鼻内镜下经泪前隐窝-翼突入路上咽旁间隙病变手术

doi:10.6040/j.issn.1673-3770.0.2023.098

摘要/Abstract

摘要： 目的探讨经泪前隐窝-翼突入路切除上咽旁间隙病变的鼻内镜下手术方法、适应证及临床效果。方法回顾性总结2016年2月至2021年8月收治的10例上咽旁间隙占位性病变患者在鼻内镜下经泪前隐窝-翼突入路完成手术情况,分析此路径手术运用特点、手术并发症及疗效。结果所有患者均在鼻内镜下经泪前隐窝-翼突入路顺利暴露肿瘤。10例中术后病理确诊为海绵状血管瘤3例,术后MRI显示均获全切;淋巴瘤2例、炎性/炎性假瘤4例及鼻咽癌1例,术后MRI显示均为次全切除。随访时间6~28个月,3例血管瘤均无复发;2例淋巴瘤,经化疗均获得完全缓解;4例炎性/炎性假瘤较术后无明显变化;1例鼻咽癌放疗后鼻咽部病灶完全缓解。10例患者术后均出现患侧硬腭麻木的并发症,其中4例患者随访时硬腭麻木未有改善。结论经泪前隐窝-翼突入路可有效显露上咽旁间隙,咽鼓管、腭帆张肌、翼内肌及翼内板,可作为该区域重要的解剖参考标志并利于颅底重要结构的保护。该入路可作为上咽旁间隙病变手术的重要供选方案。

关键词: 上咽旁间隙, 泪前隐窝, 翼突, 鼻内镜, 硬腭麻木

Abstract: Objective In this study, we aimed to evaluate the feasibility of the operative method, indications, and clinical outcomes of the endoscopic prelacrimal recess-transpterygoid approach for treating lesions in the upper parapharyngeal space. Methods We retrospectively analyzed 10 cases of upper parapharyngeal space lesions between February 2016 and August 2021. Enhanced MRI and CT scans were performed before surgery. All the patients underwent endoscopic surgery, during which the pterygoid process was exposed by removing the anterior and medial walls and soft tissues in the pterygopalatine fossa through a prelacrimal-recess approach. Furthermore, using the eustachian tube, musculus palatosalpingeus, medial pterygoid muscle, and lateral pterygoid plate as reference marks, lesions in the upper parapharyngeal space were removed under image-navigation-assisted endoscopic surgery. A week after the surgery, enhanced MRI reinspection was performed to assess the characteristics, complications, and surgical outcomes. Results All patients' lesions were fully exposed by endoscopic prelacrimal-recess - transpterygoid approach. Among the ten cases, three cases of cavernous hemangioma, two cases of lymphoma, four cases of inflammation/inflammatory pseudotumor, and one case of nasopharyngeal carcinoma were confirmed through histopathological and immunohistochemical examination. Among these, all cavernous hemangiomas were totally removed, whereas lymphomas, and inflammation/inflammatory pseudotumors, nasopharyngeal carcinoma were subtotally removed after surgery. During the post-surgery follow-up period of 6-28 months, all the cases of hemangioma exhibited no recurrence, lymphoma cases exhibited complete remission after chemotherapy, inflammation/inflammatory pseudotumor cases exhibited no significant change compared with their post-surgery condition, and nasopharyngeal carcinoma case exhibited complete remission of nasopharyngeal disease after radiotherapy. Additionally, postoperative hard palate numbness on the affected side occurred in all 10 patients, four cases of hard palate numbness exhibited no remission. Conclusion The endoscopic prelacrimal-recess-transpterygoid approach effectively exposed the upper parapharyngeal space. The eustachian tube, musculus palatosalpingeus, medial pterygoid muscle, and medial pterygoid plate can be used as anatomical reference marks in this area to facilitate removal of lesions while protecting vital structures of the skull base. This approach is advantageous for the removal of lesions located in the upper parapharyngeal space.

Key words: Upper parapharyngeal space, Prelacrimal recess, Pterygoid process, Endoscopic, Hard palate numbness

中图分类号:

R765.9

后婕,刘丁丁,王涵东,徐峥嵘,钱晓云,高下,俞晨杰. 鼻内镜下经泪前隐窝-翼突入路上咽旁间隙病变手术[J]. 山东大学耳鼻喉眼学报, 2024, 38(4): 28-35.

HOU Jie, LIU Dingding, WANG Handong, QIAN Xiaoyun, GAO Xia, YU Chenjie. Surgical treatment of lesions of the upper parapharyngeal space by endoscopic prelacrimal recess-transpterygoid approach[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2024, 38(4): 28-35.

