鼻内镜下鼻咽癌切除术的手术分型

doi:10.6040/j.issn.1673-3770.1.2019.016

摘要/Abstract

摘要： 目的

通过解剖和临床研究建立鼻内镜下鼻咽癌切除术的手术分型。

方法

使用新鲜灌注的标本进行鼻内镜下颅底区解剖，结合复发性鼻咽癌的鼻内镜手术对鼻咽癌的鼻内镜下切除术进行分型，并分析不同手术分型的临床应用。

结果

内镜下鼻咽癌切除术分为4型：Ⅰ型内镜下鼻咽癌切除术主要处理鼻咽中线区及颅底中线区的病变，用于处理rT₁和部分rT₃期的复发性鼻咽癌；Ⅱ型内镜下鼻咽癌切除术在Ⅰ型的基础上向外扩展至咽鼓管软骨段、咽旁间隙和岩斜区内侧，用于处理rT₂期的复发性鼻咽癌；Ⅲ型内镜下鼻咽癌切除术是在Ⅱ型手术的基础上向外侧扩展至岩斜区外侧、颞下窝、中颅窝底、眼眶及眶上裂、海绵窦及颅神经，处理rT₄期的复发性鼻咽癌；Ⅳ型内镜下鼻咽癌切除术用于处理侵犯颈内动脉(ICA)和颅内的复发性鼻咽癌。

结论

上述4型内镜下鼻咽癌切除术可以有效用于治疗复发性鼻咽癌，通过建立复发性鼻咽癌颈内动脉手术前的评分量表和分级策略可以有效地指导对侵犯ICA的复发性鼻咽癌的处理,为外科治疗复发性鼻咽癌提供临床指导。

关键词: 鼻咽肿瘤, 鼻内镜外科手术, 颈内动脉

Abstract: Objective

To establish the types of endoscopic endonasal nasopharyngectomy for nasopharyngeal carcinoma (NPC) based on anatomic study and clinical applications.

Methods

Dissection of the skull base using an endoscopic endonasal approach was performed on a cadaver head. The procedures of endoscopic endonasal nasopharyngectomy for recurrent NPC (rNPC) were used and established.

Results

The procedures of endoscopic endonasal nasopharyngectomy for rNPC were grouped into 4 types: type Ⅰ was used for rT₁ and rT₃ rNPC located in the midline of the nasopharynx and skull base: type Ⅱ was used for rT₂ rNPC with involvement of the cartilaginous Eustachian tube, medial petroclival region, and parapharyngeal space: type Ⅲ was used for rT₄ rNPC extending further laterally into the lateral petroclival region, infratemporal fossa, middle of the skull base, superior orbital fissure, cavernous sinus, and cranial nerves: and type Ⅳ was used for rNPC invading the internal carotid artery (ICA) and middle cranial fossa.

Conclusion

The 4 types of endoscopic endonasal nasopharyngectomy are effective for the surgical treatment of rNPC. Pre-operation evaluation and staged exposure of the ICA is reliable, which will be an effective guideline for surgical treatment of rNPC.

Key words: Nasopharyngeal neoplasms, Endoscopic surgical procedures, operative, Internal carotid artery

中图分类号:

R739.6

刘全,孙希才,于华鹏,赵可庆,张焕康,赵卫东,顾瑜蓉,李厚勇,王德辉,余洪猛. 鼻内镜下鼻咽癌切除术的手术分型[J]. 山东大学耳鼻喉眼学报, 2019, 33(2): 39-45.

Quan LIU,Xicai SUN,Huapeng YU,Keqing ZHAO,Huankang ZHANG,Weidong ZHAO,Yurong GU,Houyong LI,Dehui WANG,Hongmeng YU. Types of endoscopic transnasal nasopharyngectomy for nasopharyngeal carcinoma[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2019, 33(2): 39-45.

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影响因素	量化标准	评分
包绕范围	包绕ICA：小于1/4	0
	包绕ICA：1/4至1/2	1
	包绕ICA：1/2至3/4	2
	包绕ICA：3/4至1	3
	颈内动脉管壁受侵犯	4
肿瘤大小	肿瘤小：局限于单个ICA分段	0
	肿瘤大：跨ICA分段生长	1
肿瘤位置	肿瘤主体位于ICA前内侧(中线位置)	0
	肿瘤主体位于ICA外侧	1
	肿瘤主体位于ICA后部	2
肿瘤质地	质地软，易分离	0
	质地硬，不易分离	1
放疗次数	术前无放疗	0
	首程放疗	1
	二次及二次以上放疗	2

级别	评分	处理策略
1级	0~1分	直接切除肿瘤，仅暴露ICA受侵犯的区域。
2级	2~3分	从正常结构向ICA受侵犯区域推进，完成ICA轮廓化。
3级	4~5分	ICA闭塞试验(BOT)，360度ICA轮廓化，备好动脉夹，做好颈内动脉术中破裂预案。
4级	≥6分	ICA闭塞试验(BOT)，ICA栓塞或搭桥后，ICA保留或切除。