Endoscopic nasal endoscopic excision of nasal invagination papilloma Zhang Liqiang
Application of anatomy
Same as nasal endoscopic sinus opening.
Overview
Although nasal involute papilloma is a benign tumor, it has a destructive growth pattern, develops rapidly, and is prone to recurrence after surgery, with a recurrence rate of 25-75% and a malignancy rate of 2%. Therefore, it is often treated clinically as a malignant tumor, and the tumor should be completely removed after diagnosis. In the past, lateral nasal dissection, mid-facial lift, and maxillary sinus radical surgery were the commonly used treatment methods. After the introduction of endoscopic sinus surgery, Stammberger (198l) and Wigand (1989) reported that endoscopic nasal and sinus inversion papilloma resection was performed via the nasal cavity, and good results were achieved. Zhang Liqiang, Department of Otolaryngology, Qilu Hospital, Shandong University
The advantages of endoscopic nasal and sinus invasive papilloma resection are: the primary site and invasion area of the tumor can be directly observed under the endoscope, with a clear view; it is conducive to complete removal of the tumor and reduction of recurrence; it is convenient for post-surgical follow-up; and there is no facial scar.
Indications and contraindications of surgery
Indications Limited nasal, septal and maxillary sinus medial wall invagination papilloma; unilateral, solitary; non-recurrent tumor; no evidence of malignancy. Limited recurrence of the tumor after conventional surgery.
Contraindications Malignancy of involuted papilloma.
Pre-surgical preparation
Detailed nasal endoscopy; CT scan of the nasal cavity and sinuses.
Position and anesthesia
The patient is placed in the supine position, routinely disinfected, and sterile towels are placed. 1% bupivacaine/epinephrine solution moistened with cotton nasal mucosal vasoconstriction is used for surface anesthesia. 1% lidocaine epinephrine solution is used for local infiltration anesthesia.
Surgical points
For involuted papilloma in the septal sinus and pterygoid sinus, conventional pterygoid sinus resection is sufficient, and the adjacent mucosa and septum of the tumor should be completely removed.
Maxillary sinus invagination papilloma: fully expand the natural opening of maxillary sinus, upward to the sieve bubble, downward to the inferior turbinate, backward to the posterior wall of maxillary sinus, and forward to the lacrimal bone. If the tumor invades the septal sinus, a complete septal sinus resection should be done to remove all the tumor tissue. To prevent recurrence, the middle turbinate should also be removed. To ensure complete removal of the tumor in the maxillary sinus, a 5-mm trocar puncture needle can be inserted through the canine fossa, and the puncture needle can be withdrawn and the trocar retained. A 30-degree or 70-degree endoscope, or a maxillary sinus stoma through the middle nasal tract or through the canine fossa is applied to visualize the maxillary sinus.
For lesions in the maxillary sinus they can be resected endoscopically with a long-necked forceps through a mid-nasal tract stoma or with a maxillary sinus biopsy forceps through a canine fossa trocar.
For complete removal of the maxillary sinus lining and tumor in the maxillary sinus, two other surgical approaches can be used.
1. endoscopic medial maxillectomy: fully expand the maxillary sinus stoma in the middle nasal tract, posteriorly to the posterior wall of the maxillary sinus, upward to the orbital floor, downward to the inferior turbinate, and forward to the nasolacrimal duct. The posterior 2/3 of the inferior turbinate is excised and the lateral wall of the inferior nasal canal to the nasal floor is removed by applying an electric drill or biting forceps. To protect the nasolacrimal duct, a lacrimal probe can be inserted through the lacrimal punctum to the inferior nasal canal as a marker. If the nasolacrimal duct is already involved, the tumor should also be removed from the nasolacrimal duct and the procedure should be extended forward.
When an involuted papilloma originates in the maxillary sinus, the surgical approach needs to be selected according to the site and extent of tumor involvement. For small tumors in the maxillary sinus, maxillary sinus opening to the maxillary sinus can be done in a spacious call, combined with acinar fossa puncture. The endoscope is placed at the mouth of the maxillary sinus and the instruments are inserted into the maxillary sinus through the apical fossa puncture, although the endoscope and instruments can be switched. With this technique, it is possible to reach almost anywhere in the maxillary sinus, the only area that cannot be fully reached is the anterior wall of the maxillary sinus. If the tumor is located in the anterior wall, an endoscopic medial maxillectomy is necessary to remove it completely. If reaching the anterior wall is still difficult, interventional instrumentation at the acinar fossa puncture may be helpful. If this does not provide sufficient access to the anterior wall, an incision is made anteriorly in the septum of the contralateral nostril, a small portion of cartilage is removed, and the mucoperiosteum of the affected septum is incised slightly posterior to the contralateral septal incision, allowing the instrumentation to pass through the septum of the contralateral nostril to reach the maxillary sinus. This increases the angle of instrumentation movement and allows complete access to the anterior maxillary sinus wall.
