Secondary Reconstruction of Lacrimal Excretory System in Extensive Maxillofacial Injuries

適當的淚液分泌及排泄可以保護眼球以及提供正常的光學反射表面。分泌淚液的淚腺因為受到眼眶骨的保護，在顏面外傷的病患中，甚少受到傷害。但是淚液排泄系統在這類病患卻常受到傷害。在嚴重顏面外傷患者中，淚液排泄系統的任何位置，包括淚點（punctum）、淚小管（canaliculi）、總淚小管（common canaliculus）、淚囊（lacrimal sac）、或鼻淚管（nasolacrimal duct），均可能遭到傷害。當淚液排泄系統遭到損害後產生阻塞，病患便會有溢淚（epiphora）之現象，不但在社交上極為不便，無法佩戴隱形眼鏡，更可能因不斷的擦拭而產生感染。如果淚囊的內容物發生感染，則會產生淚囊炎，對眼球的傷害更大。當病患遭到嚴重的顏面外傷時，有時因為大量的出血，廣泛的結構破構，或嚴重的組織腫脹，醫師無法立即診斷及治療淚液排泄系統之傷害。在這種情況下，續發性重建淚液排泄系統便成為一必要之步驟。三軍總醫院整形外科自1995年2月至1996年3月，共治療9例因嚴重顏面外傷而必須接受續發性淚液排泄系統重建之病患。重建手術進行的時間約在受傷後2至6月間，病患在術前均經眼科醫師之檢查，以確定阻塞之位置，手術後追蹤時間為10至24月。其中6例為鼻淚管阻塞，（nasolacrimal duct obstruction），接受淚囊鼻腔造廔術（dacryocystorhinostomy）手術，術後結果良好，溢淚及結膜炎之症狀均得到解除。另外3為淚小管系統阻塞（canalicular obstruction）接受結膜粘膜瓣（mucosal conjuntival flap）繞道手術，術後2例得到解除溢淚及結膜炎之效果。另一例因初次顏面外傷所產生之嚴重疤痕攣縮，使得粘膜瓣阻塞，手術失敗。由這些病例所得到的經驗，我們認為治療鼻淚管阻塞之患者，淚囊鼻腔造廔術為一適當的重淚液排泄系統之手術。此一發現與國內外之文獻報告大致相符。對淚小管系統阻塞之病患我們建議採取由Huang 教授於1992年發表之結膜粘膜瓣（mucosal conjuntival flap）繞道手術。因為此一繞道手術採用自體組織，與以往常用之Pyrex tube異物繞道手術比較，有理論上及臨床上之優點。而Pyrex tube之使用應保留於mucosal conjuntival flap手術失敗之病例。此一推論，在國內尚無其他醫學中心報告，仍需更多之病例以證實此一推論。

關鍵字

淚液排泄系統；淚囊鼻腔造廔術；結膜粘膜瓣

並列摘要

We reviewed a consective series of secondary reconstruction of the lacrimal excretory system in 9 patients with extensive maxillofacial injury. The initial trauma was so severe that immediate diagnosis and treatment of the lacrimal excretory system was rendered impossible.Reconstructive surgery was performed between 2 to 6 months after the initial injury. Six patients had lacrimal duct obstruction, these patients were treated with dacryocystorhinostomy. Relief of epiphora and conjuntiva irritation was achieved in all six patients. Three patients had canalicular obstruction, and were treated with mucosal conjuctival flap bypass. Relief of epiphora and conjuntiva irritation was achieved in 2 patients. One mucosal conjuntival flap was found to be obliterated due to severe scarring which resulted from the initial injury. Despite the small number of patients in our series, we do suggest to use of a mucosal conjuctival flap to bypass the obstructed canalicular system, and to reserve the commonly used Pyrex tube for failure patients.

並列關鍵字

lacrimal excretory system ； dacryocystorhinostomy ； mucosal conjuntival flap

國際替代計量

Secondary Reconstruction of Lacrimal Excretory System in Extensive Maxillofacial Injuries

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