鼻内镜下经上鼻道径路处理孤立性蝶窦病变

目的探讨鼻内镜下处理孤立性蝶窦病变的方法及疗效。方法回顾分析1999年8月~2004年10月93例孤立性蝶窦病变病人在鼻内镜下经上鼻道径路行孤立性蝶窦病变处理。鼻内镜下切除上鼻甲后半部分,直接暴露蝶窦前壁及开口,扩大开口,处理蝶窦病变。结果所有病例均顺利完成手术,无1例发生严重并发症。随访1~2年,蝶窦炎、蝶窦脓肿、蝶窦黏液囊肿、真菌性蝶窦炎、蝶窦息肉等88例病人均无复发。其余5例病人中1例真菌性蝶窦炎术后不久侵入颅内,后经抗真菌及综合治疗痊愈;2例蝶窦顶后壁脑脊液鼻漏1次性修补成功;1例蝶窦侧壁脑脊液鼻漏修补失败;1例蝶窦血管瘤未愈。结论鼻内镜下经上鼻道进路是处理孤立性蝶窦病变安全、直接、微创、有效的治疗方法。     

儿童急性鼻窦炎眶颅并发症的诊断与治疗

目的探讨儿童急性鼻窦炎眶颅并发症的临床特点与诊疗经验。方法回顾性分析2017年1月至2021年12月于北京儿童医院接受鼻内镜手术联合药物治疗的24例急性鼻窦炎眶颅并发症患儿的临床资料, 其中男19例, 女5例;年龄13～159个月, 中位年龄47.5个月。24例病例中, 单纯眶骨膜下脓肿12例, 合并眶隔前脓肿2例, 合并眶内脓肿2例, 合并视神经炎7例, 合并海绵窦血栓性静脉炎1例。采用描述性方法分析其临床特点、脓液细菌学培养结果、治疗及预后。结果 24例病例均有发热史, 伴鼻塞流涕9例;均存在患眼肿痛、眼球突出移位, 伴视力下降7例。术中17例脓液送细菌培养, 其中阳性12例。所有患儿均接受鼻内镜手术, 一次性手术成功23例, 二次手术成功1例。术后随访5～64个月, 除术前无残余视力的2例患儿遗留永久性视力丧失外, 其余均实现临床治愈。无死亡及复发病例。结论儿童急性鼻窦炎眶颅并发症起病隐匿, 进展迅速, 对于并发视力下降、出现颅内并发症或药物治疗无效的病例, 应及时进行经鼻内镜下鼻窦开放及眼眶脓肿引流术。     

以眶尖综合征为主要表现的蝶窦病变

目的探讨表现为眶尖综合征的蝶窦病变的诊断与治疗，以降低其误诊、漏诊的发生率。方法回顾2000-2004年12例以眶尖综合征为主要表现的蝶窦病变的病例，分析其临床诊疗过程及误诊原因。结果12例患者主要以眶尖综合征为表现，8例首诊于眼科，2例首诊于心内科（有高血压病史）后转入眼科，2例首诊于神经内科后转入眼科。12例均按眼部病变致眶尖综合征给以治疗，疗效均不明显，最后转入耳鼻咽喉头颈外科。全部病例均经CT或MRI确诊。12例中蝶窦炎性病变7例（包括3例真菌性鼻窦炎）、蝶窦息肉3例、蝶窦脓囊肿2例。全部病例均行鼻内镜下蝶窦开放术，术后所有症状先后缓解甚至消失。结论以眶尖综合征为主要表现的蝶窦病变临床上少见．容易被误诊为眼部疾患，临床医师尤其是眼科医师对该病认识不足易致误诊、漏诊。CT或MRI检查是确诊的标准。鼻内镜技术改进使蝶窦疾病的治疗更安全、更有效。     

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。     

蝶窦区病变外科手术径路之探讨——附50例报告

目的：探讨切除蝶窦区病变的良好手术径路。方法：根据病变种类的不同，分别采用：（1）用鼻内镜经单侧鼻腔入路治疗双侧蝶窦病变；（2）腭部粘膜“T”形瓣翻揭 硬腭开窗入路；（3）扩大的鼻侧切开 鼻锥翻揭入路；（4）颅面联合径路；（5）骨折外移鼻中甲行鼻中隔蝶窦入路。结果：本组50例，术中视野较为开阔，清晰，因减少了手术盲目性，本组未出现医源性并发症，蝶窦区良性病变37例中，术后随访3年未见复发，蝶窦区恶性肿瘤13例中经随访，3年存活率为61.5?/13)，5年存活率为46.2?/13)。结论：为了减少手术并发症，根据蝶窦的不同病变而采取不同的手术径路是合理的。     

儿童急性鼻窦炎眶并发症五例临床分析

目的 探讨手术治疗儿童急性鼻窦炎合并严重眶并发症的疗效.方法 回顾性分析2010年11月至2011年7月连续收治的5例保守治疗无效后行鼻内镜手术治疗的儿童急性鼻窦炎眶并发症患儿的临床资料.结果 5例患儿中合并眶蜂窝织炎1例,眶骨膜下脓肿3例,眶内脓肿1例,患儿术后体温均恢复正常,眼部症状消失.复查CT或MRI见眶部及鼻部病变基本消失.结论 对于保守治疗无效的儿童急性鼻窦炎眶并发症病例应尽早行内镜鼻窦手术清除病灶,手术安全且疗效确切.     

