经鼻内镜下治疗侵及眼眶的鼻腔鼻窦恶性肿瘤36例临床分析

目的：分析经鼻内镜手术治疗侵及眼眶的鼻腔鼻窦恶性肿瘤的疗效，并探讨影响其预后的相关因素。方法：回顾性收集2010年1月至2017年12月遂宁市中心医院和四川省人民医院耳鼻咽喉头颈外科收治的36例侵及眼眶的鼻腔鼻窦恶性肿瘤患者的临床资料，随访其5年生存率和复发率及并发症等情况，并探讨影响患者预后的相关危险因素。结果：36例术后患者，2例失访，随访完成率94.4%；34例患者随访时间为8~76个月，中位随访时间26个月，平均随访(27.2±18.6)个月；随访期间肿瘤复发13例，复发率36.1%；患者术后1年、3年、5年生存率（OS）分别为86.1%、75.0%、52.8%。不同临床分期患者总体中位生存期(OS)分别为：1期60个月、2期为20个月、3期为16个月，生存曲线之间差异有统计学意义(χ2=4.252; P=0.039)；不同病理类型患者总体中位生存期(OS)分别为：鳞状细胞癌19个月、腺样囊性癌36个月、肉瘤11个月、其它恶性肿瘤49个月，生存曲线之间差异尚未显示有统计学意义(χ2=3.736; P=0.291)。多因素Cox回归分析显示，临床分期是影响患者预后的独立危险因素（P<0.05）结论：鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦恶性肿瘤疗效确切、患者创伤小，与文献报道的开放手术无显著差别。患者的预后与临床分期密切相关。     

鼻内镜手术切除治疗鼻腔鼻窦恶性肿瘤的临床疗效

目的评价鼻内镜手术切除治疗鼻腔鼻窦恶性肿瘤的临床疗效。方法将本院收入的56例鼻腔鼻窦恶性肿瘤患者分为2组,实验组行鼻内镜手术,对照组行传统鼻切开手术。比较2组手术时间,术中出血量,术后疼痛视觉模拟评分,术后并发症以及复发率的情况。结果实验组患者手术时间相比对照组短,疼痛情况也较对照组轻,并发症发生较少且复发率较低。结论鼻内镜手术切除鼻腔鼻窦恶性肿瘤的方法具有手术时间短,术后并发症少,术后复发率低的特点,值得推广应用。     

鼻内镜技术用于治疗鼻腔鼻窦恶性肿瘤的临床疗效观察

目的 探讨鼻内镜技术治疗鼻腔鼻窦恶性肿瘤的临床疗效.方法 选取80例鼻腔鼻窦肿瘤患者,40例患者鼻内镜下行手术切除(观察组),根据每个肿瘤类型和部位的不同,确定鼻内镜下手术切除范围.另40例患者行传统手术方法(对照组).比较2组手术时间,术中出血量、术后疼痛视觉模拟评分(VAS),术后焦虑自评量表评分(SAS)、术后并发症和复发率情况.结果 观察组的手术时间和术中出血量均明显少于对照组(P＜0.05);观察组术后视觉模拟评分(VAS)和焦虑自评量表评分(SAS)均明显低于对照组(P＜0.05);观察组的并发症和复发率均低于对照组(P＜0.05).结论 鼻内镜技术切除鼻腔鼻窦肿瘤损伤小、手术时间短、出血量少、术后疼痛少,术后焦虑较轻,术后并发症和复发率低,具有较好临床疗效,值得临床推广应用.     

