| objective:Nasal inverted papilloma (NIP) is a common benign tumor that arises in nasal cavity or paranasal sinuses. NIP accounts for about0.5%-44%of all the sinonasal tumors and is characterized by quite probable recurrence and malignant transformation into squamous cell carcinoma. Surgical resection is the primary treatment for NIP and thorough and complete resection of the lesion is the key for a successful operation result. External nasal approach, which was characterized by large field, was the traditional option for NIP operation, by which, extensive resection of lesions could be achieved, but always accompanied by large trauma, serious bleeding and scar left on the face. As the development of nasal endoscopic techniques, resection of NIP under nasal endoscopy was accepted and applied by large number of surgeons domestically and abroad. But the principle for selection of surgical approaches for NIP of different stages and the related operative results that could be achieved still needed to be investigated. To investigate the efficacy and surgical approach of the NIP, based on the clinical data of patients NIP summarize, the advantages and disadvantages of four surgical approaches(single endoscopic surgery, endoscopic anterior lacrimal recess approach, endoscopic combined Caldwell-Luc approach and lateral rhinotomy approach) were compared and analyzed as well as the indications. Methods:The data of121NIP cases admitted in the departments of Otolaryngology Head and Neck Surgery, Affiliated Hospital of Luzhou Medical College from Feb2007to Feb2013were retrospectively analyzed. Based on preoperative CT examination, preoperative nasal endoscopy and intraoperative findings of tumor invasion range, and according to Krouse’s classification for NIP,12cases were classified as T1stage,32cases as T2stage,71cases as T3stage and6cases as T4stage. According to the surgical approach, all patients were divided into4groups. Number of cases in each stage that selected single endoscopic surgery was12for T1stage,14for T2stage,13for T3stage and2for T4stage. Number of cases in T3stage that selected endoscopic anterior lacrimal recess approach was23. Number of cases that selected endoscopic combined Caldwell-Luc approach was9for T2stage and20for T3stage. Number of cases that selected lateral rhinotomy approach was9for T2stage,15for T3stage and4for T4stage. All patients were operated by local or general anesthesia and blood loss in surgery were recorded. By telephone and out-patient return visit, all patients were followed up. Surgical blood loss, complication rates, days of hospital stay, and recurrence rates were statistical analyzed in four surgical approach groups. Results:(1)Follow-up lasted for12to84months (average length of32months).(2)Amount of blood loss:①40±4.5ml for T1stage cases that selected single endoscopic surgery;②74±3.8ml for T2stage cases that selected single endoscopic surgery,106±4.0ml for T2stage cases that selected endoscopic combined Caldwell-Luc approach and147±5.4ml for T2stage cases that selected lateral rhinotomy approach;③114±4.6ml for T3stage cases that selected single endoscopic surgery,119±2.9ml for T3stages cases that selected endoscopic anterior lacrimal recess approach,182±5.0ml for T3stage cases that selected endoscopic combined Caldwell-Luc approach and258±5.2ml for T3stage cases that selected lateral rhinotomy approach;④225±25.8ml for T4stage cases that selected single endoscopic surgery and351±5.Oml for T4stage cases that selected lateral rhinotomy approach. For T2stage cases, there was significant difference tested by ANOVA compared blood loss volum among these four groups (P<0.05).For T3stage cases, there was no significant difference tested by ANOVA compared blood loss volum between single endoscopic surgery group and endoscopic anterior lacrimal recess approach group (P>0.05).There was significant difference among the other groups (P<0.05).For T4stage cases, there was significant difference tested by independent samples t-test between single endoscopic surgery group and lateral rhinotomy approach group (P<0.05).(3) Recurrence rate:①The recurrence rate of single endoscopic surgery group was8.3%(1/12) in T1stage;②The recurrence rate of single endoscopic surgery group in T2stage was14.3%(2/14),11.1%(1/9) in endoscopic combined Caldwell-Luc approach group and11.1%(1/9) in lateral rhinotomy approach group.③The recurrence rate of single endoscopic surgery group in T3stage was15.4%(2/13),13.0%(3/23) in endoscopic anterior lacrimal recess approach group,15.0%(3/20) in endoscopic combined Caldwell-Luc approach group and13.0%(2/15) in lateral rhinotomy approach group.④The recurrence rate of single endoscopc surgery group in T4stage was50.0%(1/2),50.0%(2/4) in lateral rhinotomy approach group. The differences in recurrence rate among these4groups were not statistically significant (P>0.05).(4)The complication rate:①The complication rate for T1stage cases selected single endoscopic surgery was0.0%(0/12);(2)For T2stage cases, the complication rate of those selected single endoscopic surgery was7.1%(1/14). The complication rate in endoscopic combined Caldwell-Luc approach group was22.2%(2/9) and33.3%(3/9) in lateral rhinotomy approach group.③For T3stage cases, the complication rate in single endoscopic surgery group was7.7%(1/13),8.7%(2/23) in endoscopic anterior lacrimal recess approach group,25.0%(5/20) in endoscopic combined Caldwell-Luc approach group and33.3%(5/15) in lateral rhinotomy approach group.④For T4stage cases, the complication rate in single endoscopic surgery group was50.0%(1/2) and75.0%(3/4) in lateral rhinotomy approach group. According to the statistical analysis using four-column table X2-test, the difference between the single endoscopic surgery group and the lateral rhinotomy approach group in T2stage cases was statistically significant (P<0.05); and the difference between the endoscopic anterior lacrimal recess approach group and the lateral rhinotomy approach group in T3stage cases was statistically significant (P<0.05).(5)Average hospitalization days:①6.2±0.1d in single endoscopic surgery group;②6.9±0.2d in endoscopic anterior lacrimal recess approach group;③7.4±0.2d in endoscopic combined Caldwell-Luc approach group;④11.5±0.2d in lateral rhinotomy approach group. The differences among these4groups were tested using ANOVA, and the difference between endoscopic anterior lacrimal recess approach group and endoscopic combined Caldwell-Luc approach group was not statistically significant (P>0.05). The average hospitalization days in single endoscopic surgery group was significantly less compared with each other group (P<0.05), the average hospitalization days in lateral rhinotomy approach group were more than the other groups(P<0.05). Conclusions:(1) All the above4surgical approaches could be used for treatment of NIP and get satisfied curative effect (2)Single endoscopic surgery has less bleeding, low incidence of complications, shorter hospital stay.(3) Single endoscopic surgery is recommended for T1and T2stage cases.(4)For T3stage cases, those without maxillary sinus invasion, single endoscopic surgery is recommended. Those with maxillary sinus invasion are suggested to choose endoscopic anterior lacrimal recess approach in order to avoid operation blind area.(5)For T4stage cases, our results indicated poor efficacy for both single endoscopic surgery and lateral rhinotomy approach groups. Therefore, optimal approach still needs further more investigation because of our few cases. |
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