Journal of Otolaryngology and Ophthalmology of Shandong University ›› 2019, Vol. 33 ›› Issue (2): 39-45.doi: 10.6040/j.issn.1673-3770.1.2019.016

• Clinical Report • Previous Articles     Next Articles

Types of endoscopic transnasal nasopharyngectomy for nasopharyngeal carcinoma

Quan LIU,Xicai SUN,Huapeng YU,Keqing ZHAO,Huankang ZHANG,Weidong ZHAO,Yurong GU,Houyong LI,Dehui WANG*(),Hongmeng YU*()   

  1. Department of Nasal and Cranial Surgery, Department of Otolaryngology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
  • Received:2019-02-04 Online:2019-03-20 Published:2019-03-28
  • Contact: Dehui WANG,Hongmeng YU E-mail:wangdehuient@sina.com;hongmengyush@163.com
  • Supported by:
    中国医学科学院内镜下鼻颅底肿瘤的外科治疗创新单元

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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

CLC Number: 

  • R739.6

Table 1

Types of endoscopic transnasal nasopharyngectomy for nasopharyngeal carcinoma"

手术分型 解剖范围 对应rT分期 颅底重建
Ⅰ型 鼻咽中线区、蝶窦、鼻腔及筛窦 rT1和rT3(中线区) 否
Ⅱ型 在Ⅰ型的基础上向外侧扩展，另包含咽鼓管软骨段、咽旁间隙和岩斜区内侧 rT2 是
Ⅲ型 在Ⅱ型的基础上向外侧扩展，包括岩斜区外侧、颞下窝、中颅窝底(硬膜外)、眼眶及眶上裂，海绵窦和颅神经 rT3(旁中线区)和rT4期(颅外) 是
Ⅳ型 在Ⅲ型的基础上广泛暴露/切除咽旁段、岩骨段和破裂孔段ICA；中颅窝内 rT4 是

Fig.1

Sagittal computed tomography image indicating the region for type Ⅰ surgery(箭头所指区域)"

Fig.2

Axial CT image indicating the region for type Ⅰ surgery (箭头所指区域)"

Fig.3

Enhanced magnetic resonance imaging indicating the disease in the midline of the nasopharynx"

Fig.4

Contouring (blue dots) of the sphenoid sinus (ss) and nasopharynx"

Fig.5

Anatomy of the parapharyngeal space. (ICA, internal carotid artery; SPCM, superior pharyngeal constrictor muscle, TVPM: tensor veli palatini muscle)"

Fig.6

Pre-operative enhanced MRI indicating the tumor invading the left parapharyngeal space and internal carotid artery of the clival, lacerated foramen, and parapharyngeal segments. MRI, magnetic resonance imaging"

Fig.7

Endoscopic transnasal transpterygoid approach into the parapharyngeal space through removal of the levator veli palatini muscle (LVPM) and cartilaginous Eustachian tube to resect the tumor involving the internal carotid"

Fig.8

Post-operative enhanced MRI revealing complete resection of the tumor. MRI, magnetic resonance imaging"

Fig.9

Anatomical exposure of the middle of the skull base, internal carotid artery of parapharyngeal segment, third division of the trigeminal nerve (V3), internal maxillary artery (IMA), and sphenoid spine (arrow)"

Fig.10

Pre-operative enhanced MRI demonstrating the tumor invading the left nasopharynx and middle of the skull base. MRI, magnetic resonance imaging"

Fig.11

Complete resection of the tumor using type Ⅲ endoscopic endonasal nasopharyngectomy"

Table 2

Pre-operative scoring of the internal carotid artery involved in nasopharyngeal carcinoma"

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

Table 3

Staging of the management of the internal carotid artery involved in nasopharyngeal carcinoma"

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。
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