鼻咽癌放疗后腭咽功能障碍的诊治

目的〓〖HTK〗探讨鼻咽癌放疗后腭咽功能障碍的可能原因及诊治措施。〖HTW〗方法〓〖HTK〗对16例鼻咽癌放疗后出现腭咽功能障碍患者（14例软腭功能障碍,2例软腭功能障碍合并硬腭穿孔）的临床诊断与处理资料行回顾性分析。〖HTW〗结果〓〖HTK〗本组病例放疗量为68～75Gy,平均放疗量70Gy,疗程2个月;腭咽功能障碍均在放疗5年后出现症状,平均发病为放疗后8.3年,2例合并硬腭穿孔者的发病都在放疗10年后出现。开放性鼻音、进食经鼻反流是腭咽功能障碍的主要症状,经体位压力进食法、带腭护板及经常性的鼻腔清洗治疗,症状可得到缓解。〖HTW〗结论〓〖HTK〗鼻咽癌放疗后腭咽功能障碍的发展缓慢,在常规放疗根治量范围内,放疗量并非主要的原因,个体的差异可能更重要;硬腭穿孔是慢性缺血性骨坏死的结果。根据患者的情况采取适当的治疗措施可以缓解症状,提高生活质量。     

鼻咽癌残留或复发外科挽救治疗的术式选择

目的 :探讨提高鼻咽癌放疗后残留或复发外科挽救治疗效果的手术方式。方法 :对经手术治疗鼻咽低分化鳞癌放疗后鼻咽部残留或复发患者 ,采取颈颌腭下颌骨翻转或上颌骨翻开及经口硬腭等手术入路切除复发病变 ;采用帽状腱膜瓣及胸大肌皮瓣进行术腔的修复和保护。结果 :手术并发症发生率为 16 % ,主要为局部感染或修复组织瓣坏死 ,术后后遗症较轻 ,腭鼻漏 4例 ,除 1例出现咬合错位外 ,其他病例功能及外观均得到满意的恢复。随诊达 3年以上 18例中死亡 8例 ,2例失访。结论 :根据复发肿瘤累及的部位及范围 ,选择最好的手术进路 ,争取相对彻底、安全地清除病变 ;同时采用方便可靠的修复办法 ,保护咽旁颅底重要结构 ,可以进一步提高手术治疗效果     

鼻咽癌放射治疗失败后的手术治疗

目的 为探索鼻咽癌放射治疗失败后的挽求治疗，回顾分析了我科手术治疗的鼻咽癌放射治疗未控或放射治疗后复发者１２１例（鼻咽病变４１例，颈部病变８０例）。术前接受放射治疗量为６０－１４５Ｇｙ，方法 手术方案：（１）鼻咽原发灶手术根据病变部位及侵及范围不同而选择不术式，包括经硬腭入路病灶切除、鼻侧切开病灶切除、颈侧入路下颌骨升支切除＋翼板切除病灶切除、经口腔入路下颌骨部分切除＋病灶切除＋胸大肌肌皮瓣修复。     

鼻咽癌复发的补救手术

选择鼻咽癌原发部位复发患者进行手术治疗,男１９例,女５例,年龄３２～６７岁（平均４８岁）。补救性手术前曾接受１～３疗程鼻咽放射治疗,剂量６０～１９０Ｇｙ。３／４的患者在２年内复发,其余６年以后复发。患者取仰卧位,全麻下施术。可采取三种进路切除肿瘤：①经腭进路：于硬腭做Ｍ形切口,分离粘骨膜瓣,视情况切除硬腭后部骨质,分离双侧腭大神经血管束。切除全部肿瘤及粘骨膜,必要时切除咽鼓管一部分,电凝止血,用带Ｔｏｌｅｙ导管的气囊、可吸收性明胶海绵和纤维素填塞鼻咽部,缝合粘膜切口,用假牙托１周。②经上颌骨进路…     

