【作者】 张晓静；

【导师】 赵玉林；

【作者基本信息】 郑州大学 ， 耳鼻咽喉科， 2011， 硕士

【摘要】 目的和背景鼻内翻性乳头状瘤(nasal inverted papilloma, NIP)是鼻腔和鼻窦粘膜常见的良性肿瘤,其临床特点是易复发、可破坏周围骨质及正常的解剖结构和有恶变为鳞状细胞癌的倾向,故NIP首选的治疗方式一直是外科手术,其手术治疗原则是根治性切除肿瘤。手术关键在于：一是彻底清除肿瘤及其累及的鼻腔鼻窦组织；二是彻底切除肿瘤基底部及其邻近的粘膜和骨质。本病传统术式为鼻外进路,但其创伤大、面部遗留疤痕,尤其是对鼻腔鼻窦的功能性保护不够。大量临床资料证实鼻外径路与鼻内镜下手术的治疗效果并无显著性差异。近年来随着鼻内镜微创技术的发展和成熟,应用精细的手术解剖技术处理病变也逐渐成熟,患者也更容易接受。本文通过临床上较常见的三种术式：单纯鼻内镜手术、鼻内镜辅助下的Caldwell-Luc手术和鼻侧切开术治疗鼻腔鼻窦内翻性乳头状瘤,对术后复发率进行统计分析,探讨鼻内镜手术在鼻内翻性乳头状瘤治疗中的临床价值。方法1临床病例资料：本文选取郑州大学第一附属医院2005年6月～2010年6月的43例住院NIP患者,所有病例随访资料完整。2手术方式及分级方法：通过病例的登记表进行回顾性分析,手术方式采用单纯鼻内镜手术、鼻内镜辅助下的Caldwell-Luc手术或鼻侧切开术,其中接受单纯鼻内镜手术治疗的病例18例,接受鼻内镜辅助下Caldwell-Luc手术方法治疗的病例15例,接受鼻侧切手术方法治疗的病例10例。对其术后复发情况进行跟踪随访,对于每个病例采用Krouse方法分级,且分别对相同级别三种手术方法的复发率进行列表计算,术后平均随访1.7年。3统计学分析：应用SPSS17.0统计软件进行计算分析,采用卡方检验(X检验),检验标准：α=0.05。结果总复发率为9.3%。单纯鼻内镜手术Ⅰ级组复发率为11.1%,Ⅲ级组复发率为33.3%,鼻侧切术Ⅲ级组复发率为25.0%,Ⅳ级组复发率为33.3%。临床分期相同的病患采用三种术式的疗效无明显差异。一次手术治愈者37例,术后复发行二次手术者4例,二次术后无再次复发。结论1鼻内窥镜下手术是治疗Ⅰ～Ⅱ级鼻内翻性乳头状瘤一种较好的方法,对于病变主要侵及窦口鼻道复合体、后组筛窦及蝶窦的Ⅲ级病例行鼻内镜下鼻窦手术也可有良好效果。其主要优点是视野清晰、避免了面部切口、术后较少阻塞泪道及较好的保留局部结构和鼻腔鼻窦粘膜功能。2对累及上颌窦内、外侧壁和底壁的Ⅲ级病例联合柯-陆进路手术可取得较好疗效,对Ⅳ级病例采用鼻侧切为首选,鼻内镜术中可有辅助作用。3鼻内窥镜手术治疗复发病例、双侧发病病例仍有较好效果。4鼻内窥镜对NIP的术前检查及术后复查都具有明显的优势,可早期发现病变,术后及时清除复发病变。更多还原

【Abstract】 Objective and backgroundNasal inverted papilloma (NIP) is a primarily benign lesion that occur in the nasal cavity and paranasal sinuses. Clinical problems include a tendency towards local destrution, recurrence and malignant transformation into squamous cell carcinoma. The surgery treatment has been the first choice for NIP, the principle of the surgery is redical resection. The key points:first, complete resection of tumor and the related nasal cavity and sinus tissue; the second is an en bloc removal of the base of the tumor and the adjacent mucosa and bone. The traditional surgical approach is though the outside nose, which has the disadvantage of facial scar, serious damage, especially the lacking of protection of nasal cavity and paranasal sinuses. Varies of clinical studies show there is no significant difference between outsider nasal approach and endoscopic sinus approach. With the development of the minimally invasive endoscopic technique in recent years, the tumor can be treated by fine surgical anatomy, this approach can be easily accepted by the patients. Objective to evaluate the clinical value of endoscope surgery in the therapy of the nasal inverted papilloma of the three processes through the statistics of the recurrence rate of single endoscope surgery, endoscopic combined with Caldwell-Luc and lateral rhinotomy approach.Methods1 Clinic data:select 43 patients who were treated in the first affiliated hospital of zheng zhou university.2 These cases are registered and retrospectively analyzed. They were operated on by single endoscope surgery, or endoscopic combined with Caldwell-Luc, or lateral rhinotomy approach. Eighteen patients were operated on by single endoscope approach. Fifteen by endoscopic combined with Caldwell-Luc, and ten by lateral rhinotomy approach.The information of recurrence is follow-up visited. Every case is graded by Krouse Method, and the recurrence rate of the three methods of different grades is calculated in tabulation. The average follow-up time is 1.7 year.3 Statistical Analysis SPSS 17.0 software was employed to analyze all date. Statistical evaluation was performed using Chi-Square test. P<0.05 was considered as statistical significance.ResultsThe total recurrence rate is 9.3%. The recurrence rate for single endoscope surergy group I is 11.1%, and the III group is 33.3%. The recurrence rate for lateral rhinotomy approach III is 25.0%, and the group IV is 33.3%. There was no statistically significant difference on the therapeutic effect of three kinds of surgical procedures in same stage. Thirty-seven patients were to be operated on for the first time. Seven patients are for the second time to be operated on. There was no relapse cases after the second surgery.Conclusion1 The single endoscopic surgery is an effective treatment for treating stageⅠ～Ⅱand stage III including OMC、posterior ethmoid、sphenoid sinus. the operating field was clean、no facial incision postoperative lacrimal duct obstruction was markedly decreased, at the same time remaining the local structures and the function of nasal mucosa better.2 Better results for patients in stage III involving maxillary sinus inner wall、lateral wall and floor wall would be achieved by combining endoscopic technique with Caldwell-Luc surgery. Lateral rhinotomy is the firstchoice in stageⅣ. Endoscopy may play a helpful role in lateral rhinotomy.3 The single endoscopic surgery has achieved good effects for recurrence cases.4 Endoscopy is a good approach for early lesion and recurrence cases.更多还原