3D打印技术在鼻-颅底外科中的应用研究进展

3D打印技术近年来在生物医学领域的应用较为广泛,虽然在鼻-颅底外科领域中的应用研究鲜有报道,但凭借其快速成型、立体化三维实物重现等优势,在鼻-颅底外科领域有着广阔的应用前景。其临床应用主要涉及鼻-颅底缺损修复、术前规划及术前手术模拟、解剖教学及培训、患者教育等方面。本文围绕3D打印技术在鼻-颅底外科领域的应用现状作一概述,同时对其发展前景进行展望。     

基于3D打印透明鼻腔模型的鼻阻力变化规律研究

目的:探讨鼻腔内最小截面积与鼻阻力互为因果的变化规律.方法:3D打印全透明可拆卸功能性鼻窦内镜手术(FESS)术后鼻腔模型30侧,在不同解剖部位用密封材料彻底堵塞气道,然后用不同截面积的可通气鼻腔引流管再通鼻腔,测量鼻阻力,再进行统计学分析.结果:①术后患者实测、3D打印模型鼻阻力分别为(0.38±0.15)Pa.s/...     

3D打印技术在鼻鼻窦恶性肿瘤外科中的应用

 目的探讨3D打印技术在鼻鼻窦恶性肿瘤切除及术后重建中的应用。方法回顾分析2015年1月~2017年6月我科收治的鼻鼻窦恶性肿瘤并进行手术治疗的10例患者临床病理资料。其中鳞癌4例,骨肉瘤1例,嗅神经母细胞瘤2例,腺样囊性癌2例,黏液表皮样癌1例。所有患者术前均行鼻鼻窦CT扫描,3D重建并打印出病变鼻窦模型,在模型上进行术前设计及模拟手术,确定肿瘤切除范围、需修复重建部位,确定手术方案后进行肿瘤切除及同期重建。术后均予以放疗并密切随访,通过CT复查与功能检查,对疗效、手术精准度及功能恢复进行评价。结果经3D打印术前设计,全部患者顺利完成肿瘤切除术,8例患者同期行缺损部位修复重建,其中6例患者上颌骨和眶壁骨质缺损植入钛网,2 例患者颅底骨质缺损较大行鼻中隔黏骨膜瓣修复,2例缺损较小且硬脑膜完整者未行骨性重建。术中能够明确肿瘤与解剖结构的位置关系并实现了全部切除、准确定位缺损并修复,精确度高。术后CT复查显示切除范围、骨缺损部位、重建外形与术前设计基本一致。10例患者术后愈合良好,无严重并发症。患者随访12~30个月,肿瘤无复发。结论3D打印技术在鼻鼻窦恶性肿瘤的外科治疗中可以实现术前设计、手术模拟及术后预测,具有较好的可行性和可靠性,有助于鼻鼻窦恶性肿瘤切除范围的确定、缺损重建,可提高鼻鼻窦恶性肿瘤手术治疗的精确性、临床治疗效果及患者术后生活质量。     

3D打印模型用于先天性小耳畸形之耳廓再造术

目的探讨自体肋软骨结合3D打印耳廓模型进行全耳廓再造术的精细化优势,以及量化的评价方法。方法对40例小耳畸形患者采用自体肋软骨结合3D打印行全耳廓再造,对再造耳廓的外观效果进行了初步的分析、评价;并对满意度进行调查。结果再造耳廓14个解剖结构效果评分总分为28分,医师评分大于20分的达70%,与健耳比较患者满意度没有统计学差异(P>0.05),再造耳廓与健康耳的相关测量数据的相关性更好,其立体感强、个性化、自然逼真,再造耳廓14个解剖结构存在。结论应用自体肋软骨结合3D打印行全耳廓再造,较精细,个性化强,是耳廓较理想的再造方法,该量化的评价方法值得推广应用。     

