经鼻内镜颅底手术中的出血原因及其处理对策

出血是鼻内镜颅底手术中最麻烦的问题,其中大血管损伤导致的致命性出血也是最危险的并发症,因此成为妨碍与限制内镜鼻颅底外科技术延伸与扩展的主要问题之一.熟悉与这类手术相关的重要血管的解剖位置与形态学特征、了解防止手术中出血的技术、掌握贴近这些血管周围的病变处理技术、以及出现血管意外损伤时的紧急处理技术和接续治疗方法,对于保障内镜鼻颅底手术的安全都有重要意义.本文重点阐述的是围绕鞍区的手术中出血的预防和处理.     

Transnasal endoscopic repair of congenital defects of the skull base in children.

OBJECTIVE: To examine imaging findings and methods of endoscopic treatment of congenital skull base defects in children. DESIGN: Retrospective study and case series. SETTING: Academic tertiary care center. PATIENTS: Four patients (aged 12 and 14 months and 8 and 13 years) were included from 1995 to 1997. Three presented with a nasal glioma, which was recurrent in 1 case. The fourth patient presented with bacterial meningitis due to a spontaneous cerebrospinal fluid leak. Computed tomography and magnetic resonance imaging were used to locate the defect of the skull base. INTERVENTION: Transnasal endoscopic resection of the glioma or the meningocele, with immediate repair of the skull base defects using free mucosal flaps and/or pediculized mucosal flaps and/or conchal cartilage together with fibrin glue and nasal packing during a 3-week period. RESULTS: None of the 4 patients has experienced recurrent cerebrospinal fluid leaks or postoperative meningitis. CONCLUSIONS: The transnasal endoscopic repair of congenital meningoceles is a reliable technique in select pediatric patients. Computed tomography and magnetic resonance imaging provide information that can be used to help the surgical procedure.     

颅眶沟通性脑膜瘤的显微外科切除和眶顶重建

目的　本研究旨在探讨颅眶沟通性脑膜瘤的诊断、手术及预后。方法　收集我科 1 996年 1月～2 0 0 3年 7月入院的 32例颅眶沟通瘤病人中经病理确诊为脑膜瘤的 1 4例病人资料 ,就其临床表现、影像学变化、手术操作、病理特点和预后等方面予以总结和分析。结果　采用额下或额颞侧方入路 ,单纯硬膜外切除 9例 ,联合硬膜外、硬膜下切除 5例。全切 1 1例 ,大部切除 3例。随访 8例 ,3例接受立体定向放射治疗 ,5例未行放射治疗 ;复发 3例 ,均未行术后放疗。结论　颅眶沟通性脑膜瘤可以侵犯颅眶结合部许多重要解剖结构 ,且有复发倾向 ;本病治疗应强调充分暴露、彻底切除、骨性重建和术后放射治疗。     

小儿鼻颅底针形内窥镜的检查与手术

目的：探讨应用针形内窥镜对小儿鼻颅底疾病进行探查与手术的方法及疗效。方法：在外径１．９ｍｍ的进口针形内窥镜及电视同图像系统监视下,对８例小儿（７ｄ￣１２岁）鼻颅底有关疾病进行探杳与手术。结果：先天性后鼻孔闭锁３例中,１例好转,３例痊愈。外伤性脑脊液鼻漏１例,经修补痊愈先天性脑膜脑膨出２例,确诊后１例暂缓治疗。另１例行内窥镜手术痊愈。颅底神经母细胞瘤２例取材作病理检查确诊。结论：在电视图像监视下应用     

Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms

BACKGROUND: The endoscopic resection of the cribriform plate during minimally invasive endoscopic resection (MIER) of the anterior skull base neoplasms may result in large anterior skull base defects. The objective of this study is to describe techniques for the management of skull base defects after MIER. METHODS: Retrospective analysis was performed on patients undergoing MIER and skull base reconstruction between April 2000 and August 2005. RESULTS: Fourteen patients underwent endoscopic resection of anterior skull base tumors and reconstruction during the study period. The mean age was 57.4 years (range, 26-84 years). The sex distribution was eight men and six women. The specific indications for resection included 11 malignant and 3 benign neoplasms. Ten patients received adjuvant therapy, and in two instances this occurred before surgery. In all instances, the dura was exposed; however, only 10 cerebrospinal fluid (CSF) leaks were encountered intraoperatively. Reconstruction of the skull base was successfully performed, most commonly in a multilayer fashion, using an array of materials including cartilage, fat, acellular dermal graft, and mucosal free grafts. Lumbar drain placement was used in seven cases for an average of 5.6 days. No postoperative CSF leaks occurred. The mean follow-up was 18.0 months (range, 1-56 months). CONCLUSION: This report describes methods for the reconstruction of the skull base after MIER. Reconstitution of the skull base barrier can be achieved through application of principles for surgical repair of CSF rhinorrhea.     

颅内外沟通性肿瘤的外科治疗

目的 探讨颅内外沟通性肿瘤的外科治疗。方法 统计分析我院自2001年1月至2005年5月治疗的32例颅内外沟通性肿瘤,其中恶性肿瘤22例,良性肿瘤10例,20例进行颅面联合进路肿瘤切除;10例在鼻内镜辅助下开颅手术切除;2例行颅外进路肿瘤切除,对颅底缺损的修复用帽状腱膜-颅骨骨膜瓣、颞肌-肌筋瓣、颅骨骨瓣、前臂皮瓣等。结果 22例恶性肿瘤中随访2年以上6例,1～2年8例,1年以下7例,1例死亡,1例脑转移带瘤生存,其余均健在。10例良性肿瘤无复发。结论 对颅内外沟通性肿瘤,应根据肿瘤的位置、大小及颅内累及的情况,选择合适的手术人路,在保证肿瘤切除彻底的前提下,尽可能的减小损伤,对部分颅内外沟通性肿瘤,鼻内镜辅助下手术,可减小创伤,同时面部无疤痕。     

Closure of complex lateral skull base defects.

OBJECTIVE: To discuss surgical reconstructive options and complications in patients with extensive lateral skull base defects. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Eligibility criteria included patients seen between July 1999 and July 2003 with malignant neoplasms of the lateral skull base requiring surgical therapy, with resultant surgical defect not amenable to primary closure. INTERVENTION: Surgical extirpation of malignant skull base neoplasm requiring free tissue transfer or rotational flap closure. MAIN OUTCOME MEASURE: Closure and healing of surgical defect, intraoperative and postoperative complications, patient survival. RESULTS: There were 11 patients, 8 males and 3 females, with an average age of 65 years. Eight patients required trapezius flap reconstruction, whereas one patient required temporalis rotational flap closure, and two patients required rectus abdominus free tissue transfers. There was one perioperative death secondary to cardiac disease. There were no immediate wound complications. One patient developed a delayed partial trapezius flap failure successfully treated with a rectus abdominus flap. CONCLUSIONS: The trapezius rotational flap is a reliable means of closing complex lateral skull base defects with minimal morbidity.     

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.     

Surgical management of skull base chondroblastoma

OBJECTIVES: Chondroblastoma is a rare tumor accounting for 1% of primary bone tumors. Chondroblastoma involving the skull base is exceedingly rare with approximately 60 cases reported. We reviewed our experience with chondroblastoma of the skull base with an emphasis on current lateral skull base approaches and long-term tumor control. STUDY DESIGN AND SETTING: A retrospective case review at a tertiary neurotology private practice group was performed over a 20-year period. Five patients were identified with skull base chondroblastoma. All patients underwent surgical intervention, and success of surgery was determined by disease-free status at last follow-up. Mean follow-up time was 5.8 years. RESULTS: Two patients underwent gross tumor removal as primary therapy. One patient underwent partial tumor removal at an outside institution, and follow-up magnetic resonance imaging demonstrated rapid growth of residual tumor. This patient was successfully treated with gross total removal of residual tumor with an infratemporal craniotomy approach. Near total tumor removal was performed in two patients because of intimate involvement of vital structures. At last follow-up, no patient had radiographic evidence of tumor recurrence. There were no significant postoperative complications. CONCLUSIONS: Gross total or near total resection of skull base chondroblastomas through lateral skull base approaches results in long-term tumor control and low complication rates.     

