鼻腔鼻窦内翻性乳头状瘤手术的术式选择

Management of sinonasal inverted papilloma:endoscopic excision vs traditional procedures

目的通过鼻内镜检查结合CT检查确定的分级系统,评价鼻内镜手术与传统术式治疗鼻腔鼻窦内翻性乳头状瘤的疗效,对不同术式选择进行探讨。方法对222例手术治疗的鼻腔鼻窦内翻性乳头状瘤病例进行分析。根据Krouse分级方法将病变分为4级Ⅰ级23例;Ⅱ级119例;Ⅲ级65例;Ⅳ级15例。其中采用鼻内镜手术者122例;采用传统的鼻部手术者100例,包括经鼻侧切开手术者56例、经鼻内入路手术者27例、柯陆手术者17例,并对所有患者术后情况进行随访。结果上述四种术式均能达到切除鼻腔鼻窦内翻性乳头状瘤病灶的目的,未出现严重的并发症。术后平均随访3 8年显示,肿瘤复发率经鼻内镜手术组18例( 14 8% ),其中Ⅰ级病变者4例、Ⅱ级9例、Ⅲ级4例、Ⅳ级1例; 11例Ⅲ级病变患者采用鼻内镜结合柯陆手术,无一例复发;鼻侧切开手术组19例(33 9% ),其中Ⅰ级病变者1例,Ⅱ级6例,Ⅲ级9例,Ⅳ级3例;柯陆手术组5例(29 4% ),其中Ⅱ级病变者3例,Ⅲ级2例;经鼻内进路手术组14例( 51 9% ),其中Ⅰ级病变者2例,Ⅱ级10例,Ⅲ级2例。初次手术复发率为26 8% ( 37 /138 ),再次手术复发率为20 9% ( 14 /67 )。结论鼻内镜手术治疗鼻腔鼻窦内翻性乳头状瘤是一种安全、有效的方法,对肿瘤涉及上颌窦的Ⅲ级病变,联合柯陆手术疗效较好。

Objective To evaluate the effect of endoscopic resection and traditional procedure in the management of sinonasal inverted papilloma with a staging system based on endoscopic examination of the nasal cavity and computed tomography (CT) scan evaluation. Methods Two hundred and twenty-two patients with sinonasal inverted papilloma treated surgically were retrospectively reviewed. There were 23 cases in stageⅠ; 119 cases in stageⅡ;65 cases in stageⅢ and 15 cases in stage Ⅳ. Among these patients, 122 cases were treated endoscopically; 100 cases were treated by traditional surgical techniques,including 56 cases with lateral rhinotomy; 27 cases with intranasal approach and 15 cases with Caldwell-Luc technique. Results The inverted papilloma was removed completely and no serious complications were encountered by all four kinds of techniques used. With an average follow-up of 3.8 years, the recurrence rate for endoscopic group was 14.8%(18/122,four patients were in group Ⅰ; nine in group Ⅱ; four in group Ⅲ; and one patient in group Ⅳ. No recurrence was found in group Ⅲ who underwent endoscopic excision combined with Caldwell-Luc procedure. The recurrence rate for lateral rhinotomy group was 33.9% (19/56, one patients in group Ⅰ; six in group Ⅱ; nine in group Ⅲ; three in group Ⅳ). The recurrence rate for intranasal approach group was 51.9% (14/27,two patients were in group Ⅰ; ten in group Ⅱ; and two in group Ⅲ). The recurrence rate for Caldwell-Luc procedure group was 29.4% (5/17,all in groupⅡ and group Ⅲ). Regardless of approaches, patients who had primary resection had a recurrence of 26.8%, whereas those with secondary resection had a recurrence of 20.9% (P=0.39). Conclusions The endoscopic surgical technique was proved to be a better method for treating sinonasal inverted papilloma in stage Ⅰand stageⅡ. Better results for patients in stage Ⅲ would be achieved by combining endoscopic technique with Caldwell-Luc procedure. As to patients with stage Ⅳ, radical external approache should be considered.