鼻内镜下蝶窦手术入路及超越蝶窦腔病变的处理

目的：探讨蝶窦及鞍区更直接的手术径路,结合影像学资料对超越蝶窦范围的相关疾病进行适当处理,防止严重并发症的发生。方法：在鼻内镜下,分别采用经前筛-后筛-蝶窦、经上鼻道-后筛-蝶窦、经鼻中隔-蝶窦以及直接以后鼻孔上缘为标志经蝶窦前壁自然口进入蝶窦等途径,对46例蝶窦占位并蝶窦骨壁破坏的病变进行处理。结果：蝶窦囊肿及脓囊肿21例,经上鼻道径路处理后痊愈;蝶窦内血肿机化1例,经上鼻道径路清除;蝶窦内血肿并颈内动脉假性动脉瘤3例,1例术中探查发生致命性大出血,后经血管内介入治疗后痊愈,其余2例仅作鼻内镜检查,经DSA证实并行血管内介入治疗后治愈;蝶窦乳头状瘤4例,均行蝶窦自然开口径路,3例治愈,1例因广泛侵犯蝶窦外侧壁仅部分切除;蝶窦胆脂瘤2例,经上鼻道入路完整切除;蝶窦内脑膜脑膨出1例,经蝶窦前壁自然口打开蝶窦,经穿刺抽出脑脊液,手术停止并加固修补暴露脑膜;蝶窦真菌病1例,经上鼻道径路清除蝶窦内病变并联合抗真菌治疗后痊愈;蝶窦恶性肿瘤3例,经前后筛径路切除蝶窦内大部分肿瘤,后辅以放化疗;鼻咽癌侵入蝶窦5例,病理检查证实后行放化疗;垂体瘤术后蝶窦脑脊液鼻漏并肉芽增生5例,经上鼻道或鼻中隔径路均一次修补成功。结论：鼻内镜下处理蝶窦及蝶窦相关疾病径路多样,适当选择径路可达到直接、安全、微创等目的。术前蝶鞍CT薄层扫描、三维重建以及DSA是防止超越蝶窦范围病变手术并发症发生的有效手段之一。     

蝶窦外侧隐窝病变的诊断与鼻内镜治疗

目的：探讨如何正确诊断蝶窦外侧隐窝病变及经鼻内镜下翼突径路处理该区域病变的相关问题。方法：26例蝶窦外侧隐窝病变患者,术前均经高分辨率CT扫描和增强磁共振检查,在全身麻醉下行经鼻内镜下翼突径路清除蝶窦外侧隐窝病变,诊断为脑脊液鼻漏伴脑膜脑膨出者同时行颅底修补手术。结果：术后病理确诊,4例为脑脊液鼻漏伴脑膜脑膨出,均一次手术修补成功;10例为蝶窦囊肿;5例为非侵袭性真菌性鼻窦炎;7例为慢性蝶窦炎。其中9例术后合并患侧颜面部上颌神经支配区域麻木感,但未给予特殊处理,约6个月后症状逐渐缓解。术后全部患者给予定期鼻内镜复查、糖皮质激素喷鼻剂、口服标准桃金娘油等治疗。随访6～53个月,病变无复发。结论：高分辨率CT扫描同时结合增强磁共振检查对于诊断蝶窦外侧隐窝病变具有重要意义;采用鼻内镜下经翼突入路处理蝶窦外侧隐窝病变,是一种微创、简捷、安全的手术入路。     

