大型鼻咽血管纤维瘤术中翼丛静脉的处理  

Study and analysis on the hemorrhage of pterygoid venous plexus in large nasopharyngeal angiofibroma resection

作　　者：李志春[1] 林昶[1] 林功标[1] 方哲明[2] 张晖萍[1] 陈缪安 周爱东[1] 兰书湛[1] 易自翔[1] 

机构地区：[1]福建医科大学附属第一医院耳鼻咽喉头颈外科,福州350005 [2]福建医科大学附属第一医院影像科 [3]福建闽东医院耳鼻咽喉头颈外科

出　　处：《临床耳鼻咽喉头颈外科杂志》2010年第6期244-246,249,共4页Journal of Clinical Otorhinolaryngology Head And Neck Surgery

基　　金：福建省财政厅科研基金(No:2009B011)

摘　　要：目的:大型鼻咽血管纤维瘤向颞下窝深入扩展时,翼丛静脉(pterygoidvenousplexus,PVP)术中凶猛出血的问题尚未见专题探讨,特报告以供参考。方法:我院1981-2009年共收治鼻咽血管纤维瘤44例,其中大型鼻咽血管纤维瘤26例,按Fisch分型Ⅲ型16例,Ⅳ型10例。术中出血量200～5200ml。回顾分析术中出血的多种因素,并对3例典型病例的术中所见和影像学资料进行分析研究。结果:3例在DSA技术有效栓塞颈外动脉对肿瘤的供血支以后,术中颞下窝出血所见和影像学资料,都明确提示PVP受损是术中大出血的重要原因之一。结论:PVP位于颞下窝内,并与头面部静脉交通,彼此之间缺少瓣膜。PVP一旦有较大损伤,头面部各方面的呈暗红色的静脉血液即迅猛从破损处涌出。若为初次手术,由于PVP完整并有脂肪垫包绕,术者可细致地将肿瘤与PVP分离,一般可以不出血。若初次手术未能全切,多半是以出血告终,则再次手术时PVP、肿瘤、肌肉和瘢痕组织往往粘连在一起,分离较难而容易出血。采取适当入路,在明视下分离颞下窝的肿块,妥善止血,而不采用手指和器械盲目快速剥离的办法,可望减少出血并达到全切肿瘤的目的。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 casescases 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.

关 键 词：鼻咽血管纤维瘤 手术 翼丛静脉 出血 

分 类 号：R766.3[医药卫生—耳鼻咽喉科]