Clinical study on endoscopic surgery for soft tissue necrosis of cranial base after radiotherapy for nasopharyngeal carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the diagnosis and surgical treatment of patients with soft tissue necrosis of cranial base after radiotherapy for nasopharyngeal carcinoma (NPC). Methods: The clinical data of 7 NPC patients with soft tissue necrosis but not bone necrosis after radiotherapy were retrospectively analyzed.They were treated in Xiangya Hospital from 2015 to 2019. The clinical manifestations, diagnosis, treatment and prognosis were analyzed. The major clinical symptoms of the 7 patients were headache in 7 cases, hearing loss in 7 cases, long-term nasal malodor in 5 cases and epistaxis in 2 cases. All patients underwent high-resolution CT, MR and magnetic resonance angiography (MRA) before operation. All cases were treated with extended transnasal endoscopic approach under general anesthesia for resection of necrotic tissue. Five cases had their affected cartilaginous segments of the eustachian tubes partially or completely resected, 7 cases were treated with myringotomy and tube insertion, and 1 case was treated with pansinusectomy. Anti-inflammatory treatment were carried out during the perioperative period. The recovery of patients was observed and recorded through regular follow-up (from 6 months to 3 years) after the operation. Results: Nasopharynx soft tissue lesions can be seen in seven patients with bone cortex integrity by CT, and small bubble shadow can be seen at junction area between skull base soft tissue lesions and skull base bone surface.MR and MRA examination showed extensive inflammatory changes of nasopharynx. Parapharyngeal irregular necrotic cavity was found in 6 cases without central enhancement, demonstrating edema of surrounding soft tissue. The necrotic tissue of all 7 patients was surgically removed. Postoperative pathological examinations confirmed that all of them were necrotic soft and cartilaginous tissue, without tumor recurrence. The symptoms of all patients were significantly alleviated after operation. Headache was cured in 5 cases and relieved in 2 cases. Nasal malodor was cured in 4 cases and alleviated in 1 case. During the follow-up period, 5 patients survived, and 2 patients who had their eustachian tube reserved died. One of them died of nasopharyngeal hemorrhage caused by recurrent nasopharyngeal necrosis 3 months after the operation. Another case died of severe intracranial infection 6 months after operation. Conclusions: The diagnosis of skull base soft tissue necrosis after radiotherapy for nasopharyngeal carcinoma needs comprehensive analysis of radiotherapy history, clinical manifestations and imaging examination. High resolution CT, MR and MRA of skull base are very important for diagnosis. Early active removal of large-scale necrotic lesions under endoscope and partial or total resection of eustachian tube cartilage according to the involvement of eustachian tube cartilage is effective means of controling skull base soft tissue necrosis after radiotherapy. The effective means of necrosis can improve the quality of life of patients.

Resection of parapharyngeal neoplasms via styloid diaphragm approach / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To evaluate the surgical technique and efficacy of the resection of parapharyngeal space neoplasm via styloid diaphragm approach.</p><p><b>METHODS</b>Thirty-three cases underwent the resection of parapharyngeal space tumors via styloid diaphragm approach from Jan 2005 to Jan 2011 were reviewed. Of the cases, 28 were with benign tumors treated by surgery alone, and 5 were malignant tumors treated by surgery plus postoperative radical radiotherapy.</p><p><b>RESULTS</b>The parapharyngeal neoplasms in all cases were completely resected via styloid diaphragm approach. The postoperative follow-up ranged from 13 months to 7 years (median = 4.6 years). No tumor recurrence was found in 30 cases, but 3 cases experienced tumor recurrence, including 1 chondrosarcoma (3 years after surgery and chemoradiotherapy), 1 chordoma and 1 adenoid cystic carcinoma (5 years after surgery and radiotherapy). Severe postoperative complications were not observed, but 2 cases showed mild mouth askew and fully recovered after 3 months, and 1 case was complicated with hoarseness and cough symptoms that disappeared after heteropathy.</p><p><b>CONCLUSION</b>Resection of parapharyngeal neoplasms via styloid diaphragm approach is an ideal surgical technique, with well-exposed surgical field, less tissue injury, and less postoperative complication.</p>

