自发性脑脊液鼻漏定位诊断的影像学征象分析

目的 通过总结自发性脑脊液鼻漏患者的影像学直接征象和间接征象,为脑脊液鼻漏修补术前瘘点的影像学定位诊断提供依据。方法 回顾性分析2017年1月—2021年3月中南大学湘雅医院耳鼻咽喉头颈外科诊治的48例患者的临床资料,所有患者术前行鼻窦颅底高分辨CT(HRCT)和核磁共振(MRI)水成像检查。术前分析其影像学直接征象和间接征象,并结合术中情况证实其瘘点位置。结果 48例患者术前经影像学瘘点判断并经手术证实瘘点位于筛板20例(41.7%),蝶窦外侧隐窝16例(33.3%),筛顶8例(16.7%),额窦后壁2例(4.2%),斜坡2例(4.2%)。研究发现不同区域的自发性脑脊液鼻漏直接征象和间接征象存在明显不同,间接征象如左右侧不对称,引流通道水肿,窦腔黏膜增厚和积液征可以用于寻找瘘点。瘘口在影像学上根据直接征象颅底骨质缺损的诊断符合率为66.7%,而联合应用CT与MRI水成像根据直接征象和间接征象联合应用的诊断符合率为100%。结论 自发性脑脊液鼻漏患者影像学的间接征象对于术前准确判断瘘点具有重要价值。     

3D打印技术在颅底肿瘤手术中的应用

目的 通过三维重建颅底肿瘤及周围的组织结构,获取颅底肿瘤及其周围结构的解剖参数,铸造并打印个体化三维模型,研究3D打印技术在颅底瘤性病变手术治疗中的作用及应用价值。方法 收集2019年5月—2021年1月天津市环湖医院收治的15例复杂颅底肿瘤(包括脑膜瘤、垂体瘤、嗅神经母细胞瘤、颅咽管瘤、神经鞘瘤、脊索瘤)患者的临床病例资料。根据患者术前影像学,如CT、 MRI、计算机断层扫描血管造影(CTA)、三维重建的原始数据,利用“MINICS”软件读取患者影像学原始图像,应用3D打印软件及三维重建技术,个性化设计颅底占位的手术方案。结果 三维重建并打印15例患者的颅底肿瘤及其周围结构的个体化模型。依据三维重建模型分析肿瘤周边重要血管的分布及走行,术中加以保护及预防损伤。15例患者均顺利完成手术,其中14例获得全切除,患者术后恢复良好,未见肿瘤复发及术后并发症;1例大部分切除患者(梭形细胞恶性肿瘤)术后复发,予手术+放疗结合的综合性治疗后好转。结论 利用3D技术打印的个体化颅底肿瘤三维模型,可用于设计和规划颅底肿瘤切除及术后修复重建,对于指导临床彻底切除肿瘤组织、保护毗邻神经、血管及术后修复缺损具有重要意义。     

以失明为首发症状的后组鼻窦囊肿3例及文献复习

目的 探讨以失明为首发症状的后组鼻窦囊肿的临床特征,以期早诊断、早治疗,避免引起严重的视力损伤。方法 对近期发生的3例首发症状为失明的后组鼻窦囊肿患者,采集病史,收集实验室及影像学检查,明确诊断后急诊行鼻内镜下鼻窦开放,清除囊肿,并行视神经减压术。术后定期随访,评估视力恢复情况。结果 3例患者术后症状均改善,1例视力恢复至光感,2例视力无改善。结论 对于出现眶周胀痛,且原因不明的急性视力下降患者,应警惕鼻窦囊肿合并感染的可能,积极进行影像学检查有助于早期诊断,及时进行手术,并减压视神经等治疗,有机会改善患者视力预后。     

罕见新生儿鼻咽部横纹肌肉瘤1例及文献复习

目的 通过报道1例新生儿鼻咽部横纹肌肉瘤（RMS）及其相关文献复习，以提高临床医师对该病的认识。方法 患者，女，16 d，出生后即发现有鼻塞、张口呼吸，吸吮时憋气、呼吸困难。鼻咽喉内镜、CT及MRI检查提示鼻咽部占位性病变，通过活检手术后病理及免疫组化检查确诊为RMS。结果 患儿经系统化疗后病情好转，8个月龄时内镜及影像学复查，局部病灶较前缩小，一般状况良好，未见头颈及全身转移。结论 发生在新生儿鼻咽部的RMS十分罕见，且位置隐匿，早期无典型临床表现，容易造成误诊及漏诊；该病恶性程度高，临床上应争取早发现、早诊断及早治疗，提高患者生存率。     