鼻内镜手术治疗鼻腔鼻窦内翻性乳头状瘤的临床效果观察

目的 探讨鼻内镜手术治疗鼻腔鼻窦内翻性乳头状瘤(SNIP)的临床效果.方法 回顾性分析93例行鼻内镜手术治疗的SNIP患者的临床资料,对患者进行Krouse分期,比较不同手术方法(单纯鼻内镜手术、鼻内镜联合改良柯-陆氏手术、鼻内镜联合鼻外进路手术)的治疗效果及术后复发情况.结果 所有患者均一次性完成手术,手术时间47~196 min,平均(94.3±25.9)min;术中出血量34~281 ml,平均(97.3±29.0)ml;术后随访时间26~62个月,平均(39.4±10.9)个月.19例KrouseⅠ期患者均采用单纯鼻内镜手术治疗,复发1例(5.26%).45例KrouseⅡ期患者中,32例采用单纯鼻内镜手术治疗,复发2例(6.25%);13例采用鼻内镜联合改良柯-陆氏手术治疗,复发1例(7.69%),两种手术方法的复发率比较,差异无统计学意义(P>0.05).25例KrouseⅢ期患者中,10例采用单纯鼻内镜手术治疗,复发6例(60.00%);15例采用鼻内镜联合改良柯-陆氏手术治疗,复发1例(6.67%),两种手术方法的复发率比较,差异有统计学意义(P<0.05).4例KrouseⅣ期患者均采用鼻内镜联合鼻外进路手术治疗,复发1例(25.00%).结论 鼻内镜手术治疗SNIP效果较好,复发率低,应根据患者肿瘤分期制定手术方案,并于术后定期复查以有效预防肿瘤复发.     

鼻内镜手术切除与传统手术治疗鼻腔鼻窦恶性肿瘤的疗效比较

目的比较鼻内镜手术切除与传统手术治疗鼻腔鼻窦恶性肿瘤的疗效。方法 2010年9月至2012年9月收治的56例患者应用传统手术治疗(对照组),2012年10月至2014年10月收治的56例患者应用鼻内镜手术切术治疗(观察组)。观察并记录两组患者的手术时间、术中出血、疼痛评分、术后并发症发生情况(颅内血肿、鼻腔粘连、视神经损伤、脑脊液漏)以及复发情况,比较手术前后患者的焦虑情绪情况。结果与对照组比较,观察组各型患者的手术时间、术中出血量、视觉模拟评分法(VAS)评分、并发症发生率、复发率、汉密尔顿焦虑量表(HAMA)评分总分及各因子分均明显降低。两组患者全部完成随访,与对照组比较,观察组患者生活质量各项指标均明显升高(P<0.01)。结论鼻内镜手术切除治疗鼻腔鼻窦恶性肿瘤可降低手术时间以及术中出血量,缓解患者的疼痛,并减少并发症以及术后复发率,改善患者的焦虑情绪,提高生活质量。     

鼻内镜在鼻腔鼻窦内翻性乳头状瘤切除术中的应用

目的探讨鼻内镜在鼻腔鼻窦内翻性乳头状瘤(SNIP)切除手术中的作用及SNIP患者的最佳手术方式选择。方法回顾性分析手术治疗的207例SNIP患者的临床资料,按照不同手术方式分为传统手术组(95例)和鼻内镜手术组(112例),其中鼻内镜手术组患者按照是否联合鼻外入路又分为单纯鼻内镜手术组(52例)和鼻内镜联合鼻外入路组(60例)。所有患者手术后定期随访。结果传统手术组患者的肿瘤复发率为44.2%,鼻内镜手术组患者的肿瘤复发率为14.3%,其中单纯鼻内镜手术组患者的肿瘤复发率为23.1%,鼻内镜联合鼻外入路组患者的肿瘤复发率为6.7%。采用鼻内镜联合鼻外入路可缩短手术时间,鼻内镜手术组患者平均住院时间低于传统手术组患者。结论鼻内镜的介入使用能够降低手术切除SNIP的复发率,提高SNIP手术切除的治疗效果。借助鼻内镜的高分辨率优势,SNIP患者采用鼻内镜联合鼻外入路手术可取得更好的疗效,值得临床进一步推广使用。     