孤立性蝶窦疾病的诊断与治疗

目的 探讨孤立性蝶窦病变的诊断与治疗。方法 对1988年1月－1999年12月我科收治的孤立性蝶窦病变14例的临床表现及诊经过进行分析。结果 14例中,炎性病变11例,异物2例,恶性肿瘤1例,临床表现以视力下降、头痛、回吸涕中带血为主。CT检查11例次,MRI检查7例均有阳性表现,12例内镜检查有7例阳性。治疗方法除1例保守治疗外,余均经手术治疗。2例经鼻外筛蝶窦径路,11例经鼻内镜下鼻腔径路。结论 对不明原因的头痛、进行性视力下降的患者,临床上应高度怀疑蝶窦病变,应及早进行鼻内镜、CT或MRI检查,早期治疗,避免严重并发症的发生,鼻内镜下经鼻腔蝶窦径路是治疗孤立性鼻窦病变的优选术式。     

经鼻内镜治疗孤立性蝶窦病变疗效分析

目的　回顾总结孤立性蝶窦病变的临床特征和治疗结果,归纳蝶窦病变的手术方式和治疗策略。方法  62例接受鼻内镜手术的孤立性蝶窦病变患者中,蝶窦真菌11例（17.7%）,蝶窦囊肿34例（54.8%）,单纯蝶窦炎10例（16.1%）,蝶窦脑膜脑膨出7例（11.3%）。所有患者术前均接受鼻窦CT检查,部分患者补充鼻窦MRI检查,所有患者均在全身麻醉下行经鼻内镜手术。5例脑膜脑膨出患者经翼突入路,2例脑膜脑膨出患者按Messerklinger术式经筛蝶入路,55例患者均行嗅裂蝶窦自然口入路。结果　随访24～75个月,平均45个月,蝶窦口开放良好58例（93.5%）,狭窄4例（6.5%）,7例脑膜脑膨出伴脑脊液鼻漏患者,均一次手术成功。临床症状完全消失42例（67.7%）,症状缓解9例（14.5%）,症状无明显变化6例（9.7%）,均为蝶窦囊肿患者,症状消失1年后再次出现5例（8.1%）,4例为蝶窦囊肿,1例为蝶窦炎患者。所有患者均无并发症出现。结论　经鼻内镜蝶窦开放手术是治疗孤立性蝶窦病变的首选方法,手术损伤小,效果肯定。     

经头皮冠状切口及经鼻内镜额筛眶占位性病变切除术的比较研究

目的:探讨经头皮冠状切口径路与经鼻内镜径路额筛眶占位性病变切除术的优缺点及适应证.方法:额筛眶占位性病变患者34例,18例行经鼻内镜额筛眶占位切除术,其中脓囊肿16例,侵袭性血管脂肪瘤1例,骨瘤1例;16例经头皮冠状切口径路手术,其中脓囊肿11例,皮样囊肿3例,表皮样囊肿1例,侵袭性血管脂肪瘤复发1例;术后随访2～4年.结果:18例行经鼻内镜径路患者术后5例仍有头昏或鼻腔胀痛症状,侵袭性血管脂肪瘤1例2年后复发.16例经头皮冠状切口径路手术患者,3例有头昏症状,12例头顶部皮肤麻木,无一例复发.结论;经头皮冠状切口径路与经鼻内镜径路额筛眶占位性病变切除各有其优缺点及适应证,不能盲目夸大其中一种术式的功能.     

蝶窦鞍区非垂体源性占位性病变的诊断

目的提高蝶窦鞍区非垂体源性占位性病变的诊断水平。方法总结分析２４例蝶窦鞍区非垂体源性占位性病变，其中良性１８例，包括蝶窦囊肿７例、颅咽管瘤６例、脊索瘤２例，鼻息肉伴鼻硬结杆菌感染侵犯蝶窦鞍区、蝶鞍神经鞘瘤、鞍内异位松果体瘤各１例。恶性肿瘤６例，分别为蝶窦神经内分泌肿瘤２例，腺样囊腺癌１例，蝶窦低分化癌１例，鼻咽癌侵犯鞍区及肺癌蝶窦转移各１例。从临床表现、体征、影像学检查及诊断治疗上进行了分析、讨论。结果２４例临床表现中１８例有头痛，１７例出现眼部症状。２４例均经ＣＴ扫描发现蝶鞍区占位性病变并提示了病变范围。结论①良恶性病变均以头痛为第一常见症状，眼部症状为第二常见症状，掌握眼部症状与蝶鞍占位的关系对及早诊断意义重大；②影像学检查对此区域病变的发现和诊断起着重要作用；③内窥镜的应用及镜下穿刺活检亦对诊断十分有帮助。良性肿瘤以手术切除为主，恶性肿瘤手术＋放射治疗。     

