Danesi G, Panizza B, Mazzoni A, Calabrese V
Division of ORL, Ospedali Riuniti di Bergamo, Italy.
Otolaryngol Head Neck Surg. 2000 Feb;122(2):277-83. doi: 10.1016/S0194-5998(00)70256-7.
Although surgery is regarded as the mainstay of treatment for juvenile nasopharyngeal angiofibromas (JNAs), ancillary treatment modalities such as radiotherapy and on rare occasions chemotherapy are still recommended by many for intracranial extension with apparent radiologic involvement of the cavernous sinus and internal carotid artery. Further, most authors undertaking surgical excision of this subgroup of patients would recommend a lateral or combined frontal and lateral approach for its removal. In a series of 49 cases of JNA, 14 were found during surgery to have intracranial extradural extension; the anterior approach was used for their removal. Although in these cases, on radiography the cavernous sinus often looked to be invaded and the internal carotid artery was displaced superolaterally, there was no difficulty in establishing a plane of dissection. Total removal was achieved in 11 of the 14 cases with a single-stage procedure. Of the 3 cases with residual tumor, only 1 occurred intracranially. Removal was achieved by a subtemporal approach in this case. For the extracranial residual tumors 1 required a midface degloving and the other, with a 1-cm residual tumor in the nasopharynx, has been treated conservatively for 6 years with no evidence of growth. No deaths or significant complications have occurred, and radiotherapy has not been required. We conclude that JNAs are tumors with a predilection for spread but that rarely invade dura, acting instead to displace it. We believe that surgery is the method of choice for treating these lesions and that an anterior surgical approach with microsurgical techniques should be used in the first instance. In the last 2 cases we preferred a midface degloving technique to avoid facial scarring and because this approach allows a widening of the surgical field if needed by the performance of bilateral maxillary free bone flaps. On the rare occasion that a lateral approach, with its attendant permanent conductive hearing loss, is found to be necessary for total tumor removal, this can be done as a staged procedure. This may be necessary when the tumor has spread lateral to the horizontal internal carotid artery.
尽管手术被视为青少年鼻咽血管纤维瘤（JNAs）治疗的主要手段，但对于海绵窦和颈内动脉有明显影像学受累的颅内扩展情况，许多人仍推荐放疗等辅助治疗方式，化疗则很少使用。此外，大多数对该亚组患者进行手术切除的作者会推荐采用外侧或额侧与外侧联合入路来切除肿瘤。在一组49例JNAs病例中，手术中发现14例有颅内硬膜外扩展；采用前路入路进行切除。尽管在这些病例中，影像学检查显示海绵窦常看似受侵，颈内动脉向上外侧移位，但建立分离平面并无困难。14例中有11例通过一期手术实现了全切。3例有残留肿瘤的病例中，仅1例残留于颅内。该病例通过颞下入路实现了切除。对于颅外残留肿瘤，1例需要进行面中部脱套术，另1例在鼻咽部有1厘米残留肿瘤，已保守治疗6年，无生长迹象。未发生死亡或严重并发症，也未需要放疗。我们得出结论，JNAs是易于扩散的肿瘤，但很少侵犯硬脑膜，而是使其移位。我们认为手术是治疗这些病变的首选方法，首先应采用前路手术联合显微外科技术。在最后2例中，我们更倾向于面中部脱套技术以避免面部瘢痕形成，并且因为这种入路在需要时可通过双侧上颌游离骨瓣扩大手术视野。在极少数情况下，如果发现为完全切除肿瘤必须采用外侧入路及其伴随的永久性传导性听力丧失，可分期进行手术。当肿瘤已扩散至水平颈内动脉外侧时可能需要这样做。