不同手术方式治疗鼻腔鼻窦内翻性乳头状瘤的疗效观察

目的探讨不同手术方式治疗鼻腔鼻窦内翻性乳头状瘤(NIP)的临床疗效。方法选取2009年2月至2016年8月间第三军医大学第二附属医院收治的126例NIP患者。根据手术方式不同分为切开组(鼻侧切开术,20例)、内镜组(鼻内镜下手术,58例)和联合组(鼻内镜下手术+柯路氏进路,48例)三组。比较三组患者的术后复发率、术中出血量及术后并发症发生率。结果切开组患者中,6例患者发生并发症,包括视力衰退1例,脑脊液鼻漏2例,伤口麻木2例,眼睛流泪1例;内镜组患者中,4例患者发生并发症,包括脑脊液鼻漏1例,伤口麻木2例,眼睛流泪1例;联合组患者中,6例患者发生并发症,包括视力衰退1例,脑脊液鼻漏2例,伤口麻木1例,眼睛流泪2例。三组患者术后并发症发生率比较,差异有统计学意义(P<0.05)。切开组患者术后并发症发生率高于内镜组患者,差异有统计学意义(P<0.05)。三组患者术中出血量比较,差异有统计学意义(P<0.01),其中切开组患者术中出血量明显高于内镜组患者与联合组患者,差异均有统计学意义(均P<0.01)。三组患者术后肿瘤复发率比较,差异有统计学意义(P=0.01)。切开组术后复发率为40.0%(8/20),高于内镜组的12.1%(7/58)和联合组的14.6%(7/48),差异均有统计学意义(均P<0.05)。结论鼻内镜下手术与鼻内镜下手术+柯路式进路治疗NIP患者的临床疗效明显优于鼻侧切开术,术后肿瘤复发率、术中出血量及术后并发症发生率均较低,值得推广。     

鼻腔及鼻窦肿瘤治疗中一些特殊情况的处理

近年来在鼻腔和鼻窦肿瘤的诊治中有三项引人瞩目的进展,即CT的应用对于确定肿瘤的部位及其扩展的范围明显地较过去更加准确。其次是超高压放射源的应用,使一些早期癌瘤单纯通过放射治疗即可达到治愈的目的,而且在放射和手术的综合治疗中起到举足轻重的作用。第三是颅面联合路切除侵及颅底的鼻腔和鼻窦肿瘤的方法逐渐被广泛地应用,使一些过去认为无法切除的肿瘤得以彻底切除,同时这一术式在提高患者的治愈率方面起到明显的良好作用。在上述技术的影响下,几年来我们在处理鼻腔和鼻窦肿瘤临床工作中取得点滴经验,报道如下。     

以鼻出血就诊的鼻腔鼻窦肿瘤42例

 目的 探讨鼻腔、鼻窦肿瘤引起的鼻出血的临床特点和治疗方法。方法 对42例患者的诊断、治疗及结果进行分析。结果 良性肿瘤25例（100 %）全部治愈，鼻出血症状消失，1例内翻性乳头状瘤术后1年复发行2次手术，术后随访1年未见复发。恶性肿瘤17例治疗后鼻出血症状消失16例（94.12 %）；生存期＞1年17例（100 %），3年10例（58.82 %），5年6例（35.29 %）。结论 手术是治疗鼻腔、鼻窦肿瘤引起的鼻出血的最佳办法，综合治疗适用于恶性肿瘤。     

A Comparison of Microdebrider Assisted Endoscopic Sinus Surgery and Conventional Endoscopic Sinus Surgery for Nasal Polypi

Nasal polyposis is often encountered in rhinology practice. Those who fail conservative management, a definitive surgery is essential to achieve sufficient ventilation and drainage of the affected sinuses by using either microdebrider or conventional instruments for functional endoscopic sinus surgery (FESS). A prospective study was conducted on 40 cases of nasal polypi in a tertiary care hospital. 20 cases were operated by conventional endoscopic instruments and 20 using the microdebrider. The study aimed at comparing the intra operative (blood loss, duration of surgery) and post operative results (crusting, scarring, discharge, symptoms, recurrence) between the two groups using Lund–Mackay scoring system and the data was statistically analysed. There was no statistically significant difference in surgical outcome for patients when either conventional endoscopic instruments or microdebrider was used. However, there was a significant symptomatic improvement in cases undergoing microdebrider FESS. Microdebrider assisted polypectomy is precise, relatively bloodless surgery though the precision depends on the surgeon’s anatomical knowledge and operative skills. Study substantiates that these instruments are helpful but not a prerequisite for successful outcomes in FESS. The study re-emphasises the utility of the microdebrider to young learning FESS surgeons.     