蝶窦鞍区非垂体源性占位病变的诊断

目的 提高蝶窦鞍区非垂体源性占位性病变的诊断水平。方法 总结分析２４例蝶窦鞍区非垂体源性占位性病变，其中良好１８例，包括蝶窦囊肿７例、颅咽管瘤６例、脊索瘤２例，鼻息肉伴鼻结杆菌感染侵犯蝶窦鞍区、蝶鞍神经鞘瘤、鞍内异位松果体瘤各１例。恶性肿瘤６例，分别为蝶窦神经内分泌肿瘤２例，腺样囊腺癌１例，蝶窦低分化癌１例，鼻咽癌侵犯区肺癌蝶窦转移各１例。从临床表现、体征、曩像学检查及诊断治疗上进行了分析、讨论。     

孤立性蝶窦病变的临床诊断与微创手术

目的　探讨孤立性蝶窦病变的临床诊断及微创手术方法。方法　对收治的 2 8例孤立性蝶窦病变的临床资料进行回顾性分析并文献复习。结果　 2 8例病人术前均经CT或 /和MRI及鼻内镜确诊。术后病理检查证实为蝶窦炎症 6例 (其中伴后鼻孔息肉 4例 )、蝶窦真菌感染 7例、蝶窦黏膜下囊肿 1 0例、蝶窦黏液囊肿 4例(其中 2例侵犯颅底及眼眶、1例至鼻中隔 )、蝶窦内翻性乳头状瘤 1例。 2 8例全部治愈。结论　对临床上有不明原因的头痛、头晕、眼部症状、回缩涕血有必要结合影像学检查及鼻内镜检查 ,以便早期确诊。鼻内镜下鼻腔进路联合切割吸引器对蝶窦病变进行微创手术是治疗孤立性蝶窦病变的一个安全有效的手术方式。     

经鼻内镜下摘除蝶鞍占位性病变（附7例分析）

目的：探讨经鼻内镜下蝶鞍手术方法的适应证、应用价值及应用前景,并探索性提出经鼻－经鼻中隔－经筛－经蝶入路摘除蝶鞍巨大肿块,方法：蝶鞍占位性病变病人共7例：垂体微腺瘤5例、巨大垂体腺瘤1例、鞍区炎性坏死性肉芽肿1例。6例采用经鼻－蝶入路;1例采用经鼻－鼻中隔－筛－蝶入路。结果：术前症状在术后均有不同程度的改善（除1例前有一眼失明者外）,无1例出现严重并发症,6例蝶鞍占位获得全切;1例获得次全切,结论：经鼻内镜下摘除蝶鞍占位性病变具有很好的推广应用前景。内镜下经鼻－鼻中隔－筛－蝶入路为蝶鞍巨大肿块的切除提供了一条较佳的手术途径。     

侵犯颅内及海绵窦鼻咽血管纤维瘤临床研究

目的 探讨侵犯到颅内及海绵窦的鼻咽血管纤维瘤的外科治疗.方法 病例包括1988年1月至2004年1月收治的经病理证实的侵犯到颅内的鼻咽血管纤维瘤16例,11～35岁.手术方法有经口腭入路、鼻侧切开入路、上颌骨中段掀翻、颅面联合进路、下颌正中裂开联合经腭入路和上颌骨翻转入路.结果 伴颅内侵犯鼻咽血管纤维瘤16例患者共行手术28次,11例为复发病变.28例次手术中11例次鼻侧切开术,颅面联合进路6例次,额颞入路2例次,经腭入路4例次,经上颌骨入路2例次,经下颌正中裂开1例次,上颌骨中段掀翻2例次.结论 扩展到颅内或海绵窦的鼻咽血管纤维瘤治疗以手术彻底切除为主,上颌骨中段掀翻、颅面联合进路及经下颌正中裂开颅底进路对于侵犯到颅内或海绵窦的肿瘤暴露较好.     