Three-layer reconstruction for large defects of the anterior skull base

OBJECTIVES: To evaluate and discuss a three-layer rigid reconstruction technique for large anterior skull base defects. STUDY DESIGN: Prospective, nonrandomized, non-blinded. SETTING: Tertiary teaching medical center. METHODS: Twenty consecutive patients underwent craniofacial resection for a variety of pathology. All patients had large anterior cranial base defects involving the cribriform plate, fovea ethmoidalis, and medial portion of the roof of the orbit at least on one side. A few patients had more extensive defects involving both roof of the orbits, planum sphenoidale, and bones of the upper third of the face. The defects were reconstructed with a three-layer technique. A watertight seal was obtained with a pericranial flap separating the neurocranium from the viscerocranium. Rigid support was provided by bone grafts fixed to a titanium mesh, anchored laterally to the orbital roofs. All patients had a computed tomography scan of the skull on the first or second postoperative day. Patients were observed for immediate and long-term postoperative complications after such reconstruction. RESULTS: Postoperative computed tomography scans showed small pneumocephalus in all patients. It resolved spontaneously and did not produce neurologic deficits in any patient. There was no cerebrospinal fluid leak, hematoma, or infection. On long-term follow-up, exposures of bone graft or mesh, brain herniation, or transmission of brain pulsation to the eyes were not observed in any patient. CONCLUSIONS: Three-layer reconstruction using bone grafts, titanium mesh, and pericranial flap provides an alternative technique for repair of large anterior cranial base defects. It is safe and effective, and provides rigid protection to the brain.     

Endoscopic management of anterior skull base encephaloceles

Encephaloceles are relatively rare phenomena produced by the protrusion of brain and dura through an anterior skull base defect. Although they can occur as congenital defects, encephaloceles can also present after trauma. The diagnosis is usually made with nasal endoscopy and imaging studies. This report reviews our recent experience repairing 5 encephaloceles in 4 patients. The diagnostic approach and the technical aspects of surgical management are discussed. Although encephaloceles are a rarity, this diagnosis should be considered as part of the differential diagnosis in evaluating a patient with a unilateral polypoid nasal mass, particularly in the setting of recurrent meningitis or cerebrospinal fluid rhinorrhea.     

Endoscopic management of anterior skull base tumors

Anterior craniofacial resection has become a standard procedure for management of lesions of the anterior skull base. During the last 2 decades, modifications of the classic anterior craniofacial resection have been reported. With the introduction of endoscopic sinus techniques and instrumentation, surgeons have begun to use endoscopic approaches for management of anterior skull base lesions.This article describes endoscopic modifications of anterior craniofacial resection.     

The pericranial flap for reconstruction of anterior skull base defects

In 1981, the senior author first reported the use of the pericranial flap for support of the brain following resection of the anterior skull base. Since the initial report, considerable experience has been gained with this flap. It is currently deployed via a bifrontal craniotomy and is placed primarily as a support beneath the frontal lobes. The pericranial flap may also be used to repair dural laceration and defects. The sinonasal surface is routinely grafted with split-thickness skin or dermis. This technique provides an excellent barrier between the sinonasal cavity and the cerebrospinal fluid, establishing a tough, fibrous platform. Herniation of intracranial contents has not occurred. One major complication has been reported in which radiation necrosis occurred during postoperative therapy, leading to progressive devitalization of the pericranial flap. Ultimately, dural repair and closure with a latissimus dorsi free flap was required. The pericranial flap repair of anterior skull base defects has a 90% complication-free and 95% overall success rate. It is simple and extremely effective. Bone grafting has not been necessary in our experience.     

