The reliable treatment choice of nasopharyngeal angiofibroma and causes of operative bleeding / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To introduce the efficacy of three surgical options for juvenile nasopharyngeal angiofibroma (JNA) resection, and causes of operative bleeding.@*METHOD@#Retrospective analysis of 36 JNAs,three surgical options were used to resect the tumor. There were 15 cases of Class I tumors , using endoscopic nasal cavity approach. Eighteen cases of class II tumors, via extended Caldwell-Luk incision, using the transantral-infratemporal fosse-nasal cavity combined approach for tumor resection. Three cases of class III tumors, the combined intracranial and extra-cranial approach was used to resect the tumor. Meanwhile, report six typical cases for reference.@*RESULT@#Fifteen (15/36) cases of class I tumors, 14 cases were completely resected for the first time without recurrence, 1 recurrence case was re-resected using the same approach. Eighteen (18/36) cases of class II tumors, 13 cases were completely resected for the first time without recurrence, 5 recurrence cases were re-resected totally. Three (3/36) cases of class III were not completely removed, and underwent about 40 Gy radiotherapy with good effects.@*CONCLUSION@#Using these three surgical options can effectively remove different types of JNA. When necessary, the intracranial residue can use radiotherapy. Under direct vision to separate the tumor, and effective hemostasis play crucial roles for complete removal of the tumor.

Management of pterygoid venous plexus hemorrhage during resection of a large juvenile nasopharyngeal angiofibroma: a review of 27 cases.

We retrospectively reviewed the cases of 27 patients who experienced intraoperative bleeding during resection of a large (Fisch type III or IV) juvenile nasopharyngeal angiofibroma (JNA). Of this group, 16 patients had a type III JNA and 11 had a type IV tumor. The degree of hemorrhaging during excision of these JNAs varied greatly among individual patients. The amount of blood lost ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. In 5 of these cases, both intraoperative observations and imaging data suggested that an important factor in the blood loss was damage to the pterygoid venous plexus (PVP). The PVP communicates with the cavernous sinus, ophthalmic vein, maxillary vein, and facial vein; no valve exists between these veins. In patients with a large JNA, the PVP is usually compressed by or adherent to the tumor. When a PVP is seriously damaged during removal of a JNA, hemorrhaging can be very profuse. Therefore, a suitable surgical approach and appropriate hemostatic procedures should be used to prevent or manage PVP hemorrhage as effectively as possible. We also describe in greater detail 5 typical cases of JNA excision that did (n = 3) and did not (n = 2) involve PVP damage.

Significance of heparanase, bFGF and VEGF in angiogenesis for nasopharyngeal angiofibroma outspreading / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To observe the expression of HPA, bFGF and VEGF in nasopharyngeal angiofibroma, and then explore its significance of inducing angiogenesis in the tumor's expansibility growth.@*METHOD@#The expression of heparanase, bFGF, VEGF and CD105 were examined in 30 (I - II period 9 cases, III - IV period 21 cases) samples from nasopharyngeal angiofibroma and 20 inferior turbinate tissues by immunohistochemical staining technique. The microvascular density (MVD) were measured by the immunohistostaining of CD105. The MVD was analyzed with the clinical stage.@*RESULT@#The positive rates of the HPA, bFGF and VEGF expression in JNA tissues were significantly higher than that in inferior turbinate group (P < 0.05). The positive rates of HPA, bFGF and VEGF expression in III - IV period were obviously higher than that in I - II period (P < 0.05). The expression of bFGF and VEGF in JNA tissues was respectively positive correlated with the HPA (r = by 0.499, 0.582, P < 0.05); In JNA tissues, the mean MVD in both HPA and bFGF positive group was higher than each one single positive group or both negative express group (P < 0.05). And the mean MVD in both HPA and VEGF positive group was higher than each one single positive group or both negative express group (P < 0.05).@*CONCLUSION@#HPA can induce angiogenesis to promote tumor growth by releasing bFGF and VEGF. Targeting the HPA can be a new direction in JNA adjuvant treatment.

Study and analysis on the hemorrhage of pterygoid venous plexus in large nasopharyngeal angiofibroma resection / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To our knowledge, study of the intraoperative profuse bleeding of pterygoid venous plexus (PVP) in large nasopharyngeal angiofibroma resection has not yet been reported. Attention should be paid to this topic in clinical practice.@*METHOD@#From 1981 to 2009, 44 cases of JNAs were treated in our hospital. Twenty-six of 44 cases were large nasopharyngeal angiofibromas according to the Fisch classification system(Fisch type III 16, type IV 10). The amount of intraoperative blood loss in these 26 cases varied from 200 ml to 5200 ml. Factors influencing intraoperative bleeding of 26 large nasopharyngeal angiofibroma resections were analyzed retrospectively. The intra-operative observations and imaging data of three typical cases were hereby studied.@*RESULT@#After embolization of the tumor-supplying branches of the external carotid artery(ECA), both the intraoperative observations and imaging data demonstrated that the pterygoid venous plexus (PVP) played a crucial role in intraoperative hemorrhage.@*CONCLUSION@#PVP in the infratemporal fossa communicates with craniofacial veins. There is no valve between these veins. Once PVP is seriously damaged, venous blood of all craniofacial veins will flow out profusely. In the first operation, the intact PVP in the fatty pad generally can be identified and separated from the tumor by delicate surgical managements. If an unsuccessful operation due to serious hemorrhage had been done previously, then scar tissue might tightly adhere with PVP, tumor and the pterygoid muscles, and separation of the tumor from PVP without bleeding is more difficult. Appropriate surgical approach and correct hemostatic procedure of every bleeding point should be done carefully under direct vision. Using finger or instrument for quick blind dissection should be prohibited.

