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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: The problem of ferocious bleeding during pterygoid venousplexus (PVP) surgery has not yet been discussed in the special case of large nasopharyngeal angiofibroma extending deep into the infratemporal fossa. Methods: A total of 44 cases of nasopharyngeal angiofibroma were treated in our hospital from 1981 to 2009, including 26 cases of large nasopharyngeal angiofibroma, 16 cases of type Ⅲ according to Fisch classification and 10 cases of type Ⅳ. Intraoperative bleeding 200 ~ 5200ml. Retrospective analysis of bleeding in a variety of factors, and 3 cases of typical cases of intraoperative findings and imaging data analysis. Results: After DSA was effective in embolizing the blood supply of the external carotid artery to the tumor, intraoperative findings of inferior temporal fossa hemorrhage and imaging data clearly indicated that PVP was one of the major causes of intraoperative hemorrhage. CONCLUSIONS: PVP is located in the infratemporal fossa and communicates with the head and facial veins with no valve between them. Once there is a greater PVP damage, the head and face in all aspects of the dark red venous blood that is rapidly from the damage at the gushing. For the first surgery, due to complete PVP and fat pad wrap, the surgeon can carefully separate the tumor and PVP, the general can not bleeding. If the first surgery failed to cut, most of them ended in bleeding, the surgery again PVP, tumor, muscle and scar tissue often adhesions together, the separation more difficult and easy bleeding. To take appropriate approach, under the clear vision of the separation of the tumor under the temporal fossa, proper hemostasis, without the use of finger and instrument blind quick stripping approach is expected to reduce bleeding and achieve the purpose of complete resection of the tumor.