内镜经鼻入路前颅底重建

目的 探讨内镜经鼻入路颅底手术后使用钛网行前颅底重建的可行性.方法 2006年4月至2007年1月,选择8例内镜经鼻颅底手术后颅底骨质缺损的患者,术中尝试内镜下经鼻入路使用钛网行前颅底重建.将钛网剪成双排网眼约3.0 cm×2.0 cm的条状,采用内镜引导下经鼻植入前颅底,依次由前向后使其横行嵌入双侧眶上壁与前颅底硬脑膜间,以修复前颅底骨质缺损.结果 8例患者中前颅底骨质缺损2例,前颅底及蝶鞍骨质缺损2例,前颅底、蝶鞍及斜坡骨质均缺损4例.组织病理学类型:嗅神经母细胞瘤2例,鳞状细胞癌1例,软骨肉瘤1例,恶性纤维组织细胞瘤1例,脑膜瘤2例,脊索瘤1例.术后随访2～10个月,1例钛网移位于鼻腔,其余7例均未发生移位,且鼻腔侧有黏膜覆盖.结论 内镜经鼻入路使用钛网行前颅底重建方法简便、安全、可行,并能够获得满意的重建效果.     

Free tissue transfer for skull base reconstruction analysis of complications and a classification scheme for defining skull base defects

OBJECTIVE: The role of free flaps in skull base reconstruction is discussed in detail. Twenty-six microvascular free tissue transfers performed in 22 patients are reviewed in detail. A classification scheme for skull base defects is presented. SETTING: Tertiary referral center. PATIENTS: Twenty-two patients with neoplasms that involve the skull base underwent a combined craniotomy and facial approach for resection. The resultant defects were reconstructed with a variety of microvascular free flaps. RESULTS: All 22 patients were ultimately successfully reconstructed with a free flap. One patient required a second free flap following ablative surgery for a recurrent tumor. The initial free flaps in three patients were unsuccessful and a second flap was required. The classification scheme was applied to all defects. CONCLUSIONS: The creation of a functional separation of the intracranial and extracranial cavities can be extremely difficult to accomplish, especially when multiple cavities (nasal, oral, pharyngeal) are violated. Free flaps provide a solution to this problem in select cases. Skull base defects can and should be classified for the purpose of communication, treatment planning, prognosis of reconstruction, and judging therapeutic outcome.     

Multidisciplinary management of skull base and craniocervical chordoma

BACKGROUND: Craniocervical chordomas often only become manifest in an advanced stage. The localisation and locally-destructive growth require a multidisciplinary diagnostic and therapeutic concept early on. The goal of the present study was to present a reproducible strategy for quality assurance. PATIENTS AND METHOD: We retrospectively analysed the hospital records of 10 consecutive patients (4 women and 6 men) whom we had treated during a period of 7 years. RESULTS: The first step in therapy was tumour resection in 9 cases. One patient initially underwent stereotactic radiation. Postoperative radiation was not included a priori, but discussed individually depending on the degree of resection, the patient's age and physical condition. After an average 5 years follow up, 100 % of patients are alive. In all patients, tumour control was achieved. CONCLUSIONS: The prognosis for patients with chordomas of the skull base has improved considerably in recent years. New technologies like intraoperative navigation and improved radiation procedures have contributed to this improvement. The basis for treatment remains, however, the greatest possible surgical exstirpation with minimal surgical morbidity. Special attention should be paid in this connection to the stability of the cervical spine and the craniocervical transition border. In advanced tumour growth, complete resection is often not possible. Proton and heavy-ion radiation are promising new forms of therapy, which can also be applied after conventional radiation has been performed. A directed multidisciplinary procedure guarantees years of survival with good quality of life in many cases.