3D打印鼻骨复位器在骨折复位手术中主观疗效的临床分析

目的分析3D打印鼻骨复位器在鼻骨骨折复位手术中的应用价值及意义。方法将2016年1月~2018年7月收治的17例单侧鼻骨骨折或双侧鼻骨骨折对侧没有移位的鼻外伤患者作为研究对象,在鼻骨骨折复位手术前及术后1个月内分别行颌面部CT扫描,术中采用3D打印鼻骨复位器复位骨折,采用VAS评分对比手术前后患者对鼻外形的满意度和鼻腔通气情况比较。结果患者鼻外形满意度VAS评分从术前 (6.353±1.607）分降到术后(1.529±1.036）分,差异具有统计学意义(P<0.01); 鼻腔通气情况VAS评分从术前(2.912±2.315）分降到术后(0.882 4±0.322 2)分,差异具有统计学意义（P<0.01）。患者鼻外形主观满意度及鼻塞主观感觉均较术前有不同程度的改善。结论3D打印鼻骨复位器行鼻骨骨折复位操作简单且复位准确率高,可达到精准复位的目的。用3D打印鼻骨骨折复位器行鼻骨骨折复位术是可行且有效的。     

3D打印辅助设计个性化游离腓骨瓣成形修复上颌骨切除术后缺损

目的探讨3D打印辅助设计个性化游离腓骨瓣成形修复上颌骨切除术后缺损的疗效。方法回顾性分析2016年1月至2018年12月,首都医科大学附属北京同仁医院收治的13例上颌骨区肿瘤术后缺损患者的病历资料,其中男7例,女6例,年龄12~55岁。其中行上颌骨次全切除4例,全上颌骨切除9例。手术根据术前CT表现在上颌骨三维图像上模拟截骨切除范围,将健侧上颌骨镜像复制到患侧缺损处,再根据镜像后的骨形态设计个性化腓骨修复的3D模型,根据3D模型进行腓骨雕塑成形和上颌骨缺损修复。分别从口腔、鼻腔、眼功能及外形恢复等方面观察3D打印辅助设计个性化游离腓骨肌皮瓣成形修复上颌骨切除术后缺损的疗效。结果随访5~40个月,1例患者术后出现皮瓣危象皮瓣坏死,余12例皮瓣全部成活。13例患者随访期间,经CT或MRI证实均未见肿瘤复发。3例患者术后出现不同程度的腭瘘,余10例患者可经口进食,无鼻腔反流。11例患者发音效果满意。全部患者鼻腔通气良好。全部患者未出现视力下降和复视,眼位正常。术后外观恢复采用视觉模拟量表(VAS)进行评估。13例患者VAS平均数为8分,除1例皮瓣坏死患者,余12例患者对外形修复满意。结论3D打印辅助设计个性化游离腓骨瓣成形修复上颌骨切除术后缺损不仅能保全口腔、鼻腔和眼的功能,而且能获得较满意的外形恢复效果。     

3D打印在功能性鼻整形手术中的应用

功能性鼻整形手术是一种恢复或改善鼻的形状和功能的手术,在术中常用到植入或非植入性材料。3D打印是材料制造行业的一次技术革新,近年来在包括生命医学的多个科学领域发展迅猛。3D打印具有个性定制、精确制作的特点,这恰好与个体化需求明显的功能性鼻整形手术契合。本文就3D打印在功能性鼻整形手术术前规划和学习、术中辅助操作和引导、植入物等方面的研究和应用进行综述,并将应用3D打印与传统方法的功能性鼻整形手术进行对比,同时展望3D打印在该领域的未来发展。     

3D打印技术在耳科学的应用

3D打印是一种基于预先设计、利用特定的材料逐层叠加,构建出三维物体的数字化制造技术。近年来,3D打印技术越来越多的被应用于包括生物医学在内的多个领域。本文就3D打印技术在耳科学教学与解剖训练、术前规划与手术模拟、修复重建等方面的应用及其在耳科学的发展前景进行综述。     

