上颌骨额突区骨折继发鼻面部畸形手术整复效果评估

上颌骨额突区骨折继发鼻面部畸形手术整复效果评估

王钟颖陈东汪涛徐洲王珮华

本文来源：《中华整形外科杂志》2023年7月第39卷第7期

DOI:10. 3760 / cma.j.cn114453-20221014-00317

作者单位：上海交通大学医学院附属第九人民医院耳鼻咽喉头颈外科上海交通大学医学院耳科学研究所上海市耳鼻疾病转化医学重点实验室，上海200011

通信作者：陈东，Email: chenjsun@sina.com

引用本文

王钟颖，陈东，汪涛，等. 上颌骨额突区骨折继发鼻面部畸形手术整复效果评估[J] . 中华整形外科杂志, 2023, 39(7) : 730-736. DOI: 10.3760/cma.j.cn114453-20221014-00317.

【摘要】

目的评估上颌骨额突区骨折继发鼻面部畸形的手术整复效果。

方法回顾性分析2009年1月至2020年12月上海交通大学医学院附属第九人民医院耳鼻咽喉头颈外科手术处理的上颌骨额突区骨折继发鼻面部畸形患者的临床资料。采用切开复位内固定术、鼻中隔矫正术、眼眶壁骨折整复术等对鼻面部畸形进行手术治疗。术后3个月，从以下3个方面对手术效果进行评估：（1）鼻面部形态，由2位医生和患者进行评估，分为非常满意、满意和不满意3个级别。（2）鼻腔通气功能客观评估，采用鼻声反射仪和鼻阻力仪进行检测，包括鼻腔最小截面积（MCA）、距前鼻孔 7 cm 的鼻腔容积（NV）、鼻腔吸气总阻力（TRi）和鼻腔呼气总阻力（TRe）。为了消除鼻黏膜肿胀带来的差异，按照外伤后至术前检查的时间将患者分为＜7 d、7~14 d、＞14 d 3组分别进行术前后比较。（3）鼻腔通气功能主观评估，采用鼻腔阻塞症状评估（NOSE）量表进行评分，总分为0～20分，分数越高鼻阻塞症状越重。采用SPSS 17.0软件进行统计分析，计量资料以±s表示，术前和术后3个月数据比较采用配对t检验，P<0.05表示差异有统计学意义。

结果共纳入83例患者，男53例，女30例；年龄7~78岁，中位数为35岁。所有患者均成功完成手术，术后软组织切口均愈合良好，鼻面部形态得到改善。术后3个月，医生对鼻面部形态表示非常满意和满意的患者分别为49例（59%）和34例（41%），自评为非常满意、满意和不满意的患者分别有51例（61%）、29例（35%）、3例（4%）。术前＜7 d（14例）、7~14 d（28例）、＞14 d（41例）组MCA分别为（0.43±0.10） cm2、（0.51±0.15） cm2、（0.50±0.14） cm2，NV分别为（9.76±2.20） cm3、（12.40±4.15） cm3、（12.40±3.87） cm3，TRi分别为（1.93±0.28） kPa·L-1·s-1、（1.96±0.24） kPa·L-1·s-1、（1.96±0.23） kPa·L-1·s-1，TRe分别为（2.02±0.35） kPa·L-1·s-1、（2.08±0.38） kPa·L-1·s-1、（2.08±0.34） kPa·L-1·s-1；术后3个月，3组MCA分别为（0.48±0.08） cm2、（0.56±0.15） cm2、（0.56±0.14） cm2，NV分别为（11.56±2.49） cm3、（14.40±4.50） cm3、（14.41±4.24） cm3，TRi分别为（1.74±0.19） kPa·L-1·s-1、（1.78±0.15） kPa·L-1·s-1、（1.78±0.14） kPa·L-1·s-1，TRe分别为（1.73±0.24） kPa·L-1·s-1、（1.79±0.24） kPa·L-1·s-1、（1.79±0.22） kPa·L-1·s-1。3组术后3个月MCA、NV均大于术前（P均＜0.01），TRe、TRi均小于术前（P均<0.01）。术后3个月，NOSE 量表评分为（4.1±1.2）分，显著低于术前的（10.5±1.8）分（P<0.01）。

