鼻内镜下额隐窝解剖特征与额窦开放手术

目的 通过术中鼻内镜下解剖额隐窝，总结与内镜额窦手术相关的镜下额窦引流通道解剖特征，探讨额窦鼻内镜手术相关问题。方法 病例资料为慢性鼻窦炎、鼻息肉患者301例(562侧)，有前期手术史者除外。术前鼻窦CT扫描证实合并额窦炎者280例(479侧)，术前根据CT扫描判定额窦引流方式；术中以钩突为参考标志，250例(421侧)行鼻内镜下额窦开放手术，并对鼻内镜下额隐窝解剖结构特征进行分型。结果 冠状CT扫描提示额窦开口于钩突与中鼻甲之间为203侧(48．2％)；额窦开口于钩突和眶纸板之间218侧(51．8％)。对应上述规律的鼻内镜下额隐窝解剖特征分型：前者属Ⅰ型203侧(48．2％)，后者属Ⅱ型218侧(51．8％)。结论 以额窦口为中心的额隐窝鼻内镜下解剖特征及分型，对额窦开放手术有重要意义；钩突上部为CT扫描和术中定位额窦口解剖参考标志。     

鼻内镜下额窦手术

传统的额窦手术多经鼻外途径完成,鼻内镜的发展使鼻内镜额窦手术成为可能。近几年来,在鼻内镜手术中,较侧重对筛窦、上颌窦病变等的处理,额窦由于其特有的解剖特点成为应用鼻内镜手术的最后几个难关之一,对额窦窦腔及鼻额管周围病变的处理还有待于进一步规范化。本文就鼻内镜下额窦手术的应用解剖及相关影像学表现、手术发展、手术方法、适应证、禁忌证和并发症等问题进行综述。     

鼻内镜下额隐窝解剖特征与额窦开放手术

目的　通过术中鼻内镜下解剖额隐窝 ,总结与内镜额窦手术相关的镜下额窦引流通道解剖特征 ,探讨额窦鼻内镜手术相关问题。方法　病例资料为慢性鼻窦炎、鼻息肉患者 30 1例 ( 5 6 2侧 ) ,有前期手术史者除外。术前鼻窦CT扫描证实合并额窦炎者 2 80例 ( 4 79侧 ) ,术前根据CT扫描判定额窦引流方式 ;术中以钩突为参考标志 ,2 5 0例 ( 4 2 1侧 )行鼻内镜下额窦开放手术 ,并对鼻内镜下额隐窝解剖结构特征进行分型。结果　冠状CT扫描提示额窦开口于钩突与中鼻甲之间为 2 0 3侧( 4 8 2 % ) ;额窦开口于钩突和眶纸板之间 2 18侧 ( 5 1 8% )。对应上述规律的鼻内镜下额隐窝解剖特征分型 :前者属Ⅰ型 2 0 3侧 ( 4 8 2 % ) ,后者属Ⅱ型 2 18侧 ( 5 1 8% )。结论　以额窦口为中心的额隐窝鼻内镜下解剖特征及分型 ,对额窦开放手术有重要意义 ;钩突上部为CT扫描和术中定位额窦口解剖参考标志     

以钩突、筛泡为标志的额窦手术

鼻内镜下额窦手术因操作空间小,观察受限,毗邻复杂、解剖变异等因素,使鼻内镜下判断额窦开口和开放成为困难,我们试图通过鼻内镜下相邻解剖的观察,探讨鼻内镜额窦手术中较恒定的解剖标志。1资料与方法1.1资料收集2002年1月~2003年1月,需额窦手术的鼻窦炎、鼻息肉住院病人40例50     

经鼻内镜下改良Lothrop手术

目的通过报告6例改良经鼻内镜下Lothrop手术经验，探讨相关技术方法的应用及手术适应证的选择。方法6例额窦病变患者，年龄6-63岁；男4例，女2例。4例中额窦骨瘤1例，额窦复发性血管瘤1例，外伤性额窦黏液囊肿2例，术后复发性额窦黏液囊肿1例，额筛窦复发性内翻性乳头状瘤1例。采用经鼻内镜下额窦底切除额窦开放引流手术(modified endoscopic Lothrop procedure，MELP)。其中2例术中在影像导航系统引导下定位和开放额窦底。结果6例均手术成功，术中和术后均未出现并发症，平均手术时间3．2h。随访6～40个月，鼻内镜检查额窦底额窦口融合开放良好，上皮化。患者术前症状消失，无复发。结论在严格适应证、合适器械及良好鼻内镜外科技术和经验的基础上，改良经鼻Lothrop手术是复杂额窦病变治疗方式的理想选择。     