鼻内镜下鼻中隔径路蝶窦手术

目的探讨利用鼻内镜手术治疗蝶窦良性病变伴有鼻中隔偏曲的方法和体会。方法26例患者均在鼻内镜下行鼻中隔径路蝶窦手术,先行鼻中隔矫正,再沿骨性中隔向后找到蝶嘴,并开放蝶窦前壁,处理蝶窦病变。结果本组患者均顺利完成经鼻中隔径路蝶窦开放,术后症状完全消失,其中24例经随访6个月至1年未见复发,其余患者中1例蝶窦囊肿在术后7个月复发,1例蝶窦后鼻孔息肉在术后10个月复发,均于门诊复查时顺利摘除。结论鼻内镜下经鼻中隔径路蝶窦开放具有创伤小、定位准确等优点,是一种安全、有效的手术方式。     

经鼻内镜治疗累及蝶窦的中颅底占位性病变

目的：探讨累及蝶窦的中颅底占位性病变的诊断治疗方法。方法：对18例累及蝶窦的中颅底硬膜外占位病变患者施行经鼻内镜手术。结果：1例原发性空蝶鞍误诊为蝶窦囊肿,1例骨纤维异常增殖、1例脑膜瘤误诊为真菌性蝶窦炎,误诊率为16.7%。17例全部切除病变,1例大部分切除肿瘤。术中出血量100～2 500 ml。15例治愈,无并发症;1例并发细菌性脑膜炎治愈;1例双眼失明;1例因肺栓塞死亡。结论：经鼻内镜治疗蝶窦和累及蝶窦的中颅底硬膜外良性占位性病变可行。术前明确诊断、术中准确定位和仔细操作是手术成功的重要保证。     

Endoscopic and KTP laser-assisted surgery for juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a highly vascular tumor arising from the area around the sphenopalatine foramen. Various radical and extended radical surgeries have been advocated to surgically excise both extranasopharyngeal and nasopharyngeal juvenile angiofibromas. However angiofibromas involving the nasopharynx, nose, and sphenoid with minimal lateral extension via the sphenopalatine foramen can also be adequately managed endoscopically either alone or with 1 of the traditional approaches. Nine cases of juvenile nasopharyngeal angiofibroma were successfully managed between January, 1999, and March, 2001, by preoperative selective embolization of the internal maxillary artery with or without external carotid artery clamping, followed by endoscopic excision. Two of the 9 cases underwent KTP/532 laser-assisted endoscopic excision, whereas the transpalatal approach was used along with the endoscope in another 2 cases. The patients remained free of disease after a median follow-up period of 17 months. We report our preliminary experience in endoscopic and KTP laser-assisted excision of juvenile nasopharyngeal angiofibroma.     

Huge nasopharyngeal angiofibroma with intracranial extension: change in the dura mater and choice of surgical management

We aimed to review (1) the imaging changes in the dura mater in cases of huge, lobulated juvenile nasopharyngeal angiofibroma, and (2) the choice of surgical management. Imaging from four cases of juvenile nasopharyngeal angiofibroma showed extrapharyngeal extension of the tumour. The sphenoid sinus, sella turcica and clivus were extensively eroded, and the tumour had spread deep into the cranial fossa. In three cases, intracranial exploration was performed to treat the intracranial tumour lobule. Subsequently, the tumours were removed using extracranial approaches. No perforation of the dura mater was found in these three cases, although the dura mater in the superior orbital fissure was congested, haemorrhagic and solid. Pre-operative imaging for two cases (i.e. the first operation for one and the second operation for the other) revealed no dura mater perforation. A transantral approach via a midfacial degloving incision was used to remove these tumours completely. We conclude that change in the dura mater is a crucial indication for the choice of management. If the dura mater is intact, a transantral approach via a midfacial degloving incision may remove the tumour successfully.     

