CAJ | 학술논문

目的探讨鼻内镜下上颌窦内侧壁入路切除上颌窦良性病变的手术径路及手术方法的可行性及疗效.方法 2003年6月至2010年8月,采用鼻内镜下经鼻腔鼻泪管前径路和鼻泪管后径路的多种方式切除上颌窦良性病变139例,其中内翻性乳头状瘤43例、真菌性上颌窦炎63例、上颌窦囊肿28例、出血坏死性息肉3例、骨瘤2例.所有病例术前行CT检查,可疑内翻性乳头状瘤患者同步行MRI检查.鼻泪管前方径路采取3种方式:梨状孔入路、泪前隐窝入路(包括解剖鼻泪管和不解剖鼻泪管2种方式)、梨状孔鼻泪管人路,共治疗97例；鼻泪管后方径路也采取3种方式:下鼻甲翻转、双蒂下鼻甲、单蒂下鼻甲,共治疗42例.观察患者术后疗效.结果全部病例在鼻内镜下经鼻彻底清除病变,保护了鼻泪管,保留了下鼻甲,无一例发生鼻泪管损伤和下鼻甲坏死.术后鼻塞、头痛、闷胀不适、异味、牙疼和麻木感等症状逐步消失.9例感觉鼻腔干燥,经鼻腔冲洗等处理后1个月左右逐渐消失.随访6 ～79个月,骨瘤和出血坏死性息肉未见复发.所有真菌性上颌窦炎患者术中均可见窦腔黏膜明显水肿、增厚,术后3个月左右逐渐消失,无一例复发.2例上颌窦囊肿患者术后10个月和18个月在上颌窦其他部位再发,但囊肿小且无临床症状未作处理.内翻性乳头状瘤患者有3例复发,1例术后17个月上颌窦口上方局限性肿物突出,病理示乳头状瘤复发,门诊予以清理后随访1年未见复发；1例于术后15个月前筛处复发,行筛窦广泛切除后随访3年未见复发；1例术后26个月上颌窦后外侧壁局部复发,二次行蒂在前方单蒂下鼻甲方式手术,术后1年再次复发,行鼻内镜下Denker手术,随访18个月未见复发征象.所有病例术后3个月上颌窦创面上皮、瘢痕覆盖,下鼻甲形态良好,下鼻道开窗者较术中明显瘢痕变小,且引流通畅无闭锁.结论鼻内镜下鼻泪管前、后径路上颌窦手术可以减小创伤,充分暴露窦腔视野,并为术后内镜复查和复发后的处理提供了视窗；保留下鼻甲避免了鼻腔外侧壁去除过多而导致的术后干燥、结痂、头痛等并发症. 目的探討鼻內鏡下上頜竇內側壁入路切除上頜竇良性病變的手術徑路及手術方法的可行性及療效.方法 2003年6月至2010年8月,採用鼻內鏡下經鼻腔鼻淚管前徑路和鼻淚管後徑路的多種方式切除上頜竇良性病變139例,其中內翻性乳頭狀瘤43例、真菌性上頜竇炎63例、上頜竇囊腫28例、齣血壞死性息肉3例、骨瘤2例.所有病例術前行CT檢查,可疑內翻性乳頭狀瘤患者同步行MRI檢查.鼻淚管前方徑路採取3種方式:梨狀孔入路、淚前隱窩入路(包括解剖鼻淚管和不解剖鼻淚管2種方式)、梨狀孔鼻淚管人路,共治療97例；鼻淚管後方徑路也採取3種方式:下鼻甲翻轉、雙蒂下鼻甲、單蒂下鼻甲,共治療42例.觀察患者術後療效.結果全部病例在鼻內鏡下經鼻徹底清除病變,保護瞭鼻淚管,保留瞭下鼻甲,無一例髮生鼻淚管損傷和下鼻甲壞死.術後鼻塞、頭痛、悶脹不適、異味、牙疼和痳木感等癥狀逐步消失.9例感覺鼻腔榦燥,經鼻腔遲洗等處理後1箇月左右逐漸消失.隨訪6 ～79箇月,骨瘤和齣血壞死性息肉未見複髮.所有真菌性上頜竇炎患者術中均可見竇腔黏膜明顯水腫、增厚,術後3箇月左右逐漸消失,無一例複髮.2例上頜竇囊腫患者術後10箇月和18箇月在上頜竇其他部位再髮,但囊腫小且無臨床癥狀未作處理.內翻性乳頭狀瘤患者有3例複髮,1例術後17箇月上頜竇口上方跼限性腫物突齣,病理示乳頭狀瘤複髮,門診予以清理後隨訪1年未見複髮；1例于術後15箇月前篩處複髮,行篩竇廣汎切除後隨訪3年未見複髮；1例術後26箇月上頜竇後外側壁跼部複髮,二次行蒂在前方單蒂下鼻甲方式手術,術後1年再次複髮,行鼻內鏡下Denker手術,隨訪18箇月未見複髮徵象.所有病例術後3箇月上頜竇創麵上皮、瘢痕覆蓋,下鼻甲形態良好,下鼻道開窗者較術中明顯瘢痕變小,且引流通暢無閉鎖.結論鼻內鏡下鼻淚管前、後徑路上頜竇手術可以減小創傷,充分暴露竇腔視野,併為術後內鏡複查和複髮後的處理提供瞭視窗；保留下鼻甲避免瞭鼻腔外側壁去除過多而導緻的術後榦燥、結痂、頭痛等併髮癥.
