鼻内镜下中鼻道联合泪前隐窝入路治疗真菌性上颌窦炎

目的 探讨鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路治疗真菌性上颌窦炎的适应证及疗效。 方法 回顾分析2008年6月至2014年6月行鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路治疗真菌性上颌窦炎32例患者的临床资料,分析联合入路的适应证、疗效及并发症。 结果 患者均完整彻底清除病变,无并发症发生。随访1年半以上,均无复发。 结论 鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路视野清晰,对上颌窦暴露充分,上颌窦霉菌清除彻底,创伤小,疗效确切,可作为鼻内镜下经中鼻道行上颌窦扩大或辅助下鼻道开窗仍无法彻底清除窦内霉菌的首选方法。     

不同内镜手术入路对翼腭窝及颞下窝的显露程度比较及其临床应用价值探讨

目的应用不同的内镜手术入路解剖翼腭窝及颞下窝,比较内镜下各手术入路的显露范围,为恰当选择内镜手术入路处理翼腭窝及颞下窝病变提供解剖学方面的依据。方法 4具8侧成人尸头标本,0°内镜引导下分别采取上颌窦后壁入路、扩大上颌窦后壁入路、鼻腔外侧壁入路、揭翻经上颌窦入路进行解剖学研究,观测各手术入路的有效显露范围。结果上颌窦后壁入路能显露翼腭窝上部和颞下窝内侧区深部;扩大上颌窦后壁入路在以上手术入路的基础上进一步显露翼腭窝下部;鼻腔外侧壁入路再进一步显露整个上颌窦和上颌窦底壁平面以上的颞下窝内外侧区;揭翻经上颌窦入路则能更进一步显露整个颞下窝。结论不同的内镜手术入路对翼腭窝及颞下窝的显露程度各不相同,以此为基础选择相应的手术入路处理不同范围的翼腭窝及颞下窝病变将有利于充分显露和有效切除病变,并尽可能避免不必要的手术损伤和并发症。     

鼻内镜手术相关的上颌窦裂孔的应用解剖研究进展

随着鼻内镜外科技术的发展,通过中鼻道或下鼻道完成上颌窦开窗,对上颌窦病灶切除或引流能够促进上颌窦病灶切除和功能的保留,已经逐渐取代caldwell-luc手术和部分鼻侧切开或鼻面翻揭手术;鼻腔外侧壁有下鼻甲和鼻泪管等重要结构,上颌窦的后外侧壁有翼腭窝和颞下窝等结构,经鼻内镜上颌窦后外侧壁进行翼腭窝和颞下窝肿瘤的切除存在明显的优势。鼻内镜鼻窦外科术后随访过程中,     

上颌窦良性占位性病变手术入路的探讨

目的探讨鼻内镜下多种手术入路治疗上颌窦良性占位性病变的方法及疗效。方法采用鼻内镜下中鼻道扩大上颌窦自然开口术、鼻内镜下中-下鼻道联合上颌窦开窗术、鼻内镜下鼻腔外侧壁切开上颌窦手术、鼻内镜下上颌窦内侧壁切除术、鼻内镜下改良Denker术等多种入路对136例上颌窦良性占位性病变进行手术治疗。结果除2例上颌窦后鼻孔息肉和1例内翻性乳头状瘤复发,经再次手术治疗痊愈外,其他患者均无复发。结论根据上颌窦良性占位性病变的不同临床特点,采用不同手术入路既可有效治愈上颌窦病变,同时可最大限度地减少手术创伤。     

不同手术入路治疗上颌窦真菌性鼻窦炎94例的临床分析

目的探讨不同手术入路治疗上颌窦真菌性鼻窦炎的临床疗效。方法回顾性分析94例上颌窦真菌性鼻窦炎患者的临床资料,分别采用3种手术径路,即柯一陆手术入路31例、鼻内镜上颌窦窦口开放入路33例、鼻内镜上颌窦窦口开放联合下鼻道开窗入路30例;比较不同术式的临床疗效。结果所有患者术后均随访12个月。其中采用柯-陆手术入路患者治愈率74．2％（23／31）,5例出现面部麻木,无溢泪及鼻腔粘连等并发症;采用鼻内镜上颌窦窦口开放人路患者治愈率81．8％（27／33）,7例患者出现鼻腔粘连,鼻内镜下直接分开后好转,无溢泪及面部麻木等症状;采用鼻内镜上颌窦窦口开放联合下鼻道开窗入路患者治愈率100％,5例患者出现鼻腔粘连,鼻内镜下直接分开后好转,无溢泪及面部麻木等并发症。结论鼻内镜上颌窦窦口开放联合下鼻道开窗入路是一种微创、安全、有效的治疗上颌窦真菌性鼻窦炎的手术方式。     