鼻腔鼻窦恶性肿瘤伴眶侵犯的眼眶处理策略

鼻腔鼻窦和眼眶相邻,鼻腔鼻窦恶性肿瘤容易侵犯眼眶,这既是肿瘤晚期表现又是其不良预后因素之一.肿瘤眶侵犯,术前采用CT和MRI进行评估,术中借助冰冻切片进行判断.肿瘤未侵犯眶骨膜,保留眶内容物;肿瘤累及眶骨膜和肌锥外脂肪范围有限或切缘阴性,对新辅助化疗、放疗等多模式治疗方案反应良好,可以考虑保留眶内容物;肿瘤广泛侵犯眶骨...     

Endoscopic Sinus Surgery in Chronic Rhinosinusitis and Nasal Polyposis: A Comparative Study

Nasal polyposis are common presentations in patients of chronic rhinosinusitis and are considered to be associated with more severe forms of disease with poor treatment outcome. The presentation and treatment outcome after endoscopic sinus surgery in patients of chronic rhinosinusitis and nasal polyposis have been analysed in this study. A prospective analysis of 90 patients of chronic rhinosinusitis who were classified into two groups depending on presence and absence of nasal polyps was performed in the study. The two groups were evaluated using subjective (patient complaints) and objective (computed tomography scan and endoscopy scores) criteria. Preoperative data were compared with data obtained 12 months post endoscopic sinus surgery. The study included 38 patients of chronic rhinosinusitis and 52 patients of nasal polyps. The patients of nasal polyp group presented with increased severity of symptoms of nasal blockage, nasal discharge and reduced sense of smell as compared to the chronic rhinosinusitis group who had significantly higher presentation of headache and facial pain. The preoperative CT scan revealed significantly higher bilateral disease with increased involvement of multiple sinuses in nasal polyp group. Post endoscopic sinus surgery both the groups showed significant improvement in their symptoms with the nasal polyp group demonstrating reduction in improvement on 1 year follow up. In our study we have found the patients with chronic rhinosinusitis and nasal polyp have varied severity of symptoms with the nasal polyp group having higher nasal symptoms and increased severity as compared to chronic rhinosinusitis group. Though the universal rationale of management by adequate drainage and ventilation of sinus is similar in both groups, there is a reduction in both objective and subjective scores during 1 year follow up in the nasal polyp group.     

Impact of Anatomical and Radiological Findings for Consideration of Functional Endoscopic Sinus Surgery

Endoscopic sinus surgery is being done more accurately and with better diagnosis and planning with the help of high resolution CT scan. It has played an invaluable role in the delineation of the sinonasal pathology and anatomic variations preoperatively. To correlate the CT scan findings with endoscopic findings with respect to anatomical variants and pathology and evaluation of its impact on surgical planning. A prospective study conducted on 300 patients who presented to the ENT out patient department with sinonasal diseases and underwent Functional endoscopic sinus surgery. There is a need to evaluate and correlate the findings to deduce the extent of relations CT findings have to that of findings observed during endoscopy as they really affect the surgical planning and outcomes.     