结论客观与主观相结合的评估方法有助于医生术前准确判断上颌骨额突区骨折所造成的鼻面部形态和功能上的缺陷，制定完善的手术计划，患者在行骨折整复术后鼻面部外观和鼻腔通气功能都得到了明显改善。

【关键词】上颌骨骨折；鼻面部畸形；鼻腔通气堵塞；鼻声反射；鼻阻力；修复外科手术

基金项目：国家自然科学基金青年项目（82201274）

Evaluation of the results of surgical revision of nasofacial deformities secondary to fractures of the frontal process of the maxilla

Wang Zhongying, Chen Dong, Wang Tao, Xu Zhou, Wang Peihua

Department of Otolaryngology, Head and Neck Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai 200011, China

Corresponding author: Chen Dong, Email: chenjsun@sina.com

【Abstract】

Objective To evaluate the effect of surgical revision of nasofacial deformity secondary to maxillary frontal process fracture.

Methods The clinical data of patients with nasofacial deformities secondary to maxillary frontal process fractures who underwent surgery in the Department of Otolaryngology, Head and Neck Surgery of Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2009 to December 2020 were retrospectively analyzed. The nasofacial deformity was surgically treated by open reduction with internal fixation, nasal septum correction, and reconstruction of orbital wall fracture. Three months after surgery, the surgical results were evaluated from the following three aspects. (1) Nasofacial morphology, which was evaluated by two doctors and the patient, and was classified into 3 levels: very satisfied, satisfied, and unsatisfied. (2) Objective assessment of nasal ventilation function, which was measured by nasal acoustic rhinometry and nasal resistance detection, including measurements of nasal minimum cross-sectional area (MCA), nasal volume 7 cm from the anterior nostril (NV), total nasal inspiratory resistance (TRi) and total nasal expiratory resistance (TRe). To eliminate the differences caused by swelling of the nasal mucosa, the patients were divided into 3 groups of <7 d, 7-14 d, and >14 d according to the time from trauma to preoperative examination for pre- and post-operative comparisons, respectively. (3) Subjective assessment of nasal ventilation function was performed using the nasal obstructive symptom evaluation (NOSE) scale, with a total score of 0 to 20, with a higher score indicating more severe nasal obstruction symptoms. The SPSS 17.0 software was used for statistical analysis, and the measurement data were expressed as Mean±SD. A paired t-test was used to compare the preoperative and 3-month postoperative data, with P<0.05 indicating a statistically significant difference.

Results A total of 83 patients were included, 53 males and 30 females, aged 7 to 78 years, with a median of 35 years. All patients underwent successful surgery, and all soft tissue incisions healed well after surgery with improved nasofacial morphology. Three months after surgery, the physicians were very satisfied and satisfied with the nasofacial morphology in 49 (59%) and 34 (41%) patients, respectively, and patients were very satisfied, satisfied, and unsatisfied in 51 (61%), 29 (35%), and 3(4%) cases, respectively. Before surgery, the <7 d group (14 cases), 7-14 d group (28 cases), and >14 d group (41 cases) had MCA values of (0.43±0.10) cm2, (0.51±0.15) cm2, and (0.50±0.14) cm2; NV values of (9.76±2.20) cm3, (12.40±4.15) cm3, and (12.40±3.87) cm3; TRi values of (1.93±0.28) kPa·L-1·s-1, (1.96±0.24) kPa·L-1·s-1, and (1.96±0.23) kPa·L-1·s-1; TRe values of (2.02±0.35) kPa·L-1·s-1, (2.08±0.38) kPa·L-1·s-1, and (2.08±0.34) kPa·L-1·s-1, respectively. Three months after surgery, in the three groups, the MCA values were (0.48±0.08) cm2, (0.56±0.15) cm2, and (0.56±0.14) cm2; the NV values were (11.56±2.49) cm3, (14.40±4.50) cm3, and (14.41±4.24) cm3; the TRi values were (1.74±0.19) kPa·L-1·s-1, (1.78±0.15) kPa·L-1·s-1, (1.78±0.14) kPa·L-1·s-1; the TRe values were (1.73±0.24) kPa·L-1·s-1, (1.79±0.24) kPa·L-1·s-1, and (1.79±0.22) kPa·L-1·s-1, respectively. In all three groups, the MCA and NV values at 3 months postoperatively were greater than the preoperative values of MCA and NV (all P < 0.01), and the TRe and TRi values at 3 months postoperatively were less than those preoperative values (all P < 0.01). At 3 months postoperatively, the NOSE scale score was (4.1±1.2)points, which was significantly lower than the preoperative score of NOSE scale score［(10.5±1.8)points］ (P<0.01).