鼻及鼻窦炎性肌纤维母细胞瘤（续上期）

患者行鼻侧切开左鼻腔鼻窦肿瘤切除术,术中见肿瘤蒂位于翼腭窝附近,去除部分眶下壁、部分硬腭骨质,将肿瘤切除。术后鼻腔填塞物撤出后,于术后3周行根治性放射治疗,剂量60Gy,放疗后门诊复查,局部又有复发,主要位于左侧翼腭窝及软腭处。     

腭咽成形术中保留悬雍垂的意义

目的　改进经典悬雍垂腭咽成形术 (uvulopalatopharyngoplasty ,UPPP)手术方法 ,探讨术中保留悬雍垂的意义 ,提高UPPP手术疗效、减少术后并发症。方法　治疗睡眠呼吸暂停综合征患者 30例。①在主观症状改善的基础上 ,应用多导睡眠图分析及咽腔解剖参数测量等项指标 ,术后随访 6个月以上 ,对术前术后所获资料进行统计学分析。②手术改进特点 :力求维持咽腔正常生理解剖形态 ,完整保留悬雍垂 ,解剖切除腭帆间隙脂肪组织 ,扩大软腭成形范围 ,平均软腭切除最高点在悬雍垂根部两侧上 1 9cm。结果　主观症状明显改善者占 87 0 % ,以AHI下降 >5 0 %为判定标准 ,有效率为5 3 3 % ,对轻、中度患者 (AHI<5 0 )有效率达 73 3 % ,无 1例出现腭咽关闭不全、咽腔瘢痕狭窄、误咽等并发症。术后咽腔解剖测量 :完整保留的悬雍垂术后 2周左右开始回缩 ,3～ 6个月接近并达到正常水平。结论　此术式可有效扩大咽腔 ,避免腭咽关闭不全等并发症 ,提高UPPP手术疗效 ;完整保留的悬雍垂依靠术后悬雍垂肌、腭帆提肌、腭帆张肌的运动及两侧软腭愈合引起的向上向外的牵拉作用 ,可以逐步回缩至正常生理水平     

鼻咽癌放射治疗失败后的手术治疗

目的为探索鼻咽癌放射治疗失败后的挽救治疗，回顾分析了我科手术治疗的鼻咽癌放射治疗未控或放射治疗后复发者１２１例（鼻咽病变４１例，颈部病变８０例）。术前接受放射治疗量为６０～１４５Ｇｙ。方法手术方案：①鼻咽原发灶手术，根据病变部位及侵及范围不同而选择不同术式，包括经硬腭入路病灶切除、鼻侧切开病灶切除、颈侧入路下颌骨升支切除＋翼板切除＋病灶切除、经口腔入路下颌骨部分切除＋病灶切除＋胸大肌肌皮瓣修复。②颈部手术，单个淋巴结转移行局部淋巴结切除术；多个淋巴结转移行颈淋巴结根治性切除术。术后放射治疗２０～８０Ｇｙ不等。结果手术并发症发生率为１０％（１２例）。随诊死亡６２例中，远处转移３０例（占４８％）。术后３年、５年生存率分别为４９％、３８％。结论①鼻咽癌首选放射治疗，首次放射治疗失败实施手术解救，术后是否再需放射治疗，视具体情况决定。②足量放射治疗对伤口愈合有影响，但只要充分作好术前准备，术中注意消灭死腔，术后加强护理，及合理应用抗生素，可以减少并发症发生。③该组死亡病例中远处转移率较高，故在今后治疗中应考虑术后化学治疗或免疫治疗以期控制远处转移。     

