3D打印辅助上颌骨切除术后缺损重建

目的：探讨3D打印技术在上颌窦恶性肿瘤外科治疗中的可行性和应用效果。方法对5例因上颌窦恶性肿瘤行手术治疗的患者,根据术前CT扫描数据,应用3 D打印技术打印出患侧上颌窦的树脂模型,在此模型上对钛网进行塑形,制备出个性化钛网,将个性化钛网植入缺损区。通过临床和CT检查,评价其颌面部外形与功能。结果所有病例手术顺利,颌面部外形恢复良好,两侧对称,未见复视及眼球内陷,植入的钛网与缺损周边骨床贴合紧密。术后随访8～30个月,经临床和CT检查未见肿瘤复发。结论3 D打印技术在上颌窦恶性肿瘤的外科治疗中具有较好的可行性和可靠性,可提高上颌窦恶性肿瘤手术治疗的精确性及临床治疗效果。     

晚期鼻腔鼻窦恶性肿瘤眶壁重建研究进展

晚期鼻腔鼻窦的恶性肿瘤累及眼眶发生率非常高,术中一期眶壁重建可以有效的减轻眼球塌陷和眼球运动障碍,维持良好的外观形象。小的眶壁缺损可以使用局部带蒂软组织瓣,大的眶壁缺损应当使用软组织瓣联合质硬材料的复合组织瓣。随着血管显微技术的发展,游离组织瓣成为可靠且应用广泛的软组织瓣。人工修复材料主要是具有良好可塑性和可靠强度的钛网,但是放疗后容易引起并发症。血管化的骨片具有足够的硬度和抗感染能力,是理想的眶壁修复材料。晚期鼻腔鼻窦恶性肿瘤眶壁修复的方法众多,最终仍需要进行个体化设计。     

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打印技术结合可塑形钛网在修复上颌骨缺损中的应用

目的探讨3D打印技术结合可塑形的个体化钛网在修复上颌骨缺损中的应用。方法回顾性分析2016年1月至2018年6月,上海交通大学医学院附属第九人民医院耳鼻咽喉头颈外科收治的因上颌骨良恶性肿瘤行上颌骨部分或全部切除、或严重复合性外伤后的获得性上颌骨缺损的患者共14例,男性12例,女性2例,年龄16~51岁。其中鳞状细胞癌2例;良性肿瘤7例,包括血管瘤1例、骨纤维异常增殖症3例、骨囊肿2例和骨巨细胞瘤1例;复合性上颌骨外伤5例。根据术前薄层CT扫描数据,通过计算机建模数据传送至3D打印机,分别打印出原始状态和重塑后的上颌骨树脂模型。在患者的原始模型上,术前模拟肿瘤切除和上颌骨重建,在重塑的模型上塑形钛网,使其能恰当重建缺损的骨结构。术中将预制好的钛网植入缺损区域,将软组织瓣复位,分层缝合,术后局部加压包扎。术后通过临床和CT检查,评价患者颌面部外形、鼻腔功能及并发症情况。采用描述性统计学方法对结果进行分析。结果所有肿瘤病例均能在术前3D打印模型预测的范围内完整切除病灶,与外伤病例在清创后植入钛网一样,无需于术中再次对钛网进行塑形和修剪,钛网可完整覆盖缺损的骨面,周边贴合紧密,钛钉固定顺利,植入钛网坚固稳定。术后随访6~20个月,患者对面部外形满意,功能恢复良好。结论3D打印技术结合可塑形钛网应用于上颌骨缺损的修复,能精确恢复上颌骨骨性结构对于软组织的支撑,恢复面部形态及功能。     

鼻内镜下鼻中隔软骨修复治疗爆裂性眼眶内侧壁骨折

目的：探讨鼻内镜下鼻中隔软骨修复治疗爆裂性眼眶内侧壁骨折的临床效果。方法：在鼻内镜下将骨折复位,将眶内容物还纳,以自体鼻中隔软骨植入骨折缺损处修复眶壁缺损,观察患者手术前后视力、复视、眼球突出度和眼位变化。结果：术后随访3个月～4年,28例患者术后均未出现患眼明显视力下降和视力丧失,术后眼球内陷度数为（1．5±0．6）mm,与术前（3．6±1．1）mm相比,差异有统计学意义（P〈0．05）。术后3个月,25例患者复视完全消失,2例患者第一眼位无复视,但仍有周边复视,1例术后第一眼位复视仍存在。26例术后眼球运动基本恢复正常,2例外展稍受限,但较术前好转。以上28例患者均未发现填充物移位、感染或排异反应。结论：鼻内镜下鼻中隔软骨修复爆裂性眼眶内侧壁骨折具有手术人路简捷、视野清晰、操作简便、损伤小、无面部瘢痕等优点,效果确信可靠。     