Surgical technique for endoscopic medial maxillectomy: First, bupivacaine and epinephrine-soaked cotton pads are placed in the nasal cavity, and the lateral wall of the nasal cavity and septum are infiltrated with 2% lidocaine and 1:80,000 epinephrine. The pterygopalatine fossa was closed with 2 ml of lidocaine epinephrine injected into the palatine foramen magnum. This reduces bleeding during incision of the medial maxillary wall and the pterygopalatine fossa. The hooked process is removed and the maxillary sinus opening is enlarged to the posterior wall of the maxillary sinus. This often requires electrocoagulation of the anterior branch of the pterygopalatine artery. The maxillary sinus opening is opened upward to the orbital floor. The inferior turbinate is removed in its entirety with inferior turbinate scissors. A scalpel is used to make a longitudinal incision from the level of the orbital floor along the anterior border of the inferior turbinate, down to the nasal floor and then along the lateral aspect of the nasal floor where it intersects with the inner wall of the maxillary sinus and back to where it intersects with the coronal plane of the posterior wall of the maxillary sinus. The full length of the anterior lacrimal crest is excised with a biting forceps and a grinding drill, and the lacrimal sac is removed, preserving the upper third of it. the bone above the nasal floor is removed with a bone gouge and grinding drill, and the remaining bone around the lacrimal fossa, the bony anterior border of the maxillary sinus and the bony crest between it and the nasal floor are removed until they are flush with the anterior and bottom walls of the maxillary sinus. The hard bone at the anterior lower border that forms the margin of the pyriform foramen can be removed with a bone chisel. Each edge of the medial wall of the maxillary sinus should be polished smooth after opening, leaving no bony ridge. In this way the entire maxillary sinus will be visualized and treated in conjunction with a 70 degree scope.
Modification of endoscopic maxillary sinus medial wall excision There are three main approaches.
I. Lateral nasal vestibular incision maxillary sinus anterior medial wall resection Wang De-hui introduced a longitudinal nasal vestibular incision at the anterior border of the inferior turbinate under the nasal endoscope, cut laterally to the edge of the pyriform foramen, then separate the soft tissue around the bones of the pyriform foramen, remove the bones of the edge of the pyriform foramen and part of the bones of the anterior medial wall of the maxillary sinus, then perform a maxillary sinus medial wall resection, and then deal with the medial lesion of the maxillary sinus. This approach helps to eliminate the disadvantage of insufficient exposure of the anterior wall of the inner maxillary sinus.
II. Inferior turbinate reversal maxillary sinus medial wall resection
For inversion papilloma originating in the maxillary sinus, Xicheng Song introduces endonasal endoscopic excision of the leptomeninges, full enlargement of the maxillary sinus opening, severing the inferior turbinate from the anterior end of the inferior turbinate about 0.5 cm from the anterior margin attachment, removing all the inferior nasal tract tissue, creating a strip of tissue flap with the inferior turbinate tipped posteriorly, and then turning the inferior turbinate posteriorly or superiorly as needed to fully expose the surgical field of the maxillary sinus cavity. The endoscope can be used at different angles to deal with lesions in all directions of the maxillary sinus. For lesions in the inferior angle of the maxillary sinus, endoscopic spatula scraping can be used to remove the lesions, and care is taken to protect the anterior nasolacrimal duct opening and the posterior pterygopalatine artery during surgery. After the lesion is completely removed, the inferior turbinate is repositioned, and the anterior inferior turbinate is cut with one stitch or with the application of otocerebral glue. Because this approach preserves the inferior turbinate, the patient will not experience a series of uncomfortable symptoms caused by excessive nasal spaciousness after surgery, and at the same time, the inferior turbinate flap is made without hindering good exposure of the lesion in the maxillary sinus.
Lateral nasal wall incision for maxillary sinus surgery with preservation of the nasolacrimal duct and inferior turbinates
This procedure, introduced by Bing Zhou, preserves the inferior turbinate and the nasolacrimal duct and is a minimally invasive approach to the medial wall resection of the maxillary sinus. The main steps are as follows: along the lateral wall of the nasal cavity above the anterior edge of the inferior turbinate (2 mm from the posterior edge of the nasal aperture), an arcuate incision is made from top to bottom of the nose, and the submucous membrane is peeled off to the most anterior part of the lateral nasal wall attachment of the inferior turbinate bone. Exposure of the maxillary sinus The root of the lateral nasal wall of the inferior turbinate is used as a marker to remove the inner wall of the maxillary sinus from anterior to posterior with an electric drill or bone chisel, and the nasolacrimal duct nasal opening is used as a marker to open the bony nasolacrimal duct and free the lower end of the nasolacrimal duct while removing the bony wall, forming a membranous inferior turbinate flap and moving it inward to reveal the maxillary sinus cavity. Removal of the lesion Usually the lesion in the maxillary sinus cavity is not removed under direct vision with 0-degree scope observation, the anterior or anterior inferior internal wall of the maxillary sinus can be removed with the aid of an angled scope, and depending on the size of the developing sinus and the location of the lesion, it is determined whether the anterior or anterior inferior internal bone wall of the maxillary sinus is expanded. After clearing the operative cavity and resetting the membranous nasolacrimal duct inferior turbinate flap, the mucosal incision is fixed with sutures in alignment, and the mucosa of the lateral wall of the inferior nasal tract is incised to make a window in the maxillary sinus of the inferior nasal tract for postoperative observation and drainage, and the operative cavity is filled.
