内镜手术治疗鼻咽癌放射治疗后颅底软组织坏死的临床研究

目的探讨鼻咽癌放射治疗(放疗)后颅底软组织坏死患者的诊断和治疗。方法回顾性分析中南大学湘雅医院耳鼻咽喉头颈外科2015—2019年收治的7例鼻咽癌放疗后颅底软组织坏死且不合并骨组织坏死患者的临床资料。7例患者中男6例,女1例;年龄45~80岁,中位年龄54岁。分析7例患者的临床表现、诊断、治疗及预后。7例患者的主要临床症状包括:头痛7例;听力下降7例;长期鼻部恶臭5例;反复鼻出血2例。7例患者术前均行颅底高分辨率CT、MR以及磁共振血管造影(MRA)检查。7例患者高分辨率CT检查可见鼻咽部软组织病灶,骨皮质完整,颅底软组织病灶与颅底骨面交界处可见小气泡影;MR、MRA检查显示鼻咽部为广泛炎性反应改变,6例可见鼻咽旁不规则坏死腔,病变中心无强化,周围软组织水肿。所有病例均采用全身麻醉内镜下扩大经鼻入路手术切除坏死组织的治疗方式。7例患者均行鼓膜切开置管术;5例行部分或全切患侧咽鼓管软骨段;1例同时行全组鼻窦开放术。7例患者均在围手术期进行抗炎等对症处理,术后随访6个月至3年,观察记录患者恢复情况。结果 7例患者手术清除的鼻咽颅底坏死组织经术后组织病理学检查,结果证实为坏死软组织及坏死的软骨组织,无肿瘤复发。全部患者术后症状均得到不同程度的改善,包括:听力提高7例;头痛消失5例,头痛缓解2例;鼻部恶臭消失4例,减轻1例。随访期间5例存活,2例死亡。2例未切除咽鼓管的患者中1例术后3个月再次出现鼻咽坏死灶,之后死于鼻咽大出血;1例术后6个月出现严重颅内感染导致死亡。结论鼻咽癌放疗后颅底软组织坏死诊断需依据患者的放疗病史、临床表现和影像学检查综合分析,颅底高分辨率CT、MR、MRA对于诊断非常重要,早期积极采用内镜下大范围坏死灶清除同时根据咽鼓管软骨受累情况行咽鼓管软骨的部分切除或全切除是治疗放疗后颅底软组织坏死的有效手段,可提高患者的生活质量。

Clinical study on endoscopic surgery for soft tissue necrosis of cranial base after radiotherapy for nasopharyngeal carcinoma

Objective To investigate the diagnosis and surgical treatment of patients with soft tissue necrosis of cranial base after radiotherapy for nasopharyngeal carcinoma(NPC).Methods The clinical data of 7 NPC patients with soft tissue necrosis but not bone necrosis after radiotherapy were retrospectively analyzed.They were treated in Xiangya Hospital from 2015 to 2019.The clinical manifestations,diagnosis,treatment and prognosis were analyzed.The major clinical symptoms of the 7 patients were headache in 7 cases,hearing loss in 7 cases,long-term nasal malodor in 5 cases and epistaxis in 2 cases.All patients underwent high-resolution CT,MR and magnetic resonance angiography(MRA)before operation.All cases were treated with extended transnasal endoscopic approach under general anesthesia for resection of necrotic tissue.Five cases had their affected cartilaginous segments of the eustachian tubes partially or completely resected,7 cases were treated with myringotomy and tube insertion,and 1 case was treated with pansinusectomy.Anti-inflammatory treatment were carried out during the perioperative period.The recovery of patients was observed and recorded through regular follow-up(from 6 months to 3 years)after the operation.Results Nasopharynx soft tissue lesions can be seen in seven patients with bone cortex integrity by CT,and small bubble shadow can be seen at junction area between skull base soft tissue lesions and skull base bone surface.MR and MRA examination showed extensive inflammatory changes of nasopharynx.Parapharyngeal irregular necrotic cavity was found in 6 cases without central enhancement,demonstrating edema of surrounding soft tissue.The necrotic tissue of all 7 patients was surgically removed.Postoperative pathological examinations confirmed that all of them were necrotic soft and cartilaginous tissue,without tumor recurrence.The symptoms of all patients were significantly alleviated after operation.Headache was cured in 5 cases and relieved in 2 cases.Nasal malodor was cured in 4 cases and alleviated in 1 case.During the follow-up period,5 patients survived,and 2 patients who had their eustachian tube reserved died.One of them died of nasopharyngeal hemorrhage caused by recurrent nasopharyngeal necrosis 3 months after the operation.Another case died of severe intracranial infection 6 months after operation.Conclusions The diagnosis of skull base soft tissue necrosis after radiotherapy for nasopharyngeal carcinoma needs comprehensive analysis of radiotherapy history,clinical manifestations and imaging examination.High resolution CT,MR and MRA of skull base are very important for diagnosis.Early active removal of large-scale necrotic lesions under endoscope and partial or total resection of eustachian tube cartilage according to the involvement of eustachian tube cartilage is effective means of controling skull base soft tissue necrosis after radiotherapy.The effective means of necrosis can improve the quality of life of patients.