复发性额隐窝内翻性乳头状瘤经鼻内镜手术

Intranasal endoscopic management of recurrent inverted papilloma of frontal recess

目的探讨复发性额隐窝内翻性乳头状瘤(inve- rted papilloma,IP)再手术的方式及经鼻内镜手术的可行性和技术要点。方法9例复发性额隐窝IP,术前接受鼻窦CT和MRI检查及鼻内镜检查。前期手术及术后组织病理检查明确诊断为IP。所有病例在全身麻醉下接受经鼻内镜下额窦手术,手术方式分别为DrafⅡ型和DrafⅢ型(经鼻改良Lothrop手术)。随访时间13个月至55个月,平均23．1个月。结果9例前期手术包括鼻侧切开1例(2次),前鼻镜下经鼻肿瘤摘除术1例,柯陆氏手术1例；经鼻内镜手术7例；所有病例接受一次手术8例,4次手术1例,包括2次鼻侧切开和2次鼻内镜手术。鼻窦CT提示累及双侧额窦3例,3例筛窦和上颌窦受累,4例骨质增生同时伴骨质吸收或破坏。术前持续鼻塞症状4例,4例脓涕,涕中带血2例,持续或间歇性头痛6例,2例无明显症状,均在鼻内镜随访时提示肿瘤复发。手术依据术中所见病灶侵犯范围采用DrafⅡa型3例,DrafⅡb型手术4例,DrafⅢ型手术2例,3例同期行筛窦和上颌窦开放切除肿瘤。组织病理学检查1例伴恶变。术后6个月局灶性复发1例,随访中处理并用平阳霉寨湿敷12周后随访至今未见复发。结论复发性额隐窝伴/不伴额窦内侵犯IP,在技术熟练和严格适应证基础上,结合专用额窦手术器械,经鼻部分或全部切除额窦底扩大开放额窦,可彻底切除额窦内病灶。

OBJECTIVE To explore the operative methods for recurrent inverted papilloma of frontal recess（RIPFR）and the possibility of intranasal endoscopic surgery and its key technique points. METHODS Nine cases of RIPFR were included in this study. Paranasal sinus CT scan and MRI were taken for these patients preoperatively. Inverted papilloma was confirmed by histopathologic examination postoperatively. All patients were treated endoscopically with Draf Ⅱor Draf Ⅲ procedure（modified Lorthop procedure, MLP）under general anesthesia. The followup period ranged from 13 to 55 months（mean, 23.1 month）. RESULTS The prior operations included lynch procedure（1 case/ 2 times）,endonasal operation（1 case）, Caldwell-Luc operation （1 case）and endoscopic sinus surgery（7 cases）. Among 9 cases, 8 cases had one prior operation, 1 case had 4 prior operative experiences which included 2 times of lynch procedure and endoscopic sinus surgery respectively. Paranasal sinus CT and MRI demonstrated that the lesion involved bilateral frontal sinus in 3 cases and the ethmoid and maxillary sinus was involved in 3 cases. Neoosteogenesis and bone erosion or destroyed were seen in 4 cases. Four cases had nasal obstruction. Purulent discharge was seen in 4 cases. Mucoid discharge with blood was seen in 2 cases. Persistent or intermittent headache were encountered in 6 cases. Two cases had no symptoms and they were found tumor recurrent during follow-up. Three patients had undergone Draf Ⅱ a operation, 4 cases Draf Ⅱ b operation and 2 Draf Ⅲ operation（MLP）.Three cases received ethrnoidectomy and antrostomy simultaneously. Postoperative histopathology proved that 9 cases were inverted papilloma. One patient, who had a local recurrence 6 months after operation, had evidence of canceration. The lesion was cleared during follow-up and wet dressing soaking with bleomycinum happened until now. CONCLUSION Combined with special instruments for frontal sinus, the RIPFR with or without invasion of frontal sinus could be removed on the basis of proper indications and well-trained skill. Partial or total dissection of frontal floor should be setectad.