Endoscopic posterior septectomy for patients with nasopharyngeal tumor / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To explore the techniques, advantages and disadvantages, indications and cautions of a surgical approach for the resection of nasopharyngeal tumor.</p><p><b>METHODS</b>Ten cases with nasopharyngeal tumors were recruited in this study, of them, 3 cases with residual nasopharyngeal carcinoma after chemoradiotherapy, 2 cases with cavernous angioma, 2 cases with benign mixed tumor, 1 malignant mixed tumor, 1 adenoid cystic carcinoma, and 1 chordoma. All patients underwent endoscopic resection of posteroinferior quarter part of nasal septum, and then the removal of nasopharyngeal tumors through bilateral transnasal approach.</p><p><b>RESULTS</b>Total resection of the tumor was achieved for all cases without severe surgical complications. All cases with benign tumors, with following-up of 6-18 months, showed no recurrence. Of 6 cases with malignant tumors, with following-up of 12-48 months, 5 cases showed no recurrence, and 1 case was suspected to relapse one year postoperatively, but not with any lesion enlargement after another 6 month follow-up.</p><p><b>CONCLUSIONS</b>Posteroinferior quarter part of nasal septectomy is preferred for endoscopic resection of nasopharyngeal tumors because it can provide a panoramic view on nasopharyngeal cavity and tumors, thus, facilitating the removal of nasopharyngeal tumors.</p>

Prevention and management of complications of endoscopic surgery for nasal-skull base neoplasms / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To analyze the surgical complications of endoscopic nasal-skull base surgery. The secondary objective was to propose the preliminary strategies for prevention and treatment of complications.</p><p><b>METHODS</b>One hundred and thirty two patients with nasal-skull base tumors undergoing endoscopic or endoscope-assisted surgery were included in this study. Surgical approaches included endoscopic endonasal transethmoidal approaches, endoscopic endonasal transseptal transsphenoidal approach, extended endoscopic endonasal transseptal transsphenoidal approach, endoscopic transmaxillary posttrial wall approach, extended endoscopic transmaxillary posttrial wall approach, endoscopic nasal lateral wall dissection, maxillary osteotomy approach and endoscopic transoropharyngeal approach. These approaches were selectively used to resect the tumors in the area of nasal-skull base.</p><p><b>RESULTS</b>The total resection of the tumors was obtained in 104 patients (104/132, 78.8%), with 29.5% (39/132) incidence of complications, including profuse bleeding, nerve injury, cerebrospinal fluid leakage, diabetes insipidus, electrolyte imbalance, hyperglycemia, and psychological disturbance. No catastrophic complications, sequelae and operative mortality encountered. Four months to 8 years' follow up (median 3.0 years) indicated that recurrence rate of the benign tumor was 9% (9/100) without died case, and 3-year and 5-year survival rates of the malignant tumor were 75.0% and 55.6%, respectively.</p><p><b>CONCLUSIONS</b>Strategies proved to be effective in reduction of the overall incidence of the complications, especially in minimizing the catastrophic complications and sequelae. The strategies were as follows: first, according to original site, extension and characteristics of the tumor, designing appropriate endoscopic approaches for the treatment of skull base tumor; second, recognizing reliable surgical access points and safe plane of the dissection; third, predicting surgical risks preoperatively and proposing the corresponding plan to avoid these risks; fourth, acquainted with the endoscopic skills and familiarized the skull base structures; lastly, ensuring the correct management of the interdisciplinary problems with close collaboration with the interdisciplinary medical personnels.</p>

Surgical approaches for different stages of nasopharyngeal angiofibromas / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To explore the optical surgical approaches for the resection of early and advanced stage of nasopharyngeal angiofibromas.</p><p><b>METHODS</b>Twenty two male patients aged 9 - 30 years (median 16 years) hospitalized in Xiangya Hospital from June 2003 to July 2006 with nasopharyngeal angiofibroma were recruited. Five operative approaches were selected according classification of juvenile nasopharyngeal angiofibroma described by Fisch. Six cases with stage I nasopharyngeal angiofibroma underwent endoscopic transnasal surgery. Six cases with stage II and 2 cases with stage III underwent endoscopic endonasal middle meatal transmaxillary-antrum approach. Three cases with stage III and 2 cases with stage IV underwent endoscopic endonasal middle and inferior meatal approach with extended transmaxillary-antrum resection. One case with stage IV underwent microscopic preauricula infratemporal fossa approaches combined with endoscopic endonasal middle and inferior meatal transantral approach. Two cases with stage IV underwent nasomaxillary osteotomy approach.</p><p><b>RESULTS</b>After surgery, CT scan or MR image showed that total removal of the tumor was achieved in 21 patients. One patient who received subtotal resection were performed by second endoscopic surgery and obtained total resection. No postoperative complications have been encountered in all treated patients. Nine months to 3 years follow up indicated that no cases recurred after surgery.</p><p><b>CONCLUSIONS</b>Appropriate surgical approach should be selected according to the clinical classification and whether the tumor has extended into whole nasal cavity, lateral fossa infratemporalis, intracranial or not. Such approaches might better facilitate the complete removal of nasopharyngeal angiofibromas and reduce the surgery-related injury.</p>