鼻内镜下鼻窦骨纤维异常增殖症累及颅底或眼眶的手术治疗

目的 探讨鼻内镜下鼻窦骨纤维异常增殖症累及颅底或眼眶的手术治疗与经验总结。方法 回顾性分析2017年7月—2020年12月南京大学医学院附属鼓楼医院耳鼻咽喉头颈外科收治的13例采用鼻内镜手术治疗累及颅底或眼眶的鼻窦骨纤维异常增殖症患者的临床资料,结合手术治疗及术后疗效进行综合评价。结果 13例患者术后均无严重并发症,受累颅底或眼眶病变组织彻底切除,无眼球功能障碍及脑脊液鼻漏。随访6～48个月,所有患者均无复发。结论 对于累及颅底或眼眶的鼻窦骨纤维异常增殖症的患者,鼻内镜结合导航及等离子技术可彻底切除病变组织以达到功能重建的效果。     

15例咽旁隙肿瘤回顾性分析

目的 总结15例咽旁隙肿瘤的临床诊治经验,为选择手术适应证、减少手术并发症提供借鉴。方法 15例咽旁隙肿瘤经增强CT和MRI等术前检查予以充分评估后,采用经口径路手术切除5例、经颈侧径路切除6例、经颈侧腮腺径路切除4例。结果 所有患者肿瘤均成功切除,1例术后即刻出现颅底大出血,用明胶海绵等压迫填塞后成功止血;3例恶性肿瘤患者中2例患者术后接受放疗,1例失访,其余患者随访1.5~5年,均无复发。结论 根据肿瘤部位,结合患者需求选择合适手术方式,能彻底切除肿瘤,术前充分的影像学评估对制定手术方案和预防手术并发症至关重要。     

鼻颅底沟通性肿瘤的诊断及外科治疗

目的 探讨鼻颅底沟通性肿瘤的诊断及外科治疗方法。方法 回顾性分析2011年1月—2021年12月华中科技大学同济医学院附属同济医院神经外科诊治的37例鼻颅底沟通性肿瘤的临床资料,男23例,女14例;年龄6~67岁,平均年龄49岁。其中恶性肿瘤27例,良性肿瘤10例,肿瘤直径4.7~8.5 cm,平均直径6.3 cm。所有患者均采用头颈部影像学检查协助诊断后行开颅显微手术+颅底重建,恶性肿瘤术后进一步行放化疗,术后所有患者均定期随访,恶性肿瘤随访5~10年,平均8.3年;良性肿瘤随访1~11年,平均6.7年。结果 所有患者均顺利完成手术,无严重并发症,恶性肿瘤5年生存率63.0%(17/27);1例良性肿瘤(非典型脑膜瘤)术后5年复发再次经双侧额底入路手术治疗。结论 神经外科首诊的鼻颅底沟通性肿瘤往往颅内肿瘤为主体,开颅手术全切或大部分切除+妥善颅底修复意义重大。     

鼻中隔黏膜瓣重建鼻咽部放疗后坏死有效率的Meta分析

目的 系统评价鼻咽癌患者应用鼻中隔黏膜瓣重建鼻咽部放疗后坏死(PRNN)清创术后鼻咽部缺损的有效性。方法 应用计算机检索Pubmed、Cochrane Library、Embase、Web of Science等英文数据库,以及中国知网(CNKI)、万方(WANFANG)、维普(VIP)等中文数据库,检索时间为自数据库建立至2021年2月1日,检索鼻中隔黏膜瓣修复PRNN术后鼻咽部缺损的临床研究。由两位研究者独立筛选文献、提取资料后,应用RStuido软件进行效应量分析。结局指标为鼻中隔黏膜瓣重建鼻咽部缺损的有效率。此外,搜索并分析仅以鼻咽坏死组织清创治疗PRNN的研究作为参考。结果 初次检索获得文献1005篇,根据纳入及排除标准,最终纳入5篇单臂回顾性研究,共145例患者,鼻中隔黏膜瓣重建鼻咽部缺损成功率为84%(95%CI=[0.72,0.96],I²=74%)。同时,检索到9篇仅以鼻咽坏死组织清创治疗PRNN的研究,其上皮化率为47%(95%CI=[0.31,0.62],I²=94%)。结论 鼻中隔黏膜瓣作为有效的修补材料,可用于PRNN清创手术中鼻咽部缺损的重建,需要更多的前瞻性队列研究或随机对照试验以进一步研究。     

