RU2566203C2 - Method of ablating juvenile skull base angiofibroma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used in ablation of juvenile nasopharyngeal and skull base angiofibroma. transnasal endoscopic access is realised. Tumour is removed from nasal cavity centripetally with partial resection of lower edge of middle nasal turbinate. Antrostomy is realised at the level of natural anastomosis in case of expressed extension of tumour into pterygopalatine and infratemporal fossae. In case of inessential extension of tumour into pterygopalatine fossa antrostomy is realised at the level of posterior end of middle nasal turbinate. Ablation of tumour from lumen of sphenoid sinus is realised by direct transnasal access with resection of superior nasal turbinate and ablation of anterior wall of sinus by means of bone cutting-off pliers. Exposure of tumour part, located on posterior parts of nasal cavity and nasopharynx on the opposite side, is realised biportally through both halves of nasal cavity, with preservation of posterior parts of nasal septum.

EFFECT: method makes it possible to ablate tumour in radical way from the least traumatic access with preservation of a number of anatomical structures and avoid formation of large post-operational cavity.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in removing juvenile angiofibroma of the nasopharynx and base of the skull

Currently, the term "juvenile nasopharyngeal angiofibroma" (Juvenile Nasopharyngeal Angiofibroma) is generally accepted in foreign English-language literature. In Russian-language literature, the name "youthful angiofibroma of the base of the skull" is proposed and used.

Juvenile angiofibroma of the base of the skull (hereinafter - SAOCH) refers to benign tumors of mesenchymal origin and has a pronounced destructive growth. The disease occurs only in male adolescents during puberty. The frequency of occurrence ranges from 1-3 to 5 cases per year per 10,000 patients with head and neck tumors.

YuAOCH looks like a tumor of dense consistency (sometimes cartilage density), cyanotic in color with a smooth surface on which blood vessels, hemorrhages, and areas of necrosis can be traced. Given the angiomatous structure of the tumor, damage to it or an attempt to remove it leads to massive bleeding.

The tumor begins to grow, as a rule, from the pharyngeal-main fascia, filling the nasopharynx and nasal cavity in the early stages (mainly on one side). At a later date, the neoplasm fills the sphenoid sinus, maxillary sinus, pterygopalatine and infratemporal fossae, located in the latter in the form of dumbbell processes. In advanced cases, angiofibroma destroys the walls of the orbit, grows into the anterior and middle cranial fossae, the cavernous sinus, leading to serious complications.

Currently, surgical removal is the main treatment for SAOCH.

A known method of removing juvenile angiofibroma of the base of the skull, including the use of an intranasal endoscopic technique (Ph. Eloy, et al., "Endonasal endoscopic resection of juvenile nasopharyngeal angiofibroma", Rhinology, 2007, Vol.45, No. 1, p.24-30).

When using this method, the following actions are performed.

The first stage, to visualize the upper parts of the SJAOC, perform anterior and posterior ethmoidectomy with resection of the middle turbinate, medial anthrostomy. This allows you to identify the perpendicular plate of the palatine bone.

The flap of the mucous membrane of the lateral wall is taken up and posterior to the region of the posterior end of the middle nasal concha to expose the wedge-palatine opening and to monitor the effectiveness of embolization of the maxillary artery.

Then put metal clips on the main trunk or terminal branches of a.sphenopalatina, remove the perpendicular plate of the palatine bone and the posterior wall of the maxillary sinus up and laterally to the infraorbital nerve canal, after which, using the curved aspirator tip and Blakesley 45 ° forceps, the contents of the pterygo-anatomy are isolated.

When the tumor is isolated and brought to the middle of the nasopharynx, a resection of the bone part of the nasal septum is performed.

Tumor growth in the sinus of the sphenoid bone is removed with curved forceps, then the bottom of the sinus is reamed. The internal adductor arteries coagulate with bipolar coagulation or are pressed with adrenaline turundas. After isolation of the tumor, it is reduced to the oral cavity and removed in a single block.

The disadvantage of this method is the high invasiveness when removing the tumor due to the formation of a large postoperative cavity.