经鼻内镜额窦脑脊液鼻漏修补术初探

目的探索额窦脑脊液鼻漏修补术的进路、修补方法和手术技巧。方法对9例额窦后壁和4例额隐窝后外侧壁脑脊液鼻漏患者进行手术修补，其中首次手术行鼻内镜下修补术12例，联合进路1例；术后观察手术疗效及并发症情况。结果13例患者中12例一次修补成功，1例二次修补成功。出现并发症2例，其中1例为术后颅内感染，行鼻外引流、额窦填塞术治愈；另1例为阻塞性额窦囊肿，行鼻内镜下额窦开放术治愈。结论经鼻内镜可以成功修补可视的额窦后壁脑脊液鼻漏，但要注意额窦口及漏口大小，防止术后额窦阻塞，诱发阻塞性额窦囊肿、额窦炎和颅内感染；对于额窦内不可视的脑脊液鼻漏和额窦口扩大困难的病例，建议行联合进路修补术。     

额窦中隔气房影像学及内镜下临床特征

目的探讨额窦中隔气房(FSC)的影像学特征及内镜下临床特征。方法收集2016年7—12月鼻内镜手术术前鼻窦三维CT检查发现额窦中隔气房患者23例，按照Wormald额窦手术分型，行内镜下额窦手术，术中开放FSC，明确额窦引流通道与FSC的位置关系及临床特征。结果鼻窦CT影像学显示：FSC开口在额窦内6例，开口在额隐窝者17侧；FSC单个气房者16例，2个气房者7例；所有患者均行内镜下额窦手术, Wormald 3级手术17例， Wormald 5级手术3例（复发性鼻息肉病骨质硬化明显2例、复发性乳头状瘤1例），Wormald 6级手术1例；经额隐窝径路内镜下开放FSC 18例，经额窦底近中线开放FSC 5例。结论术前鼻窦CT三维重建，明确FSC及其与额窦引流通道影像学特征；内镜下经额隐窝径路或额窦底中线径路开放FSC，是额窦手术的重要步骤。     

改良鼻丘入路额窦手术方式分析

目的探讨鼻内镜下额窦病变的改良鼻丘入路手术方式。方法选择2010年2月～2011年5月在我院行鼻内镜下额窦开放术的106例(155侧)患者,随机分为2组,经改良鼻丘入路额窦开放术56例(85侧),以钩突为主要参考标志的鼻内镜下额窦开放术50例(70侧)。结果两组患者随访6～12个月,平均9个月,鼻内镜下评价:鼻丘入路组疗效优于钩突入路组,有效率分别为97.65%和88.57%,两组比较有显著差异(χ2=5.24,P<0.05);CT评价:鼻丘入路组疗效优于钩突入路组,有效率分别为97.65%和84.29%,两组差异有统计学意义(χ2=8.92,P<0.05)。结论鼻内镜下改良鼻丘入路治疗额窦病变的手术方式,可获得较满意的疗效,值得临床推广。     

鼻内镜下额窦开放术并置双管引流治疗慢性额窦炎

目的：探讨鼻内镜下额窦开放并置管引流术疗效,以期找到一种提高慢性额窦炎治愈率的有效方法。方法：68例（130侧）慢性额窦炎行功能性鼻内镜额窦手术患者,随机分为3组,A组：鼻内镜下额窦开放术并置双管引流术;B组：鼻内镜下额窦开放术并置管引流、倍氯米松滴注;C组：鼻内镜下单纯额窦开放术。结果：3组患者平均随访18个月,鼻内镜下评价3组患者治愈率,A组为93％,B组为93％,C组为71％。B组与C组疗效比较,差异有统计学意义。未见严重手术并发症。结论：慢性额窦炎手术成功与否与术后额窦开口是否再次狭窄或者闭锁密切相关,鼻内镜下额窦开放术后持续6个月以上置双管引流可降低额窦口再次狭窄或者闭锁概率,而且置管保留6～12个月比较合适。我们建议这种方法应用于病情复杂的成人患者或者任何儿童患者。     

额窦的临床解剖与手术

额隐窝区域解剖复杂、多变，周围毗邻重要结构，使得额窦手术难度增大，对于额隐窝区域的临床解剖和手术技巧研究成为近十年来鼻外科研究领域的热点问题。随着鼻内镜技术的发展，多种处理额窦复杂病变的内镜技术应运而生。本文对额隐窝区域比较容易混淆的解剖学术语进行了总结归纳，并介绍了一种实用的额窦临床解剖系统。列数几种比较成熟的鼻内镜下额窦手术的方法以及各自的特点，探讨长期的术后观察与处理对额窦手术成功的重要性。     

