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。     

鼻内镜下治疗蝶窦非垂体源性病变53例

目的:探讨蝶窦非垂体源性病变的诊断及鼻内镜治疗方法。方法:53例蝶窦非垂体源性病变患者均经CT扫描发现蝶鞍区病变并提示了病变范围。8例局限性病变者经蝶窦前壁自然口入路完成手术,2例鼻咽纤维瘤侵犯蝶窦者经鼻中隔中线入路,其余经上鼻道或蝶筛入路暴露病变。结果:53例蝶窦非垂体源性病变中,蝶窦囊肿及脓囊肿23例、蝶窦真菌感染8例、蝶窦出血性息肉2例、垂体瘤切除术后蝶窦炎性肉芽肿1例、蝶窦乳头状瘤5例、蝶窦脑脊液鼻漏1例、蝶窦骨化纤维瘤2例、鼻咽血管纤维瘤侵犯蝶窦2例、筛蝶窦脑膜瘤1例均行鼻内镜下蝶窦开放切除病变或修补脑膜,术后症状明显改善;蝶窦内血肿并颈内动脉假性动脉瘤3例仅作鼻内镜检查,经DSA证实并行血管内介入栓塞治疗后治愈;蝶窦恶性肿瘤3例,经蝶筛入路切除蝶窦内大部分肿瘤后辅以放化疗;鼻咽癌侵犯蝶窦2例病理检查证实后行放化疗。结论:蝶窦鞍区病变以头痛、眼部症状为常见症状,CT、MRI及DSA检查对蝶窦病变的及早发现和诊断起着重要作用,鼻内镜下处理蝶窦病变径路多样,选择适当径路可达到直接、安全、微创等目的。     

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。     

Intrasphenoidal transsellar encephalocele repaired by endoscopic approach

Spontaneous sphenoidal encephaloceles are rare entities. In the case of intrasphenoidal encephaloceles, most defects are temporosphenoidal and occur in the lateral wall of the sphenoidal sinus. There have been to our knowledge only 7 reports of medial, transsellar encephaloceles in the literature. We report a case of intrasphenoidal transsellar encephalocele that was successfully managed through an endoscopic approach with complementary lumboperitoneal shunting. This disorder presents a challenge in surgical management because of the involvement of opticochiasmatic structures, the hypothalamopituitary axis, and the delicate vasculature of the circle of Willis in and around the encephalocele, besides proximity to the cavernous sinus. Rhinologists should be aware of these malformations, since the optic nerve or chiasma may be totally exposed in the sphenoidal sinus in the course of this disease. This case illustrates the need for magnetic resonance imaging in case of sphenoidal abnormalities, as well as the possibility of endonasal repair without a transcranial approach for large intrasphenoidal encephaloceles.     

蝶窦口的影像解剖测量及其临床意义

目的测量蝶窦口与周围解剖结构的影像解剖数据,为临床提供相关数据。方法选取30例蝶窦无异常的健康成年志愿者行鼻窦薄层扫描,并行矢状位及冠状位的重建,利用工作站对蝶窦口与周围结构进行测量。结果蝶窦口的最大上下径为(2.28±0.52)mm,左右径为(2.06±0.32)mm,蝶窦口与前鼻孔的距离为(72.34±3.67)mm,蝶窦口与蝶窦顶壁、后壁、下壁及外侧壁的最大距离分别为(10.64±3.99)、(17.68±2.78)、(13.25±3.50)、(8.76±3.79)mm。结论蝶窦口为经蝶手术的重要解剖标志,扩大蝶窦口应自蝶窦口向内下方扩大,向上不易超过(10.64±3.99)mm,向外侧不易超过(8.76±3.79)mm。     

Determining leak locations during transnasal endoscopic repair of cerebrospinal fluid rhinorrhea

Objective

For transnasal endoscopic repair procedures to be successful, it is critical to identify leak locations during surgery. We aim to evaluate different methods to more accurately detect leak locations during the endoscopic repair of cerebrospinal fluid rhinorrhea.