应用Medpor板行鼻腔鼻窦恶性肿瘤切除术后眶壁缺损一期重建的疗效观察

目的　分析鼻腔鼻窦恶性肿瘤（ma l i g n a n t sinonasal tumors，MSTs）侵犯眶壁术后使用高密度聚乙烯生物材料Medpor（以下简称Medpor板）一期修复的效果。方法　回顾性分析2008～2016年就诊于鞍山市中心医院耳鼻咽喉科的5例确诊MSTs侵犯眶壁的患者，均采用Medpor板对MSTs切除术后眶底或眶内壁缺损进行一期修复。结果　全部病例中1例术后2年死亡失访，其余4例随访5年以上。全部病例均见纤维软组织肉芽覆盖Medpor板，切口且均为一期愈合，植入材料均无感染和排斥的情况，术后眶区无明显肿胀，无放疗后皮瓣坏死，无眼眶下移，无眶底修补材料外漏，无复视。讨论　应用Medpor板修复鼻腔鼻窦肿瘤术后眶壁缺损术后疗效明显，复查病理均为炎性肉芽组织，无复发，眼功能保留完好。且应用Medpor板操作简便，可塑性高，利于手术后观察，并可减轻患者经济负担，尤其对基层医院临床中MSTs术后眶壁修复重建的手术治疗有较高的实用价值。     

局部晚期口鼻相关恶性肿瘤切除后的重建修复及并发症的处理

目的 探讨局部晚期口鼻相关恶性肿瘤的修复重建及术后并发症处理的应用价值。方法 回顾性分析原发于鼻腔鼻窦,硬腭及上颌牙槽的局部晚期口鼻恶性肿瘤33例,继发口腔癌术后复发病例侵犯口鼻恶性肿瘤3例,病理类型主要为鳞癌和小涎腺恶性肿瘤。术前CT和MRI检查,所有病例肿瘤均不同程度破坏鼻腔鼻窦,上腭,眶周,颅底区域,根据病情采用不同手术入路完整切除病灶后,采用游离股前外侧皮瓣,游离腓骨肌皮瓣及钛网等修复方法重建缺损并随访疗效及并发症。结果 所有病例均成功切除肿瘤,一期重建均成功,皮瓣成活,外形恢复可,无明显口鼻瘘,脑脊液瘘,眶底及面部塌陷。术后中位随访期12个月,出现咽鼓管闭塞中耳积液8例,鼻泪管溢泪5例,吞咽障碍6例。结论 手术切除是口鼻相关恶性肿瘤的一种有效治疗方法,一期修复重建及积极处理并发症对改善患者外形及生活质量具有重要意义,对术后的综合治疗提供了便利。     

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。     

35例鼻眼相关疾病的诊治分析

目的：回顾分析鼻眼相关疾病的诊治结果，提高鼻眼相关疾病的诊治水平。方法:回顾分析35例鼻眼相关疾病患者的临床资料。结果:35例中, 鼻源性眼眶蜂窝织炎6例，外伤性鼻眶骨折、视神经管骨折4例，鼻窦黏液囊肿11例，内翻性乳头状瘤3例，鼻窦恶性肿瘤11例。鼻眼病变特征：炎性病变以眶壁破坏吸收为主，良性肿瘤则表现为眶壁受压移位，恶性肿瘤以眶壁破坏为主。结论:鼻窦与眼眶关系密切, CT扫描有助于此区域病变的早期诊断、指导治疗及观察预后;良性肿瘤以手术切除为主,恶性肿瘤需采用手术加放疗等综合治疗。     

Long-term results following reconstruction of maxillary sinus wall defects with titanium micro-mesh: a CT-based study]