Combined external and endoscopic frontal sinusotomy with stent placement: a retrospective review

OBJECTIVES: To examine the long-term results of combined external and endoscopic frontal sinusotomy using frontal sinus stents and to compare our results with those reported for the endoscopic Lothrop procedure. STUDY DESIGN: We performed a retrospective review of 40 patients with chronic frontal sinusitis refractory to medical management who underwent a total of 62 combined external and endoscopic frontal sinusotomies with stent placement. All procedures were performed by the senior author at Vanderbilt University Medical Center. MAIN OUTCOME MEASURES: Postoperative nasofrontal duct patency and subjective patient improvement based on the last clinical examination. RESULTS: The overall patency rate of the nasofrontal duct was 79% (95% confidence interval [CI] of +/-10%.) The overall subjective patient improvement rate was 78% (95% CI of +/-14%.). The average length of stent placement was 5 weeks. The mean patient follow-up time was 12 months. There were no surgical complications. The nasofrontal duct patency rate and patient improvement rate from our study did not differ statistically from results reported by other authors using the endoscopic Lothrop procedure. CONCLUSION: We have found endoscopic frontal sinusotomy, in conjunction with external frontal sinusotomy and placement of frontal sinus stents, to be as effective in obtaining frontal sinus patency rates and overall patient improvement rates as the endoscopic Lothrop procedure.     

Use of the 70-degree diamond burr in the management of complicated frontal sinus disease

OBJECTIVES/HYPOTHESIS: Management of frontal sinus disease may require drill-out of bone in the frontal recess for access, ventilation, and drainage of the sinus cavity; removal of osteitic foci; or resection of neoplastic tissue. Technological advances, particularly burrs with angles of 70 degrees and stereotactic navigational imaging, offer new opportunities to provide access and minimize trauma. The preliminary study evaluates the safety and efficacy of such minimally invasive approaches. STUDY DESIGN: Retrospective review. METHODS: The authors describe the use of a 70-degree diamond burr in a series of 10 patients with complicated frontal sinus disease who underwent endoscopic frontal sinusotomy under stereotactic imaging guidance. RESULTS: The diagnoses consisted of frontal sinus mucocele (n = 4), chronic frontal sinusitis (n = 1), Pott's puffy tumor after frontoethmoid fracture (n = 1), and recurrent inverting papilloma (n = 4). Partial septectomy was required in 6 of 10 patients. No complications were attributable to the drill-out procedure, despite a pre-existing frontoethmoid bony dehiscence in 6 of 10 patients. One patient had a CSF leak during removal of tumor from the skull base. One patient required revision frontal sinusotomy 10 months after the initial procedure, and another required further surgery for residual inverting papilloma on the medial orbital wall. All frontal sinusotomies were patent at last follow-up (mean period, 9.3 mo). CONCLUSION: Extended endoscopic frontal sinusotomy may be necessary in the management of complicated frontal sinus inflammatory disease and inverting papilloma. The 70-degree diamond burr is a safe and effective tool for access to the frontal recess. Complication rates appear to be similar to those for other extended frontal sinusotomy approaches.     

Modern concepts of frontal sinus surgery

OBJECTIVES/HYPOTHESIS: To validate the endonasal surgical approach to frontal sinus in inflammatory sinus disease, trauma, and selective tumor surgery, and to define the role of external approaches to the frontal sinus. Endonasal frontal sinusotomy can range from endoscopic removal of obstructing frontal recess cells or uncinate process to the more complex unilateral or bilateral removal of the frontal sinus floor as described in the Draf II-III drainage procedures. In contrast, the osteoplastic frontal sinusotomy remains the "gold standard" for external approaches to frontal sinus disease. METHODS: A retrospective review of 1286 patients undergoing either endonasal or external frontal sinusotomy by the authors at four university teaching programs from 1977. Prior author reports were updated and previously unreported patient series were combined. RESULTS: Six hundred thirty-five patients underwent type I frontal sinusotomy, 312 type II sinusotomy, and 156 type III sinusotomy. A successful result was seen in these groups, 85.2% to 99.3%, 79% to 93.3%, and 91.5% to 95%, respectively. External frontal sinusotomy or osteoplastic frontal sinusotomy was successfully performed in 187 of 194 patients. Clinical symptoms, endoscopic findings, computed tomography, and magnetic resonance image scanning, and reoperation rate measured postoperative success. CONCLUSIONS: A stepwise approach to the surgical treatment of frontal sinusitis, trauma, and selective benign tumors yields successful results as defined by specific criteria which vary from 79% to 97.8%. The details of specific techniques are discussed, essential points emphasized, and author variations noted.     