3D技术在鼻内镜手术精准治疗鼻前颅底恶性肿瘤中的应用

目的 探讨3D技术在鼻内镜手术精准治疗鼻前颅底恶性肿瘤及颅底功能重建手术中的作用。 方法 对21例鼻颅底恶性肿瘤患者术前行鼻窦冠状位CT或MRI扫描,并行3D影像重建及模型打印,根据3D成像及模型了解鼻颅底恶性肿瘤侵及范围、颅底及眶壁骨质的缺损大小形状,制定鼻内镜手术术式、肿瘤精准切除范围及颅底功能精准重建方法。 结果 患者肿瘤均一次手术全切除,其中6例行颅底功能精准重建术,无脑脊液鼻漏及颅内感染并发症。术后病理示鳞癌9例,嗅母细胞瘤5例,腺样囊腺癌3例,横纹肌肉瘤4例。术后行正规放疗,横纹肌肉瘤患者加化疗。经平均随访36个月,未发现肿瘤复发及与本肿瘤相关的死亡。 结论 3D成像及打印模型能清楚显示鼻颅底恶性肿瘤范围、颅底及眶壁骨质缺损的大小及形状,并有助于术者选择最佳内镜手术入路及手术方案,有重要临床指导作用。     

鼻瓣区狭窄的治疗

鼻瓣区狭窄造成的鼻塞容易被忽略，医师的注意力常过多的集中在下鼻甲和鼻中隔。因此，很多患者因鼻塞而经历多次下鼻甲手术。笔者治疗1例患者，经历6次下鼻甲手术，最后下鼻甲中后份几乎全无，患者仍诉通气不良，夜间睡眠时将一笔帽插于鼻孔，尚能入睡。因此，对鼻瓣区病变的处理应该给予足够的重视。既往对鼻瓣区各种病变的处理以手术为主，近年随着低温等离子射频技术及整形技术等的应用，对该病变的处理有了更多治疗方法的选择。特别是应用低温等离子射频消融术处理鼻瓣区软组织病变，有其独特优势。     

鼻中隔穿孔患者手术前后鼻腔通气功能的变化

目的探讨鼻中隔穿孔患者手术前后鼻腔主客观通气功能的变化。方法对1 8例鼻中隔穿孔患者术前、术后分别行鼻阻力测量（Rhinomanometry,RM）、鼻呼吸量测量（Nasalspirometry,NS）,并同时利用视觉评分系统（visual analogue scale,VAS）对患者的鼻塞症状进行评分。采用SPSS 16.0统计软件,对手术前后的数据进行配对t检验,并对VAS评分和RM、鼻呼吸量比率（nasal partitioning of airflow ratio,NPR）进行相关性分析。结果术前RM、NPR和VAS评分分别为（0.365±0.124）kPa.s/L、0.28±0.14、3.46±1.02,术后分别为（0.32±0.112）kPa.s/L、0.18±0.1 2、1.7 4±0.64;手术前后的VAS评分差异有统计学意义（P〈0.01）,RM、NPR无统计学意义（P〉0.0 5）。手术前后VAS评分和RM、NPR相关系数分别为0.638、0.687,但无统计学意义上的相关性;手术前后RM、NPR之间差异有统计学意义（P〈0.01）,其相关系数为0.864。结论鼻中隔穿孔患者鼻阻力、鼻呼吸量客观通气功能和主观通气功能VAS评分具有一定的相关性,对选择手术侧别和制定手术方案具有一定的指导意义。     