Conclusion The combination of objective and subjective assessment method can help the surgeon to accurately determine the nasofacial morphological and functional defects caused by the fracture of the maxillary frontal process area before surgery and to formulate a perfect surgical plan. The patients’ nasofacial appearance and nasal ventilation functions were significantly improved after the fracture revision surgery.

【Key words】Maxillary fractures; Nasal and facial deformity; Nasal airway obstruction; Acoustic rhinometry; Nasal resistance; Reconstructive surgical procedures

Fund program: National Natural Science Foundation of China (Youth Program) (82201274)

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine（SH9H-2023-T160-1）.

上颌骨额突紧邻鼻骨外侧缘，在鼻面部外伤中很容易受累而骨折。据统计，鼻骨合并上颌骨额突骨折的患者数量远多于单纯性鼻骨骨折患者［1］。上颌骨额突区骨折有别于面中部多发性骨折，前者的就医诉求主要是外鼻畸形、鼻出血及鼻腔堵塞等，患者往往没有额、颧、眼、口腔等部位的形态畸形和功能障碍，容易被误诊为鼻骨骨折［23］。事实上，上颌骨额突的解剖位置比较特殊，涉及到梨状孔外侧缘、上颌骨及眶下缘。在处理这一区域的骨折时，单纯鼻骨矫正术往往无法获得满意效果，后期遗留的鼻面部不对称畸形也与之有关［3］。另外，上颌骨额突区骨折直接破坏鼻腔穹隆结构，影响鼻腔通气道。之前的研究大多注重美学修复，对鼻腔通气功能的考量略显不足［4-5］。在处理上颌骨额突区骨折的过程中，不仅要考虑患者的鼻面部外形，而且应重视功能的恢复，尤其是鼻腔通气功能。我们对收治的上颌骨额突区骨折致鼻面部畸形伴鼻腔通气障碍患者的临床资料进行分析研究，探讨患者鼻面部外形和鼻腔通气功能的恢复情况，评估手术整复效果。

资料与方法

一、资料选择

回顾性分析2009年1月至2020年12月在上海交通大学医学院附属第九人民医院耳鼻咽喉头颈外科接受手术的上颌骨额突区骨折患者的临床资料。纳入标准：（1）年龄为2~80岁，性别不限；（2）有明确鼻面部外伤史；（3）外伤时间小于60 d；（4）外伤后出现鼻面部畸形和鼻腔通气障碍；（5）采用切开复位内固定术、鼻中隔矫正术、眼眶壁骨折整复术等方法进行治疗；（6）有完整的术前及术后3个月的随访资料。排除标准：（1）鼻咽部及口腔颌面部手术史；（2）鼻咽部及口腔颌面部良、恶性肿瘤史；（3）全身急慢性疾病史；（4）近期鼻部及全身用药史；（5）慢性鼻炎、鼻窦炎病史；（6）动眼障碍、眼裂形态改变。本研究经上海交通大学医学院附属第九人民医院伦理委员会批准（SH9H-2023-T160-1），患者同意将其资料用于本研究。