목적 탐토비내경하상합두내측벽입로절제상합두량성병변적수술경로급수술방법적가행성급료효.방법 2003년6월지2010년8월,채용비내경하경비강비루관전경로화비루관후경로적다충방식절제상합두량성병변139례,기중내번성유두상류43례、진균성상합두염63례、상합두낭종28례、출혈배사성식육3례、골류2례.소유병례술전행CT검사,가의내번성유두상류환자동보행MRI검사.비루관전방경로채취3충방식:리상공입로、루전은와입로(포괄해부비루관화불해부비루관2충방식)、리상공비루관인로,공치료97례；비루관후방경로야채취3충방식:하비갑번전、쌍체하비갑、단체하비갑,공치료42례.관찰환자술후료효.결과전부병례재비내경하경비철저청제병변,보호료비루관,보류료하비갑,무일례발생비루관손상화하비갑배사.술후비새、두통、민창불괄、이미、아동화마목감등증상축보소실.9례감각비강간조,경비강충세등처리후1개월좌우축점소실.수방6 ～79개월,골류화출혈배사성식육미견복발.소유진균성상합두염환자술중균가견두강점막명현수종、증후,술후3개월좌우축점소실,무일례복발.2례상합두낭종환자술후10개월화18개월재상합두기타부위재발,단낭종소차무림상증상미작처리.내번성유두상류환자유3례복발,1례술후17개월상합두구상방국한성종물돌출,병리시유두상류복발,문진여이청리후수방1년미견복발；1례우술후15개월전사처복발,행사두엄범절제후수방3년미견복발；1례술후26개월상합두후외측벽국부복발,이차행체재전방단체하비갑방식수술,술후1년재차복발,행비내경하Denker수술,수방18개월미견복발정상.소유병례술후3개월상합두창면상피、반흔복개,하비갑형태량호,하비도개창자교술중명현반흔변소,차인류통창무폐쇄.결론비내경하비루관전、후경로상합두수술가이감소창상,충분폭로두강시야,병위술후내경복사화복발후적처리제공료시창；보류하비갑피면료비강외측벽거제과다이도치적술후간조、결가、두통등병발증.
Objective To explore the feasibility and effectiveness of the approaches and methodology of the endoscopic surgery for maxillary sinus lesions through the medial wall of the maxillary sinus.Methods From Jun.2003 to Aug.2010,endoscopic surgery through anterior or posterior nasolacrimal duct approaches to remove maxillary sinus lesions were conducted in 139 patients.Among them there were 43 cases with inverted papilloma,63 cases with fungal maxillary sinusitis,28 cases with maxillary sinus cyst,3 cases with hemorrhagic necrotic polyps,and 2 cases with osteomas.All patients underwent preoperative CT scans,and patients with inverted papillomas also had MRI tests.Anterior-nasolacrimal canal paths included 3 ways:pyriform aperture,lacrimal bone recess (dissecting nasolacrimal duct or not were 2 subtypes),pyriform aperture-nasolacrimal duct approaches,and 97 patients were treated.Posterior-nasal lacrimal duct paths were also divided into 3 subtypes:the inferior turbinate flip flap,double pedicle inferior turbinate,single pedicle inferior turbinate,and 42 patients were treated.The postoperative effects were observed.Results All lesions were completely removed under endoscope,the nasolacrimal ducts and inferior turbinates were protected,no nasal lacrimal duct injury and inferior turbinate necrosis were found.Postoperative nasal congestion,headache,swelling discomfort,strange odor,dental pain and numbness and other symptoms gradually disappeared.Nine patients felt nasal dryness,and after nasal washing for about 1 month,the symptom gradually disappeared.Patients were followed up for 6 months to 79 months.In case of osteoma,and hemorrhagic and necrotic polyps,no recurrences were found.Apparent edema,hypertrophy of sinus mucosa could be seen during the surgery in all patients with fungal maxillary sinusitis,and the edema gradually disappeared after 3 months or so,with no relapse.Two cases of maxillary sinus cysts were found in other parts of the maxillary sinus 10 months and 18 months after the surgery,but the cysts were small and asymptomatic,so no further management needed,and they were still under follow-up.Three patients,recurred.In 1 case with inverted papilloma,a local lump on the opening were found 17 months after the surgery,and was removed in out-patient department and pathology showed papillary tumor recurrence,no relapse was found 1 year later; 1 patient had recurrence in anterior ethmoid sinus 15 months after operation,total ethmoidectomy was done and no relapse was found in 3 years.One patient had local recurrence in the posterolateral wall of the maxillary sinus 26 months after operation,and the secondary surgery was done via single pedicle inferior turbinate.The papilloma relapsed again after 1 year,an endoscopic Denker surgery was performed,with no recurrence after 18 months of follow-up.Three months after surgery,the maxillary sinus was scar-covered in all cases.Inferior turbinate maintained good shape,compared to those with inferior nasal meatus windowing surgery.Scars were significantly smaller,but no latch or obstruction of drainage were found.Conclusions Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach can reduce the trauma,fully expose the sinuses,and facilitate postoperative treatment and review with a window.Retained inferior nasal turbinate is helpful to avoid dryness,crusting,headache and other complications due to too much removal of nasal exteral walls.