BACKGROUND: Extensive bony defects of maxillary sinus walls have to be reconstructed to prevent long-term complications. Different autogenous, allogeneic, and alloplastic materials, e.g., titanium mesh, are used for reconstruction. MATERIAL AND METHODS: In 26 patients large defects of the facial and laterodorsal walls of the maxillary sinus were reconstructed using titanium micro-mesh. The mean follow-up period was 49 months (5 months-10 years). All patients were examined with computed tomography applying multiplanar reconstruction techniques and three-dimensional volume rendering. RESULTS: In the CT scans stable scars of 3-6 mm thickness could be found on the antral surfaces of all titanium meshes bridging the defects. In 70% of the patients the volume of the reconstructed maxillary sinus reached 80-100% of the contralateral side. Volume losses were not due to poor adaptation of the titanium mesh but were caused by thickening of maxillary sinus walls or traumatic malpositions. In 77% of the patients ventilation of the maxillary sinus was undisturbed. After mesh removal neither facial contour disturbances nor changes of sinus volume were noted. Soft tissue invasion into the sinus was prevented by a stable scar which had formed underneath the mesh. Three-dimensional reconstruction confirmed symmetrical facial contours in all patients. CONCLUSIONS: The titanium micro-mesh offers a simple and effective alternative to autogenous tissue with stable long-term results for reconstruction of large maxillary sinus wall defects.     

Silent sinus syndrome: lack of orbital findings in early presentation

BACKGROUND: Silent sinus syndrome (SSS) is an uncommon disease process, classically described as unilateral maxillary sinus opacification that presents with enophthalmos and atelectasis of bony sinus walls from chronic negative pressure. Patients are largely free of characteristic rhinosinusitis symptoms. METHODS: Operative reports, clinic notes, and radiological studies were reviewed for cases of SSS treated in a tertiary care institution over a 7-year period. Presenting symptoms, radiological features, and surgical findings were evaluated. RESULTS: Seventeen cases of SSS were identified. Presentation ranged from incidental computed tomography (CT) scan findings to unilateral enophthalmos with altered midface anatomy. Facial pain ipsilateral to the disease process occurred in 30% of cases. Vision changes were uncommon. Radiological studies universally revealed an opacified maxillary sinus on the affected side. Maxillary sinus walls were contracted and demineralized with significant orbital floor depression in 11 advanced cases. Four early cases revealed only lateralized uncinate process on CT scan without increased orbital volume, and two moderate cases showed increased orbital volumes on CT scan without clinical enophthalmos. All patients had a significantly lateralized uncinate process at surgery, often closely apposed to demineralized orbital walls. CONCLUSION: Some authors maintain that SSS presentation must include enophthalmos. However, our series shows cases of lateralized uncinate processes and increased orbital volumes on CT scan, as would be seen in classic SSS, but lacking clinical enophthalmos. Such cases should be considered as potentially representing early SSS, before the development of clinical orbital findings.     

Reconstruction of paranasal sinus and orbit using polymeric and metalloceramic materials in traumas

43 patients with injury of the paranasal sinus walls and the orbit were treated surgically: 23 osteoplastic operations on the walls of the orbit and maxillary sinus and 20 operations of the walls of the frontal sinus. Complete recovery of anatomofunctional and cosmetic structure was achieved in 36(83.7%) patients, satisfactory results were observed in 7(16.3%) patients. Diagnosis and surgical treatment are outlined of injuries of the facial skeleton with repair of frontal, orbital and maxillary bone defects with plates made of superhighmolecular polyethelene and network titanium covered with biosital. The result of the operation depends on early and accurate diagnosis and treatment, valid choice of surgical technique and aftercare.     

Orbital wall thickness and the spread of infection from the paranasal sinuses

Ninety-three human skulls (80 adults and 13 children) have been examined and the extent of thin bone in the party walls between the orbit and the frontal, ethmoidal and maxillary sinuses has been assessed. Translucent bone is most often present in the lateral wall of the ethmoidal labyrinth and least often in the floor of the frontal sinus. In children such bone is present significantly less often in the roof of the maxillary sinus (P less than 0.001) than in adults. Computerized tomography scans and clinical data from 6 patients with orbital cellulitis were reviewed. In one of these an inferolateral subperiosteal abscess of the orbit was associated with a defect in the roof of the maxillary sinus. Two patients had a medial subperiosteal abscess associated with ethmoiditis and in one there was direct continuity between the abscess and the adjacent ethmoidal cells. In another case a superolateral abscess was demonstrated in continuity with a surgical defect in the floor of the frontal sinus. We conclude that the ethmoidal, frontal or maxillary sinuses may be sources of orbital infection and that spread occurs either by direct extension through the sinus wall or by local thrombophlebitis.     