In the case of involuted papilloma originating in the maxillary sinus, sometimes there may be a dead end in the operation through the above approach, a labiogingival incision can be added to remove part of the anterior wall of the maxillary sinus through a canine fossa approach, and the lesion in the maxillary sinus can be removed with the aid of endoscopy. This combined approach, with adequate tumor exposure but greater trauma, is indicated for recurrent intramaxillary sinus papillomas.
Endorectal papilloma of the frontal sinus is removed routinely through the nose after clearing the airspace of the frontal saphenous fossa on one side and opening the natural opening of the frontal sinus. Usually, the side with normal frontal saphenous fossa is chosen for surgery; for bilateral lesions, the side with wider frontal saphenous fossa is chosen for frontal sinus opening first. The anterior superior part of the nasal septum is resected forward with the posterior border of the frontal sinus opening (posterior wall of the frontal sinus) as the safe boundary, forming a defect area of about 1.5cm×1.5cm behind the nasal bone in front and the posterior border of the frontal sinus opening in the back. The upper edge of the nasal septum at the base of the skull corresponds to the floor of the frontal sinus. The frontal sinus floor was opened along the inner wall of the frontal sinus (frontal septum) on one side as a marker and guide (midline principle), and the upper edge of the nasal septum was removed with the back of the nasal bone as the anterior boundary and the posterior edge of the frontal sinus opening as the posterior boundary, i.e., the frontal sinus floor; after opening the frontal sinus on the opposite side, part of the frontal septum was occluded to fully expand the frontal sinus floor and fuse both sides of the frontal sinus into a larger through opening. At the end of the operation, absorbable hemostatic damask containing antibiotics, instant gauze or oil gauze strips were routinely filled and removed in 24-48 h. Nasal cleaning was started the day after the extraction of the nasal stuffing.
The above procedure is a modified Lothrop procedure. If the frontal sinus is well pneumatized and the papilloma involves the lateral part of the frontal sinus, it is still difficult to ensure complete removal of the tumor by applying this procedure.
For suspected bone, partial bone can be removed by electric drill and local electrocoagulation if necessary to avoid residual tumor.
Post-operative management Lifetime endoscopic follow-up for recurrence and evaluation of surgical success should be done at least 24 months. If there is recurrence, radical surgery should be performed. Complication prevention and control Tumor recurrence is mostly caused by incomplete resection of tumor. Small tumor can be removed under local anesthesia with nasal endoscopy, and the base can be treated with laser to reduce the chance of recurrence. If the tumor is larger in extent, it needs to be treated by surgery again. Other complications are the same as endoscopic sinus opening. Evaluation 1. endoscopic surgery should be selected for early, limited tumors. the use of CT and endoscopy helps in the early diagnosis of involuted papilloma and creates an opportunity for endoscopic surgery. 2. the middle turbinate is removed and cannot be palliated. 3. all mucosa of the primary site (especially the maxillary and septal sinuses) is removed, the suspected involved bone is removed, and the septal sinus airspace must be excised cleanly. The medial wall of the maxillary sinus should also be largely excised, including the inferior turbinate if necessary. Incomplete surgical excision is the fundamental factor of recurrence; the bone in the primary site of the tumor in the maxillary sinus can be polished with a gold drill to ensure that no tumor infiltrates through the bone suture in the lower wall of the maxillary sinus. 4. In cases of recurrent recurrence, post-surgical radiotherapy can be supplemented; 5. For involuted papilloma with primary origin in the maxillary sinus or extensive invasion of the maxillary sinus, complete removal of the tumor is difficult with endoscopic surgery alone, and the tumor can be removed in conventional surgery (maxillary sinus 6. If the tumor is found to be extensive and bleeding aggressively during the endoscopic surgery and cannot be completely removed, the surgical approach should be changed at any time, and this should be explained to the patient and family members before the surgery.
Endorectal papilloma without malignancy is a purely mucosal lesion, and its therapeutic regression depends not only on the removal of all visually visible lesions, but also on the host immunity and defense of the mucosa itself. The most difficult sites for resection are the lateral frontal sinus and the anterior wall of the maxillary sinus.