All cells of the ethmoid labyrinth are removed with a resection of the middle nasal concha to visualize the neoplasms that extend into the sphenoid sinus, and the bone part of the nasal septum is resected to visualize the posterior parts of the opposite side of the nasal cavity and nasopharynx.

There is also a transnasal endoscopic method for removing juvenile angiofibroma of the skull base (Renuka A., Bradoo R.A., Muranjan SN, Nerurkar N.K. et al., “Endoscopic Excision of Angiofibroma: a comprehensive approach”, Indian Journal of Otolaryngology and Head and Neck Surgery, 2003, No. 55 (4), p. 255-262).

When using this method, the following actions are performed.

A thorough audit of the nasal cavity is carried out using endoscopes 0 °, 30 °, 45 °, assessment of the prevalence of the tumor and its fusion with the anatomical formations of the nasal cavity.

Dissection of the neoplasm from the middle and lower nasal concha is carried out, partial resection of the middle nasal concha to achieve greater visibility, anthrostomy and removal of the medial and posterolateral walls of the maxillary sinus to provide access to the pterygopalatine and temporal fossae.

Then carry out the selection of the tumor from the above anatomical formations, clipping the maxillary artery, ethmoidectomy and transetmoid opening of the sphenoid sinus.

The anterior and lower walls of the sphenoid sinus are removed with the tumor removed from its lumen, the tumor is separated from the posterior sections of the nasal septum and the posterior-lateral walls of the nasopharynx, and the tumor is removed through the oropharynx.

In this case, mono- and bipolar coagulation is used at all stages of the operation to achieve the best hemostatic effect.

The disadvantage of this method is the high invasiveness when removing the tumor due to the formation of a large postoperative cavity.

Perform ethmoidectomy in the absence of a tumor in the cells of the ethmoid labyrinth; transetmoid opening of the sphenoid sinus in combination with the release of education with the help of additional coagulation.

The disadvantage of this method is that they coagulate and clip the maxillary artery, without taking into account the fact that adequate superselective embolization of the tumor-feeding arteries provides the necessary hemostasis.

Closest to the technical nature of the claimed solution is a method of removing juvenile angiofibroma of the skull base (D. N. Kapitanov et al. “Endoscopic endonasal access when removing juvenile angiofibroma of the nasopharynx”, Russian Rhinology, 2009, No. 4, pp. 18-21).

This method is as follows.

Endoscopic removal of the tumor is carried out during the first two days after selective embolization of the vessels feeding the tumor under endotracheal anesthesia.

Two surgeons participate in the operation using the “four arms” technique. They access the area of the pterygopalatine fossa and the lower wall of the orbit, widely opening the maxillary sinus according to the standard method, and remove its posterior wall.

Then the tumor is isolated from the area of the pterygopalatine fossa, if possible, clipping of the blood supply vessels is carried out.

The tumor node is separated from the nasal septum, bipolar coagulation of the area of attachment of the tumor to the septum until it is completely isolated, resection of the posterior edge of the vomer directly before the tumor is performed.

Then the tumor is isolated by displacing it down and posteriorly, into the choana and the nasopharynx, sphenoidotomy is performed, traction of the node located in the sphenoid sinus, the tumor is isolated from the posterior-upper and lateral walls of the nasopharynx with a wide suction-raspator.

At the end of the operation, the tumor is displaced into the oropharynx and removed through the oral cavity, the operating cavity is revised, and small vessels are coagulated.

The disadvantages of the method are: resection of the bone part of the nasal septum to visualize the posterior portions of the opposite side of the nasal cavity, which leads to bleeding from the terminal branches a. sphenopalatina; the allocation of education using additional coagulation of the periosteum, wide anthrostomy, which in turn leads to the formation of a large postoperative cavity.

The technical result of the proposed solution is to reduce the morbidity when removing the tumor, to reduce the postoperative cavity.