内镜经口入路行鼻咽癌放疗后肿瘤残留切除或咽旁隙转移及复发淋巴结清扫术

 目的探讨内镜经口入路行鼻咽癌放疗后咽旁隙残留或复发淋巴结清扫术的有效性及可行性。方法回顾性分析2015年3月～2017年10月南方医科大学珠江医院耳鼻咽喉科收治的12例鼻咽癌放疗后咽旁隙淋巴结残留或复发患者的临床资料,所有患者术前均行影像学检查诊断,其中5例单纯行内镜下经口入路咽旁隙淋巴结清扫术,7例因有鼻咽癌原发灶残留或者复发同时行鼻咽-颅底肿瘤切除术。结果12例（共13侧）患者手术顺利,术后均未出现声嘶、进食呛咳及颈内动脉损伤等并发症,1例患者出现口内切口感染,1例患者切口部分缝线松脱,均经对症处理后痊愈。术后随访至2018年4月,中位随访23个月（6～36个月）,所有患者术后均未出现咽旁隙内再发转移灶。结论内镜下经口入路行鼻咽癌放疗后咽旁隙淋巴结清扫术可有效地切除转移灶,且手术创伤小,并发症少,术后恢复快,具有临床应用价值。     

后颅凹撑开器在经腭径路直切暴露鼻咽部病变中的作用

腭径路行鼻咽肿瘤手术,具有面部无瘢痕、创伤小、操作简单的优点,是鼻咽部手术的经典。由于鼻咽位置深在、腭黏膜瓣的阻挡,术者仍觉视野不够满意。我们运用神经外科后颅凹撑开器,采用腭正中直切口,从腭中线撑开,可以有效地暴露鼻咽部病变。1临床资料1.1一般资料鼻咽肿瘤手术患者15例,男14例,女1例;年龄15~50岁。经相关检查诊断为脊索瘤2例,鼻咽鼻腔型鼻咽纤维血管瘤5例,鼻咽癌放疗后残留或复发8例。1.2方法气管切开,插管麻醉,仰卧垫肩,头后垂固定于头架上,Davis开口器张开口腔,暴露整个腭咽区,腭正中直切口,从硬腭前缘黏膜切开直至软腭、悬…     

鼻咽纤维血管瘤手术经验

鼻咽纤维血管瘤的治疗包括:手术切除、电凝固术、放疗、冷冻、内分泌疗法等。目前唯只手术和放疗有效。随着手术方法的改进和为减少术中失血的术前措施的应用,多数学者对于颅外鼻咽纤维血管瘤仍以手术切除作为主要治疗手段,而对未能切除的侵入颅内的肿瘤部分,术后采取放射治疗。作者报告18例鼻咽纤维血管瘤,平均年龄16岁。17例经腭进路切除肿瘤。1例肿瘤扩展到翼腭窝、颞下窝、上     

Role of computed tomography imaging in predicting response of nasopharyngeal carcinoma to definitive radiation therapy

PURPOSE: The purpose of this study was to investigate the role of posttreatment computed tomography (CT) scans in assessing response of nasopharyngeal carcinoma (NPC) to definitive radiotherapy. MATERIAL AND METHODS: Between March 1999 and October 2003, a total of 132 consecutive patients with newly diagnosed NPC were studied. Sixty-one patients with AJCC stage I or II NPC were treated with radiation only; 71 patients with stage III or IV disease but no evidence of distant metastasis were treated with concurrent chemoradiotherapy. All patients received CT scans of the head and neck, nasopharyngoscopy, and biopsies of primary sites at 4 to 6 months after completion of radiotherapy. Clinical response of the primary tumor as determined by comparison of pre- and posttreatment CT scans was correlated to pathology results. RESULTS: The median follow-up time for all patients was 25 months (range, 9-40 months). Radiologic progression was seen in five patients, stable disease in 18 patients, and radiographic partial (rPR) and complete responses (rCR) were seen in 67 and 42 patients, respectively, at 4 to 6 months of follow up. Biopsies of the nasopharynx were positive in six patients. For patients with rCR, two patients (4.8%) had positive biopsies. Four patients with residual disease (rPR, stable, or progressive disease) after treatment had positive biopsies. The positive and negative predictive values, sensitivity, and specificity of CT scans in evaluating the NPC response to radiotherapy were 0.04, 0.95, 0.67, and 0.32, respectively. CONCLUSIONS: Pathologic CR for nasopharyngeal carcinoma is usually evident at 4 to 6 months after definitive radiotherapy; however, there is no correlation between pathologic and radiographic response. Although longer follow up is required to define the relationship between radiographic and pathologic responses with respect to disease control, we find CT scan at 4 to 6 months after radiotherapy to be neither sensitive nor specific in predicting the response of primary NPC to radiotherapy.     

