鼻内镜下犬齿窝径路治疗上颌窦病变

鼻内镜下犬齿窝径路治疗上颌窦病变 【摘要】  探讨一个损伤少～方便快捷且效果好的鼻内镜下的上颌窦手术治疗上颌窦病变。方法:2002年3月至今～设计在患侧唇龈沟第三齿上方做一纵形切口1 1.5?cm～分离至犬齿窝骨质～用骨凿或电钻做1?cm左右的骨孔～清除此处的上颌窦黏膜～置入鼻内镜～检查上颌窦内的病变情况～如果为上颌窦黏膜下囊肿～去除囊壁～妥善止血,上颌窦自然窦口正常者～无须扩大窦口～在上颌窦内的创面上和犬齿窝骨窗处贴附止血纱布～缝合2针～也可以应用耳脑胶粘合。如果为上颌窦息肉～处理方法基本同上颌窦囊肿。如果为上颌窦曲菌病～就需要扩大上颌窦自然窦口1 1.5?cm～鼻腔内可不必填塞～如需扩大自然窦口～可填塞膨胀海绵。结果:36例均一期愈合～鼻腔通畅～症状消失～经过4个月 4年的随访观察～未见病变复发～仅2例有短暂的唇部麻木～7 8?d后康复。2例扩大自然窦口处有肉芽生长～经处理后肉芽消失。结论:本术式有视野清晰～处理病变方便～并发症少～不宜发生严重的反应～窦口引流自然～符合上颌窦黏膜的正常生理特点。 【关键词】  上颌窦 外科手术 犬齿窝     ,ABSTRACT,  Objective: Operation in the maxillary sinus tends to injure the debouchement of the nasolacrimal canal in the inferior nasal meatus and the walls of the fossa orbitalis. We tried to find a program with the least injury, duration and that was the most convenience.  Methods: From March 2002 to the present, we designed an upright cut of 1 to 1.5 cm in the side labiogingival groove of the ill side above the canine tooth, separated to the bone in canine fossa, drilled a  hole of 1 cm with an osteotome or electrodrill, removed the local mucosa, inserted an  endoscope, and inspected the lesions inside. If submucous cysts were found, the  capsule wall was removed and proper hemostasis was performed; if the mucosa was normal, there was   no  need to  enlarge the aperture, an  absorbable hemostatic gauze was laid in the  wound surface and the hole, and sutured with  2 stitches; or adhered with biological glue. In  patients with an  antral polyp, the management was  the same as the cases with sumucosa cyst. In  patients with aspergillosis, we enlarged the apertures to 1 1.5?cm, did  not pack the nasal cavity, if we enlarged the apertures, we may pack expansive sponge. The face was oppressed  with a four head belt,  the plug was taken out  after 48 or 72 hours according to the pathogenetic condition, and stitches  were taken out after 4 or 5 days. Results: Primary healing was found in all 36 cases, with an unobstructed nasal cavity and disappearance of the symptom. No relapse was found in the period of four months to four  years of followup; only 2 cases complained about transient numbness in the  upper lips. All patients recovered after 7 8 days. Granulations were found in the enlarged aperture in 2 cases, and they disappeared after treatment. Conclusion: The feature ofthe operation is