口腔内上顎全摘による上顎癌の治療
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概要
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Radical resection for maxillary cancer has been performed as early as one and a half centuries ago. Since then much progress has been made in the treatment of maxillary cancer. The most effective way seems to be a radical maxillectomy in combination with radiation treatment. However, the clinical results are yet in general far from satisfactory.<BR>Most of the operative procedures hitherto proposed to require facial incision. In 1947, the author developed a transoral maxillectomy technique which is unique in not involving facial incision. This technique has been used successfully in the Otorhinolaryngological Clinic of the Kyushu University in 120 cases thereafter to 1961. During nearly same period, 120 cases were operated with the usual external maxillectomy technique with facial incision and Denker's method was used in 10 other cases. As the most common initial symptom, nasal obstruction in 31.2 per cent, nasal hemorrhage in 14.0 per cent, toothache in 12.8 per cent and swelling of the cheek in 11.6 per cent have been found among these 250 cases. Cervical lymphnodes were palpated during the first examinations in about 28.4 per cent of the cases. However, the cases, in which metastases were actually confirmed by histological examination after the removal by radical neck dissection, amount to only 11.5 per cent.<BR>Recently, we have analyzed the microvibration curves obtained from the patients with maxillary cancer. Invisible microvibration from the body surface was led through the pick-up laid on the cheeks or on the supraorbital area of the patient and was subsequently recorded by MT analyzer. Findings of the recorded curves indicated that the microvibration coefficient (counts per square) in case of maxillary cancer is much larger than that in sinusitis patients as well as in normal cases-the last being the lowest.<BR>Although the use of Ohngren's malignancy plane offers considerable advantages in assessing extention of nasal tumours and their classification, its bilateral division alone is not always quite adequate. In order to set an anatomically appropriate division, the author proposes the vertical plane through the margin of Apertura piriformis and Lamina lateralis processus pterygoidei. The use of the combination of these two gives a clearer picture of the extention of tumour i. e. the invasion area type. In total 250 cases were classified into the 10 combinations according to their extention. Prognosis and other problems could be judged more adequately using these planes.<BR>Preoperative radiation treatment with 60Co was also used in combination with radical maxillectomy. The most effective dosis has been found to be over 3000 rad according to the results of histopathological examinations.<BR>The operation was conducted under general anesthesia with nitrous oxide or Fluothane using nasotracheal intubation through contralateral nose. In the majority of the cases, radical neck dissection and a ligation of an external carotic artery were done right before radical maxillectomy.<BR>The technique of radical maxillectomy will be described briefly. Palatal D-form incision is made followed by extensive dissection of anterior surface of maxilla. Using electric saw, zygomatic bone is separated and the frontal process of maxilla is also divided by the same technique. Palate is transected along its midline. After dividing the bony junction of maxilla, traction is applied laterally and downwards in order to loosen the maxilla from its surrounding structures which is subsequently removed en bloc. If necessary, orbital content can also be removed transorally. The space thus formed should be packed tightly with rubber bag containing alginate hydrocolloidal paste right after the operation, in order to avoid the occurrence of facial retraction, shrinkage of wound diameter and other deformities. Temporal palatal pelote is used until epithelialization of the wound is completed. Permanent prosthesis is used thereafter.
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