鼻内镜下泪前隐窝入路治疗上颌窦良性病变

目的经鼻内镜下泪前隐窝入路治疗上颌窦良性病变,并探讨其适应证、并发症及手术方式。方法回顾性分析43例经鼻内镜下泪前隐窝入路治疗上颌窦良性病变的病例,其中术前及术后病理确诊的上颌窦内翻性乳头状瘤15例,窦内病变镜下检出菌丝或孢子的真菌性上颌窦炎8例,上颌窦囊肿12例,上颌窦后鼻孔息肉6例,上颌窦异物2例。所有病例手术前均行鼻窦冠状位或水平位CT扫描。患者在局麻下以下鼻甲前缘为中心切口,解剖内移鼻泪管-下鼻甲瓣经泪前隐窝进入上颌窦腔处理上颌窦内病变,复位鼻泪管-下鼻甲瓣,缝合手术切口并行下鼻道开窗。结果 43例患者术中均完全清除窦内病变,术后随访6～24个月,下鼻甲形态愈合良好,术腔上皮化,无溢泪、面部麻木等并发症。2例上颌窦内翻性乳头状瘤术后6个月局部复发,原手术入路切除,随访1 8个月无复发。3例术后鼻腔粘连,局部分离,随访12个月无复发。结论经鼻内镜下泪前隐窝入路进入上颌窦是一种微创、安全、有效的处理上颌窦良性病变的手术方式,可作为鼻内镜下经中鼻道行上颌窦自然口开窗无法彻底切除窦内病变组织的首选治疗方法。     

鼻侧切开额眶颧颞联合入路切除颅颞下窝上颌窦沟通瘤

目的：探讨鼻侧切开额眶颧颞联合入路切除累及中颅窝、中颅底、颞下窝的上颌窦恶性肿瘤的效果，并对手术方法做适当改进。方法：采用鼻侧切开额眶颧联合入路同期对2例侵犯中颅窝、中颅底、颞下窝的上颌窦恶性肿瘤进行了手术切除。结果：2例肿瘤均完整切除，手术后出现暂时性偏瘫1例，无手术死亡病例。结论：联合入路切除颅、颞下窝、上颌窦沟通瘤，术野显露良好，切除肿瘤更彻底、更安全，重建颅底方便。     

鼻内镜手术治疗后鼻孔息肉

目的　研究鼻内镜手术治疗后鼻孔息肉的方法和疗效。方法　回顾2009年1月～2013年12月我科经鼻内镜手术治疗的后鼻孔息肉患者59例,并对后鼻孔息肉的临床特点、手术入路的选择以及疗效进行分析和讨论。结果所有患者后鼻孔息肉均起源于上颌窦,50例患者采用鼻内镜下经上颌窦口入路行息肉切除术,6例患者采用鼻内镜联合下鼻道上颌窦开窗入路行息肉切除术,3例患者采用经鼻内镜联合柯-陆氏入路上颌窦开窗行息肉切除术。3例患者术后复发接受2次手术,手术成功率95.4%。结论　根据息肉基底部的位置不同选择不同的手术入路,彻底切除息肉的基底部是避免后鼻孔息肉复发的关键。     

经鼻内镜手术治疗鼻咽血管纤维瘤7例

目的：探讨鼻内镜下切除鼻咽血管纤维瘤的临床效果。方法：对7例鼻咽血管纤维瘤患者采用鼻窦切割吸引器逐渐吸切去除血管瘤组织，并将根部的骨膜给予去除。结果：7例患者手术均一次性成功，未见肿瘤组织残留。术后随诊3～18个月未见肿瘤复发，未出现严重并发症。结论：鼻内镜下用鼻切割吸引器切除鼻咽血管纤维瘤是治疗鼻咽血管纤维瘤较好的术式，值得推广应用。     