To achieve the specified technical result in a method for removing juvenile angiofibroma of the base of the skull localized in the nasal cavity, nasopharynx, sphenoid sinus, pterygopalatine fossa and reaching the infratemporal fossa, including transnasal endoscopic access, performing an anthrostomy to remove the tumor from the pterygopalatine fossa, according to the proposal, the tumor is removed nasal cavities centripetally with partial resection of the lower edge of the middle nasal concha, carry out an anthrostomy at the level of the natural anastomosis when expressed the spread of the tumor into the pterygopalatine and infratemporal fossa, and with a slight spread of the tumor into the pterygopalatine fossa - at the level of the posterior end of the middle nasal concha, while the tumor is removed from the lumen of the sphenoid sinus by direct transnasal access with resection of the superior nasal concha and removal of the anterior sinus wall using of bite bites, the allocation of the part of the tumor located in the posterior sections of the nasal cavity and the nasopharynx on the opposite side is carried out biportally through both halves nasal cavity, keeping the back of the nasal septum.

The method is illustrated by drawings, where in FIG. 1 depicts the step of resection of the lower edge of the middle turbinate; in FIG. 2 shows the centripetal tumor isolation from the opposite side; in FIG. 3 presents the stage of anthrostomy; in FIG. 4 shows the opening of the pterygopalatine fossa; in FIG. 5 shows the step of removing a tumor from the sphenoid sinus, and removing the tumor from the pterygopalatine fossa.

The following positions are used in the drawings: 1 - tumor; 2 - middle nasal concha; 3 - raspator; 4 - nasal septum; 5 - gauze turunda; 6 - pterygopalatine fossa; 7 - sphenoid sinus; 8 - maxillary sinus; 9 - the back wall of the maxillary sinus; 10 - Carrison's bone bite; 11 - Blakesley tongs.

The method is as follows.

Endonasal interventions are performed using the Karl Stortz endoscopic stand and 0 °, 30 °, and 90 ° optics under endotracheal anesthesia for the first two days after preliminary superselective embolization of the vessels supplying the tumor.

To achieve maximum vasoconstriction, turunds moistened with 10% s solution are injected into the nasal cavity. lidocaini with drops of adrenaline.

Then the tumor 1 is visualized, the edges of the tumor 1 are examined, its free spots and its exact attachment site are determined.

The lower free edge of the middle turbinate 2 is resected, its medialization is performed (Fig. 1). Then, with the help of endoscopic raspators 3, a centripetal separation of the tumor 1 from its attachment site is performed, for example, the lateral surfaces of the nasopharynx, the posterior sections of the nasal septum 4, and the nasopharynx arch. Resection of the posterior nasal septum 4 is not performed. Isolation of tumor 1 in the posterior parts of the nasal cavity and nasopharynx on the opposite side is carried out through the corresponding half biportally (through both halves of the nasal cavity) (Fig. 2).

In the process of tumor isolation, 1 mobilized, free areas are squeezed to the nasopharynx using wide gauze turundas 5, which allows you to freely work in the deeper lateral sections of the nasal cavity, pterygopalatine fossa 6 and sphenoid sinus 7.

When the tumor 1 is located in the area of the pterygopalatine fossa 6, to create an approach to the neoplasm, a partial resection of the medial wall of the maxillary sinus 8 - (anthrostomy) is performed on the affected side (Fig. 3).

The level of anthrostomy is determined by the degree of spread of the tumor 1 into the pterygopalatine fossa 6. In the case of pronounced spread, the medial wall of the maxillary sinus 8 is opened at the level of the natural anastomosis of the maxillary sinus 8.

With a slight growth of the tumor 1 towards the pterygopalatine fossa 6, the anthrostomy is performed at the level of the posterior end of the middle nasal turbinate 2. This allows, in the first case, to provide the necessary overview for the isolation of the tumor 1 from the lateral sections of the pterygopalatine fossa 6, and in the second, to preserve the medial wall as much as possible maxillary sinus 8.

The thin medial wall of the maxillary sinus 8 is opened using a raspator 3, entering the lumen of the sinus, using the bone forceps, the medial wall is removed to the posterior portions, a part of the thinned, crushed tumor 1 anterior to the posterior wall of the maxillary sinus 9 is removed using the Kerrison bite 10 (Fig. four).