Materials and methods

We performed a retrospective chart review of 39 cases undergoing endoscopic repair of cerebrospinal fluid rhinorrhea. The leak locations were determined using preoperative nasal endoscopy, radioisotope scanning, the intraoperative image-guided system, and intraspinal normal saline injection.

Results

The cerebrospinal fluid leak location was in the sphenoidal sinus in 9 cases, the ethmoid sinus in 17 cases, and in the frontal sinus in 1 case. The leak locations could not be determined in the remaining 12 cases using this method alone. For these 12 cases, after the ethmoid sinus was opened and the lateral wall of sphenoidal sinus was exposed with the aid of the intraoperative image-guided system, outflow of cerebrospinal fluid was present on the lateral wall of sphenoidal sinus (in 1 case) and on the ethmoid roof (in 3 cases). Furthermore, using intraspinal saline injection (20-30 ml), leak locations were detected in the sphenoidal sinus (2 cases) and in ethmoid sinus (6 cases) of the remaining cases.

Conclusion

For cerebrospinal fluid rhinorrhea patients whose leak locations are difficult to determine, surgeons can increase their operative success rates by performing radioisotope scanning and intraspinal saline injections and by using image-guided surgical systems. These safe and effective methods can be used to successfully detect leak locations during transnasal endoscopic repair of cerebrospinal fluid leaks.     

鼻内镜下蝶窦手术

目的探讨鼻内镜下蝶窦病变的处理方法及疗效。方法采用鼻内镜手术对37例蝶窦病变进行手术治疗,根据不同病变情况,采用不同的入路及处理方法。结果所有病变均获得痊愈。2例真菌性蝶窦炎病例蝶窦口出现反复狭窄闭锁。经多次换药处理后治愈。1例蝶窦癌患者术后3年肿瘤复发。其它患者病变均无复发。结论根据蝶窦病变的不同临床特点,采用不同鼻内镜手术入路和处理方法,既可有效治愈蝶窦病变,同时可最大限度地减少手术创伤。     

Age-specific stages of pneumatization of the spenoidal sinus in children based on the results of computed and magneto-resonance tomography

The present study had the objective to evaluate specific features of pneumatization along with the growth rate of the sphenoid bone and the size of the sphenoidal sinus in children of different age. To this effect, computed and magneto-resonance tomograms of paranasal sinuses taken from 100 patients at the age from 2 to 15 years were analysed retrospectively. The data thus obtained included the size (length, height, and width) and anatomic position of the canals for the internal carotid artery and optic nerve with respect to the walls of the sphenoidal sinus as well as age-specific growth dynamics of this sinus. Its formation was followed up from the age of 1 year till 3-5 years. Pneumatization of the sphenoidal sinus was evaluated. It is recommended that the results of the study should be taken into consideration when carrying out endonasal diagnostic procedures and surgical endoscopic interventions during the childhood period.     

A case of mycotic sphenoidal sinusitis with stone formation

A 40-year-old white female was seen with the chief complaint of recurrent episodes of severe pulsating occipital headache. The headache was temporarily controlled with the treatment of antibiotics only to recur. Sinus X-ray revealed an increased radio-opacity in the left sphenoidal sinus. The sinus walls showed sclerotic reaction. X-Ray CT demonstrated a small piece of metallic density within the soft-tissue density. Intranasal sphenoidotomy was performed under general anesthesia. A small piece of stone, measuring 3 X 2 X 1.5mm, was found in the sphenoidal sinus, with purulent discharge and caseous concrements. Histopathologic examination of the caseous concrements demonstrated fungal hyphae with branching and septate suggesting Aspergillus sp. Chemical analysis of the stone (3mg dried weight) was done and it consisted of calcium phosphate (88%) and calcium carbonate (12%). Postoperative course for five years was uneventful, and postop. CT confirmed the aerated sphenoidal sinus.     