二、方法

（一）术前准备

1. 三维CT扫描

所有患者于术前3 d行全头颅三维CT检查，扫描范围自颅顶至舌骨层面，层厚1.25 mm。

2. 鼻面部形态评估

术前由2位参与手术的医生对患者鼻面部形态进行评估，包括鼻背塌陷或偏曲程度、眼眶是否凹陷、面部是否有不对称畸形等；拍摄患者头面部图像，包括正位、左右侧位、45°斜位及鼻底位。

3. 鼻腔通气功能的客观性评估

术前3 d通过鼻声反射仪和鼻阻力仪对患者鼻腔通气功能进行评估。考虑到受伤后不同时间点鼻腔黏膜肿胀程度不同，为了消除黏膜肿胀带来的差异，按外伤后至术前检查的时间分为3组：包括＜7 d、 7~14 d、＞14 d组。（1）鼻声反射：选择合适的鼻管并将声管对着患者一侧鼻孔，让其张口，经鼻呼吸检查密闭性，然后屏住呼吸，连续3次进行检测，并取均值。随后对另一侧鼻腔进行测试。得到面积-距离曲线，记录鼻腔最小截面积（minimum cross-sectional area，MCA）及距前鼻孔7 cm的鼻腔容积（nasal volume，NV）［6］。（2）鼻阻力检测：将硅胶管与患者的一侧鼻孔相对，并进行固定，然后将面罩扣于患者面部，让患者闭嘴平静呼吸，得到不同压差下的压力-流速曲线，做好记录。最终获得鼻腔吸气总阻力(total inspiratory resistance，TRi)、鼻腔呼气总阻力(total expiratory resistance，TRe)［7］。

4. 鼻腔通气功能的主观性评估

术前3 d，采用鼻腔阻塞症状评估（nasal obstruction symptom evaluation，NOSE）量表对患者鼻腔通气功能进行主观性评估，其分值为0～20分，数值越高表示鼻阻塞症状越重［6］。

（二）手术方法

根据术前三维CT、鼻腔及面部检查结果，确定骨折数量、部位、方向，拟定手术方案。

手术在经口插管全身麻醉下进行，患者取平卧位,从受伤侧鼻孔内穹窿处切开，用剥离子在骨膜层面分离至上颌骨额突及鼻骨表面，松解骨折断端纤维连接组织；在同侧下睑缘以 1∶ 20 万肾上腺素溶液局部浸润，切开皮肤及皮下组织，分离至眶骨下缘，暴露上颌骨额突区、眶下缘与眶内侧壁交界处骨折线，以牵引钉牵拉使错位的骨折断端对合复位，伴有眶底骨折者同期置入钛网作为支撑，用钛板钛钉固定；累及上颌骨且骨折断端错位明显者需增加唇龈沟切口，分离暴露至梨状孔边缘及上颌骨额突骨折处，牵拉复位塌陷骨质，用钛板钛钉固定。将鼻骨复位器从鼻腔进入，轻抬下陷的鼻骨。睑缘切口用6.0尼龙线缝合，口内和鼻内切口用5.0可吸收线缝合。术后鼻腔填塞膨胀海绵，4~5 d后取出。

（三）术后效果评估

术后3个月，对患者行全头颅三维CT扫描，并拍摄与术前对应体位的照片；由2位参与手术的医生和患者对术后鼻面部形态进行评估，分为非常满意、满意和不满意；对鼻腔通气功能进行客观和主观评估，方法同术前。

三、统计学方法

采用SPSS 17.0软件对数据进行统计分析，计量资料以±s表示，术前、后数据比较采用配对t检验，P<0.05表示差异有统计学意义。

结果

一、一般资料

......