鼻内镜下鼻咽血管纤维瘤切除术及疗效随访

摘要

目的 探讨鼻内镜下鼻咽血管纤维瘤(juvenile nasopharyngeal angiofibroma,JNA)切除术手术方法的演变及疗效随访.方法 回顾性分析2002-2009年入院接受经鼻内镜下切除术的59例JNA患者的病例资料.采用Radkowski分期系统,将Ⅰa～Ⅱb期分为A组,Ⅱc～Ⅲb期分为B组,观察记录术前分期、供血动脉、手术时间、出血量、术后残留或复发情况及其他术后并发症.结果 组21例,确诊年龄平均23.9岁,手术时间(106.0±43.7)min,出血量介于10～2000 ml,中位数出血量为200 ml;随访3～74个月(失访3例,中位随访时间36个月).B组38例,确诊年龄平均16.2岁,手术时间(152.9±58.0)min,出血量介于100～7000 ml,中位数出血量为400 ml;随访3～87个月(失访5例,中位随访时间25个月).随访期内A组无复发病例.B组1例患者行数字减影血管造影术后出现丘脑梗死,后痊愈,6例复发.两组手术时间和复发曲线的差异有统计学意义(t=-3.232,P=0.002;P=0.03).结论 鼻内镜下切除JNA时出血控制手段及强调瘤体附着骨组织的处理,以及采用切除部分或全部翼突及上颌窦后外侧壁,是切除肿瘤的关键;无翼肌间隙和颅底骨质受累的JNA(Radkowski分期Ⅰa～Ⅱb)效果良好,复发率低;Radkowski分期Ⅱc及以上的JNA有残留和复发的风险.%Objective To present the changes of surgical approaches for the resection of juvenile nasopharyngeal angiofibromas(JNA)and the follow-up results.Methods The clinical records of 59 patients with JNA treated under endoscope between 2002 and 2009 were reviewed retrospectively.The patients were divided into two groups:Group A(RadkowskiⅠa-Ⅱb)and Group B(Radkowsik Ⅱc-Ⅲb).The tumor stages,feeding vessels,operating time,complications and recurrence were observed and recorded.Results There were 7 patients with stageⅠa,3 patients with stageⅠb,5 patients with stage Ⅱ a,6 patients with stage Ⅱ b,4 patients with stage Ⅱc,23 patients with stage Ⅲa,11 patients with stage Ⅲb.The average age at diagnosis in Group A(21 cases)was 23.9 years old.The average operating time was(106.0±43.7)min.The follow-up ranged from 3 months to 74 months(median 36 months)except for 3 missing cases.The average age at diagnosis in Group B(38 cases)was 16.2 years old and the average operating time was(152.9±58.0)min.The follow-up ranged from 3 months to 87 months(median 25 months)except for 5 missing cases.During follow-up,6 patients in group B recurred.Infarction of thalamencephalon happened in 1 patient in group B who recovered totally afterwards.The difierence in operating time between two groups was statistically significant(t=-3.232,P=0.002).The life table was used to evaluate the survival curves and Log-rank test showed that the difference of recurrent time between two groups was statistically significant(P=0.03).Conclusions The key techniques to remove tumor are bleeding control,drilling-out the bone that tumor invaded.Transpterygoid or posterolateral wall of maxillary sinus approach are recommended for tumors that extend to infratemporal fossa.Small and intermediate-sized JNA which have no deep invasion of skull base(Radkowski Ⅰ a-Ⅱ b)have a low morbidity.JNA at Radkowski stage Ⅱ c and above have residual and recurrent risk.