小钻孔鼻内双入路内镜下额窦开放术的临床价值研究

目的：探索小钻孔、鼻内双入路内镜下额窦开放术的临床价值。方法：根据术前鼻内镜及CT检查结果进行评估,挑选术中可能出现引流通道识别困难的26例慢性额窦炎患者进行研究。双入路组11例（13侧）,采用小钻孔、鼻内双入路内镜下额窦开放术,首先在额窦前壁钻直径4～5mm骨孔,通过注水冲洗、光照、顺行法放入导管等方法显示额窦引流通道位置,经鼻内、鼻外双入路行额窦开放术;鼻内镜组15例（18侧）,常规行鼻内镜下额窦开放术,采用Friedman的“钩突径路”术式。术后定期随访处理。结果：双入路组均顺利找到额窦开口,完成额窦开放,无手术并发症;鼻内镜组出现眶纸板损伤2例,筛前动脉损伤1例。随访10～24个月,双人路组额窦口通畅11侧（85％）,狭窄2侧;鼻内镜组通畅15侧（83％）,狭窄3侧;两组均无完全堵塞者。结论：前壁小钻孔、鼻内双入路内镜下额窦开放术治疗慢性额窦炎安全性高,疗效好,可提高术者对额窦引流通道解剖认知水平及额窦手术技能,值得在基层医院推广。     

The endoscopic management of chronic frontal sinusitis associated with frontal sinus posterior table erosion

Expansile inflammatory diseases of the frontal sinuses may produce erosion of the posterior table of the frontal sinus. In these instances, the bone between sinus mucosa and intracranial dura is absent. Over the past decade, endoscopic frontal sinusotomy has emerged as the preferred technique for the treatment of refractory chronic frontal sinusitis. Endoscopic approaches also have a role in the most advanced instances of frontal sinusitis. A retrospective chart review of patients who were treated for frontal sinusitis with erosion of the frontal sinus posterior table was performed. Eight patients were identified. All patients underwent endoscopic frontal sinusotomy; some patients required multiple endoscopic procedures. Complete frontal recess dissection with identification of the frontal ostium was achieved for all involved frontal sinuses. In all cases, this postoperative result was monitored by CT scans (where indicated) and serial nasal endoscopy, which demonstrated good frontal sinus aeration and normal mucociliary clearance. Antibiotics were administered for culture-documented bacterial exacerbations, and systemic steroids were given for management of allergic fungal sinusitis and sinonasal polyposis associated with asthma. No patient underwent frontal sinus obliteration or cranialization. No suppurative intracranial complications were noted during the postoperative period. Endoscopic frontal sinusotomy can be used safely for the definitive management of frontal sinusitis associated with posterior table erosion. In fact, endoscopic techniques may represent the preferred approach for the treatment of this problem. Such an approach avoids the morbidity of more destructive alternatives (such as obliteration), and serves to create a frontal sinus with normal mucociliary clearance.     

Endoscopic Management of the Frontal Recess in Frontal Sinus Fractures: A Shift in the Paradigm?

OBJECTIVES: To evaluate alternative management strategies for anterior table frontal sinus fractures involving the frontal sinus outflow tract. STUDY DESIGN: A prospective cohort of patients with anterior table frontal sinus fracture with frontal outflow tract involvement documented by computed tomography (CT) scan was examined between 1999 and 2001. METHODS: A select group of patients with anterior table frontal sinus fracture involving the frontal outflow tract was treated with open reduction of bony fracture without osteoplastic obliteration of the frontal sinus. Serial CT scans were obtained starting at 8 weeks after injury. Patients with persistent frontal sinus obstruction after medical treatment underwent an extended endoscopic frontal sinusotomy or a modified endoscopic Lothrop procedure. RESULTS: Fourteen patients sustained frontal sinus fractures and were treated during the study period. Seven patients were included in the modified treatment algorithm, with a mean follow-up of 18 months. All patients had concurrent facial fractures: superior orbital rim (n = 5), naso-orbital-ethmoid complex (n = 2), mandible (n = 2), and midface (n = 2). All 7 patients underwent open repair of the facial fractures. Postoperatively, 5 patients had spontaneous frontal sinus ventilation. Two patients, both of whom had naso-orbito-ethmoid fractures, had persistent frontal sinus obstruction clinically and radiographically. These patients were successfully managed with an endoscopic frontal sinus procedure. CONCLUSIONS: A select group of patients with frontal sinus and outflow tract fracture may be managed with open repair of the anterior table fracture without obliteration. In these cases, suspected frontal outflow tract obstruction can be managed expectantly. Failed frontal sinus ventilation may require endoscopic frontal sinus surgery to reestablish mucociliary clearance.     