经鼻内镜手术治疗硬脑膜外来源的海绵窦区肿瘤

目的探讨经鼻内镜切除硬脑膜外来源的海绵窦肿瘤的可行性,并介绍手术入路选择、海绵窦重要结构保护和出血控制。方法硬脑膜外侵犯海绵窦的肿瘤39例,其中为垂体腺瘤17例、鼻咽纤维血管瘤5例、神经鞘膜瘤6例、脊索瘤6例、腺样囊性癌2例、软骨瘤2例、纤维肉瘤1例。根据肿瘤原发的部位和范围,分别选择内镜下经鼻中隔经蝶、扩大鼻中隔经蝶、扩大上颌窦后壁、翼突根和鼻外上颌骨等入路切除肿瘤。结果33例肿瘤获得全切（全切率84．6％）;6例肿瘤获得次全切（次全切率15．4％）,无致残和致死性手术并发症。结论只要选择手术入路恰当,手术中保护海绵窦重要结构,采取合理的措施控制海绵窦出血,经鼻内镜切除硬脑膜外来源的海绵窦肿瘤是可行的。     

Endoscopic sinus surgery for juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a rare tumour of the head and neck with very specific characteristics: adolescent males, choana-nasopharynx, pterygomaxillary fossa widening, specific and intense vascularisation. Staging is very important in the decision of the surgical approach. Endoscopic management of juvenile nasopharyngeal angiofibroma is technically possible after preoperative embolisation. Up to now 13 angiofibroma have been treated using the endonasal endoscopic sinus surgery approach in Belgium (Leuven 8; Mont-Godinne 2; Ghent 1; Liege 1; Woluwe 1). In smaller tumors endoscopic resection has been successful in four cases without any recurrence. Five larger tumors, extending in the pterygomaxillary fossa, were also successfully resected. Extension into the infratemporal fossa or the cavernous sinus can be endoscopically removed, but recurrences may occur as they do after classical, external approaches. In conclusion, the endoscopic approach is an acceptable alternative in small to middle sized juvenile nasopharyngeal angiofibroma.     

Recent advances in the treatment of juvenile angiofibroma

PURPOSE OF REVIEW: Juvenile nasopharyngeal angiofibroma is a rare vascular tumor almost exclusive to the nasopharynx of adolescent males. Traditionally, juvenile nasopharyngeal angiofibroma has been treated surgically using open surgical approaches and has been associated with frustratingly high recurrence rates. This article reviews recent contributions to the study and treatment of this disease. In particular, advances in minimally invasive endoscopic resection of juvenile nasopharyngeal angiofibroma are evaluated. RECENT FINDINGS: The growth patterns of juvenile nasopharyngeal angiofibroma are evaluated. Young age does not appear to correlate with more aggressive disease. The major recent advance in the treatment of juvenile nasopharyngeal angiofibroma has been the application of endoscopic endonasal surgery to the treatment of select tumors. This article reviews the indications and inclusion criteria recently put forth to help select patients for this minimally invasive approach. In properly selected patients with Radkowski stage I and II lesions, recurrence rates range between 0 and 7%. Advanced lesions continue, in most cases, to require open approaches, some of which are also presented. SUMMARY: With proper patient selection, endoscopic resection of juvenile nasopharyngeal angiofibroma is feasible and may be preferable to traditional open approaches. Results suggest that after endonasal resection, disease recurrence is low. Most larger lesions, especially those with intracranial spread, continue to require open approaches for complete resection.     

Strictly endoscopic and harmonic scalpel-assisted surgery of nasopharyngeal angiofibromas: eligible for advanced stage tumors

CONCLUSIONS: With the assistance of the harmonic scalpel, endoscopic surgery is eligible for advanced nasopharyngeal angiofibromas with skull base or infratemoporal fossa invasion. OBJECTIVES: To evaluate the safety and efficacy of strictly endoscopic removal of early and advanced stage nasopharyngeal angiofibromas. Patients and methods. Eight operations for seven consecutive patients presenting with a nasopharyngeal angiofibroma were performed via minimally invasive endoscopic resection by a single surgeon (M.K.C.). All patients were operated with curative intent. RESULTS: Using Radkowski staging, one, two, one, one, and three tumors were stage Ia, IIa, IIb, IIc, and IIIa lesions, respectively. All the tumors were removed successfully by strictly endoscopic surgery. No complications associated with the operation occurred. The average follow-up was 54 months. One recurrence (14.3%) occurred in this series and the salvage surgery was performed by second curative endoscopic procedure.     