经鼻内镜颅底进路手术的探索

目的 探讨经鼻内镜颅底进路手术的可行性和适应证范围。方法 分别采用经鼻内镜前颅底进路和蝶窦后上壁进路完成前颅窝异物取出术、前颅窝嗅神经母细胞瘤和脑膜瘤切除术、侵入前颅窝的鼻腔内翻性乳头状瘤切除术、侵入中颅窝的巨大蝶窦囊肿切除术、原发性中颅窝鞍旁岩尖部胆脂瘤切除术、侵入鞍区的占位性病变切除术共9例。结果 9例手术均获成功，未发生术中和术后并发症。除1例低分化鳞癌鞍区占位性病变术后2年死于其他非相关性疾病外，另外良性（5例）和恶性（3例）占位性病变随访1-7年未见复发。结论 紧靠颅底的颅内占位性疾病外，另外良性（5例）和恶性（3例）占位性病变随访1-7年未见复发。结论 紧靠颅底的颅内占位性病变有经鼻内镜手术的可能性，但是适应证选择应非常严格，术者必须具备熟练的解剖学知识、手术技巧和经验，并配备先进的手术设备。对范围局限的恶性病变，应强调手术后的综合性治疗。     

鼻源性颅内并发症

化脓性鼻窦炎可引起颅内并发症，其死亡率为27～53％。1985年1月至1990年12月共治疗226例颅内并发症，有症状者219例，无症状者7例。219例有症状者中，男124例女95例，年龄1～60岁。22例（1％）脑膜炎，17例（8％）硬膜外积脓，127例（58％）硬膜下积脓，38例（17％）脑脓肿，15例（7％）脑脓肿并硬膜下积脓。所有病人均行经鼻外额筛窦进路根治性鼻窦手术。166例行额筛窦切除术，38例行筛窦切除术（5例双侧），131例行蝶窦切除术。所有患者均行鼻窦冲洗。颅内病变由神经外科医师行急诊引流手术。在抗牛素时代以前，脑膜炎是昌窦炎最常见的颅…     

经鼻内镜手术治疗鼻腔鼻窦骨源性良性肿瘤——附14例报告

目的探讨经鼻内镜手术治疗鼻腔鼻窦骨源性肿瘤的可行性及手术技巧。方法回顾性分析1998年6月-2012年5月经鼻内镜手术治疗的14例鼻腔鼻窦骨源性肿瘤的临床资料。所有患者均于术前行鼻窦高分辨CT（HRCT）检查,确定肿瘤的位置和侵犯范围。手术均在全身麻醉下进行,经鼻内镜手术11例,鼻内镜辅助鼻外径路手术3例。其中行肿瘤彻底切除9例,部分切除5例。结果所有患者术后平均随访5年7个月。2例侵及眶内及前颅窝的骨化纤维瘤患者分别于术后2个月和8个月复发,接受第2次手术后1例病变基本控制,目前仍在随访中,另1例去外院接受了第3次鼻颅脑联合手术再复发,仍在观察中;1例骨母细胞瘤患者采用经鼻经额联合径路内镜手术,但侵入前颅窝相当于鸡冠处的肿瘤仍有残留,术后2年患者因左侧眶内及颅内肿物复发去外院行开颅手术后失访;其余患者随访至今未见复发。所有病例均未发生其他严重并发症。结论鼻腔鼻窦骨源性肿瘤局限于鼻腔鼻窦者经鼻内镜手术可彻底切除;但当肿瘤破坏颅底突入颅腔或肿瘤侵及颈内动脉、视神经等重要结构时,单纯内镜下肿瘤不易彻底切除,需多学科的联合手术或其他辅助治疗。     

鼻内镜在治疗鼻源性眶内脓肿中的应用

目的：探讨鼻内镜治疗鼻源性眶内脓肿的疗效。方法：对46例鼻源性眶内脓肿行内镜下切开引流及病灶根治术。结果：41例患者（89.1%)达到治愈，2例由于球后视神经炎而视力差，另有3例残留不同程度的眼球运动障碍，结论；对于鼻源性眶内脓肿应在脓肿切开的同时治疗原发病灶，鼻内镜对此类手术有优势，但仍需注意并发症的发生。     

