鼻侧切开术对鼻通气功能的影响

目的 :探讨鼻侧切开上颌窦内侧壁切除术对鼻通气功能的影响。方法 :对 16例鼻腔鼻窦良性肿瘤患者行鼻侧切开上颌窦内侧壁切除术 ,随诊观察 6个月～ 2 .5年 ,观察内容包括主观感觉、CT和声反射鼻测压计检查等项目。结果 :患者在术后 3个月内有鼻阻塞等不适 ,3个月后随着鼻腔内干痂消失则无明显鼻阻塞感 ;术后患侧鼻阻力明显下降 ,而总鼻阻力下降则无前者明显 ;鼻粘膜在术后 1年内随时间的延长逐渐增厚 ,以上颌窦内侧壁下缘残壁和下鼻甲残缘等有骨性隆起部位的增生尤为显著 ,之后则无明显变化。结论 :鼻侧切开上颌窦内侧壁切除术对鼻腔通气功能无显著影响 ,是治疗鼻腔鼻窦肿瘤的理想术式之一。     

The management of sinonasal inverted papilloma: our experience

The inverted papilloma of the nose and paranasal sinuses is a controversial disease. It invades surrounded structures, shows a high recurrence rate after surgical excision and may coexist with squamous cell carcinoma. The use of the optimal surgical approach and technique is of the utmost importance, as it is related to the possibility of recurrence. In cases of tumors of limited size a conservative local excision is sufficient, while, in larger tumors filling the nasal cavity and the paranasal sinuses a more aggressive strategy is needed, such as a medial maxillectomy after lateral rhinotomy. In this paper we present our experience from treating 42 sinonasal inverted papillomas, using a surgical technique which is based on the conservation of as much part of the healthy lateral nasal wall as possible. This modified medial maxillectomy allows us to create a limited in size and normally functioning nasal cavity, thus minimizing the disadvantages of the classical medial maxillectomy without jeopardizing the safety of the operation.     

An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function

Objective: The lateral rhinotomy and medial maxillectomy procedure, while known to interrupt nasal valve supports, has not previously been reported to adversely affect nasal airway function. The purpose of this study was to utilize state-of-the-art techniques to objectively analyze the impact of this procedure on nasal airway function. Design: The study design was retrospective and subject controlled. Methods: The study population was derived from an academic, tertiary-referral, otolaryngology—head and neck surgery department with an estimated catchment population of 4 million people. Subjects included 21 consecutive, long-term postoperative patients who had undergone lateral rhinotomy and medial maxillectomy for inverted papilloma. Objective measures included vestibular cephalometric measurements, airflow rhinomanometry, and acoustic rhinometry. Results: Statistically significant results reveal that although lateral rhinotomy and medial maxillectomy are associated with alar collapse, both overall nasal airflow and valve areas are increased. Conclusion: Lateral rhinotomy and medial maxillectomy does not adversely affect nasal airway function. This appears to be the result of concomitant resection of the functionally dominant inferior turbinate. This suggests that lateral rhinotomy performed in conjunction with operations not requiring inferior turbinectomy, such as anterior craniofacial resection, may adversely affect nasal airway function. Key Words: Lateral rhinotomy, medial maxillectomy, nasal airway function, airflow, rhinomanometry, acoustic rhinometry.     

Transnasal endoscopic medial maxillectomy as the initial oncologic approach to sinonasal neoplasms: the anatomic basis

