鼻内镜下鼻泪管前径路和后径路切除上颌窦良性病变

目的 探讨鼻内镜下上颌窦内侧壁入路切除上颌窦良性病变的手术径路及手术方法的可行性及疗效.方法 2003年6月至2010年8月,采用鼻内镜下经鼻腔鼻泪管前径路和鼻泪管后径路的多种方式切除上颌窦良性病变139例,其中内翻性乳头状瘤43例、真菌性上颌窦炎63例、上颌窦囊肿28例、出血坏死性息肉3例、骨瘤2例.所有病例术前行CT检查,可疑内翻性乳头状瘤患者同步行MRI检查.鼻泪管前方径路采取3种方式:梨状孔入路、泪前隐窝入路(包括解剖鼻泪管和不解剖鼻泪管2种方式)、梨状孔鼻泪管人路,共治疗97例；鼻泪管后方径路也采取3种方式:下鼻甲翻转、双蒂下鼻甲、单蒂下鼻甲,共治疗42例.观察患者术后疗效.结果全部病例在鼻内镜下经鼻彻底清除病变,保护了鼻泪管,保留了下鼻甲,无一例发生鼻泪管损伤和下鼻甲坏死.术后鼻塞、头痛、闷胀不适、异味、牙疼和麻木感等症状逐步消失.9例感觉鼻腔干燥,经鼻腔冲洗等处理后1个月左右逐渐消失.随访6 ～79个月,骨瘤和出血坏死性息肉未见复发.所有真菌性上颌窦炎患者术中均可见窦腔黏膜明显水肿、增厚,术后3个月左右逐渐消失,无一例复发.2例上颌窦囊肿患者术后10个月和18个月在上颌窦其他部位再发,但囊肿小且无临床症状未作处理.内翻性乳头状瘤患者有3例复发,1例术后17个月上颌窦口上方局限性肿物突出,病理示乳头状瘤复发,门诊予以清理后随访1年未见复发；1例于术后15个月前筛处复发,行筛窦广泛切除后随访3年未见复发；1例术后26个月上颌窦后外侧壁局部复发,二次行蒂在前方单蒂下鼻甲方式手术,术后1年再次复发,行鼻内镜下Denker手术,随访18个月未见复发征象.所有病例术后3个月上颌窦创面上皮、瘢痕覆盖,下鼻甲形态良好,下鼻道开窗者较术中明显瘢痕变小,且引流通畅无闭锁.结论鼻内镜下鼻泪管前、后径路上颌窦手术可以减小创伤,充分暴露窦腔视野,并为术后内镜复查和复发后的处理提供了视窗；保留下鼻甲避免了鼻腔外侧壁去除过多而导致的术后干燥、结痂、头痛等并发症.

Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach

Objective To explore the feasibility and effectiveness of the approaches and methodology of the endoscopic surgery for maxillary sinus lesions through the medial wall of the maxillary sinus.Methods From Jun.2003 to Aug.2010,endoscopic surgery through anterior or posterior nasolacrimal duct approaches to remove maxillary sinus lesions were conducted in 139 patients.Among them there were 43 cases with inverted papilloma,63 cases with fungal maxillary sinusitis,28 cases with maxillary sinus cyst,3 cases with hemorrhagic necrotic polyps,and 2 cases with osteomas.All patients underwent preoperative CT scans,and patients with inverted papillomas also had MRI tests.Anterior-nasolacrimal canal paths included 3 ways:pyriform aperture,lacrimal bone recess (dissecting nasolacrimal duct or not were 2 subtypes),pyriform aperture-nasolacrimal duct approaches,and 97 patients were treated.Posterior-nasal lacrimal duct paths were also divided into 3 subtypes:the inferior turbinate flip flap,double pedicle inferior turbinate,single pedicle inferior turbinate,and 42 patients were treated.The postoperative effects were observed.Results All lesions were completely removed under endoscope,the nasolacrimal ducts and inferior turbinates were protected,no nasal lacrimal duct injury and inferior turbinate necrosis were found.Postoperative nasal congestion,headache,swelling discomfort,strange odor,dental pain and numbness and other symptoms gradually disappeared.Nine patients felt nasal dryness,and after nasal washing for about 1 month,the symptom gradually disappeared.Patients were followed up for 6 months to 79 months.In case of osteoma,and hemorrhagic and necrotic polyps,no recurrences were found.Apparent edema,hypertrophy of sinus mucosa could be seen during the surgery in all patients with fungal maxillary sinusitis,and the edema gradually disappeared after 3 months or so,with no relapse.Two cases of maxillary sinus cysts were found in other parts of the maxillary sinus 10 months and 18 months after the surgery,but the cysts were small and asymptomatic,so no further management needed,and they were still under follow-up.Three patients,recurred.In 1 case with inverted papilloma,a local lump on the opening were found 17 months after the surgery,and was removed in out-patient department and pathology showed papillary tumor recurrence,no relapse was found 1 year later; 1 patient had recurrence in anterior ethmoid sinus 15 months after operation,total ethmoidectomy was done and no relapse was found in 3 years.One patient had local recurrence in the posterolateral wall of the maxillary sinus 26 months after operation,and the secondary surgery was done via single pedicle inferior turbinate.The papilloma relapsed again after 1 year,an endoscopic Denker surgery was performed,with no recurrence after 18 months of follow-up.Three months after surgery,the maxillary sinus was scar-covered in all cases.Inferior turbinate maintained good shape,compared to those with inferior nasal meatus windowing surgery.Scars were significantly smaller,but no latch or obstruction of drainage were found.Conclusions Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach can reduce the trauma,fully expose the sinuses,and facilitate postoperative treatment and review with a window.Retained inferior nasal turbinate is helpful to avoid dryness,crusting,headache and other complications due to too much removal of nasal exteral walls.