鼻咽癌放疗前后鼻窦炎发生机制及其防治措施

目的:分析鼻咽癌(NPC)患者放疗前后鼻窦炎发生的影响因素,并探讨防治放疗后继发鼻窦炎的措施和手段。方法:回顾性统计分析231例NPC患者放疗前后发生鼻窦炎的影响因素及部分患者的治疗效果。结果:231例NPC患者中,放疗前98例患有鼻窦炎,放疗后165例发生鼻窦炎,其中T分期较高、鼻腔有解剖变异的患者放疗后鼻窦炎发生率较高,有鼻咽局部治疗的患者鼻窦炎发生率较低,放疗前就有鼻窦炎的患者,绝大部分患者放疗后不仅没有得到改善反而有所加重。结论:放疗前鼻窦炎的发病率随临床分期的加重而递增,窦口鼻道复合体的解剖变异、鼻腔解剖变异仍然是其发生的重要因素。对于放射治疗的NPC患者,T分期较高、解剖变异、鼻咽局部治疗以及放疗状况与放疗后鼻窦炎的发生有关,加强放疗前鼻窦炎的治疗以及放疗中、后期鼻咽局部治疗可减少放疗后鼻窦炎的发生。     

鼻咽癌局部扩散与远处转移的相关性

目的:探讨鼻咽癌局部和区域扩散与远处转移的相关性。方法:分析204例鼻咽癌初治患者的临床资料(其中放疗后无瘤生存≥5年者101例,为无瘤组;放疗后远处转移者103例,为转移组),重新阅读其治疗前CT片,确定局部扩散范围和方式,并进行单因素和Cox模型分析。结果:单因素分析表明,鼻窦侵犯,颅底破坏,脑神经损害,咽旁间隙侵犯程度,颈淋巴结转移侧数、个数、大小及活动度,临床分期,T分期与N分期均具有统计学意义(均P<0.05);多因素分析只显示鼻窦侵犯,脑神经损害,颈淋巴结转移侧数、个数和大小,临床分期具有统计学意义;对局部扩散各种因素与区域扩散相关性分析显示,无论是局限性病变,还是颅底、咽旁间隙等扩散,转移组并区域淋巴结转移及其转移程度(N2,3)均明显高于无瘤组(P<0.05或P<0.01)。结论:区域淋巴结转移及其程度是鼻咽癌放疗后远处转移最主要、最恒定的因素,原发灶局部扩散主要是通过区域淋巴结转移来影响远处转移。     

Electrophysiological change in the tensor veli palatini muscle after radiotherapy

Conclusion: Electromyography of the tensor veli palatine (TVP) was abnormal and showed mainly myogenic impairment in patients with nasopharyngeal carcinoma (NPC) with secretory otitis media (SOM) after radiotherapy. The diseased ears showed impairment in opening functions of the eustachian tubes (ETs). Objectives: To characterize electrophysiology of the TVP muscle using electromyography (EMG) in patients with SOM after radiotherapy of NPC. Methods: Twenty healthy volunteers and 20 patients with NPC and SOM after radiotherapy were chosen for assessment of EMG of the TVP during swallowing. Results: The measurements of average duration and amplitude of action potential, swallowing contraction duration, and peak voltage in NPC patients with both SOM (n = 25) and healthy ears (n = 6) were significantly lower than those of ears (n = 38) in healthy controls (p < 0.01). In patients with NPC, the average action potential duration and swallowing contraction duration in ears with SOM were lower than those of subjects with healthy ears (p < 0.05), whereas no significant difference was found in average amplitude of action potential and peak voltage between them.     