参考文献

[1] Li LF, London NR Jr, Prevedello DM, et al. Endonasal endoscopic transpterygoid approach to the upper parapharyngeal space[J]. Head Neck, 2020, 42(9): 2734-2740. doi:10.1002/hed.26127
[2] Tanjararak K, Upadhyay S, Thiensri T, et al. Potential surgical exposure of the parapharyngeal internal carotid artery by endonasal, transoral, and transcervical approaches[J]. J Neurol Surg B Skull Base, 2018, 79(3): 241-249. doi:10.1055/s-0037-1607289
[3] Galli J, Rolesi R, Gallus R, et al. Parapharyngeal space tumors: our experience[J]. J Pers Med, 2023, 13(2): 283. doi:10.3390/jpm13020283
[4] 周兵, 黄谦, 崔顺九, 等. 内镜下经鼻泪前隐窝入路切除翼腭窝及颞下窝神经鞘瘤[J]. 中华耳鼻咽喉头颈外科杂志, 2013, 48(10): 802-806. doi: 10.3760/cma.j.issn.1673-0860.2013.10.003 ZHOU Bing, HUANG Qian, CUI Shunjiu, et al. Removal of Schwannoma in the pterygopalatine and infratemperal fossa via endoscopic prelacrimal recess approach[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery, 2013, 48(10): 802-806. doi: 10.3760/cma.j.issn.1673-0860.2013.10.003
[5] 崔昕燕, 陈峰, 钱晓云, 等. 微型高频针状电极在鼻内镜下泪前隐窝入路手术中的应用[J]. 临床耳鼻咽喉头颈外科杂志, 2017(23): 1844-1847. doi:10.1320/j.issn.1001-1781.2017.23.015 Cui XY, Chen F, Qian XY, et al. Application of the microdissection needle for endoscopic prelacrimal recess approach[J]. Journal of Clinical Otorhinolaryngology Head and Neck Surgery, 2017(23): 1844-1847. doi:10.1320/j.issn.1001-1781.2017.23.015
[6] 周兵, 韩德民, 崔顺九, 等. 鼻内镜下鼻腔外侧壁切开上颌窦手术[J]. 中华耳鼻咽喉头颈外科杂志, 2007, 42(10): 743-748. doi:10.3760/j.issn: 1673-0860.2007.10.006
[7] Orlando P, Locatello LG, Gallo O, et al. Endoscopy-assisted transoral approach for parapharyngeal space tumors: our experience and a systematic review of the literature[J]. World J Otorhinolaryngol Head Neck Surg, 2023, 9(1): 79-90. doi:10.1002/wjo2.55
[8] 赵建东, 文艺, 纵亮, 等. 原发性咽旁间隙肿瘤治疗的回顾性分析[J]. 临床耳鼻咽喉头颈外科杂志, 2020, 34(8): 743-747. doi:10.13201/j.issn.2096-7993.2020.08.015 ZHAO Jiandong, WEN Yi, ZONG Liang, et al. Retrospective analysis of treatment of primary parapharyngeal space tumor[J]. Journal of Clinical Otorhinolaryngology Head and Neck Surgery, 2020, 34(8): 743-747. doi:10.13201/j.issn.2096-7993.2020.08.015
[9] Jiang CY, Wang WQ, Chen SW, et al. Management of parapharyngeal space tumors: clinical experience with a large sample and review of the literature[J]. Curr Oncol, 2023, 30(1): 1020-1031. doi:10.3390/curroncol30010078
[10] 陈贤明, 赵敏, 甄泽年, 等. 经口腔上颌结节入路切除咽旁间隙肿瘤[J]. 中国耳鼻咽喉颅底外科杂志, 2011, 17(1): 22-24 CHEN Xianming, ZHAO Min, ZHEN Zenian, et al. Resection of parapharyngeal space tumor through oral maxillary tubercle approach[J]. Chinese Journal of Otorhinolaryngology-Skull Base Surgery, 2011, 17(1): 22-24
[11] 于龙刚, 王琳, 张胜男, 等. 经口内镜翼下颌皱襞内侧入路咽旁间隙良性肿瘤切除术[J]. 中华耳鼻咽喉头颈外科杂志, 2022, 57(1): 36-41. doi: 10.3760/cma.j.cn115330-20210428-00236 YU Longgang, WANG Lin, ZHANG Shengnan, et al. Transoral endoscopic resection of benign tumors in parapharyngeal space via medial pterygomandibular raphe approach[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery, 2022, 57(1): 36-41. doi: 10.3760/cma.j.cn115330-20210428-00236
[12] 陈明浩, 张秋航, 侯佳蒙, 等. 经口三种入路切除咽旁间隙肿瘤的应用分析[J]. 山东大学耳鼻喉眼学报, 2023, 37(2): 26-32. doi:10.6040/j.issn.1673-3770.0.2022.066 CHEN Minghao, ZHANG Qiuhang, HOU Jiameng, et al. Clinical analysis of three endoscopy-assisted transoral approaches in the operative management of parapha-ryngeal space tumors[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2023, 37(2): 26-32. doi:10.6040/j.issn.1673-3770.0.2022.066