Orbital complications of infected mucocele in the paranasal sinuses

ObjectiveInfected mucocele of the paranasal sinuses can induce orbital infection, including orbital subperiosteal abscess, which may lead to life-threatening intracranial complications. Effective diagnosis is important, and treatment should be aggressive. This paper presents our experiences in endoscopic surgical management of orbital complications secondary to infected paranasal sinus mucoceles.MethodsFrom our retrospective review of the medical charts for 82 patients with 92 sides diagnosed with paranasal sinus mucoceles, we present 7 sides in 7 adult patients with orbital complications secondary to infected mucoceles. The collected data include the suggested etiology, side of sinus involvement, localization of abscess in the orbit, orbital wall bone defects caused by mucocele compression, ophthalmic symptoms, duration between symptom onset and initial visit, operation date, type of surgery performed, and follow-up.ResultsThe mucocele was located in the ethmoid-frontal region in 9.8% of the sides (9/92), in the frontal sinus in 7.6% (7/92), in the ethmoidal sinus in 9.8% (9/92), in the maxillary sinus in 67.4% (62/92), in the maxillary-ethmoidal sinus in 3.3% (3/92), and in the sphenoid sinus in 2.2% (2/92). The patients with ethmoid-frontal mucoceles had a significantly higher incidence of orbital complications (6/9) as compared with the other sub-types of mucoceles (frontal, 0/7; ethmoidal, 0/9; maxillary, 1/62; maxillary-ethmoidal, 0/3; sphenoid, 0/2). Chandler's classification showed Type I in one, Type II in three, and Type III in three. Sinus involvement was observed at the ethmoid-frontal sinuses in six cases and the maxillary sinus in one case. All seven cases had a partial defect of the orbital wall bone (lamina papyracea, or inferior orbital wall bone) by mucocele compression, and the patients underwent endoscopic marsupialization. For the cases with subperiosteal abscess, the lamina papyracea was also removed partially for draining the abscess. In all cases, symptoms were resolved without any recurrence of the mucocele.ConclusionsInfected ethmoid-frontal mucoceles with a defect of the lamina papyracea tend to induce orbital infection, so prompt surgery for the infected mucoceles should be considered early even with Types I and II, before visual acuity is impaired, because surgery is the only curative treatment for the mucoceles.     

Complications of sphenoid sinusitis

Regarding the skull base, no structure is as centrally located as the sphenoid sinus. It sits at the junction of the anterior and middle cranial fossae, and is surrounded by vital structures. Although relatively rare, complications of the inflammatory and infectious conditions of sphenoid sinusitis are the result of direct extension of disease to the surrounding tissues, or a propagated thrombophlebitis through valveless veins, which connect the paranasal sinuses with the orbit, cavernous sinus, and intracranial cavity. The spread of inflammation and/or infection from the sphenoid sinus to the orbit and cavernous sinus causes 5 distinct clinical entities: (1) preseptal cellulitis, (2) orbital cellulitis, (3) subperiosteal abscess, (4) orbital abscess, and (5) cavernous sinus thrombosis. The list of possible intracranial complications of sphenoid sinusitis includes meningitis, skull base osteomyelitis, and epidural, subdural, or cerebral abscess. A high index of suspicion must accompany any patient with unresolving sinusitis, increasing or changing symptoms, including the development of visual changes, ophthalmoplegia, focal neurologic signs, seizures, mood alterations, or persistent headache despite adequate therapy. Early identification and therapeutic intervention for orbital and intracranial complications of sphenoid sinusitis are paramount to a favorable prognosis.     

双侧扩大蝶窦成形术在蝶窦病变中的应用

目的探讨双侧扩大蝶窦成形术在蝶窦病变中的应用价值。方法2012年12月～2017年6月,解放军南京总医院耳鼻咽喉头颈外科采用双侧扩大蝶窦成形术治疗蝶窦病变患者42例,随访6～53个月,观察其手术疗效及并发症。 结果15例难治性蝶窦炎患者术后蝶窦口开放良好,术腔清洁,均治愈;其余患者均彻底切除病灶,其中1例真菌性蝶窦炎伴颅内感染并发热患者术后予抗真菌治疗3个月后颅内病灶吸收,2例蝶窦癌、1例蝶窦脊索瘤患者及1例嗅神经母细胞瘤侵犯蝶窦及颅内患者术后均行放疗。42例患者术后除2例嗅觉减退及1例视力下降无明显好转外,余症状均明显缓解,未发生动脉性鼻出血、嗅觉减退及鼻中隔穿孔等并发症,术后患者术腔黏膜均上皮化良好,黏膜完全上皮化时间平均8.6周。2例蝶窦癌患者分别随访10、14个月,蝶窦脊索瘤患者随访10个月,均未复发;1例嗅神经母细胞瘤侵犯蝶窦及颅内患者随访8个月未复发。所有患者随访至今,均未发现蝶窦口再闭。结论采用双侧扩大蝶窦成形术治疗蝶窦病变,术野暴露清晰,蝶窦开放充分,术腔上皮化时间短,手术安全性高,术后随诊处置直观,是一种值得推广的手术方法。     