电子鼻咽喉镜直视下环杓关节拨动复位术治疗环杓关节脱位的疗效分析

目的 探讨电子鼻咽喉镜直视下环杓关节拨动复位治疗的疗效,为环杓关节脱位的治疗提供参考。方法 回顾性分析2016年9月—2021年3月收治17例明确诊断为单侧环杓关节脱位并在局部麻醉下经电子鼻咽喉镜直视下环杓关节拨动复位术的患者临床资料,比较拨动复位前后电子鼻咽喉镜检查、发声障碍指数量表（VHI-10）及听觉感知（GRABS）评估总嘶哑度G。结果 治疗前17例患者均有发音疲劳、不同程度的声音嘶哑、声带运动障碍及声门闭合不良。17例患者经复位术后4周均诉发音嘶哑改善;电子鼻咽喉镜检查声带运动恢复正常15例（88.24%）;2例（11.76%）患侧声带动度较术前改善,但仍较健侧稍差,声门闭合较前改善。与复位前比较,复位后VHI-10功能、生理、情感三个维度及总分均降低（P<0.05）;G0为8例,G1为7例,G2为2例。结论 局部麻醉下电子鼻咽喉镜直视下杓状软骨拨动复位是治疗环杓关节脱位的安全、简便、有效的方法。     

内镜下65例鼻颅底肿瘤切除后颅底重建临床分析

目的 探讨鼻内镜下鼻颅底肿瘤切除后采用游离中鼻甲黏膜（FMT）、阔筋膜、鼻中隔带蒂黏膜瓣（HBF）行颅底缺损重建治疗脑脊液鼻漏的临床效果。方法 回顾性分析65例在鼻内镜下行鼻颅底肿瘤切除且行颅底重建治疗脑脊液鼻漏患者的病例资料。根据颅底缺损大小及部位选择修补材料,缺损<1.5 cm,均采用FMT（24例）;缺损≥ 1.5 cm,优先选择HBF（16例）,但当HBF无法获取或不适用（缺损位于额窦后壁）,选择阔筋膜（25例）。分析患者的修补效果并比较阔筋膜与HBF的修补结果。结果 采用FMT行颅底缺损重建治疗的患者有2例出现术后脑脊液漏,一次性修补成功率为91.7%;采用阔筋膜治疗的患者有1例出现术后脑脊液漏,一次性修补成功率为96%;采用HBF治疗的患者有1例出现术后脑脊液漏,一次性修补成功率为93.8%;总体成功率93.8%。采用阔筋膜行颅底修补的患者术后出现颅内感染2例、肺部感染0例、术后鼻出血2例,采用HBF行颅底修补的患者术后出现颅内感染1例、肺部感染2例、术后鼻出血2例,两种颅底修补方法术后并发症均无明显差异。结论 鼻内镜下采用HBF、阔筋膜或FMT行颅底重建治疗脑脊液鼻漏均可获得较为满意的结果。FMT对于较小（<1.5 cm）的缺损是可靠的修补材料;对于较大的缺损（≥ 1.5 cm）,HBF或阔筋膜均可以采用且获得相似的结果,当HBF无法获取或不适用（缺损位于额窦后壁）,选择阔筋膜是可行的。     

Endoscopic management of skull base osteoradionecrosis

OBJECTIVE: Osteoradionecrosis is one of the most serious complications in radiotherapy of nasopharyngeal carcinoma. We describe a new endoscopic approach to resolve resultant skull base osteoradionecrosis. The objective of this study is to evaluate the efficacy of endoscopic management of skull base osteoradionecrosis. STUDY DESIGN: A prospective study of the outcome of endoscopic management for patients with skull base osteoradionecrosis. METHODS: Between 1994 and 1998 six patients who had irradiation previously for nasopharyngeal carcinoma had skull base osteoradionecrosis. A sinoscopic approach was applied for diagnosis and sequestrectomy. This diagnosis was based on the criterion of exposed necrotic bone after removing all crust in the nasopharynx and further confirmed on pathological examination after sequestrectomy. Effective cure was defined as intact mucosal coverage without any ulcer or exposed necrotic bone observed in the nasopharynx and the absence of antecedent accompanying symptoms after management. RESULTS: Six patients (10%) were symptom free. Five (83.3%) patients had effective cure. There was no surgical morbidity or mortality. CONCLUSION: Endoscopic sequestrectomy is a justified approach to skull base osteoradionecrosis.     