Surgical policy in patients with basally advanced form of juvenile nasopharyngeal angiofibroma

The authors has modified surgical policy in a basicranially extending form of juvenile nasopharyngeal angiofibroma (JNA) which is classified into tumors of stage I, II and III. Basally advanced tumors were diagnosed in 28 of 40 JNA patients: basicranially extended tumor (n=12, 30%), stage I tumor invading nasopharynx, nasal cavity, sphenoid sinus (n=4, 14.3%), stage II tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses (n=9, 32.1%), stage III tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses, infratemporal fossa, orbit, maxillary sinus and parapharyngeal space (n=15, 53.6%). Differential surgical treatment according to Owens (stage I tumors), Denker (stage II tumors), Moure (stage III tumors) provides radical removal of the tumor in the majority of the patients (87.7%) and therefore is an effective therapy of surgical treatment of the above patients.     

影像导航下鼻内镜手术58例临床分析

目的　探讨影像导航技术在鼻内镜手术中应用的有关问题。方法　回顾性分析 5 8例患者 ,其中慢性鼻窦炎、鼻息肉 39例、孤立性蝶窦炎 6例、坏死性上颌窦炎 3例、蝶窦囊肿 5例、鼻咽纤维血管瘤 2例 ;鼻颅沟通性脑膜瘤、外伤性脑脊液鼻漏、外伤性视神经损伤各 1例。所有病例均采用BrainLab影像导航系统及鼻内镜实施手术。结果　影像导航术前准备时间 (包括配准、头架定位、常规器械注册等 ) 10～ 2 0min ,平均 15min。 5 2例手术区域影像标志与实体解剖标志间的误差≤ 1 5mm ,6例 >3mm。影像导航可准确定位视神经等解剖标志 ,无手术并发症发生。结论　影像导航系统与内镜相驳接 ,不仅可以帮助术者在术中定位鼻腔、鼻窦、颅底的解剖结构 ,并可使手术视野扩展到内镜之外 ,使术者在术野中进行手术操作的同时 ,能顾及到术野周围的重要结构。特别是在复杂的手术中 ,可提高手术的精确性和安全性     

影像导航下鼻内镜手术58例临床分析

OBJECTIVE: To evaluate the availability and our experience of intraoperative image-guidance in endoscopic nasal surgery. METHODS: Fifty-eight cases of endoscopic nasal surgery with intraoperative image-guidance were retrospectively reviewed, including 39 cases of chronic sinusitis with or without nasal polyp; 3 cases of necrotizing maxillary sinusitis; 6 cases of sphenoid sinus cyst; 2 cases of nasopharyngeal angiofibroma; 1 case of cranio-nasal meningioma; 1 case of traumatic cerebrospinal rhinorrhea; 1 case of traumatic optic nerve lesion. All patients were operated on with Brain Lab operation imaging navigation system and nasal endoscope. RESULTS: The preoperative preparatory time would take 10-20 minutes, including coordination, head holder localization, conventional instrument registration. In our cases, the localization accuracy between 3-D image landmarks of navigation system and actual anatomical landmarks was less than 1.5 mm. The optic nerve and other anatomical points could be orientated accurately in intraoperative procedures. No complication occurred. CONCLUSIONS: Nasal endoscope combined with image-guidance systems provides accurate anatomical localization of nasal cavity, sinuses and anterior skull base with enlarged operation field. It is possible for surgeons to observe the surrounding important anatomical structures during endoscopic nasal surgery. It could increase the effectiveness and decrease surgical complications, especially in complicated cases.