鼻咽血管纤维瘤手术治疗51例分析

目的比较鼻咽血管纤维瘤的治疗方法。分析各手术方式及术前超选择性动脉栓塞对不同分期患者治疗的优缺点。方法回顾性分析1989年2月—2004年10月51例鼻咽血管纤维瘤手术方式,采用Fisch分期,Ⅰ、Ⅱ期患者33例,经腭进路22例,鼻内镜手术11例;Ⅲ、Ⅳ期患者18例,经鼻侧切开9例,面中掀翻+LefortⅠ或同侧上颌骨拆装4例,颅面联合进路5例。51例患者中23例术前行超选择性瘤体供血动脉栓塞,其中Ⅳ期7例,Ⅲ期8例,Ⅱ期5例,Ⅰ期3例。结果术中平均出血量为1010ml,23例选择性瘤体供血血管栓塞患者,术中出血量200~870ml,平均485ml(x-±s,485ml±202ml);未栓塞组出血量500~3500ml平均1600ml(1600±757)ml,栓塞组平均出血量低于未栓塞组平均出血量(t=7·48,P<0·05)。术后1次复发8例,2次复发2例。术后复发时间平均为26·4个月(9~48个月)。结论术前行血管造影及血管栓塞对减少术中出血量具有临床意义。对于Ⅰ、Ⅱ期的患者,选择鼻内镜手术,可以避免传统手术创伤对患者术后颅面部生长发育的影响。对于Ⅲ、Ⅳ期患者,采用面中掀翻、LefortⅠ或同侧上颌骨拆装不仅有利于肿物的根治性切除,而且能够达到术后咬合关系影响小和美容佳的目的。     

Endoscopic treatment of juvenile nasopharyngeal angiofibromas: our experience and review of the literature

The endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) emerges as an alternative approach to open procedures due to reduced morbidity and comparable recurrence rates. The purpose of this study was to present our experience with the endoscopic management of JNA using retrospective chart review of ten male patients (mean age 15.7 years) with JNA who were treated endoscopically at our institution between the years 2003 and 2010. According to the Radkowski’s system, one patient was at stage Ia, two at stage Ib, one at stage IIa, two at stage IIb, two at stage IIc (infratemporal fossa invasion) and two at stage IIIa (clivus erosion). Six patients underwent preoperative embolization. The endoscopic treatment involved total ethmoidectomy, middle meatal antrostomy, sphenoidotomy, clipping of the sphenopalatine artery and its branches and drilling of the pterygoid basis. All patients underwent magnetic resonance imaging 3 months postoperatively and then if indicated clinically. Mean follow-up was 23.7 months (range 3–70). All but one patient were free of macroscopic disease. A patient with stage IIb JNA developed a recurrence after 9 months. The residual tumor was resected endoscopically and the sphenopalatine foramen widened by drilling. The patient is free of disease 25 months postoperatively. The intra-operative blood loss was not excessive (200–800 ml, mean: 444 ml) and no patient required a blood transfusion. Patients were discharged after 4–8 days (mean 5 days). One patient developed postoperative infraorbital nerve hypoesthesia. Results showed that endoscopic treatment of stage I and IIa/b JNA is a valid alternative to external approaches. For select tumors with limited infratemporal fossa invasion and skull base erosion, the endoscopic approach may also be indicated. It is a safe and effective treatment modality due to the lack of external scars, minimal bone resection and blood loss and low recurrence rate.     

侵犯颅内及海绵窦鼻咽血管纤维瘤临床研究

目的 探讨侵犯到颅内及海绵窦的鼻咽血管纤维瘤的外科治疗.方法 病例包括1988年1月至2004年1月收治的经病理证实的侵犯到颅内的鼻咽血管纤维瘤16例,11～35岁.手术方法有经口腭入路、鼻侧切开入路、上颌骨中段掀翻、颅面联合进路、下颌正中裂开联合经腭入路和上颌骨翻转入路.结果 伴颅内侵犯鼻咽血管纤维瘤16例患者共行手术28次,11例为复发病变.28例次手术中11例次鼻侧切开术,颅面联合进路6例次,额颞入路2例次,经腭入路4例次,经上颌骨入路2例次,经下颌正中裂开1例次,上颌骨中段掀翻2例次.结论 扩展到颅内或海绵窦的鼻咽血管纤维瘤治疗以手术彻底切除为主,上颌骨中段掀翻、颅面联合进路及经下颌正中裂开颅底进路对于侵犯到颅内或海绵窦的肿瘤暴露较好.     