鼻内镜下切除累及额窦及其引流通道的内翻性乳头状瘤

目的鼻腔鼻窦内翻性乳头状瘤是头颈部常见的良性肿瘤之一，但累及额窦及其引流通道的内翻性乳头状瘤既往报告不多。本研究采用经鼻内镜手术治疗累及额窦及其引流通道的内翻性乳头状瘤，探讨相应术式的适应证及疗效。方法累及额窦及其引流通道的乳头状瘤患者9例（男8例，女1例），年龄23～70岁，中位年龄52岁。所有患者术前均接受CT检查，5例行MRI检查，组织病理学诊断均为内翻性乳头状瘤。根据病变范围进行分期，然后进行经鼻内镜手术治疗并观察疗效。结果根据Krouse分期系统，所有患者病变均为13期，经鼻内镜手术顺利切除肿瘤，其中肿瘤的根基部位于额隐窝外侧壁者4例，采用DrafⅡA型手术；肿瘤根基部位于额隐窝和额漏斗内侧壁和后壁，以及外侧壁和后壁者3例，采用DrafⅡB型手术；he瘤根基部位于额隐窝和额漏斗后壁，或者内侧壁和后壁，且肿瘤累及双侧额窦者2例，采用DrafⅢ型手术。所有患者均在鼻内镜下随访，其中3例术后复查CT，随访5～34个月，中位随访时间16个月。术后组织病理学检查结果均符合术前诊断，未发现局部恶变。结论术前CT和病理检查对明确病变部位和性质至关重要，MRI检查可起到良好的辅助作用。经鼻内镜手术去除累及额窦及其引流通道的T3期乳头状瘤，可取得良好的近期疗效。     

The five year experience with endoscopic trans-septal frontal sinusotomy

Endoscopic trans-septal frontal sinusotomy (TSFS) represents a unique surgical approach to the floor of the frontal sinus. Although the final result can have similarities to the modified Lothrop procedure in that the intersinus septum may be drilled out, endoscopic TSFS represents a novel approach that can be valuable in patients with certain anatomic configurations. Endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist to augment treatment of refractory frontal sinus disease. This procedure is best considered for patients with favorable anatomy who have significant frontal sinus disease and cannot be managed adequately through an endoscopic frontal sinusotomy.     

Endoscopic trans-septal frontal sinusotomy: the rationale and results of an alternative technique.

Endoscopic transseptal frontal sinusotomy (TSFS) represents an alternate approach to surgical treatment of chronic frontal sinus disease that is refractory to traditional modes of medical and surgical therapy. We retrospectively reviewed our experience with endoscopic TSFS from 1995-1997. Twenty-one procedures were performed through a transseptal approach. One patient was excluded for failure to follow-up, for a total of 20 procedures. Patients were followed with serial endoscopic examinations and a telephone questionnaire with a mean follow-up of 12 months (Range 1-24 months) and 16 months (range 5-31), respectively. The primary indication for surgery was frontal recess stenosis after previous endoscopic frontal sinusotomy in 17/20 (85%). Three patients were considered poor candidates for a primary endoscopic frontal sinusotomy. Patency was maintained in all patients during the follow-up period. A diameter of greater than 3 mm was confirmed by passage of a curved suction in 19/20 (95%). Of the 19 patients that were evaluated via a telephone questionnaire, 17 patients (89.5%) reported some degree of improvement in their nasal/sinus symptoms, and 12/18 patients (67%) felt the frequency of medication requirements was less than that before undergoing endoscopic TSFS. We conclude that endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist, to augment treatment of refractory frontal sinus disease. This procedure seems especially suited for revision surgery in those patients with acquired frontal sinus stenosis. In revision operations with distorted anatomical landmarks, localization of the frontal sinus may be improved with the aid of 3-dimensional computer assisted localization systems. Unlike traditional frontal sinus obliteration, endoscopic TSFS does not preclude radiographic assessment postoperatively, and allows for endoscopic evaluation of the frontal sinus in the office setting.