A prospective study of p53 expression and its correlation with clinical response of radiotherapy in nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS: Nasopharyngeal carcinoma (NPC) is a common malignant neoplasm of the head and neck that occurs in people in the southeastern Asian area, including Taiwan. The significant association of p53 expression in NPC suggested that p53 overexpression seemed to occur at an early stage in the development of NPC. Alterations of p53 status were probably the most commonly encountered in head and neck carcinomas, and there was extensive evidence that p53 status might determine tumor response to therapy. Ionizing radiation was studied extensively for the relationship between its damaging effect and p53 status in human cancer cells. STUDY DESIGN: This study was carried out to investigate whether there was any correlation between overexpression of p53 protein and locoregional tumor response in patients with NPC treated with 7000 cGy of radiotherapy. METHODS: Sixty-eight patients (50 males, 18 females) with NPC who were diagnosed and treated with radiotherapy were studied prospectively. Before they had received a radiation dose of 7000 cGy in 35 fractions, five fractions a week, p53 status from a nasopharyngeal biopsy was studied using immunohistochemical staining (IHC). RESULTS: The locoregional response rate of primary tumor was analyzed statistically. Forty-seven patients (69.1%) showed positive p53 staining in their tumors. There were 5 positive stains in 6 squamous cell carcinomas (SCC; 83.3%), 34 positive in 53 non-keratinizing carcinomas (NKC; 64.2%), and 8 positive in 9 undifferentiated carcinomas (UC; 88.9%). The mean ages for patients with three different histopathologies were 48.5, 46.1, and 61.1 years. There were 8 patients (7 positive stains, 1 negative stain) with residual tumor after radiotherapy and all were NKC (6 males, 2 females). Therefore, the clinical response rate of primary tumor was 85.1% in positive p53 immunostaining (40 of 47 cases), 95.2% in those with no immunostaining (20 of 21 cases); the former was poorer in locoregional tumor response than the latter, but there was no significant difference (P > .05, chi2 test). CONCLUSIONS: We conclude that there is no statistically significant correlation in locoregional response of primary tumor between p53 overexpression and radiotherapy in patients with NPC (P > .05, Fisher exact test).     

鼻咽癌放疗后第二原发舌癌的临床分析

目的探讨鼻咽癌放疗后第二原发舌癌的临床特点及治疗效果，探索影响其预后的因素。方法1975年1月1日-2000年12月31日在中山大学肿瘤防治中心头颈科接受首治的舌癌患者共1263例，从中筛选此前有鼻咽癌放疗史者共53例，采用Kaplan—Meier法计算累积生存率，Cox回归方法进行多因素分析。结果53例中40例患者死亡，接受治疗的51例患者总的5年和10年生存率分别为41．64％、35．69％；舌癌发生在舌尖、侧缘、舌腹和舌背分别为0例、26例（49．06％）、8例（15．09％）和19例（35．85％）；舌癌临床检查颈淋巴转移6例（11．32％）后经病理证实为3例（5．66％）；第二原发舌癌治疗后18例复发（33．96％）。单因素分析提示原发灶大小（P=0．0005）、临床TNM分期（P=0．0017）影响预后；多因素分析显示临床与病理综合分期（P=0．000）、两癌发生的时间间隔（P=0．003）是影响预后的独立因素。结论鼻咽癌放疗后第二原发舌癌发生在舌背的比例较高，其淋巴转移率较低；临床和病理综合分期以及两癌发生的时间间隔是影响预后的独立因素；对鼻咽癌放疗后第二原发舌癌进行早期诊断，行手术或包含手术的综合治疗，可能会获得更好的疗效。     