蝶窦良性侵袭性病变的临床诊治分析

目的　探讨蝶窦良性侵袭性病变的临床特点及内镜治疗。方法　回顾性分析19例蝶窦良性侵袭性病变的临床资料。19例均行内镜下经蝶入路病变切除。结果　内 翻性乳头状瘤6例,骨化纤维瘤7例,软骨瘤2例,嗜酸性肉芽肿4例。临床症状以头痛及视觉障碍多见。影像学共同特征是蝶窦骨壁破坏,周围结构受不同程度侵袭。术中发生脑脊液鼻漏1例,I期修复成功。术后全部患者无眶内及颅内并发症。随访3～5年,手术全切除15例无复发;次全或大部分切除4例,1例病灶无增大;3例复发,其中1例再次手术治愈,2例恶变并颅内转移死亡。结论　蝶窦良性侵袭性病变呈恶性肿瘤样行为,具有侵袭性、易复发性。内镜下彻底切除病变是防止复发的重要治疗方法。但有别于恶性肿瘤,应注意避免扩大切除范围。     

Clinical characteristics and outcome in patients with isolated sphenoid sinus aspergilloma

Objective

Isolated sphenoid sinus aspergilloma (ISSA) is a rare disorder that is difficult to diagnose in a timely manner. These lesions can also extend to adjacent structures and thereby cause severe complications. ISSA patients with orbital complications typically have a poor prognosis even when surgical interventions have been successful. We here reviewed 30 ISSA cases with respect to clinical characteristics and treatment outcomes.

Methods

A group of 30 patients diagnosed with ISSA between January 1990 and October 2010 were retrospectively reviewed in terms of clinical manifestations, endoscopic findings, radiologic imaging data, and treatment results. We also compared the clinical manifestations and treatment results between patients with and without orbital complications.

Results

Old age (median, 55 years) and a female predominance (23 women in the study) were noted. The most commonly reported symptom was headache (80%) and the average duration of the symptoms before diagnosis was 8.1 months. On radiologic examination, including CT and MRI scans, 13 patients showed bony wall erosions and five patients demonstrated orbital complications including diplopia and visual loss. The appearance of a bony wall erosion on a CT scan and the acute onset of ISSA symptoms were found to be significant factors in the onset of orbital complications (P = 0.003 in each case). Endoscopic sphenoidotomy was performed in all 30 cases. Most of the preoperative symptoms among the patients, including headache, facial pain, and postnasal drip, were improved after surgery. Among the five patients in the study group with orbital complications, diplopia was completely resolved after surgery in each case but there was no improvement in visual loss.

Conclusions

An early diagnosis of ISSA, although not easy, is important to prevent complications arising from extensions of these lesions beyond the sphenoid sinus. Our present study demonstrates that ISSA could be effectively treated with an endoscopic sphenoidotomy, and that timely intervention is needed in patients with a sinus bony wall to prevent irreversible complications such as visual loss.     

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。     

孤立性蝶窦疾病18例临床分析

目的：探讨孤立性蝶窦疾病的诊断及合理的治疗方法。方法：回顾性分析18例经鼻内镜手术治疗的孤立性蝶窦疾病患者的临床资料。结果：18例中，炎性疾病l5例(急性炎症2例，慢性炎症3例，囊肿8例，真菌病2例)，恶性肿瘤3例。经鼻内镜手术后随访3个月至半年，蝶窦前壁开窗通畅，窦腔各壁光滑，症状明显改善，无并发症发生。结论：头痛是孤立性蝶窦疾病的常见症状，另有视力损害、血性涕及其他脑神经麻痹症状，CT、MRI及鼻内镜检查为其诊断提供有力依据；鼻内镜手术治疗是一种安全、有效、简便的方法。     

Otitis media and CNS complications.

Intracranial complications from otitis media can be quite devastating to the patient if an early diagnosis is not made. Patients may develop meningitis, venous sinus thrombosis or cranial nerve palsies, as well as intracranial abscess. The presenting features in such cases may be subtle and include headache, nausea, vomiting, personality changes and signs of increased intracranial pressure as well as focal neurological deficits. A case of intracranial brain abscess is presented in a patient with a history of chronic otitis media with cholesteatoma. Delay in the diagnosis of intracranial complications of otitis media can lead to improper treatment with increased morbidity and mortality. The etiology and treatment of complications affecting the CNS is discussed.