鼻腔和鼻窦内翻性乳头状瘤74例分析

１９８０～１９９１年收治鼻腔、鼻窦内翻性乳头状瘤（下称ＩＰ）７４例，全部为单侧发病，平均年龄４５．９岁。采用鼻内或鼻内＋Ｃａｌｄｗｅｌｌ－Ｌｕｃ手术或鼻侧切开术＋液氮冷冻治疗，总复发率３５．２％，其中恶变率为２１．６％（１６／７４），作者认为本病术前应作详细的影像学检查，尔后选择治疗。如病变局限，应在鼻内窥镜下作鼻内保守性手术，病变广泛或复发的病历应作鼻侧切开，内侧上颌骨摘除，术中采用液氮冷冻治疗，术后密切随访。     

内镜辅助下经鼻蝶入路手术治疗垂体瘤的临床效果分析

目的探讨垂体瘤患者采用内镜辅助下经鼻蝶入路手术治疗的临床疗效。方法选取90例垂体瘤患者,按照随机数字表法分为对照组(经鼻前庭-鼻中隔-蝶窦垂体瘤切除术)与观察组(内镜辅助下经鼻蝶入路手术),各45例。比较两组患者术中出血量、肿瘤残留、肿瘤体积缩小程度及内分泌激素下降比例。结果观察组术中出血量和肿瘤体积缩小程度及内分泌激素下降比例分别为(83.9±11.7)ml、(90.3±12.2)%、(85.9±12.1)%,与对照组[(351.2±42.8)ml、(53.7±7.4)%、(41.9±8.6)%]比较,差异具有统计学意义,P<0.05;观察组肿瘤残留率(4.4%)明显低于对照组(31.1%),差异具有统计学意义,P<0.05。观察组治疗优良率明显高于对照组,而术后并发症明显少于对照组,差异具有统计学意义,P<0.05。结论应用内镜辅助下经鼻蝶入路手术治疗垂体瘤疗效明显优于经鼻前庭-鼻中隔-蝶窦垂体瘤切除术,且具有较高安全性,因此可值得推广应用。     

Malignancies of the nasal cavity and paranasal sinuses: long-term outcome with conventional or three-dimensional conformal radiotherapy

PURPOSE: To evaluate the long-term clinical outcome and toxicity of conventional and three-dimensional conformal radiotherapy for malignancies of the nasal cavity and paranasal sinuses. METHODS AND MATERIALS: Between January 1976 and February 2003, 127 patients with histologically proven cancer of the paranasal sinuses (n = 119) or nasal cavity (n = 8) were treated with preoperative (n = 61), postoperative (n = 51), or primary (n = 15) radiotherapy, using conventional (n = 74) or three-dimensional conformal (n = 53) techniques. No elective neck irradiation of the cervical lymph nodes was performed in N0 patients. RESULTS: Median follow-up was 5.6 years (range, 3-307 months) for all patients, and 7.3 years (range, 47-307 months) for patients still alive at the close-out date. The actuarial 5-year local control, overall survival, and disease-free survival rates were 53%, 54%, and 37%, respectively. Only 6 (5%) of all 127 patients and 4 (3%) of 122 originally N0 patients developed a regional failure in the neck. Distant metastasis occurred in 20% of patients. Both primary tumor extent and lymph node involvement were the most important prognostic factors, together with squamous cell carcinoma histology. CONCLUSION: Local failure remains the dominant cause of poor outcome for patients with sinonasal cancer, despite aggressive local treatment with combined surgery and radiotherapy in operable patients. Distant metastasis and certainly regional relapse were much less common sites of failure. Overall survival remains poor, suggesting the need for more efficacious local and possibly systemic therapy.     

Iatrogenic Injury to Medial Rectus After Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is the mainstay of the treatment in sinus disorders, to re-establish the drainage of the affected sinus. The close proximity of the orbital structures to paranasal sinuses makes them vulnerable to inadvertent injury during the sinus surgery. Medial rectus (MR) muscle is the most commonly injured extraocular muscle during ESS due to its anatomic proximity to the thin medial wall of the orbit. This is a non-comparative, retrospective, interventional case series of six patients presenting with MR injury after ESS. We discuss the management, outcome and review the published literature. A total of six patients met the inclusion criteria. The presenting complaints were diplopia, squinting and limitation of ocular movements. Two patients underwent surgical exploration of the MR muscle and reattachment of the muscle along with injection botulinum to the antagonist lateral rectus muscle. Two patients who had small angle strabismus and who were able to fuse were advised orthoptic exercises and prisms as management. Remaining two patients were advised surgical intervention to correct strabismus but they declined further surgical intervention. Management of MR injury following ESS is complex, often resulting in suboptimal outcomes. Since early intervention is associated with better outcomes, early referral by otolaryngologists to ophthalmologists would result in better outcome.     