孤立性蝶窦疾病的临床分析

目的:探讨孤立性蝶窦疾病的临床特点和治疗方法,提高首诊准确率和治愈率,避免产生严重并发症.方法:回顾性分析46例孤立性蝶窦疾病患者的临床表现、影像学特点、病理类型和外科治疗效果.结果:本病主要症状为头痛和视力损害;影像学检查见蝶窦占位,部分可有骨质破坏;病理检查显示蝶窦炎症8例,真菌病19例,囊肿10例,息肉9例;全部患者经鼻内镜蝶窦开放手术.随访6个月以上,绝大部分患者症状明显好转,检查蝶窦开口通畅,窦腔无分泌物,窦壁光滑.结论:孤立性蝶窦疾病症状无特异性,鼻内镜和CT或MRI检查能提高术前诊断率,内镜鼻窦手术是治疗的首选术式.     

鼻内窥镜手术治疗蝶,筛窦囊肿17全地

目的：对鼻内窥镜手术治疗蝶、筛窦囊肿疗效进行评估。方法：回顾总结１７例鼻内窥镜手术治疗蝶、筛窦囊肿及３￣９年阴访的资料。结果：１７例央内窥镜下均良好暴露术野,术后囊腔得到充分引流;１５例获得满意疗效,无严重并发症发生。结论：鼻内窥镜下囊肿开放引流术是一种治疗蝶、筛窦囊肿安全、有效的方法。     

A comparison between sinus radiographic findings and the macroscopic appearances of the para-nasal sinus mucosa

The results of a retrospective study comparing the preoperative state of the sinus mucosa with the pre-operative sinus radiographic findings are reported. In contrast to a low false-positive rate, the incidence of false-negative reporting in the ethmoidal and sphenoidal air cell systems was 43-55% and was 20% in the maxillary sinuses.     

鼻内窥镜手术治疗蝶、筛窦囊肿17例报告

目的：对鼻内窥镜手术治疗蝶、筛窦囊肿疗效进行评估。方法：回顾总结１７例鼻内窥镜手术治疗蝶、筛窦囊肿及３～９年随访的资料。结果：１７例在内窥镜下均良好暴露术野,术后囊腔得到充分引流;１５例获得满意疗效,无严重并发症发生。结论：鼻内窥镜下囊肿开放引流术是一种治疗蝶、筛窦囊肿安全、有效的方法     

Nitric oxide production in the sphenoidal sinus by the inducible and constitutive isozymes of nitric oxide synthase

OBJECTIVE: To study the production of nitric oxide (NO), and the presence of different isoforms of the NO-synthesising enzyme, NO-synthase (NOS), in the paranasal sinus. MATERIALS AND METHODS: Ten patients, undergoing surgery for pituitary adenoma, were examined for the presence of NO gas in the sphenoidal and maxillary sinus. The distribution of different NOS isozymes in mucosal biopsies from sphenoid and maxillary sinus and ethmoidal cells was studied. RESULTS: The mean concentration of NO was 2575 ppb in the sphenoidal sinus and 6792 ppb in the maxillary sinus. Morphological analyses revealed intense NADPH-diaphorase staining throughout the epithelium. Immunoreactivity against NOS2 (inducible NOS) was observed in the apical cell layer but not of the basal layer. NOS1 (neuronal NOS)-immunoreactivity was mainly seen in the subapical part of the epithelium and NOS3 (endothelial NOS)-immunoreactivity was observed only in the most apical part of the epithelium. CONCLUSION: NO concentration in the sphenoidal sinus is about the same as in the nasal cavity and approximately half of the concentration found in the maxillary sinus. All of the three main different isozymes of NOS can be demonstrated in the mucosa of the sphenoidal and maxillary sinus and ethmoidal cells, NOS2 being the most abundant isoform.     

