鼻内镜下脑脊液鼻漏修补术

我们于2000—05—2011-10经鼻内镜修补脑脊液鼻漏31例,取得较满意的效果,报告如下。     

Endoscopic repair of cerebrospinal fluid leak in paediatric patients

BackgroundIn scientific literature exist fewer case series regarding endoscopic treatment of paediatric cerebrospinal fluid fistulas. Compared to craniotomy endoscopic repair does not reach wider consent even if craniotomy carries higher complications rate.ObjectiveThe aim of the present study was to report our institutional experience on paediatric cerebrospinal fluid leak to demonstrate the safety and efficacy of the endoscopic approach in a variety of cases.MethodsClinical records of all paediatric patients who underwent endoscopic repair of anterior and middle fossa skull base defects are reviewed for several parameters.Results10 patients were enrolled, 6 males and 4 females with a mean age of 10 years. The aetiology of the leak was congenital in 2 cases, trauma-induced in 6 cases and iatrogenic in 2 cases. In all the cases the defect was localized by computed tomography. Remedial was obtained using multiple grafts technique with autologous materials during a single procedure in all but one case, this one case requiring a second operation for delayed recurrence. The mean follow-up duration is 36 months.ConclusionCSF fistulas can be approached in paediatrics of any age with high success and low complications rate using the endonasal technique.     

脑脊液鼻漏的治疗

目的总结脑脊液鼻漏治疗的临床经验,评价不同的治疗方法,提出脑脊液鼻漏外科治疗的术式.方法回顾分析1991年3月～2001年11月83例脑脊液鼻漏.共有5种治疗形式,保守治疗17例,开颅手术修补8例, 鼻外入路修补术2例,显微镜下鼻内入路修补术3例,鼻内镜下修补术54例.分析保守治疗的时间及外科治疗各组病例的病因、伴发病、漏口部位及修补材料等.讨论手术时机、手术适应证和术中的关键问题.结果随访6个月～9年.17例保守治疗全部治愈,平均治愈时间16 d.开颅手术8例、鼻外入路的2例和显微镜下鼻内入路的3例均治愈.54例鼻内镜下修补术者1次手术治愈49例(90.1%);2次手术治愈2例(2/4),3次手术治愈1例,4次手术治愈1例,最终成功率98%,1例额窦漏口者第一次手术失败后改为鼻外入路修补成功.结论鼻内镜下脑脊液鼻漏修补术是外科治疗脑脊液鼻漏的首选术式,其他术式可依病情需要适当选择.外伤性或手术并发的脑脊液鼻漏保守治疗的时间一般为2～4周,个别病例可达6～8周.     

经鼻内镜下脑脊液鼻漏修补术

目的探讨经鼻内镜下脑脊液鼻漏修补术的临床应用。方法2003年10月～2008年12月诊治的38例行经鼻内镜下脑脊液鼻漏修补术的患者,其中外伤性脑脊液鼻漏21例,自发性脑脊液鼻漏10例,其他原因7例。结果术后随访6个月～3年,1次手术成功率为92.1%。2次手术成功2例,1例3次手术成功,术后脑膜炎和急性梗阻性脑积水各1例。结论经鼻内镜下脑脊液鼻漏修补术成功率高,创伤小,应作为首选治疗方法;漏口定位和处理、适宜的外科修补技术及术后处理是手术成功的关键。     

经鼻内镜脑脊液鼻漏修补术15例

目的：总结鼻内镜治疗脑脊液鼻漏的要点及可靠的诊断定位方法。方法：回顾性分析15例脑脊液鼻漏患者,其中外伤引起者10例,医源性4例,原发性1例。其中6例经2～6周保守治疗无明显好转给予经鼻内镜下修补术;2例外伤性脑脊液鼻漏经神经外科开颅修补失败后转入我科手术治疗;1例复杂的多发性颅底骨折并双侧额窦后壁缺损致脑脊液鼻漏,经鼻内镜修补成功（DraftⅢ型）。缺损最大者2.5 cm×1.5 cm,所有患者术前均经实验室生化检查确诊,均予以CT和（或）MRI检查和经鼻内镜检查。10例给予脑池造影结合超薄螺旋CT扫描。结果：所有患者均一次治愈,平均随访时间20个月（8～40个月）,无复发。1例术后有轻微头疼,经保守治疗后缓解。脑池造影结合超薄螺旋CT扫描定位精确,10例均经术中确定。结论：鼻内镜下脑脊液鼻漏修补术是外科治疗脑脊液鼻漏的首选术式。脑池造影结合超薄螺旋CT扫描是目前最好的影像学定位方法。随着鼻内镜相关器械质量提高及新器械的开发应用,手术范围可能进一步扩大。     