Lacrimal hyposecretion: a surgical complication of juvenile nasopharyngeal angiofibroma.

PURPOSE: The aim of this study was to evaluate lacrimal hyposecretion in the surgical management of juvenile nasopharyngeal angiofibroma (JNA) and discuss how to prevent and treat this expected surgical complication. MATERIALS AND METHODS: Six cases of JNA were extirpated surgically in the last 3 years in our department. The clinical signs, results of the total tear secretion test (Schirmer I test), imaging studies, surgical findings, and pathologic changes in these cases are reviewed retrospectively. RESULTS: Three of the 6 cases developed an irritated dry eye on the affected side postoperatively as a result of lacrimal hyposecretion, caused by damage to or partial removal of the pterygopalatine ganglion and vidian nerve. On follow-up for 1 to at least 2 years, the clinical signs disappeared in 2 cases, whereas there was no improvement in 1 case. CONCLUSIONS: If a JNA originates near the pterygopalatine foramen adjacent to the pterygopalatine ganglion and vidian nerve, these may be damaged or partially removed intraoperatively. The consequent lacrimal hyposecretion can be a temporary or permanent complication. SIGNIFICANCE: A few reports have described lacrimal hyposecretion as a surgical complication of JNA; there have been no articles reporting the prognosis of this complication or the related pathologic findings of the involved pterygopalatine ganglions. Prevention of this complication remains a clinical challenge.

Perioperative managements of huge lobulated nasopharyngeal angiofibromas with intracranial extensions / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To summarize our experience of successful and failed management in 8 huge lobulated nasopharyngeal angiofibromas with intracranial extensions, and introduce some key points of perioperative treatments.@*METHOD@#Eight male case with an average age of 18 years, were all lobes extending into middle and/or anterior cranial fossa, in which 5 cases revealed blood supply from the internal carotid arteries and 3 cases were reoperated because of recurrence. Preoperatively, the tumor were evaluated by CT, CTA, MRI and/or MRA, and super selective embolization of the feeding arteries were crucial procedures. The combined craniofacial approaches were used to excise these tumors.@*RESULT@#Five cases were removed completely, and 3 cases were removed partly in which 2 were due to serious bleeding caused by lack of DSA technique at that time and 1 were due to neglecting the tumor lobe in the sphenoid sinus of the other side.@*CONCLUSION@#Reasonable perioperative management are very important for control of intra-operative blood loss, complete remodeling of the tumor and avoiding complication.

Early diagnosis and treatment of the tympanic isthmus obstruction / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To evaluate the treatment and diagnosis of early tympanic isthmus obstruction and dysfunction of eustachian tube.@*METHOD@#Three hundred patients (338ears) suffering from early tympanic isthmus obstruction were examinated and observed from 1991 to 2004, and were injected triamcinolone into tympanic cavity at the position of hypokinesis or blockaded the external acoustic meatus according to different state of the illness.@*RESULT@#Two hundred and sixty of three hundred case were cured, thirty cases were improved, ten cases were inefficacy.@*CONCLUSION@#Tympanic isthmus obstruction is a pathognostic type of secretory otitis media. There is significant difference between tympanic isthmus obstruction and secretory otitis media caused by dysfunction of eustachian tube. Prolonged tympanic isthmus obstruction is a reason of primary cholesteatoma of epitympanum's pathogeny. It is important to diagnose and treat of the tympanic isthmus obstruction early.

Significance of a glenoid fossa approach for management of extensive lesions in the lateral skull base.

OBJECTIVE: This article is designed to relate our experiences with a glenoid fossa approach for exposing the outer border of extensive lesions in the lateral skull base. MATERIALS AND METHODS: In this series, there were five large paragangliomas with the longest diameter of 6.5 cm in length, one large jugular schwannoma with extratemporal components, and one severe case of petromastoiditis with otogenic pachymeningitis, edema of the temporal lobe, and mental disorder. All lesions of these cases were treated via a glenoid fossa approach combined with other reasonable approaches. RESULTS: The glenoid fossa approach resulted in crucial advantages: 1) it effectively exposes the outer border of extensive lesions in the lateral skull base; 2) it provides safe distal control of the facial nerve and internal carotid artery in the skull base; 3) it obviates the need for anterior transposition or rerouting of the facial nerve; and 4) it obviates sacrifice of the intact middle ear or section the mandibular condyle. There is no postoperative mandibular dysfunction because the mandibular articular capsule and articular tubercle are kept intact. CONCLUSION: On the basis of our experiences, the glenoid fossa approach is a safe, quick, and useful design for adequate exposure of the outer border of extensive lesions in lateral skull base surgery.

Herpesviridae and laryngeal neoplasia / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the relationship between herpesviridae and malignant or benign laryngeal diseases.Method:128 paraffin-embedded laryngeal squamous cell carcinoma and laryngeal epithelium hyperplastic lesions were detected by polymerase chain reaction (PCR) and PCR-ISH for herpesviridae. Result:HSV-1 was detected in 10 cases by PCR,among them 3 were laryngeal squamous cell carcinoma (LSCC),1 was carcinoma in situ(CIS),4 were laryngeal polyps and 2 were laryngeal keratosis. Except 1 LSCC and 1 CIS, 8 of 10 cases were positive while detected by PCR-ISH. In benign diseases, signals were shown from basal layer to superficial cell; in malignant lesions, the signals were scattered in the diseases.Conclusion:Most of laryngeal diseases were not related to herpesviridae, but HSV-1 may acts as initiator in the development of a few cases.