Investigation for cervical lymph node metastasis in unknown primary sites

In patients with cervical adenopathy, especially, those of cervical lymph node metastasis with no detectable primary tumor, diagnosis and treatment planning can become confused. We evaluated 36 patients with cervical lymph node metastasis of unknown origin between 1985 and 2002. Primary sites were detected in 20 before treatment. The other 36 patients clearly had no primary lesions when treatment started. Primary sites were 5 cases of oropharynx, 2 of the parotid gland, and 1 each of larynx, nasopharynx, hypopharynx, and malignant lymphoma detected in 11 after treatment for cervical lymph nodes. No primary lesion was found in 28 patients. The neck LN stage was N1 in 11 patients, N2 in 29, N3 in 11, and unknown in 8. To detect the primary site, we conducted "random" biopsy, panendoscopy, and radiographic evaluation including FDG-PET. Biopsy sites were the nasopharynx, palatine and lingual tonsil, and piriform sinus. Some 35 patients (59.3%) underwent random biopsy, and primary sites were found this way in 5 patients (14.3%). The 36 who had no primary lesion were treated for cervical lymph nodes, of whom 24 underwent neck dissection. Chemotherapy and radiotherapy were the treatment of choice in many cases. We analyzed 31 patients for 5 year survival. Overall survival was 63.7%, disease-specific survival 69.2%, and disease-free survival 46.8%. In another analysis a statistically significant difference was seen in survival among patients who had neck surgery or not (85.7% vs. 38.9%, p = 0.029; log rank test). Analysis suggested that primary sites should be studied by CT, MRI, FDG-PET, and panendoscopy, including random biopsy. The primary site cannot be detected, treatment should initially involve cervical adenopathy with combined surgery, chemotherapy, and radiotherapy. After treatment, the patient should be followed up carefully to find the primary lesion.     

鼻咽癌死亡病例临床资料分析

目的 :研究鼻咽癌患者死亡因素。方法 :对 1974～ 1990年收治的 6 77例鼻咽癌死亡患者的临床资料进行系统分析。结果 :本组患者男女之比为 4 .3∶1,4 0～ 6 0岁年龄组最多 ,以低分化鳞癌为主 ,Ⅲ Ⅳ期病例占81.3% ;放疗与化疗联合治疗组存活时间较单纯放疗组长 ,5 4 .9%死于远处转移 ,2 0 .9%死于局部或区域淋巴结未控制。结论 :鼻咽癌主要死因为远处转移、局部或区域淋巴结未控制 ,化疗与放疗联合治疗有可能延长生存时间 ,降低死亡率     

鼻咽癌雌孕激素受体表达与远处转移的相关性

目的：探索雌孕激素受体——雌激素受体（ER）和孕酮受体（PR）表达与鼻咽癌远处转移的相关性,为预后判断提供参考指标。方法：用免疫组织化学SP法检测81例鼻咽癌患者的组织标本。结果：①ER和PR在鼻咽癌组织中的阳性表达率分别为35．8％和53．1％;②PR在T分期中其表达强度有统计学意义（P〈0．01）,PR在Ⅳ。阳性表达率和表达强度均明显高于其他各期（均P〈0．01）;③ER和PR在远处转移患者（包括放疗前和放疗后）中的阳性表达率均明显高于放疗后无瘤生存5年以上患者（P〈0．01和P〈0．05）。结论：鼻咽癌组织中ER和PR阳性表达与远处转移呈正相关,阳性表达尤其强阳性者提示预后不良。内分泌治疗有可能减少或推迟远处转移的发生。     

鼻咽癌放疗后咽鼓管功能障碍的几种类型

目的：了解鼻咽癌放疗后咽鼓管功能障碍的类型及其影响。方法：对32例(50耳)鼻咽癌放疗后有咽鼓管功能障碍的患者进行常规检查、听力计检查、鼓室导抗图法检查、咽鼓管一鼓室气流动态法(TTAG)检查、咽鼓管音响法检查和内镜检查咽鼓管咽口。结果：咽鼓管异常开放2例(4耳)，患者症状较轻。咽鼓管粘连5例(7耳)，咽鼓管完全阻塞17例(27耳)，咽鼓管不全阻塞8例(12耳)，后三者症状相似，主要导致分泌性中耳炎。结论：鼻咽癌放疗后可导致不同类型的咽鼓管功能障碍，对耳功能产生损害，对其了解将有助于针对性治疗方法的确定。