Changes in Acoustic Parameters of Voice After Endoscopic Sinus Surgery in Patients with Nasal Polyposis

Our aim was to evaluate acoustic voice analysis of patients diagnosed with nasal polyps before and after endoscopic sinus surgery. Forty-three patients diagnosed with nasal polyposis who had undergone endoscopic sinus surgery were included in this prospective study. Patients were divided into three groups according to the stage of nasal obstruction before the surgery. Acoustic voice analyses were performed on each patient before the endoscopic sinus surgery and six weeks following the surgery with the multi-dimensional voice program. Jitter, shimmer, F₀ frequency, and noise to harmonic ratio (NHR) parameters were obtained for acoustic analysis. Our investigation showed that Jitter, shimmer and NHR values decreased, and F₀ value increased in the postoperative period in patients that had a partial nasal obstruction before the surgery. Non-significant increases were also observed in these four parameters after the surgery in cases with total or near-total nasal obstruction. We also found that the postoperative changes in shimmer values between the Stage III patients and the patients in other stages were statistically significant (P = 0.027). Voice changes that became more marked with increasing stages of the nasal polyposis. According to our results, patients should be informed of the possible alterations in speech following major surgical interventions on the paranasal sinuses.     

Sinonasal Anatomical Variations: Their Relationship with Chronic Rhinosinusitis and Effect on the Severity of Disease—A Computerized Tomography Assisted Anatomical and Clinical Study

Abstract

The anatomy of the sinonasal area has a very wide rage of anatomical variations. The significance of these anatomical variations in pathogenesis of rhinosinusitis, which is the commonest disease in the region, is still unclear. The aims of the study were to compare the rate of sinonasal anatomical variations with development and severity of chronic rhinosinusitis patients. CT scan of paranasal sinuses images of 99 individuals were retrospectively reviewed. 65 cases of chronic rhinosinusitis (study group) who had undergone endoscopic sinus surgery were compared with 34 cases without chronic rhinosinusitis (control group). Also in study group Lund-Mackay score of the sinus disease were calculated and compared to the rate of related anatomical variations. There were 74 (74.7 %) males and 25 (25.2 %) females with ages ranging from 13 to 70 years (mean 32.2 years). The anatomical variations recorded were: Septal deviation 47 (72.3) in study and 25 (73.5 %) in control group, concha bullosa 27 (41.5 %) in study and 18 (52.9 %) in control group, overpneumatized ethmoid bulla 17 (26.1 %) in study and 14 (41.1 %) in control group, pneumatized uncinate 3 (4.6 %) in study and 3 (8.8 %) in control group, agger nasi 42 (64.6 %) in study and 19 (55.8 %) in control group, paradoxical middle turbinates 9 (13.8 %) in study and 4 (11.7 %) in control group, Onodi cell 6 (9.2 %) in study and 2 (5.8 %) in control group, Haller’s cells (infraorbital ethmoid cell) 9 (13.8 %) in study and 7 (20.5 %) in control group. None of these results were statistically significant between study and control group (p > 0.05). Lund-Mackay score (which was assumed to show the severity of the disease) of the maxillary, ethmoid and frontal sinus were calculated and compared to rate of septal deviation, concha bullosa, agger nasi cells. No significant correlation was conducted (p > 0.05). The results of study showed no statistically significant correlation between sinonasal anatomical variations and pathologies of the paranasal sinus. Also these anatomical variations did not increase the severity of pre-existing sinusitis significantly.

Level of Evidence

This is a retrospective cohort study (2b).