Midilli R, Karci B, Akyildiz S
Department of Otolaryngology, Ege University Faculty of Medicine, Bornova 35100, Izmir, Turkey.
Int J Pediatr Otorhinolaryngol. 2009 Mar;73(3):401-8. doi: 10.1016/j.ijporl.2008.11.005. Epub 2009 Jan 4.
To determine the general characteristics of 42 patients who were operated for juvenile nasopharyngeal angiofibroma (JNA); and to determine the important aspects and the advantages of endoscopic transnasal approach over other techniques.
Forty-two patients with JNA, 12 of whom were operated with endoscopic transnasal approach at a tertiary care center between March 1987 and February 2008 were evaluated retrospectively. The general characteristics of the patients, presenting signs and symptoms, the surgical approach performed, tumor stage, whether preoperative embolization was performed and rates of recurrence were studied. Patients who underwent surgery with endoscopic transnasal approach were compared to others who underwent surgery with different techniques.
One patient was female and the remaining 41 patients were male. Twelve patients underwent endoscopic removal of the tumor. Lateral rhinotomy was used for 10 patients, degloving approach for 7 patients, transpalatal approach for 6 patients, combined approach for another 6 patients and finally midfacial splitting for 1 patient. Seventeen percent of the patients had referred with recurrent diseases. According to staging system of Radkowski, about half of the patients belonged to stage IIA or IIC. The mean age was 16 and the most common presenting symptom was nasal obstruction. Preoperative embolization rate was 59.5% while recurrence rate in the postoperative period was 17%. In non-endoscopic approaches, the tumor contiguity and operative plan were determined via radiological data. In operations performed with endoscopic transnasal approach in patients with JNA, the radiological data as well as a detailed endoscopic tumor examination were utilized and it was observed that tumor invaded the middle turbinate in 67% and both the septum and middle turbinate in 42% of the patients. While preoperative embolization was performed only in larger tumors before 1998, it was recruited in all subjects after 1998. Preoperative and postoperative hemorrhage were less, and durations of packing and hospitalization were shorter in patients operated with endoscopic approach plus preoperative embolization.
Endoscopic transnasal approach has advantages of no non-cosmetic sequela, less hemorrhage and no disruption in facial skeleton. Besides, this method allows better visualization of tumor contiguity and enables dissection and ligature of vascular structures in JNA surgery. The rate of tumors associated with middle turbinate and septum is greater than that is assumed in patients with JNA. Starting the tumor excision with partial resection of the middle turbinate and subperiostal dissection of the septum and anterior sphenoidal wall, and avoiding direct contact with the tumor might decrease the amount of bleeding.
确定42例接受青少年鼻咽血管纤维瘤（JNA）手术患者的一般特征；确定鼻内镜经鼻入路相对于其他技术的重要方面及优势。
回顾性评估42例JNA患者，其中12例于1987年3月至2008年2月在一家三级医疗中心接受鼻内镜经鼻入路手术。研究患者的一般特征、临床表现及症状、所采用的手术入路、肿瘤分期、是否进行术前栓塞及复发率。将接受鼻内镜经鼻入路手术的患者与采用其他技术手术的患者进行比较。
1例为女性，其余41例为男性。12例患者接受了肿瘤的内镜切除。10例患者采用鼻侧切开术，7例采用掀翻术，6例采用经腭入路，6例采用联合入路，最后1例采用面中部劈开术。17%的患者为复发性疾病。根据Radkowski分期系统，约一半患者属于IIA期或IIC期。平均年龄为16岁，最常见的临床表现为鼻塞。术前栓塞率为59.5%，术后复发率为17%。在非内镜入路中，通过影像学资料确定肿瘤毗邻关系及手术方案。在JNA患者鼻内镜经鼻入路手术中，利用影像学资料及详细的内镜肿瘤检查，发现67%的患者肿瘤侵犯中鼻甲，42%的患者肿瘤侵犯鼻中隔和中鼻甲。1998年前仅对较大肿瘤进行术前栓塞，1998年后所有患者均采用术前栓塞。采用内镜入路加术前栓塞的患者术前及术后出血较少，填塞及住院时间较短。
鼻内镜经鼻入路具有无美容后遗症及面部骨骼无破坏、出血少的优势。此外，该方法能更好地观察肿瘤毗邻关系，便于在JNA手术中分离及结扎血管结构。JNA患者中肿瘤累及中鼻甲和鼻中隔的比例高于预期。从中鼻甲部分切除及鼻中隔和蝶窦前壁骨膜下分离开始肿瘤切除，避免直接接触肿瘤，可能会减少出血量。