Breast carcinoma metastatic to the nasopharynx

A case report of a patient with adenocarcinoma of the breast with metastasis to the nasopharynx is described. The patient presented initially with pulmonary metastasis followed later by metastasis to the left jugulo-digastric lymph nodes. A prominent but asymptomatic nasopharyngeal mass was concomitantly discovered on head and neck examination. Three months later, symptoms of panhypopituitarism developed. Invasion of the base of the skull and pituitary were documented. Patients with adenocarcinoma of the breast and high cervical node metastasis should have a thorough otolaryngologic and head and neck evaluation. Metastatic carcinoma to the nasopharynx is an extremely rare occurrence. Only two cases of bronchogenic carcinoma of the lung and two cases of hypernephroma metastatic to the nasopharynx have been reported in the literature (Bernstein et al., 1966). We present what we believe to be the first case of metastatic adenocarcinoma of the breast to the nasopharynx.     

Diagnosis and management of skull base osteoradionecrosis after radiotherapy for nasopharyngeal carcinoma

OBJECTIVE: The objective of this study was to investigate the diagnosis and management of skull base osteoradionecrosis (ORN) after radiotherapy for nasopharyngeal carcinoma (NPC). METHODS: The general information, clinical manifestations, and treatment outcomes were retrospectively evaluated in 15 patients with skull base ORN after radiotherapy for NPC. RESULTS: The common symptoms of skull base ORN included foul odor, headache, and epistaxis. Endoscopic examination showed exposed bone or sequestration in the nasopharynx. The characteristic findings according to computed tomography included the following: bone was destroyed extensively and symmetrically or regionally; bone was exposed to the air cavity; sequestration can be observed; and small air bladder was present in the parenchyma. There were nine patients regional skull base ORN receiving surgery, two of whom died of postradiation temporal lobe necrosis and seven of whom survived for 2 to 7 years. Conservative treatments were provided to six patients, including five patients with extensive skull base ORN and one patient with regional ORN, among which three patients died of nasopharyngeal bleeding, one patient died of exhaustion, and two patients survived for 3 to 5 years. CONCLUSIONS: Clinical diagnosis of skull base ORN was based on symptoms, computed tomography, or magnetic resonance imaging and endoscopy. The final confirmation was according to pathologic examination. Surgery had the best effect. Extensive ORN accompanied by radiation brain damage or cranial nerves damage had poor prognosis. Nasopharyngeal bleeding and exhaustion were the main causes of death.     

脱氧葡萄糖-正电子发射断层显像在鼻咽癌放疗后鼻咽颅底病变的诊断效果研究

目的探讨脱氧葡萄糖-正电子发射断层显像（F-18-fluoro-2-deoxyglucose positron emission tomography，FDG-PET）在鼻咽癌放疗后鼻咽颅底病变中的诊断价值。方法通过9例行FDG-PET、CT和（或）MRI检查，以及内镜下鼻咽颅底病灶探查活检术的鼻咽癌放疗后患者，比较FDG-PET、CT和（或）MRI与病理活检结果。结果9例鼻咽癌放疗后患者中CT和（或）MRI提示枕骨斜坡复发7例，可疑复发2例；FDG-PET鼻咽颅底有浓聚灶9例；病理确诊复发3例，慢性炎症和（或）骨组织部分坏死6例。PDG—PET诊断准确率是33．3％（3／9），假阳性率为66．7％（6／9）。结论FDG-PET对鼻咽癌放疗后鼻咽颅底病变诊断有一定假阳性率，确诊需根据内镜下的病理诊断。     

Real time in-vivo miniature endoscopic surveillance system for imaging of nasopharynx

ObjectiveTo test the feasibility of a real time miniature endoscope system for imaging the nasopharynx.Study designPreclinical assessment on skull model and cadaver.MethodsA 3.5 mm miniature endoscope was fabricated and the image capture of the nasopharynx was investigated by positioning the miniature camera system at the posterior free edge of the vomer bone. Wireless real time transmission of the images and quality was tested in a skull model. Next, three nasopharyngeal surveillance miniature camera system were developed for possible clinical translation. Two prototypes were anchored on the nasal septum and the last prototype was designed using a patient self-administered surveillance process. These prototypes were tested for feasibility on both the phantom skull and cadaveric model. Risk assessments were also performed to assess risk, safety and validate the reliability of the material utilized for clinical translation.ResultsInsertion and anchorage of the miniature surveillance endoscope prototypes at the vomer bone were feasible on all 3 prototypes. The quality of captured images was reasonable and miniaturized camera was responsive to pan at different angles so that the entire nasopharynx may be surveyed. Risk assessments on the material such as pull out test, breaking force analysis, finite element test and tensile strength test were reliable for possible clinical translation.ConclusionsReal time miniature endoscope system for surveillance of nasopharyngeal cancer is feasible. Clinical translation of this technology was possible but requires further refinement in enhancing image quality and wireless transmission of the captured images.     