Differential diagnosis of sinugenic enophthalmos

BACKGROUND: Spontaneous enophthalmos without recent trauma is a rare condition. Its origin is difficult to evaluate. METHOD: Specific properties of this symptom complex are presented based on a literature review and on case reports. Possible connections between enophthalmos and paranasal sinus diseases as well as differential diagnoses are analysed. PATIENTS: 1. 31 year old female patient with right spontaneous enophthalmos and no history of trauma. CT-imaging disclosed tissue formation in the maxillary sinus, partially destroyed medial orbital wall and floor, descended orbital contents following Caldwell-Luc procedure several years previously. After endonasal surgery of ethmoidal and maxillary sinus with removal of a large cyst good functional and cosmetical result. 2. 25 year old male patient complaining of pain in the periorbital region, presenting with left enophthalmos and superonasal deviation of the eyeball. MRI and CT revealed a tumor in the orbital floor region with total destruction of the roof of the maxillary sinus. Removal of the tumor by a combined lateral rhinotomy and subciliary approach. Diagnosis: Leiomyoma. Orbital reconstruction with PDS-sheet. Postoperatively, improved globe position and motility. No recurrence during three year follow-up. CONCLUSION: When evaluating the causes of enophthalmos, chronic diseases of the paranasal sinuses or their walls must be considered. Surgical therapy is promising.     

上颌窦恶性肿瘤侵及骨壁的CT影像与组织病理对比观察分析

目的　通过术前CT影像与术后组织病理检查对比分析,探索和评价CT诊断上颌窦恶性肿瘤的窦内外侵犯的应用价值和受累骨壁的准确性。方法　无淋巴结及远处转移的上颌窦鳞状细胞癌患者11例,术前给予组织病理学检查、增强CT扫描,根据CT影像特征和范围实施上颌骨部分切除或全切除,标记切下的骨组织标本的部位和方位,给予常规固定、脱钙、包埋、切片和HE染色,光镜下观察各壁上颌骨的骨组织病理学改变。结果　11例患者鼻腔鼻窦增强CT扫描显示上颌窦内侧壁均有破坏吸收（4例内壁缺失）,其中侵犯前壁6例,上壁7例,底壁3例,后外壁9例;组织病理学检查见除外内壁缺失患者外,上颌窦内壁均有肿瘤细胞侵犯,且前壁和底壁均有肿瘤细胞侵及,其中上壁4例,后外壁4例;术前CT表现为骨质内壁虫蚀样改变但骨壁连续无中断且伴有增厚硬化的骨壁,术后病理验证无肿瘤侵及。结论　术前CT骨壁的破坏并不意味着骨质被肿瘤侵犯,而且上颌骨各壁侵犯的机率是不同的;综合分析发现术前CT表现为骨质内壁呈虫蚀样改变但骨壁连续无中断且伴有增厚硬化的“改建性骨破坏”者,术后病理验证无肿瘤侵及骨壁;术后常规选取上颌骨骨组织病理分析,可以补充术前CT诊断上颌窦恶性肿瘤侵犯范围的不足,从而精确判断肿瘤的T分级,可能为选择微创的手术方式及术者术后评估手术效果、更科学的制定术后综合治疗提供更有力的依据。     

颅底术后骨质缺损的钛网重建

目的探讨钛网在颅底重建中的可行性和外科技术。方法回顾性分析2002年11月至2004年11月采用钛网修复的11例颅底缺损患者的临床资料及随访结果。结果11例患者中颅底肿瘤6例，颅底骨纤维异常增生症3例，脑膜脑膨出2例。手术人路：经颅面联合入路手术7例，经额入路及扩大经额入路3例，经面中部掀翻入路1例。修补中、侧颅底2例，前、中颅底及蝶鞍6例，前颅底及眶板3例。术后短期内3例患者有少量无症状性颅内积气，未经治疗而自愈；1例患者发生短暂性脑脊液鼻漏，局部明胶海绵填塞及碘纺纱条压迫后自愈。术后平均随访14．4个月，无钛网移位和颅内感染等并发症。结论钛网用于颅底大型骨质缺损修复是安全的、可行的。