Anatomical study on the sphenoidal sinus and petrous apex cells

Morphological relation between the sphenoidal sinus and the petrous apex cell was studied using HRCT images obtained by 339 adults and 43 infants. The adults were classified into normal group (without chronic otitis media or its surgery) 237 cases, and otitis group (chronic otitis media or its post. op.), 102 cases. The posterior extent of the sphenoidal sinus was evaluated in reference to the carotid canal, and the petrous apex cells were evaluated by their mode of distribution in the apex. In the normal adults, no evident relation was seen between the posterior extent and the mode of distribution. Although adult normal female showed statistically significant better development of the posterior extent, sinus-cell relation was similar between both sexes. The adult normal group and otitis group behave similarly by sinus-cell relation, i.e., no evident relation, although inhibited mode of distribution was seen by otitis group. When the adult and infant were compared, the sinus-cell relation was similar and the posterior extent suffered underdevelopment by infant. The distance, between the posterior extension of the sphenoidal sinus and the apex cell at the medial-anterior tip of the petrous bone, is between 8-16 mm and the contact of the both separated by thin bony wall (less than 0.5 mm) was seen in 3 adult cases (0.9%). Both the sphenoidal sinus and the petrous apex cells are under genetic influence of variable degree, separate genes seem to be at work, thus effecting no evident relation between the two. Apart from the internal or genetic influence, environmental or outer influence also affects the development of the two, less than the genetic.(ABSTRACT TRUNCATED AT 250 WORDS)     

累及颅内的蝶窦粘液囊肿(3例报告)

目的 总结侵犯颅内的蝶窦粘液囊肿的临床特征及预后。方法 回顾性分析近6年来我院收治的3例侵及颅内的蝶窦粘液囊肿的临床资料。结果3例巨大蝶窦粘液囊肿分别有不同程度的蝶鞍部、斜坡和中颅窝等颅内侵犯,除鼻部症状外,共同的临床表现是较剧烈的持续性头痛;1例合并右眼视力下降仅有光感,1例合并双眼视力减退,1例有左侧外展神经麻痹;3例均无内分泌症状。3例病人均行鼻内镜蝶窦粘液囊肿切除术,术后头痛迅速缓解,受损脑神经部分恢复;术后1~2个月均头痛完全消失,分别有双眼视力轻度下降和左侧三叉神经麻痹的2例病人在术后1个月完全恢复,另1例右眼视力仅有光感者术后随访1年视力无好转。结论 侵及颅内的蝶窦粘液囊肿常表现为持续性头痛、脑神经麻痹和不同程度的视力下降,其中持续性头痛是最常见症状;术后视力恢复的程度与术前视力受损时间和程度有关。鼻内镜蝶窦粘液囊肿切除术是一种较简便、安全、有效的治疗方法。     

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。     

Ciliary beta frequency of sphenoidal sinus mucosa after cryopreservation

Objective. In vitro studies of human ciliary activity require specimens of healthy ciliated epithelium in relatively large quantities. It should be non-pathological and preferably preserved. We studied the effect of cryopreservation on the ciliary beat frequency (CBF) of mucosa from the sphenoidal sinus of patients who underwent trans-sphenoidal pituitary surgery. Materials and methods. Sphenoidal sinus mucosa from 10 patients was immersed in two cryopreservatives. One with 10% dimethylsulfoxide (DMSO) the other in human sperm preservation medium (HSPM). CBF was measured when the specimens were fresh and then at intervals of 1 week, 1 month and 3 months after cryopreservation in liquid nitrogen and a thawing procedure. Results. Mean CBF values recorded before cryo preservation did not differ significantly from the values measured after cryopreservation. CBF did not change during a period of 4 h.The rather low mean CBF value (5.4 Hz) was due to a reversible ciliotoxic effect of DMSO and HPSM. A pilot study however showed normal values when the samples were rinsed with neutral medium after thawing. Conclusion. We conclude that sphenoidal sinus mucosa is an appropriate source of ciliated mucosa for in vitro experiments. This finding makes the creation of a ‘mucosa-bank’ a realistic option.     

Neonatal mature teratoma of the sphenoidal sinus: a case report

Teratoma in the head and neck region is very rare. We treated a child with a mature congenital teratoma that arose from the right sphenoidal sinus. He is doing well after early surgical treatment with endoscopic endonasal resection of the tumor.