累及咽峡区的颌面颈部静脉畸形143例治疗分析

Treatment analyses of 143 patients with maxillofacial and cervical venous malformations involved in isthmus faucium area

目的 回顾性分析累及咽峡区的颌面颈部静脉畸形的临床病例资料,总结该类复杂疾病的治疗经验.方法 2012年1月至2016年1月山东省临沂市肿瘤医院共收治累及咽峡区的颌面颈部静脉畸形患者143例.其中男70例,女73例,年龄1 ～52岁,中位年龄14.5岁.其中累及1个咽峡区亚解剖位者19例（孤立病变）,累及2个及以上亚解剖部位者124例（其中广泛累及3个及以上亚解剖部位者63例）.143例中合并面颈部病变50例;伴有睡眠时打鼾98例;伴发音含混不清49例;合并扁桃体Ⅱ°以上肥大者19例;3例患者外院行气管切开,10例患者行预防性气管切开,余接受经口气管插管全麻下治疗.143例患者中单纯无水乙醇病变内注射消融治疗94例;病变切除9例;无水乙醇注射消融＋手术切除40例.对咽峡区合并颌面颈等多部位的广泛性复杂病变,配合瘤体网状缝扎、巨舌缩小成形以及颌颈瘤体切除等治疗方法.对于扁桃体区静脉畸形或合并扁桃体Ⅱ°以上肥大者术中切除病变扁桃体.采用Achauer等提出的4级分级标准对治疗效果进行评价.采用SPSS 18.0软件进行统计学分析.结果 32例术后需保留气管插管24 ～48 h,除2例拔管后出现呼吸困难,急行气管切开外,其余均顺利拔管.无术中或术后肺动脉痉挛或肺栓塞病例.治疗前后合并打鼾（χ^2=105.431）,发音含混不清（χ^2=59.698）,扁桃体Ⅱ°以上肥大（χ^2 =33.530）3项差异有统计学意义（P值均〈0.01）.全组随访1～4年,远期疗效评定为Ⅰ级0例,Ⅱ级3例,Ⅲ级17例,Ⅳ级123例（其中病变完全消失62例,无复发）.结论 对咽峡区静脉畸形可行无水乙醇病变内注射消融治疗,对咽峡区合并颌面颈等多部位的广泛性复杂病变,可配合瘤体网状缝扎、巨舌缩小成形以及颌颈瘤体切除术,对扁桃体区静脉畸形或合并扁桃体Ⅱ°以上肥大者可术中切除病变扁桃体.该系列治疗方法疗效确切、治愈率高、功能保留完好,注射技巧掌握适当并发症少.

Objective To analyze the clinical data and summarize therapeutic experiences of cervicofacial venous malformations involving isthmus faucium area.Methods Clinical records from 143 patients with venous malformations involving isthmus faucium area treated at our hospital between January 2012 and January 2016 were reviewed.There were 70 males and 73 females.Age ranged from 1 to 52 years old,with a median age of 14.5 years.There were 19 cases with lesions involving in only 1 subanatomic area above and 124 cases with lesions involving in more than 1 subanatomic areas,including 63 cases with lesions involving in more than 2 areas.There were 50 patients presenting with additional maxillofacial and cervical lesions.Clinical symptoms included snoring （n =98）,indistinct phonation （n =49）,and tonsil hypertrophy more than degree Ⅱ （n =19）.Tracheotomy was performed in 3 patients prior to hospitalization,contigency tracheotomy during hospitalization in 10 patients,and oral trachea cannula in other patients.All therapeutic procedures,including single chemical ablation with ethanol injection （n =94）,single lesion resection （n =9） and both of them （n =40）,were performed under general anesthesia.Treatment remedies included mesh suture,macroglossia reduction and excision of maxillofacial and cervical lesions for patients presenting with extensive malformations extending to maxillofacial and cervical area.Tonsil resection were done in patients having tonsil venous malformations or tonsil hypertrophy more than degree Ⅱ.Achauer＆#39;s 4-grade criterion was applied to evaluate the treatment outcomes.SPSS 18.0 software was used to analyze the data.Results Trachea cannula were not extubated untill 24 to 48 hours after treatment.Emergency tracheotomy was done in 2 cases after extubations because of dyspnea,and successful extubations were obtained in other cases.There were no advents of pulmonary vascular spasm or pulmonary embolism.There was significant difference between before and after operation （snore：χ^2 =105.431,ambiguous pronunciation：χ^2 =59.698,tonsil hypertrophy more than degree Ⅱ：χ^2 =33.530,all P 〈0.01）.The patients were followed-up for 1-4 years,and there were 123 cases at grade Ⅳ （complete disappear of lesions in 62 cases without recurrence）,17 at grade Ⅲ,3 at grade Ⅱ,and no case at grade Ⅰ.Conclusions Chemical ablation with ethanol injection for venous malformations involving isthmus faucium area is recommended,wheras combined remedies including injection,mesh suture,macroglossia reduction,and excision of cervicofacial lesions are suggested in treatment of extensive lesions extending to maxillofacial and cervical area.Tonsil resection should be done in patients having tonsil venous malformations or tonsil hypertrophy more than degree Ⅱ,which is safe and highly effective,with good reservation of function,in the treatment of maxillofacial and cervical venous malformations involving isthmus faucium area.