内镜手术治疗鼻咽癌放射治疗后颅底软组织坏死的临床研究

目的探讨鼻咽癌放射治疗(放疗)后颅底软组织坏死患者的诊断和治疗。方法回顾性分析中南大学湘雅医院耳鼻咽喉头颈外科2015—2019年收治的7例鼻咽癌放疗后颅底软组织坏死且不合并骨组织坏死患者的临床资料。7例患者中男6例,女1例;年龄45~80岁,中位年龄54岁。分析7例患者的临床表现、诊断、治疗及预后。7例患者的主要临床症状包括:头痛7例;听力下降7例;长期鼻部恶臭5例;反复鼻出血2例。7例患者术前均行颅底高分辨率CT、MR以及磁共振血管造影(MRA)检查。7例患者高分辨率CT检查可见鼻咽部软组织病灶,骨皮质完整,颅底软组织病灶与颅底骨面交界处可见小气泡影;MR、MRA检查显示鼻咽部为广泛炎性反应改变,6例可见鼻咽旁不规则坏死腔,病变中心无强化,周围软组织水肿。所有病例均采用全身麻醉内镜下扩大经鼻入路手术切除坏死组织的治疗方式。7例患者均行鼓膜切开置管术;5例行部分或全切患侧咽鼓管软骨段;1例同时行全组鼻窦开放术。7例患者均在围手术期进行抗炎等对症处理,术后随访6个月至3年,观察记录患者恢复情况。结果 7例患者手术清除的鼻咽颅底坏死组织经术后组织病理学检查,结果证实为坏死软组织及坏死的软骨组织,无肿瘤复发。全部患者术后症状均得到不同程度的改善,包括:听力提高7例;头痛消失5例,头痛缓解2例;鼻部恶臭消失4例,减轻1例。随访期间5例存活,2例死亡。2例未切除咽鼓管的患者中1例术后3个月再次出现鼻咽坏死灶,之后死于鼻咽大出血;1例术后6个月出现严重颅内感染导致死亡。结论鼻咽癌放疗后颅底软组织坏死诊断需依据患者的放疗病史、临床表现和影像学检查综合分析,颅底高分辨率CT、MR、MRA对于诊断非常重要,早期积极采用内镜下大范围坏死灶清除同时根据咽鼓管软骨受累情况行咽鼓管软骨的部分切除或全切除是治疗放疗后颅底软组织坏死的有效手段,可提高患者的生活质量。     

Rare site of an adenoid cystic carcinoma in the nasopharynx

We report the case of a 63-year-old patient suffering from a nasopharyngeal adenoid cystic carcinoma. She presented with increased oral secretion and pharyngeal irritation, Horner's syndrome, and trigeminal neuralgia. Magnetic resonance imaging scans revealed a tumor of the nasopharyngeal space invading the right cranial base. Lymph node metastases were clinically excluded. The histological sample confirmed an adenoid cystic carcinoma, which was therapeutically treated with adequate radiotherapy. Based on the presented case report and a review of the literature, we discuss the diagnosis and treatment of adenoid cystic carcinomas of the nasopharynx.     

鼻内窥镜在反复鼻咽部活检中的作用

目的研究在鼻内窥镜下实施鼻咽部活检术诊断鼻咽癌的意义。方法52例行鼻内窥镜下鼻咽 部活检术。结果所有患者均1次行鼻内窥镜下鼻咽部活检术,24例诊为鼻咽癌,28例病检为鼻咽部黏膜慢 性炎症。阴性者随访1年以上,无1例后诊为鼻咽癌。结论在鼻内窥镜下实施鼻咽部活检术能检查鼻咽部 各个部位,可在一处反复活检取得深层组织且能控制标本的大小,用此法可以确认鼻咽癌。     

Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado

IntroductionThe most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial.MethodsA randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0.Results128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The p-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results.DiscussionSurgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed.ConclusionsUltrasound-guided and serially guided percutaneous drainage is the best therapeutic option in patients with mild and/or moderate dental infections.