鼻阻塞的主观评价与客观鼻测量的相关性研究

目的 探讨鼻阻塞时检查者和患者的主观评价与客观鼻测量之间是否有相关性.方法 检查者和患者均采用视觉模拟量表(visual analog scale,VAS)对鼻阻塞程度进行评价.客观鼻测量采用主动后鼻测压仪和鼻声反射测量仪进行.以配对t检验分析检查者的临床评价和患者VAS均数的差异,以Spearman等级相关分析评价客观鼻测量结果单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积的关系,以及检查者的临床评价、患者VAS与上述客观鼻测最结果的相关性.结果 本组病例经统计学分析,316例患者中,减充血前后单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积间呈负相关(r值分别为-0.430、-0.554、-0.373、-0.600,P值均＜0.001).减充血前后,检查者的临床评价与患者VAS均数呈正相关,差异均有统计学意义(r值分别为0.630、0.526,P值均＜0.001),二者均与鼻气流阻力有一定的正相关关系(减充血前:检查者的临床评价与鼻气流阻力r=0.530,P=0.000,患者VAS与鼻气流阻力r=0.351,P=0.000;减充血后:检查者的临床评价与鼻气流阻力r=0.452,P=0.000,患者VAS与鼻气流阻力r=0.216,P=0.000),与鼻道容积和鼻腔最小横截面积均有一定的负相关关系(减充血前:检查者的临床评价与鼻道容积r=-0.411,P=0.000,患者VAS与鼻道容积r=-0.325,P=0.000,检查者的临床评价与鼻腔最小横截面积r=-0.507,P=0.000,患者VAS与鼻腔最小横截面积r=-0.384,P=0.000;减充血后:检查者的临床评价与鼻道容积r=-0.391,P=0.000,患者VAS与鼻道容积r=-0.209,P=0.000,检查者的临床评价与鼻腔最小横截面积r=-0.471,P=0.000,患者VAS与鼻腔最小横截面积r=-0.286,P=0.000).检查者的临床评价与客观鼻测量参数的相关系数大于患者VAS与客观鼻测最参数的相关系数.结论 鼻阻力测压与鼻声反射测量的结果有一定的相关性.检查者的临床评价与患者VAS存在一定的正相关关系.两者均与客观鼻测量参数存在一定的直线相关关系.     

主观感觉评估与解剖结构及鼻功能测量在慢性鼻窦炎中的相关性研究

目的 探讨主观感觉测量与解剖结构及鼻功能测量在慢性鼻窦炎疾病中的相关性.方法 选择2019年9月-2020年10月在山西医科大学附属汾阳医院耳鼻咽喉科就诊的慢性鼻窦炎患者43例.分别应用视觉模拟量表评估患者鼻塞主观症状;Lund-Mackay评分和Lund-Kennedy评分系统评估鼻窦CT及鼻内镜检查结果;鼻声反射、...     

Does Nasal Obstruction Mean That the Nose Is Obstructed?

Objectives/Hypothesis: It is still a matter of controversy to what extent the sense of nasal obstruction is associated with objective measures for nasal space and airflow. Knowledge about this is important in the evaluation of nasal complaints and the planning of its treatment. In this study, we evaluated the relationship between subjective nasal obstruction and the corresponding anatomic and physiological nasal parameters using acoustic rhinometry (AR) and peak nasal inspiratory flow (PNIF). Study Design: Two thousand five hundred twenty‐three consecutive patients were included in this cross‐sectional study. Eligible subjects were adults referred to the Ear, Nose, and Throat Department, Sørlandet Hospital, Kristiansand, Norway, for evaluation of chronic nasal or sleep related complaints. Methods: Subjects underwent AR and nasal flow measurements. Subjective grading of nasal obstruction was obtained by a nasal obstruction visual analogue scale. Associations between nasal obstruction visual analogue scale scores, AR, and PNIF were assessed using multiple linear regression, adjusting for age, gender, body mass index, and asthma, allergy, and smoking history. Results: The sense of nasal obstruction was associated with nasal cavity volumes in both anterior and middle segments of the nasal cavities, with minimal cross‐sectional areas in middle segments and for the nasal cavity as a whole, and with PNIF. Associations with minimal cross‐sectional areas in anterior segments did not reach significance. Conclusions: The present study demonstrates highly significant associations between the subjective sensation of nasal obstruction and corresponding measures for nasal cavity volume, area, and airflow. We conclude that AR and PNIF are valuable objective instruments for evaluation of subjective nasal obstruction.     

Pediatric nasal valve surgery: Short-term outcomes and complications

Objectives

To examine the short-term outcomes and complications of open nasal valve surgery in children under 16 years of age. Study design: case series and chart review study setting: an urban, tertiary, pediatric otolaryngology practice.