OBJECTIVE: To demonstrate an anatomic basis for endoscopic medial maxillectomy with excision of the lateral nasal wall to the nasal floor, including the inferior turbinate, and nasolacrimal duct. Transnasal endoscopic medial maxillectomy involves complete resection of the lateral nasal wall with boundaries that are inferior to the nasal floor; superior to the cribriform plate and fovea ethmoidalis; anterior to the anterior maxillary wall, including the nasolacrimal duct; and posterior to within 5 mm of the eustachian tube. Transnasal endoscopic medial maxillectomy provides exposure for endoscopic resection of the orbital wall, pterygopalatine fossa, pterygoid plates, nasopharynx, and anterior skull base when indicated. DESIGN: Volumetric analysis of the maxillary sinus was performed on axial and coronal computed tomographic scans of 19 adult patients for a total of 38 maxillary sinuses. SETTING: Tertiary care medical center. PATIENTS: Nineteen adult patients with tumors of the head (but outside the sinonasal region). INTERVENTIONS: Radiographic analysis. MAIN OUTCOME MEASURES: The total volume of the maxillary sinus, volume above and below the superior attachment of the inferior turbinate, and volume anterior to the nasolacrimal duct were measured. RESULTS: The mean (SD) total volume of the maxillary sinus was 20.1 (4.2) cm(3), whereas its volume inferior to the superior attachment of the inferior turbinate was 12.9 (3.7) cm(3) and anterior to the nasolacrimal duct was 1.1 (0.6) cm(3). The mean (SD) volume of the maxillary sinus inferior to the superior attachment of the inferior turbinate was 64% (12%), whereas the nasolacrimal duct obscured the transnasal anterior exposure of the maxillary sinus. CONCLUSION: Without excision of the lateral nasal wall inferiorly to the nasal floor and anteriorly, including the nasolacrimal duct, over half of the maxillary sinus would be inaccessible for procedures directed at neoplasms within the maxillary sinus.     

Angiosarcoma of the nasal cavity.

Angiosarcoma of the nasal cavity is extremely rare. We present a case of angiosarcoma of the nasal cavity in an eight-year-old boy. He was treated with medial maxillectomy via lateral rhinotomy. The histological diagnosis was confirmed by immunohistological stain with Factor VIII-like antigen. Magnetic resonance imaging (MRI) was useful in determining the extent of the tumour.     

Inverting papilloma of the nose: analysis of 48 patients

Forty-eight cases of inverting papilloma of the nose and paranasal sinuses treated by a number of surgeons at the University of Toronto from the years 1976 to 1985 are presented. Age at diagnosis, duration of symptoms, male predominance, associated symptoms and location of tumor were found to be similar to previous studies. A 4% incidence of an associated nasal carcinoma was found while 2% progressed to papillary squamous carcinoma. A minimum five-year follow-up was obtained in 18 cases, demonstrating an overall recurrence rate of 39%. Polypectomy resulted in a 75% recurrence, compared to a 27% recurrence rate following lateral rhinotomy and medial maxillectomy. The average disease-free period was 4.1 years. Lateral rhinotomy and medial maxillectomy is suggested as the minimum procedure to control inverting papillomas of the lateral nasal wall. Lesions confined to the septum can be best managed by wide local excision. An extended period of follow-up is recommended in all of these patients.     

The clinical behavior of inverting papilloma of the nose and paranasal sinuses: report of 112 cases and review of the literature

Between 1944 and 1987, 112 patients with inverting papilloma of the nasal cavity were treated. The average duration of follow-up for this population was 6.2 years. The most common symptoms were nasal obstruction and history of previous surgery for nasal "polyps". Recurrence rates were lower when treatment consisted of lateral rhinotomy with medial maxillectomy (14%) vs. transnasal operation with a sinus procedure (35%) or transnasal operation alone (58%). Recurrence rates between men and women were not significantly different when treatment methods were analyzed; however, a higher-than-expected association with tobacco usage was noted. Eight (7%) of the 112 patients had associated nasal carcinoma. Current treatment is lateral rhinotomy with medial maxillectomy to prevent troublesome and potentially malignant recurrent disease.     

'Medial maxillectomy' for lateral nasal wall neoplasms

Lateral rhinotomy and "medial maxillectomy," an en bloc resection of the medial maxillary sinus, ethmoid sinus with the lamina papyracea, medial orbital floor, and lacrimal fossa-duct, have been advocated for lateral nasal wall neoplasma. Experience with 35 (of 41) patients followed up at least 30 months (median, 57 months) postoperatively is reported. There was a 9% recurrence for benign tumors and 15% for malignant neoplasms, the latter only in the patients with nonmelanoma malignant neoplasms not receiving postoperative radiotherapy. The most frequent complications were cavity crusting, epicanthal scarring, and epiphora.     