the  small upright cut in the labiogingival grooves, small windowing in canine fossa, and delicate operation in the   sinus cavity with a clear visual field. Lesions  may be treated conveniently, which lead to less complications and less severe reactions. The  maxillary sinus drains naturally, accords to the normal physiological functions and  also  problems are avoided that happen in other approaches.     ,KEY WORDS,  Sinus; Surgica 1l procedures, operative; Canine tooth fossa    1994年起我们用双径路鼻内镜下 处理上颌窦病变～随访观察了大量患者的临床资料,1,～2002 年3月至2006年9月～又单纯应用鼻内镜下的犬齿窝径路 处理上颌窦病变36例～取得了很好的临床效果～报告如下。     1  资料与方法     1.1  临床资料  36例中 男24例～女12例,26 52岁～平均38岁。其中上颌窦黏膜 下囊肿27例,上颌窦息肉6例,上颌窦曲菌病3例。     1.2  手术方法  行患侧 眶下神经阻滞麻醉及唇龈沟黏膜下浸润麻醉～鼻腔内应用1% 丁卡因棉片行黏膜表面麻醉。在患侧唇龈沟第三齿上方做一 1 1.5?cm的纵形切口(封三彩图6)～分离至犬齿窝骨质(封 三彩图7)～置入拉钩～应用骨凿或电钻做1?cm左右的骨孔 ,封三彩图8,～清除此处的上颌窦黏膜～置入鼻内镜～检查 上颌窦内的病变情况～如果为上颌窦黏膜下囊肿～去除囊壁～妥善止血～上颌窦自然窦口正常者～无须扩大窦口～在上颌窦内的创面上和犬齿窝骨窗处贴附止血纱布～缝合2针～也可以应用耳脑胶粘合,封三彩图9,。如果为上颌窦息肉～处理方法基本同上颌窦囊肿者。如果为上颌窦曲菌病～就需要扩大上颌窦自然窦口1 1.5?cm～鼻腔内可以不必填塞～如果扩大自然窦口～可以填塞膨胀海绵。面部应用四头带压迫固定～根据病变情况在48?h或72?h时取出填塞物～4 5?d拆线。     2  结  果     36例均一期愈合～鼻腔通畅～症状消失～经过4个月 4年的随访观察～未见病变复发～仅2例有短暂的唇部麻木～7 8?d后康复,2例扩大自然窦口处有肉芽生长～经处理后肉芽消失。     3  讨  论     3.1  上颌窦手术的有关问题  鼻内镜下的上颌窦手术是近几年比较盛行的手术方法～手术径路主要有经下鼻道径路、上颌窦自然窦口径路、 下鼻道-犬齿窝双径路,2,。经过多年的临床观察～我们发现这三种径路都有缺陷～第一种容易损伤鼻泪管的下鼻道开口,第二种容易损伤眶壁,第三种有第一种的缺陷～费事且损伤大。前两者均不容易观察到上颌窦的各个壁～后者因为置入两个穿刺针～从穿刺针操作～有些钳子不能进入～所以容易遗留病变～如何解决这些问题～是临床上需要注意的。古老的柯-陆氏手术盛行了百多年～为众多的上颌窦病变的患者解除了疾苦～但是柯-陆氏手术后遗留面部的麻木感～彻底的黏膜的清除～下鼻道的造口等都是引发手术效果不佳和容易出现并发症的问题。     3.2  径路的选择应用  我们经过几年的探索研究～采用经唇龈沟处做小的纵切口～避免了横切口所带来的面部麻木的弊病～而在暴露好的犬齿窝仅做1?cm左右的骨孔即可～鼻内窥镜和器械可以一起进入上颌窦内～恰如其分、视野清晰的处理上颌窦病变～如果处理完病变～上颌窦口是正常的～妥善止血后就可以结束手术。如果上颌窦口处有病变需要处理～就从上颌窦内扩大窦口～尽量避免下鼻道的造口。     3.3  关于上颌窦黏膜的处理  上颌窦黏液毯引流方向不管如何造口～始终都是向 着自然窦口的,3,～所以手术时尽量保留窦腔内的黏膜～上颌窦的自然窦口如果正常～不要轻易扩大～就是有轻微的黏膜病变～也要尽量保留～手术后采用药物治疗以恢复至正常组织,4,。     3.4  本手术的特点  经过唇龈沟的纵形小切口～犬齿窝的小骨窗～窦腔内的轻巧的处理～是本手术的特点～有视野清晰～处理方便～并发症少～手术简单快捷～严重并发症少～自然窦口引流自然～符合上颌窦黏膜的正常生理特点～又避免了其他径路容易发生的各种问题。   【参考文献】   ,1, 张庆泉～张宝玉～陈秀梅～等. 双径路鼻内镜下治疗上颌窦良性病变,J,.山东医大基础医学院学报～2000～14,3,:168 169. ,2, 于德林～马有祥. 鼻内镜双径路治疗上颌窦病变,J,.临床耳鼻咽喉科杂志～1998～12,2,:90 91. ,3, Maeyama T. A study of experimental sinusitis in rabbit,J,. Auris Nasus Larynx, 1981, 8:87. ,4, Ohashi Y, Nakai T. Functional and morphological pathology of chronic sinusis mucous membrane,J,. Acta Otolaryngol, 1983, (suppl 397):11.