Methods

Children under 16 years of age who had undergone nasal valve surgery with cartilage grafting for functional indications were identified. Patients with cleft-related nasal deformities were excluded. Charts were reviewed for indications and short-term outcomes (patient satisfaction and postoperative complications within the first 90 days). A literature review assessed prior outcomes in adult nasal valve patients.

Results

Fifteen pediatric patients, 15 years old or younger, were identified as having undergone open nasal valve repair utilizing septal or auricular cartilage grafts. Patient age ranged from 6 to 15 years. Surgical indications were nasal obstruction with nasal valve stenosis related to either previous trauma (n = 10), congenital deformity (n = 3), iatrogenic injury (n = 1) or hemangioma of infancy (n = 1). All patients noted improvement of symptoms at the 90 day interval or later. There was one episode of self-limited epistaxis, which occurred on postoperative day 7 following splint removal.

Conclusions

In children, an obstructive nasal breathing pattern may be caused by nasal valve collapse, which can be addressed with nasal valve surgery. This small series suggests that short-term results in children may be similar to those observed in the adult population. Pediatric nasal valve surgery outcomes have not been described previously; studies focused on long-term outcomes following pediatric nasal valve surgery are needed.

Level of evidence

4.     

A computer method for assessing satisfaction with hearing aids

The purpose of this study was to evaluate a new clinical assessment, the Dynamic Assessment of Hearing Aids (DAHA), for a large clinical population. Unlike traditional questionnaire methods, the DAHA has patients use an intuitive graphical computer interface to record visual analogue ratings of satisfaction with various features of their hearing aids (e.g. clarity, cost, appearance). Data were collected from 191 participants.A subset of participants returned for retest. The DAHA items assess satisfaction with hearing aids within four domains: communication, physical features, sound quality, and personal reactions. The concurrent validity was determined by comparing DAHA results to those obtained with the satisfaction with amplification in daily life (SADL). Ratings for personal reactions to hearing aids indicate the most satisfaction, and ratings for communication (especially group conversations and phone use) indicate the least satisfaction. The DAHA total score was found to have good test/retest and high internal consistency. Concurrent validity was supported by a strong correlation between total scores on the DAHA and the SADL. Results suggest the DAHA maybe an effective tool for clinical use.

Sumario

El objetivo de este estudio fue valorar un nuevo instrumento clínico, la “Evaluación dinámica de Auxiliares Auditivos” (DAHA), en una amplia población. A diferencia de los cuestionarios tradicionales, con el DAHA los pacientes utilizan una interfase gráfica intuitiva para grabar apreciaciones de satisfacción análogas visuales de varios atributos de sus auxiliares auditivos (p.ej. claridad, costo, apariencia). Se colectaron datos de 191 participantes. Un subgrupo de participantes regresó para una re-evaluación. Los ítem del DAHA evalúan la satisfacción que proporcionan los auxiliares auditivos en cuatro áreas: comunicación, características físicas, calidad de sonido y reacciones personales. La validez concomitante se determinó comparando los resultados del DAHA con los obtenidos en el de “Satisfacción con Amplificación en la Vida Diaria” (SADL). Los índices de reacciones personales a los auxiliares indicaron la mayor satisfacción y los índices de comunicación (especialmente conversación grupal y uso de teléfono) indicaron la menor satisfacción. Se encontró que la calificación total del DAHA tiene una alta consistencia interna y una buena calificación test/re-test. Hubo una alta correlación entre la calificación final en el DAHA y la de SADL. Los resultados sugieren que el DAHA puede ser una herramienta de uso clínico efectiva.     