Modified transnasal endoscopic medial maxillectomy with medial shift of preserved inferior turbinate and nasolacrimal duct

Although transnasal endoscopic medial maxillectomy (TEMM) is effective for the treatment of inverted papilloma (IP) in maxillary sinus (MS), it involves resection of the inferior turbinate (IT). TEMM also involves resection of the nasolacrimal duct (ND) in many cases to gain better access. Therefore, we developed a novel procedure in which the preserved IT and ND are shifted medially for a complete resection of IP in the MS. Incision was made in the mucosa of the lateral wall along the anterior margin of the IT. After removal of the medial maxillary wall except the ND and the lateral nasal mucosa, the anterior lateral mucosa of the nose, including the IT and the ND, was shifted in the medial direction to allow wider access to the MS. The tumor was removed together with the attachment through the anterior side of the ND. This modified TEMM was performed in 10 patients with IP. The IT and ND were preserved in all patients. We have not observed epiphora after this surgery. The advantages of the novel approach presented herein include: 1) preservation of the IT, ND, and lateral nasal mucosa; 2) wide access to the MS by shifting the IT, ND, and lateral nasal mucosa in the medial direction; and 3) direct access to the MS through anterior space of the ND, resulting in easier operation with a straight endoscope and instruments. This approach is a safe and effective method to obtain wide and straight access to the MS and to resect IP in the MS.     

Complications following rhinotomy. Review of 148 patients

For the period 1974 to 1988, 148 patients undergoing 162 rhinotomies at The Mount Sinai Medical Center, New York, for a variety of benign and malignant neoplasms were reviewed with particular attention to postoperative complications. The effects of certain predisposing factors such as prior rhinotomy, lateral versus total rhinotomy, additional medial maxillectomy or craniofacial resection, and preoperative irradiation or nasal bone erosion are discussed. In addition, a surgical technique of rhinotomy with medial maxillectomy is presented that includes maneuvers designed to prevent these complications.     

Basaloid Squamous Cell Carcinoma in Nasal Cavity

Basaloid squamous cell carcinoma (BSCC) is often founded in the head and neck region. However, BSCC in the sinonasal tract is rare. We report here on the case of a 58-yr-old woman who presented with nasal obstruction and epistaxis. Computed tomography and examination of the nasal cavity revealed a tumor mass that originated from the right inferior turbinate with erosion of the nasal floor. The tumor that was attached to the inferior turbinate, the lateral nasal wall and the eroded right side hard palate, and so all this was resected. Histopathologic examination of the excised tumor confirmed BSCC in the nasal cavity. We report here on a nasal cavity BSCC that was treated with partial maxillectomy only.     

Nasomaxillary frame translocation in medial maxillectomy

Medial maxillectomy is the standard operation for en bloc resection of the lateral nasal wall with portions of the maxillary and ethmoid sinuses. Although most reports comment on good to excellent cosmetic results, nasal collapse is a possible complication of the procedure and is best explained by the loss of lateral nasal wall support. To overcome this problem, we describe a technique with temporary mobilization of a bone frame around the ipsilateral pyriform aperture, including one nasal bone, and fixing it to its original position at the end of the operation.     

Sinonasal neuroendocrine carcinoma: a case report

Neuroendocrine carcinoma (NEC) is rare. We report a case of probable sinonasal NEC in a 73-year-old man who had presented with a history of right nasal obstruction, nasal discharge, and recurrent epistaxis. On examination, a red, friable, gelatinous, polypoid mass with a tendency to bleed was seen in the right nasal cavity. Computed tomography revealed that the lesion was confined to the right nasal cavity; coincidental or reactive opacification was seen in the adjacent sinuses. The final histologic evaluation of the excised biopsy specimens yielded a diagnosis of an invasive, poorly differentiated NEC, probably a large-cell variant, with the differential diagnosis lying at a point somewhere between poorly differentiated large-cell NEC and high-grade olfactory neuroblastoma. The patient underwent a right lateral rhinotomy and medial maxillectomy followed by adjuvant radiotherapy. At 20 months of follow-up, he exhibited no sign of recurrence.     