[13] 徐斌, 鲍洋洋, 周水洪. 经口径路机器人辅助咽旁间隙肿瘤切除术的优势与局限性[J]. 中华耳鼻咽喉头颈外科杂志, 2018, 53(10): 794-797. doi: 10.3760/cma.j.issn.1673-0860.2018.10.016 XU Bin, BAO Yangyang, ZHOU Shuihong. The advantage and disadvantage of transoral orbotic surgery for parapharyngeal tumors: a systemic review[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery, 2018, 53(10): 794-797. doi: 10.3760/cma.j.issn.1673-0860.2018.10.016
[14] Liu Q, Wang H, Zhao WD, et al. Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base[J]. Eur Arch Otorhinolaryngol, 2020, 277(3): 801-807. doi:10.1007/s00405-019-05761-6
[15] 李海艳, 翟翔, 何京川, 等. 经鼻内镜切除旁中线颅底良性病变的手术入路选择[J]. 临床耳鼻咽喉头颈外科杂志, 2022, 36(5): 352-356. doi:10.13201/j.issn.2096-7993.2022.05.006 LI Haiyan, ZHAI Xiang, HE Jingchuan, et al. Selection of surgical approach for resection of benign lesions of skull base near midline through nasal endoscope[J]. Journal of Clinical Otorhinolaryngology Head and Neck Surgery, 2022, 36(5): 352-356. doi:10.13201/j.issn.2096-7993.2022.05.006
[16] 郑朝攀, 曾小燕, 张博, 等. 内镜经翼突入路切除中颅底恶性肿瘤30例临床分析[J]. 山东大学耳鼻喉眼学报, 2020, 34(6): 42-48. doi:10.6040/j.issn.1673-3770.0.2020.094 ZHENG Chaopan, ZENG Xiaoyan, ZHANG Bo, et al. Clinical analysis of the endonasal transpterygoid approach to the resection of malignant tumors involving the middle skull base of 30 cases[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2020, 34(6): 42-48. doi:10.6040/j.issn.1673-3770.0.2020.094
[17] Battaglia P, Turri-Zanoni M, Dallan I, et al. Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors[J]. Otolaryngol Head Neck Surg, 2014, 150(4): 696-702. doi:10.1177/0194599813520290
[18] 刘全, 刘娟, 王欢, 等. 内镜经翼突及上颌窦前壁上咽旁间隙的解剖[J]. 解剖学报, 2021, 52(6): 940-944. doi:10.16098/j.issn.0529-1356.2021.06.016 LIU Quan, LIU Juan, WANG Huan, et al. Endoscopic transpterygoid transmaxillary approach to the upper parapharyngeal space[J]. Acta Anatomica Sinica, 2021, 52(6): 940-944. doi:10.16098/j.issn.0529-1356.2021.06.016
[19] 刘卫卫, 王晓敏, 蔡常琦, 等. 内镜下经鼻-翼突入路切除翼突周围颅底病变的临床分析[J]. 中国耳鼻咽喉颅底外科杂志, 2020, 26(2): 135-138. doi:10.11798/j.issn.1007-1520.202002006
[20] 周兵, 韩德民, 崔顺九, 等. 蝶窦外侧隐窝脑膜脑膨出鼻内镜下经翼突径路手术[J]. 中华耳鼻咽喉头颈外科杂志, 2007, 42(5): 328-333. doi: 10.3760/j.issn: 1673-0860.2007.05.004 ZHOU Bing, HAN Demin, CUI Shunjiu, et al. Endoscopic transpterygoid intervention of meningoencephalocele within lateral recess of sphenoid sinus[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery, 2007, 42(5): 328-333. doi: 10.3760/j.issn: 1673-0860.2007.05.004
[21] 刘全, 孙希才, 于华鹏, 等. 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. doi: 10.6040/j.issn.1673-3770.1.2019.016 LIU Quan, SUN Xicai, YU Huapeng, et al. Types of endoscopic transnasal nasopharyngectomy for nasopharyngeal carcinoma[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2019, 33(2): 39-45. doi: 10.6040/j.issn.1673-3770.1.2019.016
[22] 姜彦. 鼻内镜下经鼻翼突径路旁中线颅底手术[J]. 山东大学耳鼻喉眼学报, 2017, 31(2): 16-24. doi: 10.6040/j.issn.1673-3770.0.2017.115 JIANG Yan. The endoscopic endonasal transpterygoid approach in lateral midline skull base[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2017, 31(2): 16-24. doi: 10.6040/j.issn.1673-3770.0.2017.115

多维度评价

Viewed

Full text

Abstract

Cited

Shared

Discussed