Thus, create the necessary space for the allocation of tumors from the pterygopalatine fossa 6.

Then carry out the removal of the "spurs" of the tumor 1 from the sphenoid sinus 7 using forceps Blakesley 11, while making a resection of the upper turbinate. The thinned anterior wall and fragments of the lower wall of the sphenoid sinus are removed using a raspator 3 and bone cutters 10. Tumor 1 is removed from the pterygopalatine fossa 6, placed into the oropharynx and removed with forceps in a single block through the oral cavity, under endonasal control (Fig. 5).

The method is illustrated by the following examples.

Example 1. Patient S., born in 1994 He entered the clinic of the Department of Ear Pathophysiology of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech of the Ministry of Health and Social Development of the Russian Federation with complaints of gradually increasing difficulty in nasal breathing, periodic nosebleeds.

From the anamnesis it is known: considers himself sick since December 2009. Objectively: the bulging of the cheek-cheekbone region is determined on the left, nasal breathing is absent. With endoscopy: the nasal mucosa is pink, the nasal concha are swollen, in the left half of the nasal cavity is a neoplasm of cyanotic color, round, dense texture, sometimes covered with fibrin, filling the nasal cavity on the left, the posterior parts of the nasal cavity on the right, nasopharynx.

Computed tomography and magnetic resonance imaging of the paranasal sinuses were performed - a picture of a nasopharyngeal neoplasm with spreading into the nasal cavity, ethmoid labyrinth cells on the left in the left half of the sphenoid sinus, left pterygopalatine fossa. The histological conclusion is juvenile angiofibroma.

To plan possible intraoperative blood loss, the patient underwent angiography followed by embolization of the vessels supplying the tumor.

On angiograms in the projection of the base of the skull, a hypervascular neoplasm is determined, more on the left, which is supplied mainly from the pool of the left and right maxillary arteries. The internal carotid arteries do not participate in the blood supply. Performed embolization of the right maxillary artery and embolization of the collaterals of the left maxillary artery.

Surgical intervention was performed - removal of the tumor from the endonasal access under the control of endovideo equipment.

Intervention was performed using an Karl Stortz endoscopic stand and 0 °, 30 ° and 90 ° optics under endotracheal anesthesia.

Turundas moistened with 10% s solution are installed in the nasal cavity. Lidocaini with drops of adrenaline. The lateral position of the inferior nasal concha was made on the affected side using a direct raspator. The lower free edge of the middle turbinate was resected with a part of the tumor “soldered” to it, its medialization was performed.

Then, with the help of endoscopic raspators, a centripetal separation of the tumor from the lateral surfaces of the nasopharynx, posterior sections of the nasal septum, nasopharyngeal arch, anterior wall of the sphenoid sinus was performed. In the process of tumor isolation, mobilized, free areas were squeezed to the nasopharynx using wide gauze turundas. A partial resection of the medial wall of the maxillary sinus on the left was made.

The thin medial wall of the maxillary sinus was opened using a raspator at the level of the natural anastomosis, entering the lumen of the sinus, using the bone forceps, the medial wall was removed to the posterior portions, a part of the thinned, crushed by the tumor anterior, posterior wall of the maxillary sinus was removed with the help of a vykuser bent spoons.

The removal of the "spurs" of the tumor from the sphenoid sinus was performed, while the upper turbinate was resected. The thinned anterior wall and fragments of the lower wall of the sphenoid sinus were removed using a raspator and bone bites.

The tumor is reduced into the oropharynx and removed with forceps in a single block through the oral cavity, under endonasal control and with parallel traction of the part of the tumor located in the pterygo-pit.

The nasal cavity was loose plugged. Blood loss was 400 ml. No bleeding was observed.

Example 2. Patient S., 15 years old, was admitted to the surgical clinic of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech of the Ministry of Health and Social Development of the Russian Federation with complaints of difficulty in nasal breathing on the right, periodic nosebleeds from the right half of the nose.