Inverted papilloma: new classification and guidelines for endoscopic surgery

BACKGROUND: Surgery is the gold standard in the management of inverted papilloma (IP); however, the approach and extent of the surgical procedure are still controversial. Moreover, there is still no universal staging system of IP to plan surgery and/or evaluate results. We performed a retrospective study. METHODS: A new classification depending on the origin of the lesion was used to plan surgery in 70 cases of IP. Conservative transnasal endoscopic excision was performed in lesions arising from the nasal septum and lateral nasal wall (type I IP, 42 cases) and radical transnasal endoscopic medial maxillectomy was performed in lesions arising from the maxillary sinus (type 1 IF, 28 cases). RESULTS: Excluding cases with a follow-up of <2 years, follow-up for periods ranging between 2 and 13.3 years with a median of 78 months showed recurrence in a single case of type I (3.2%) and 2 cases of type II (9.5%). CONCLUSION: The new classification system, based on the origin of IP, is a simple tool for grading IP. It can be used to define cases suitable for conservative excision or radical medial maxillectomy. Both could be performed transnasally and endoscopically.     

Bilateral Lateral Rhinotomy Incisions for Medial Maxillectomies in the Management of Pediatric Invasive Fungal Sinusitis

Objective To determine if simultaneous, bilateral lateral rhinotomies for medial maxillectomies would result in central skin or bone loss in pediatric patients with invasive fungal disease. Study Design Retrospective chart review. Setting Tertiary care children's hospital. Patients Three children underwent surgery between April 1996 and June 1998. Ages at treatment ranged from 11 to 14 years. All had bilateral, biopsy‐proven invasive fungal disease of the lateral walls of the nose. All were undergoing chemotherapy for acute lymphocytic leukemia (ALL) or acute myelocytic leukemia (AML). Intervention Bilateral lateral rhinotomies for medial maxillectomy. Two of 3 also had simultaneous total septectomy. Main Outcome Measure Skin survival and patient survival. Results All three patients had bilateral simultaneous medial maxillectomy for invasive fungal disease in the presence of profound pancytopenia secondary to treatment of leukemia. One patient had minor nasal edema postoperatively, but none showed any loss of the central nasal skin or facial skeleton. All patients survived the invasive fungal disease with follow‐up of at least 24 months. All patients underwent multiple debridements after the original surgery, and 3 of 6 eyes had permanent epiphora requiring dacryocystorhinostomies. Conclusions Bilateral simultaneous lateral rhinotomies are safe in children and did not result in any central skin loss. Aggressive bilateral surgery for invasive fungal disease is compatible with a good esthetic outcome and long‐term survival.     

鼻内翻性乳头状瘤kamel分期对术式选择的意义

目的 研究以鼻内翻性乳头状瘤(NIP)起源为主要依据的临床分期,用以指导手术和评价术后疗效。方法 回顾性分析55例NIP手术病例。男37例,女18例,男女比例为2∶1,27~78岁。右侧23例,左侧32例,未发现双侧发病者。11例有NIP手术史。25例术前病理检查证实为NIP,按照kamel分期,其中Ⅰ型30例、Ⅱ型25例。 结果 Ⅰ型NIP行鼻内镜下局部切除术(30例),Ⅱ型NIP行鼻内镜下局部切除术(4例)、鼻内镜下上颌窦内侧壁切除术(11例)、鼻内镜下双径路手术(10例)。复发率：Ⅰ型复发率为6.7％(2/30),Ⅱ型复发率为16.0％(4/25),总复发率为10.9％(6/55)。和检索资料相比复发率差异无统计学意义。结论 NIPⅠ型手术采取鼻内窥镜下局部切除术,Ⅱ型采取鼻内镜下上颌窦内壁切除术或经唇龈沟切口上颌窦前壁开窗结合经鼻内镜手术(双径路手术)。术后复发率和报道资料复发率相比没有统计学意义,说明这种基于疾病来源新的Kamel方法临床分型对手术治疗有指导意义,并且经鼻内镜鼻内翻性乳头状瘤切除和传统方法相比有较大优势。     

Endoscopic endonasal sinus surgery for post-operative maxillary cysts

Surgical treatment for postoperative maxillary cysts uses a Caldwell-Luc or endonasal approach. Endoscopic endonasal surgery has become the treatment of choice in postoperative maxillary cyst, and many postoperative maxillary cysts have been classified. Due to the importance of cyst medial wall sites, we classified cysts into 4 types by location. Those whose, medial wall was close to the middle meatus, inferior meatus, or nasal lateral wall, we termed middle meatus, inferior meatus, and nasal lateral wall types. When the lateral cyst was not close to the nasal cavity but to another cyst, we termed the cyst continuous. We opened all nasal cavity cysts as far as possible. For continuous types, we determined location of the lateral cyst 3-dimensionally before surgery. We first opened medial cysts and opened the lateral cyst through the medial cyst. The tube was placed the lateral cyst to the nasal cavity. We opened all 45 cysts in 29 patients to the nasal cavity. As of this writing, no cysts connected to the nasal cavity have recurred.     

