Recurrence of nasopharyngeal carcinoma and application of endoscopic surgery

Yan JIANG

Journal of Otolaryngology and Ophthalmology of Shandong University 2019, 33 (2): 1-11. DOI: 10.6040/j.issn.1673-3770.1.2019.011

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Radiotherapy is the conventional treatment for nasopharyngeal carcinoma. Although the 5-year survival rate has greatly improved, there are still several cases of recurrent or residual nasopharyngeal carcinoma. The treatment principles of recurrent or residual lesions include second-course radiotherapy, chemotherapy, and surgery. The complications following radical radiotherapy and second-course radiotherapy seriously affect the quality of life in patients. The current surgical methods include open surgery and endoscopic surgery. Open surgery can provide a sufficiently open field of operation, but is associated with some serious damage. Endoscopic nasopharyngeal carcinoma resection has been carried out lately, and only few medical institutions in China perform these operations. However, with the emergence of the concept of endoscopic skull base surgery and new medical instruments and equipment, endoscopic nasopharyngeal carcinoma surgery has become a good surgical choice. However, this requires strict surgical indications, skills of endoscopic skull-base surgery, and long-term follow-up.

Fig.8 A man with nasopharyngeal carcinoma showed recurrence, skull necrosis, liquefaction necrosis in the eustachian tube area, intractable headache, mouth and nose odor (white arrow refers to the exposed internal carotid artery), 6 months after the first radical radiotherapy
A-D. Preoperative nasopharyngeal magnetic resonance (MR) shows necrosis of the right nasopharynx, local liquefaction, invasion of the internal carotid artery rupture zone, and lack of bone; E-H. Postoperative nasopharyngeal MR shows clearing of the lesion.

常发生颌骨骨髓炎和颅骨坏死。一般表现为放疗进程中或放疗后出现颌骨周围的红、肿、热、痛，部分出现颌骨压痛、颈部僵硬，患者不敢咬合、张口受限或者转颈受限。颅底放射性骨坏死临床上表现为鼻腔口腔恶臭味、药物无法控制的头痛、间断性鼻出血，影像学可以显现颅底骨质缺如、鼻咽部组织肿胀、失去正常骨性结构，内镜下表现为颅底骨质裸露或死骨形成、软组织内见小气泡等特征性表现，甚至部分患者显示颈内动脉管裸露在颅底的感染灶内。对于这类病例，需要积极抗感染治疗，如无效或明确有大面积死骨形成、颈内动脉裸露，应积极行手术探查，术前需行颈部、颅脑血管CTA或MRA检查，明确有无假性动脉瘤，有条件的建议术前行颈内动脉、颌内动脉栓塞术，以保证术中颈内动脉不发生溃破大出血。手术以清理死骨、坏死软组织为主，对于颈内动脉管，需要同期行组织重建加以保护[29](图8)。