【作者】 陶仲强； 司勇锋； 肖泉； 邓卓霞； 张政； 周日晶； 黄波；

【Author】 Tao Zhong-Qiang Si Yong-Feng Xiao Quan Deng Zhuo-Xia Zhang Zheng Zhou Ri-Jing Huang Bo Department of Otorhinolaryngology, Peoples Hospotal of Guangxi Autonomors Region, Nangning 530021.

【机构】 广西壮族自治区人民医院耳鼻咽喉科；

【摘要】 目的: 鼻咽癌的治疗主要是采用放疗,但其复发率较高,而复发后再放疗又存在许多严重并发症。单一治疗手段已难以包揽鼻咽癌的治疗任务。长期以来,人们一直在探索一条既安全又能充分暴露鼻咽及咽旁周围间隙的进路来进行鼻咽癌挽救手术。方法:自2004年来我们对4例鼻咽癌复发患者采用翼点进路加上颌骨外翻进路切除累及鼻咽旁间隙及侵入颅内肿瘤。4例患者均为男性年龄在43—57岁之间, 平均46．5岁,按92年福州分期。3期2例,4期2例,先行放疗并化疗1个疗程,再在放疗过程中同时化疗1个疗程,共用PDD200mg,5-FU7．5g。首程放疗剂量,直线加速器,鼻咽部原发灶72-76GY,颈部组织量56-60GY,治疗结束时复查CT扫描显示2例鼻咽部肿瘤明显缩小,2例完全消失。这 4例患者先后在治疗后1年半-3年鼻咽部肿瘤复发,但颈部淋巴结无复发,亦未发现远处转移。4例患者复发后均以头颅 CT及MRI检查。4例患者术前病理均为低分化鳞癌。手术方法,上颌骨外翻进路作Weber-Ferguson切口,从鼻旁向下绕过鼻翼达鼻小柱,至上唇正中切开骨面沿睑缘下1cm取横形切口向外延伸至颧弓,自硬腭中线向后切开粘骨膜,加同侧软硬腭交界处切口。用电锯锯开颧弓,锯开上颔骨前壁以及内壁与鼻侧粘膜,再沿中线锯开硬腭,凿开翼颌连接,将上颌骨肌皮瓣向前外翻开,显露鼻腔,鼻咽腔和翼腭窝,逐步用电刀切除肿瘤。由神经外科完成开颅手术,全部采用翼点入路,以翼点为中心作额颞部(翼点)游离骨瓣,打开侧裂池,放出脑脊液,脑压下降。于显微镜下操作,逐步切除肿瘤,肿瘤切除后,颅底硬脑膜进行修补并以带蒂颞肌翻转颞下进行颅底重建,切除肿瘤残腔放置外引流条。结果:术后 4例患者面部切口一期愈合,无脑脊液鼻漏,骨部对位良好, 无明显的咬颌功能障碍。术后病理1例为海绵区转移性或浸润性鳞状细胞癌,其他3例为海绵窦纤维脂肪组织,未见癌。鼻咽部术后标本2例为纤维结缔组织广泛玻璃样变性及慢性炎细胞浸润,内见退变的鳞癌癌巢,2例为低分化鳞癌。治疗后随访6—23个月,首次采用这一术式的患者治疗后1年11个月鼻咽部大出血死亡,其余3例仍然存活,一般状况尚可。结论:上颌骨外翻转入路适用鼻咽,鼻咽旁间隙部位的肿瘤切除,同时对于累及颞下窝,蝶窦、后筛,眶尖及中颅窝,海绵窦等部位的肿瘤也提供良好的手术暴露,上颌骨翻转后其路径短,显露清楚,可在直视下止血操作,处理颅底,海绵窦也十分方便,有其他手术进路难以取代的优势。结果表明,鼻咽切除术是治疗复发性鼻咽癌安全有效的方法,在医生的相互协作下,还可以切除侵入颅内的肿瘤。鼻咽癌的颅内侵犯,海绵窦是最早出现和最常见的部位。随着颅底外科技术的不断进步,以往一些认为难以手术治疗的颅底肿瘤已取得较好的疗效,颅底沟通瘤,由于其同时侵及颅内外,涉及神经外科,耳鼻咽喉科,眼科有关专业知识,处理起来颇为棘手,传统的治疗办法多由各科分别处理,不仅难以一次切除肿瘤,增加病人的痛苦,因此,不同学科的联合,寻找一种理想的手术途径,一直是有关学科共同关心的问题。由神经外科采用翼点入路,可以满意地显露海绵窦,在显微镜下分块切除肿瘤,可以避免损伤重要的血管神经。本组所采用的2种手术方式能够较好地暴露鼻咽癌颅内外病变,并进行肿瘤切除,对鼻咽癌复发患者采用手术及术后放射治疗等积极措施可取得一定的治疗效果。更多还原

【Abstract】 Objective: The mainstay of nasopharyn-geal carcinoma(NPC) tretment is radiotherapy. however, locaregional failure is still main cause of death. Reirradiation of the primary recurrent was accompanied by significant morbidity. To study new surgical approach to resect the tumors in the paranasopharyngeal space and in the skull base fro fecurrent NPC. Methods: Four cases with primary recurrent of NPC after chemotherapy(wlth PDD 200mg, 5-FU 7.5g)and radiation (with dosege 72-76GY) failure. AU patients had biopy-provent primary recurrence. The magnetic resonance imaging scans had finding the NPC is extension to invade the parapharyngeal space and involve the cavernous sinus in all 4 cases. Operated on by throngh a Weber-Ferguson incision, the whole maxillary was freed form bony connections and swing laterally while remaining attached to the masseter muscle and the cheek flap. Then the skull base and paronasopharyngeal space was expose, so the tumor could be resected completely. Then the preronal approach is used by neurosurgeons, Postauricular "C" form incision to resect temporal bone, after temporal cranictomy, the temporal lobe is retracted to expose the temporal base, the tumor can then be removed from the cavernous simus. The skull base by the use of temporal muscles to fill up the cavity and the rotating periosteum of the temporal bone to repair the dura defect. Results: The facial wouds in all 4 healed primarily with no evidence of necrosis of the maxillary, cerebrospinal fluid rhinorrhea and trismns. The 4 case underwent a second course of radiotherapy with dosage 6GY after operative for 6 weeks. The 4 patients were followed up for 6-23 months. To date 1 case have died of massive bleeding, 3 cases had survival. Conclusion: The surgical approach to the nasopharynx has been the focus of interest since the development of skull base surgery. The preronal approach and maxillary swing approach is proven method for access to the paranasopharynx and middle cranial fossa. The tumors of NPC in these region can be adeguatly exposured and safely resecte, the associated morbidity is low. Comparing with radiotherapy alone, The surgery combining radiotherapy has more effective for NPC reccurence.更多还原