Current treatment of nasal vestibular stenosis with CO2-laser surgery; prolonged vestibular stenting versus intraoperative mitomycin application. A case series of 3 patients

These case studies describe three cases of unilateral nasal vestibular stenoses caused by chemical cauterization. Each case was treated with CO₂-laser surgery together with intraoperative topic application of mitomycin or prolonged vestibular stenting for prevention of restenosis. Two patients received intraoperative mitomycin application and one patient received prolonged vestibular stenting. Results were documented using high-resolution photographs. The follow up period ranged from 1 year and 3 months to 4 years and 9 months. All patients improved after CO₂-laser surgery. No complications were reported. We consider CO₂-laser surgery for relief of nasal vestibular stenosis as a feasible surgical technique for relieve of nasal vestibular stenosis. Prolonged vestibular stenting seems to be an important factor for the prevention of restenosis in which the value of intraoperative mitomycin application without prolonged vestibular stenting remains uncertain.     

Is topical local anaesthesia necessary when performing paediatric flexible nasendoscopy? A double-blind randomized controlled trial

OBJECTIVE: To evaluate the effectiveness of lignocain 2% and oxymetazoline 0.025% compared to oxymetazoline 0.025% alone when administered prior to fibreoptic nasendoscopy in paediatric patients. STUDY DESIGN: Prospective, randomized controlled, double-blind study. A group of 56 children, undergoing nasendoscopy to determine adenoidal size, were randomized into two groups and received either lignocain 2% and oxymetazoline 0.025% or oxymetazoline 0.025% alone prior to fibreoptic nasendoscopy. SETTING: A tertiary care Paediatric Hospital. METHOD: The endoscopist recorded the ease of performance of the procedure, cooperation of patient and quality of the view achieved using a visual analogue scale (VAS). The pain and anxiety levels of the child were recorded before, during and immediately after the procedure, using a VAS. The duration of performing the procedure was recorded from insertion of the endoscope into the nostril until removal. RESULTS: All 56 children were able to undergo the endoscopy and the full anxiety and pain assessment was done. Three children were excluded because they have undergone nasendoscopies before. Of the 53 patients included, 27 children received solution A (oxymetazoline 0.025%) and 26 children received solution B (oxymetazoline 0.025% and lignocain 2%). There was no statistical difference between the two groups regarding the duration of the endoscopy, quality of view, ease of performance and cooperation of the patients. The median pain and anxiety scores were not significantly different between the two groups. CONCLUSIONS: This study concludes that the use of a decongestant (oxymetazoline) for paediatric nasendoscopy is just as effective as the use of oxymetazoline with lignocain. Pain and anxiety is not increased in the absence of lignocain.     

低温等离子射频消融术治疗药物性鼻炎27例

目的 探讨低温等离子射频消融术(LPRFA)治疗药物性鼻炎的疗效。 方法 对27例药物性鼻炎患者实施双侧下鼻甲LPRFA,统计并分析患者术前、术后3个月、术后6个月视觉模拟评分(VAS)和Lund-Kennedy鼻内镜评分及鼻阻力测量值。 结果 VAS鼻内镜评分术前评分为(7.82±0.92)、术后3个月评分为(2.15±0.99),术后6个月评分为(2.26±1.06);Lund-Kennedy鼻内镜评分:术前评分为(3.22±0.58)、术后3个月评分为(1.15±0.86),术后6个月评分为(0.63±0.56);与术前相比,进行了LPRFA的患者术后3个月、6个月的VAS和Lund-Kennedy鼻内镜评分明显降低,差异有统计学意义(P<0.05);鼻窦CT和鼻内镜检查示鼻黏膜恢复良好,总鼻道较术前通畅,患者自述鼻塞症状明显改善,术前吸气总鼻阻力值为(0.97±0.50)kPa/L·s,呼气总鼻阻力值为(0.35±0.23)kPa/L·s,术后3个月的吸气总鼻阻力值为(1.01±0.84)kPa/L·s,呼气总鼻阻力值为(0.35±0.19)kPa/L·s,术后3个月患者吸气和呼气总鼻阻力值明显降低,差异有统计学意义(P<0.05)。 结论 采用LPRFA治疗药物性鼻炎后,患者鼻塞等鼻部症状明显缓解,生活质量得到提高,并在随访期(6个月)中,患者疗效稳定,LPRFA治疗药物性鼻炎值得临床推广应用。