经鼻内镜脑脊液鼻漏修补术的方式和方法分析

目的：探讨脑脊液鼻漏的最佳治疗方法。方法：45例经鼻内镜行脑脊液鼻漏修补术患者,42例经鼻进路,3例经鼻及鼻外双进路。采用患者自体游离阔筋膜、捣碎的肌肉,剥去骨质带骨膜的中鼻甲或下鼻甲作为修补移植物,修补采用内贴修补法、堵塞修补法、外贴修补法和充填修补法。结果：1次性手术修补成功44例（97．8％）。术后并发脑膜炎3例,额窦区感染皮瓣下积液1例。45例住院治疗7～30d,平均11d。随访5个月～7年,无复发。结论：对于前颅底小瘘口和鞍底、斜坡处瘘口的脑脊液鼻漏,经鼻内镜脑脊液鼻漏修补具有明显优势。修补方式、方法和修补材料的正确选择是修补成功的关键。     

Endoscopic management of cerebrospinal fluid rhinorrhea

Cerebrospinal fluid rhinorrhea and meningoencephaloceles extending into the nasal cavity from the anterior, middle, and posterior cranial fossae often are managed by otolaryngologists. A thorough understanding of the underlying pathophysiology, management principles, and treatment options is essential to achieve optimal outcomes. Surgical and medical management is highly individualized and depends on many factors, including etiology, anatomic site, and underlying intracranial pressure. This article highlights the history, physiology, pathophysiology, diagnosis, surgical techniques, and postoperative care relevant to nasal cerebrospinal fluid leaks and encephaloceles.     

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience

OBJECTIVES/HYPOTHESIS: Many reports have advocated the feasibility of using an endoscope for the treatment of cerebrospinal fluid (CSF) rhinorrhea and skull base defect, and diversified endoscopic techniques and repairing materials have recently been proposed. This study determined the effectiveness of endoscopic repair of CSF leaks and interpreted the indications of the lumbar drain. STUDY DESIGN: Retrospective follow-up. METHODS: A total of 39 patients with CSF rhinorrhea (20 traumatic, 13 iatrogenic, and 6 spontaneous) were treated in one institution over a 10-year period. An underlay procedure was used to make eight (20.5%) repairs by way of a turbinate composite graft (4 patients), turbinate mucosa graft (3 patients), or the Dura Substitute (Preclude) (1 patient). A free turbinate graft with the applied fibrin glue was used to repair the defect by way of an overlay procedure in 23 (59.0%) lesions. Abdominal fat was used to repair the other eight (20.5%) lesions. RESULTS: Defects in the cribriform plate and anterior ethmoid sinus comprised the majority (61.5%) of all lesions. The successful rates for overlay, underlay, and fat obliteration procedures were 91.3% (21/23), 87.5% (7/8), and 100% (8/8), respectively. There were no statistical difference between underlay and overlay techniques (P = .792, Student's t test). Lumbar drainage was performed in 18 of 39 (46.2%) cases. Most patients required nasal packing (89.7%) and prophylactic parenteral antibiotics (97.4%). CSF rhinorrhea was resolved during the first attempt in 36 of 39 (92.3%) patients. All leaks were successfully repaired after a second attempt. No major complications were encountered. CONCLUSION: The endoscopic approach is safe and effective for the treatment of CSF rhinorrhea, even in the cases not successfully treated by previous neurosurgical approaches. Lumbar drain was suggested for defects in the frontal and sphenoid sinus and defects associated with meningocele or encephalocele. Complete exposure of the defect, appropriate selection of a fitting graft, as well as accurate placement and stabilization of the graft are critical to the success of repair.     

经鼻内镜外伤性脑脊液鼻漏修补术

目的探讨鼻内镜下外伤性脑脊液鼻漏修补术的方法和疗效。方法回顾性分析2008年11月-2012年5月收治的8例外伤性脑脊液鼻漏患者,采用鼻内镜下修补术,并对其手术方法和疗效进行总结。结果1次手术治愈7例,1例再次手术治愈。1例术后并发颅内感染,经对症支持治疗后全愈出院。随访6-24个月,无复发。结论鼻内镜下脑脊液鼻漏修补术是一种安全、有效和微创的手术方式。     

自发性脑脊液鼻漏临床分析

目的探讨自发性脑脊液鼻漏的诊治方法。方法回顾性分析13例自发性脑脊液鼻漏的临床特征、影像学特点及诊治方法与疗效。结果13例自发性脑脊液鼻漏患者,通过询问病史,收集鼻漏出液行葡萄糖定性定量检测,鼻内镜检查和CT、MRI影像学检查均得以确诊,保守治疗无效,均行鼻内镜下修补术,术后随访6个月～6年,均无复发,无脑膜炎等并发症,手术修补成功率100％。结论葡萄糖定性定量检测、鼻内镜检查及CT、MRI影像学检查是诊断自发性脑脊液鼻漏的主要方法,鼻内镜下寻找漏口及修补术具有微创、并发症少及成功率高等优点,是自发性脑脊液鼻漏的首选治疗方法。     