Association of verrucous carcinoma and inverted papilloma in the sinonasal tract

It is well known that inverted papilloma (IP) is sometimes associated with malignancies; however, the association of IP with verrucous carcinoma (VC) is extremely rare. We herein report a case of IP in the nasal cavity with VC in the maxillary sinus. A 73-year-old Japanese woman presented with a 3-month history of right-sided nasal obstruction and repetitive epistaxis. A biopsy of the mass was performed and the pathological result proved to be IP. Computed tomography and magnetic resonance imaging revealed a moderately enhanced soft-tissue lesion filling the right nasal cavity and a ring-enhanced expansive lesion in the maxillary sinus. Under a tentative diagnosis of IP of the nasal cavity with maxillary empyema, she underwent right medial maxillectomy via a lateral rhinotomy approach, and a histopathological diagnosis of IP in the nasal cavity with VC in the maxillary sinus was obtained. Her postoperative clinical course was uneventful. She is currently free from symptoms, and there is no evidence of recurrence 5 months after surgery. The pathology, clinical manifestation, and treatment of VC associated with IP are reviewed from literature.     

Does evaluation of tumor volume or/both origination site better guide to optimal surgery for inverted papilloma?

IntroductionSinonasal inverted papilloma is noted for its high rate of recurrence. Staging systems aid to reduce recurrence and avoid excessive surgeries by guiding the selection of the optimal surgical approach.ObjectiveTo evaluate the effectiveness of different endoscopic approaches in inverted papilloma by assessing tumor origin site and tumor volume.MethodsKrouse classification system that is based on tumor volume was used for staging; furthermore, tumor origin sites were grouped as lateral nasal wall, medial wall and other walls of maxillary sinus. The main treatment method for all patients was endoscopic sinus surgery. Endoscopic extended middle meatal antrostomy, endoscopic Caldwell-Luc and endoscopic medial maxillectomy were the additional surgery types performed in different combinations.ResultsFifty-five patients (42 male) with a mean 54.9 ± 14.4 years of age were included. 37 patients were diagnosed with advanced stage inverted papilloma (67.2 %). Recurrence was observed in 12 patients (21.8 %). In early stage lateral nasal wall origination, no recurrence was observed in the simple tumor resection group (0/10). In early stage medial wall origination, no recurrence was observed in the extended middle meatal antrostomy group (0/8). In advanced stage medial wall origination, the recurrence rates of extended middle meatal antrostomy, extended middle meatal antrostomy + endoscopic Caldwell- Luc and endoscopic medial maxillectomy were 100.0 %, 53.8 % and 13.6 %, respectively (p  = 0.002). In advanced stage other walls of maxillary sinus origination, recurrence rates of extended middle meatal antrostomy + endoscopic Caldwell-Luc and endoscopic medial maxillectomy were 20 % and 16.6 %, respectively (p  = 0.887).ConclusionTumor origin site, tumor stage and surgery types show an impact on recurrence. Despite the fact that tumor origin site singly could lead to appropriate selection of the surgery type in most cases, tumor stage carries substantial importance in selection of surgery type for sinonasal-inverted papilloma. An operation plan regarding both tumor volume and tumor origin site may aid surgeons in selecting optimal endoscopic surgical method to avoid recurrence or excessive surgeries.     

Solitary fibrous tumor in the maxillary sinus treated by endoscopic medial maxillectomy

Solitary fibrous tumor (SFT) is an uncommon neoplasm that usually arises from the pleura. Recently, SFTs have been reported in the head and neck area. SFTs of the nasal cavity and paranasal sinuses are extremely rare, with only 24 cases reported in the English literature. We describe an SFT that arose from the left maxillary sinus and extended to the nasal cavity. The tumor was removed by endoscopic medial maxillectomy, which permitted monobloc excision of the lesion. The patient is without the evidence of the disease 12 months after surgery.