From the anamnesis it is known: considers himself sick for 6 months. With endoscopy: the nasal mucosa is pink, the nasal concha is moderately swollen, in the right half of the nasal cavity, a cyanotic neoplasm spreading into the nasopharynx from the lower edge of the middle nasal concha, rounded, of a dense consistency, the left half of the nose is free, the nasopharynx is 2/3 performed by the neoplasm.

Computed tomography and magnetic resonance imaging were performed - a picture of a nasopharyngeal neoplasm with spreading to the right half of the nose, right half of the sphenoid sinus, slightly to the right pterygopalatine fossa. The histological conclusion is juvenile angiofibroma. The patient underwent angiography followed by embolization of the vessels supplying the tumor. On angiograms in the projection of the base of the skull, a hypervascular neoplasm is determined, more to the right. The blood supply is mainly from the pool of the right v / h artery. The internal carotid arteries do not participate in the blood supply. Performed embolization of the right v / h artery.

Surgical intervention was performed - removal of the tumor from the endonasal access under the control of endovideo equipment. Intervention was performed using an Karl Stortz endoscopic stand and 0 °, 30 °, and 90 ° optics under endotracheal anesthesia. After anemization of the mucous membrane of the nasal cavity, the lateral position of the right lower nasal concha was performed. The lower free edge of the middle nasal concha was resected with a part of the tumor “soldered” to it, its lateral position was performed. Then, with the help of endoscopic raspators, a centripetal tumor was isolated from the lateral surfaces of the nasopharynx, posterior sections of the nasal septum, nasopharyngeal arch, and the anterior wall of the sphenoid sinus. A partial resection of the medial wall of the maxillary sinus was performed on the right at the level of the posterior end of the middle nasal concha. The thin medial wall of the maxillary sinus, the perpendicular process of the palatine bone, and part of the posterior wall of the maxillary sinus were removed using the Kerrison bite. The spurs of the tumor were removed from the sphenoid sinus, while the resection of the superior turbinate, removal of the thinned anterior wall and fragments of the lower wall of the sphenoid sinus was performed. The tumor was reduced into the oropharynx and was removed with forceps in a single block through the oral cavity, under endonasal control. Tampons are installed in the nasal cavity. Blood loss was 250 ml. Postoperative bleeding was not observed.

The inventive method allows you to perform a gentle anthrostomy at the level of the middle and posterior third of the middle turbinate, and, as a result, allows you to save the front of the medial wall of the maxillary sinus and provide access to the pterygopalatine fossa. Also, the inventive method allows at the stage of tumor isolation in the posterior sections of the nasal cavity and nasopharynx not to remove the posterior part of the nasal septum, and, as a result, avoids bleeding from the terminal branches a. sphenopalatina of the opposite side. Isolation of the tumor is performed biportally - through both halves of the nose.

Thus, the claimed method allows to radically remove the tumor from all the anatomical regions involved in the pathological process from less traumatic access while maintaining a number of anatomical structures, to avoid the formation of a large postoperative cavity and to shorten the duration of the hospital stage.

Claims (1)

A method for removing juvenile angiofibroma of the base of the skull localized in the nasal cavity, nasopharynx, sphenoid sinus, pterygopalatine fossa and reaching the infratemporal fossa, including transnasal endoscopic access, performing an anthrostomy to remove the tumor from the pterygopalatine fossa, characterized in that the tumor is removed from the nasal cavity from the center by resection of the lower edge of the middle nasal concha, an anthrostomy is performed at the level of the natural anastomosis with a pronounced spread of the tumor into the pterygopalatine and temporal the fossa, and with a slight spread of the tumor into the pterygopalatine fossa - at the level of the posterior end of the middle nasal concha, the tumor is removed from the lumen of the sphenoid sinus by direct transnasal access with resection of the superior nasal concha and removal of the anterior sinus wall using bone cutters, isolation of part of the tumor located in the posterior sections of the nasal cavity and the nasopharynx on the opposite side, biportally through both halves of the nasal cavity, while maintaining the posterior sections of the nasal septum .

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