脑脊液鼻漏修补术成败的关键因素研究

目的：总结脑脊液鼻漏的治疗经验。方法：回顾性分析16例脑脊液鼻漏患者的临床资料,探讨脑脊液鼻漏的病因、影像学特点及漏口位置、大小、修复方法对疗效的影响。结果：16例患者中自发性脑脊液鼻漏10例,外伤性脑脊液鼻漏2例,感冒后出现脑脊液鼻漏3例,脑膜脑膨出伴脑脊液鼻漏1例。CT检查明确漏口位置11例,磁共振水成像检查明确漏口位置7例。漏口位于额窦3例,鼻腔顶部3例,筛顶6例,蝶窦4例。手术均在鼻内镜下完成,修补材料均采用自体材料;均一次修复成功,无手术并发症发生。随访10-42个月,无一例复发。结论：术前应用CT和磁共振水成像能准确判断脑脊液鼻漏漏口的位置、大小,术中修补材料的选择、漏口周围移植床的处理及修补材料与移植床的完全接触是确保手术成功的重要因素。     

自发性脑脊液鼻漏的诊断与治疗

目的 探讨自发性脑脊液鼻漏的诊断和治疗方法.方法 回顾性研究17例自发性脑脊液鼻漏的诊断程序、内科治疗方法和鼻内镜下手术修补的效果.结果 17例自发性脑脊液鼻漏患者,经鼻腔溢出物糖定性定量检测、鼻内镜检查和CT、MRI影像学检查而得到确诊,保守治疗愈合2例,余15例经手术治疗而全部愈合.结论 鼻腔溢出物糖定性定量检测和CT、MRI检查是诊断自发性脑脊液鼻漏的主要方法,鼻内镜下经鼻进路手术修补漏口是最适合的治疗方法.     

自发性脑脊液鼻漏临床治疗

目的　研究自发性脑脊液鼻漏好发部位及治疗方法。方法　回顾性分析2008年5月～2013年11月我科收治的自发性脑脊液鼻漏患者30例临床资料,包括临床表现、好发部位、采取的手术方式以及随访结果。结果　本组30例患者中漏口位于筛顶14例、筛板9例、蝶窦6例、额窦后壁1例。1例患者采用鼻外入路行脑脊液鼻漏手术修补,余患者均采用鼻内入路在鼻内镜下行手术修补,27例患者1次性手术成功,3例患者接受2次手术,一次手术成功率90%,30例患者随访6个月～6年均未复发。结论　准确定位瘘口位置、选择合理的手术方式以及妥善进行术后围手术期处理是手术治疗自发性脑脊液鼻漏成功的关键。     

脑脊液鼻漏24例临床分析

目的:探讨脑脊液鼻漏的诊断,治疗方法及其效果。方法:回顾性分析2003-01-2008-09收入武汉大学人民医院耳鼻咽喉头颈外科和神经外科的24例脑脊液鼻漏患者临床资料,耳鼻咽喉头颈外科18例,神经外科6例。结果:随访4～72个月24例患者均获治愈,保守治疗6例,手术治疗共18例,其中经鼻内镜下手术12例,鼻外入路4例,显微镜下经鼻入路2例。结论:经鼻内镜修补术在治疗经保守治疗无效的脑脊液鼻漏中具有安全,有效,创伤小,复发率低,术后头面部无切口的优点,尤其适用于漏口位于筛板和蝶窦区的患者。而对于复杂、缺损口较大、鼻内镜不易观察到漏口的脑脊液鼻漏,应选择鼻外或颅内入路术式进行修补。     

以脑脊液鼻漏为首发症状的垂体瘤1例

1病例报告患者,女,25岁。因反复右鼻流清涕1个月余就诊。患者有月经过少病史。1个月余前无明显诱因出现右鼻流清涕,在当地医院诊断为变应性鼻炎,给予抗过敏治疗,未见好转,仍有清水样鼻涕,低头时可连续流出。来我院体检示：双侧中鼻道、嗅裂无脓涕,双侧鼻腔黏膜苍白色。鼻内镜检查示：右侧蝶筛隐窝有清亮液体流出,考虑为脑脊液鼻漏。鼻窦螺旋CT平扫示：双侧蝶窦黏膜增厚,内可见密度增高影填充;鞍底可见骨质破坏。     

Incidence,etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery

OBJECTIVES/HYPOTHESIS: The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR). STUDY DESIGN: Retrospective chart review. METHODS: Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%). RESULTS: Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases. CONCLUSIONS: Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.