主张大量口服强的松，但笔者认为这不是必需的，如果术前准备充分，炎症得到了有效控制，术后术腔、窦腔肿胀，依靠抗生素、局部激素和鼻腔冲洗应该可以控制。
结构恢复期：创面修复后至肿胀消退，约需3-6个月或更长时间。
这个阶段相当于许庚、李源教授“术腔创面愈合过程3个阶段”中的第2、3阶段[4]。这个阶段的关键是做好药物治疗和内镜随访。能否彻底消除脓性分泌物，控制息肉复发，更为重要的是完善药物治疗，但前提条件是，前期手术和创面修复期已经做的足够完善，无需反复内镜下重新处理。
对于一个真正需要手术的慢性鼻-鼻窦炎，在严重的慢性炎症和手术创伤同时存在的情况下，即便是恰如其分的综合药物治疗，6个月内完成结构恢复，进入功能恢复，依然十分困难。这个阶段，鼻-鼻窦黏膜处于一种“休克”状态，几乎失去了所有的抗病力，包括抗菌（细菌、真菌）、抗变态反应等，这一时期治疗的目的是让鼻-鼻窦黏膜从这种“休克”状态中复苏，故而也可称之为功能复苏期。此时，药物治疗是必需的，无奈的，被动的。既往，息肉复发，脓性分泌物持续存在，除了术前药物治疗不充分外，也与这个阶段没有给予充分而恰当的综合药物治疗密切相关。需要注意的是：在未接受系统药物治疗的情况下，3个月内能够迅速完成结构恢复，进入功能恢复的病例，其鼻窦手术的必要性存在质疑。
药物治疗原则：
①创面修复前，脓性分泌物常常并不多，大约在术后1-2个月，脓性分泌物会有不同程度的增加或/和加重。此时切忌内镜检查，而是首先给予大剂量静脉滴注抗生素，同时口服中成药，局部喷用激素，鼻腔药物冲洗，等等。待脓性分泌物减少，症状改善后，一般为1-2周，再酌情实施内镜检查。
②假若水肿明显，没有脓性分泌物。可口服大环内脂类药物（如：罗红霉素、克拉霉素等），酌情加用口服中成药，局部喷用激素，鼻腔药物冲洗。每2周复诊1次，但切忌内镜下频繁清理。期间如果患者自感症状加重，应随时复诊，对症给予药物治疗，笔者称之为：弹性随访策略。
③依据“轻微炎症持续存在” 的特点，在恢复顺利的情况下，仍应该给予小剂量大环内脂类药物连续服用；炎症加重，给予短期大剂量抗生素冲击治疗；轻微炎症持续存在和炎症加重间歇性发作交替出现，是此阶段的典型表现。
功能恢复期：从肿胀消退到功能重新建立，也是从达到临床治愈，到真正的功能恢复，大约需要1-2年，甚至更长时间。
这个阶段，恢复顺利者，炎症仍会偶有发作，依然需要给予交替进行的小剂量维持和大剂量冲击的药物治疗策略。所不同的是，小剂量维持已经成为治疗的主角，大剂量治疗已经很少使用。部分病情严重，恢复不顺利者，炎症迁延存在，如上所述的大剂量药物治疗难以避免，小剂量维持常常只是辅助。此类病例在超过1年以上继续药物治疗的情况下，仍会逐步改善。
笔者在远期随访中发现，部分已经上皮化的窦腔，在更长时间的随访中，会再次出现脓性分泌物、黏膜水肿，及时处理，可逐步减少其炎症的反复发作，直至痊愈。显然，感染、变态反应等等，可以在短期内得以控制，但感染、变态反应及感染免疫所造成的影响却不能被同时消除，更不能在感染、变态反应和感染免疫尚未得到有效控制的情况下，使黏膜功能得以恢复。
参考文献：
1.韩德民, 诸小侬, 山下公一. 鼻内窥镜手术疗效分析. 中华耳鼻咽喉科杂志, 1992, 27: 348-350
2.中华医学会耳鼻咽喉科学分会，中华耳鼻咽喉科杂志编辑委员会. 慢性鼻窦炎鼻息肉临床分型分期及内窥镜鼻窦手术疗效评定标准. 中华耳鼻咽喉科杂志, 1998, 33: 134
3.专题讨论：慢性鼻窦炎鼻息肉鼻内窥镜手术后综合处理意见. 中华耳鼻咽喉科杂志, 2001; 36(3):237-240
4. 许庚, 李源, 谢民强, 等. 功能性内窥镜鼻窦手术后术腔粘膜转归阶段的划分及处理原则. 中华耳鼻咽喉科杂志, 1999, 34: 302-305
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