Endoscopic and KTP laser-assisted surgery for juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a highly vascular tumor arising from the area around the sphenopalatine foramen. Various radical and extended radical surgeries have been advocated to surgically excise both extranasopharyngeal and nasopharyngeal juvenile angiofibromas. However angiofibromas involving the nasopharynx, nose, and sphenoid with minimal lateral extension via the sphenopalatine foramen can also be adequately managed endoscopically either alone or with 1 of the traditional approaches. Nine cases of juvenile nasopharyngeal angiofibroma were successfully managed between January, 1999, and March, 2001, by preoperative selective embolization of the internal maxillary artery with or without external carotid artery clamping, followed by endoscopic excision. Two of the 9 cases underwent KTP/532 laser-assisted endoscopic excision, whereas the transpalatal approach was used along with the endoscope in another 2 cases. The patients remained free of disease after a median follow-up period of 17 months. We report our preliminary experience in endoscopic and KTP laser-assisted excision of juvenile nasopharyngeal angiofibroma.     

Endoscopic resection of nasopharyngeal angiofibromas by combined transnasal and transoral routes

PURPOSE: To determine the role of endoscopic surgery in decreasing intraoperative bleeding, morbidity, and hospitalization period of juvenile nasopharyngeal angiofibroma resection and to describe combined endoscopic transnasal and transoral approaches. PATIENTS AND METHODS: Twelve cases of juvenile nasopharyngeal angiofibroma diagnosed by endoscopic examination, computed tomography, and angiography were selected for endoscopic resection. Tumor staging ranged from stage I(A) to II(B). Ten patients underwent preoperative selective arterial embolization, and in 1 case selective arterial ligation was used. In general, the tumors were approached endoscopically through nasal and oral cavities with 0 degrees and 30 degrees 4-mm telescopes without any incision and no packing at their termination. RESULTS: The patients were followed by endoscopy and computed tomography. There was a dramatic decrease in intraoperative bleeding and postoperative morbidity. No early postoperative complications were seen. Two recurrences were observed in 12 patients up to a mean follow-up of 15 months. CONCLUSIONS: Minimal bleeding, decreased morbidity, and shorter hospitalization period were the main reasons that prompted us to use endoscopic technique for the removal of juvenile nasopharyngeal angiofibroma. Adding transoral endoscopic approach to the transnasal endoscopic approach provides 2-sided exposure and appreciate access to angiofibroma.     

Strictly endoscopic and harmonic scalpel-assisted surgery of nasopharyngeal angiofibromas: eligible for advanced stage tumors

Conclusions. With the assistance of the harmonic scalpel, endoscopic surgery is eligible for advanced nasopharyngeal angiofibromas with skull base or infratemoporal fossa invasion. Objectives. To evaluate the safety and efficacy of strictly endoscopic removal of early and advanced stage nasopharyngeal angiofibromas. Patients and methods. Eight operations for seven consecutive patients presenting with a nasopharyngeal angiofibroma were performed via minimally invasive endoscopic resection by a single surgeon (M.K.C.). All patients were operated with curative intent. Results. Using Radkowski staging, one, two, one, one, and three tumors were stage Ia, IIa, IIb, IIc, and IIIa lesions, respectively. All the tumors were removed successfully by strictly endoscopic surgery. No complications associated with the operation occurred. The average follow-up was 54 months. One recurrence (14.3%) occurred in this series and the salvage surgery was performed by second curative endoscopic procedure.     

Exclusively endoscopic removal of juvenile nasopharyngeal angiofibroma: trends and limits

OBJECTIVE: To determine the feasible conditions for exclusive endoscopic resection of juvenile nasopharyngeal angiofibroma. DESIGN: Retrospective study of 20 patients, with a mean follow-up of 22 months. SETTING: Six academic referral hospitals. INTERVENTIONS: All patients had a preoperative computed tomographic or magnetic resonance imaging scan and at least 1 follow-up computed tomographic and/or magnetic resonance imaging scan 6 or 12 months after surgery. Exclusive endoscopic removal was performed using conventional functional endoscopic sinus surgery instrumentation after preoperative embolization. RESULTS: Using Radkowski staging, 4, 7, and 9 patients had stage I, II and IIIA tumors, respectively. Seven patients were operated on for a recurrence after open surgery. Extension toward the sphenoid sinus, pterygomaxillary fossa, or infratemporal fossa could be removed. There was no attempt at endoscopic removal of deep skull base or temporal fossa invasion. The mean surgery duration was 135 minutes; mean dimensions of the tumor were 4.5 x 4 x 3 cm; and mean blood loss was 350 mL (median, 300 mL). No recurrences occurred in this series; there were small asymptomatic remnants in 2 cases. CONCLUSIONS: An exclusively endoscopic management of juvenile nasopharyngeal angiofibroma appears to be effective for small to medium tumors. It should be considered as a first-choice option for these cases (in view of the minimal bleeding, shorter duration, and efficacy).