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.     

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。     

空蝶鞍合并脑脊液鼻漏的特点及临床治疗

目的:探讨空蝶鞍合并脑脊液鼻漏的特点及治疗方法。方法:空蝶鞍合并脑脊液鼻漏患者8例,其中2例行1次脑脊液鼻漏修补术,4例行2次鼻内镜下脑脊液鼻漏修补手术,1例行开颅联合鼻内镜脑脊液鼻漏修补术及脑室腹腔分流术,1例行鼻内镜脑脊液鼻漏修补术复发后保守治疗治愈。部分患者术后行腰大池引流1周,卧床3周。结果:1例患者术后出现脑出血,行开颅手术后治愈,随访2年未复发;1例术后2年复发,保守治疗治愈;2例在3年后复发,再次手术1年未复发;1例1年后复发,再次手术修补并行脑室腹腔分流术后半年未复发;1例患者术后半年未复发;1例患者术后5年复发,后再次手术。结论:空蝶鞍合并脑脊液鼻漏的患者临床上少见,治疗以鼻内镜手术修补为主,但术后易复发,反复发作者可以考虑行脑室腹腔分流术。术后需长期随访复查。     

鼻内镜下脑脊液鼻漏修补术

目的 探讨鼻内镜下脑脊液鼻漏修补术的手术方法和治疗效果.方法 回顾性分析1996-2010年诊断为脑脊液鼻漏的54例患者的临床资料,所有患者均行鼻内镜下脑脊液鼻漏修补术.其中,外伤性25例,自发性17例,医源性12例.采用颞肌、颞肌筋膜、中鼻甲黏膜、鼻中隔黏膜、下鼻甲黏膜、阔筋膜、大腿肌肉、腹部脂肪、钩突黏膜、鼻窦黏膜等进行修复.结果 54例患者中,49例一次修补成功,1例2次手术修补成功,1例3次手术修补成功,1例在外院再次手术成功,1例修补不成功,未再治疗,1例术后1年半复发,未再治疗.术后并发症:4例术后出现高热,1例术后出现一过性浅昏迷并高热,1例术后出现癫痫,1例患者术后出现气颅,均经保守治疗痊愈.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,手术成功率高,应作为首选治疗方法;准确的漏口定位,选择合适的入路和适宜的修补方法是手术成功的关键.     

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。     

脑脊液鼻漏15例临床分析

目的：探讨脑脊液鼻漏的诊断和治疗。方法：对15例脑脊液鼻漏患者临床治疗资料作回顾性分析。结果：随访3个月～5年,15例患者全部治愈。其中行保守治疗4例,鼻外入路修补7例,鼻内镜修补4例。结论：经鼻内镜修补脑脊液鼻漏操作简单、创伤小、定位准确、术后患者恢复快。但对某些病例,联合鼻外进路可弥补内镜下操作困难和不足,有助于提高1次修补成功率。     

经鼻内镜额窦脑脊液鼻漏修补术初探

目的探索额窦脑脊液鼻漏修补术的进路、修补方法和手术技巧。方法对9例额窦后壁和4例额隐窝后外侧壁脑脊液鼻漏患者进行手术修补，其中首次手术行鼻内镜下修补术12例，联合进路1例；术后观察手术疗效及并发症情况。结果13例患者中12例一次修补成功，1例二次修补成功。出现并发症2例，其中1例为术后颅内感染，行鼻外引流、额窦填塞术治愈；另1例为阻塞性额窦囊肿，行鼻内镜下额窦开放术治愈。结论经鼻内镜可以成功修补可视的额窦后壁脑脊液鼻漏，但要注意额窦口及漏口大小，防止术后额窦阻塞，诱发阻塞性额窦囊肿、额窦炎和颅内感染；对于额窦内不可视的脑脊液鼻漏和额窦口扩大困难的病例，建议行联合进路修补术。     

经鼻内窦镜筛蝶窦脑脊液鼻漏修补术

采用内窥镜鼻窦外科技术修补筛窦，蝶窦脑脊液鼻漏５例，其中４例是外伤性，经保守治疗无效者，１例是经鼻内窥镜筛板－前颅底进路切除侵入鼻腔的脑膜瘤时发生的严重脑脊液鼻漏。５例均一次手术治愈，介绍了修补术的方法，并就经鼻内窥镜脑脊液鼻漏修补术的有关问题进行了讨论。     

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。     

脑脊液鼻漏修补术后复发再手术

目的探讨脑脊液鼻漏修补术失败的原因及再次手术成功的经验。方法回顾分析1983年5月~2000年11月收治的19例脑脊液鼻漏修补术失败再手术的病例资料。其中修补手术术后10 d内即发现仍有脑脊液鼻漏的12例,1个月后再次出现脑脊液漏的7例,分别采用鼻外筛窦入路、额鼻联合入路、鼻内镜入路再行手术修补。结果19例中再次手术1次修补术成功的18例,进行2次手术成功的1例,随访5~17年无复发。结论选择合适的手术径路及修补材料,准确的漏口定位和正确的漏口处理及修补方法是确保手术成功的关键。     

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis

OBJECTIVES/HYPOTHESIS: Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair. METHODS: We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients. RESULTS: Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication. CONCLUSION: The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.     

Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus

BACKGROUND: Multiple reports have demonstrated the efficacy of the transnasal endoscopic repair of cerebrospinal fluid (CSF) leaks of the anterior cranial base. The literature, however, lacks a comprehensive clinical study specifically addressing the transnasal endoscopic repair of CSF leaks of the sphenoid sinus. OBJECTIVE: To ascertain the factors that significantly affect the surgical outcome after transnasal endoscopic repair of CSF leaks of the sphenoid sinus. METHODS: We retrospectively reviewed the medical records of all patients who underwent an endoscopic transnasal repair of CSF leaks of the sphenoid sinus at our teaching hospitals. RESULTS: Twenty-four patients with CSF leaks of the sphenoid sinuses that were repaired by the transnasal endoscopic approach were included in our study. Causes of the CSF leaks included trauma, surgery, neoplasms, and idiopathic causes. Obliteration was the most common technique used to repair the CSF fistulas (used in 15 [58%] of 26 procedures). Grafting materials included banked pericardium, mucosa, turbinate bone, and mucoperichondrium placed by underlay or onlay grafting or abdominal fat used to obliterate the sphenoid sinus. Twenty-two patients were successfully treated on the first attempt. A persistent leak in 2 patients with previously unrecognized high-pressure hydrocephalus was repaired during a second endoscopic surgery, quickly followed by ventriculoperitoneal shunting. CONCLUSIONS: Assuming an adequate repair, other factors such as the cause, the size of the defect, the technique and material used to repair the defect, and perioperative management do not affect the surgical outcome significantly. Untreated high-pressure hydrocephalus can lead to a recurrence or persistence of the leaks and should be suspected in patients with posttraumatic, idiopathic, or recurrent CSF leaks.     

鼻内镜下自体材料脑脊液鼻漏修补术(附16例临床分析)

目的 评价采用自体材料经鼻内镜脑脊液鼻漏修补术的手术方法和治疗效果。 方法 回顾性分析2010年至2015年诊断为脑脊液鼻漏的16例患者的临床资料。所有患者行鼻内镜下脑脊液鼻漏修补术,其中自发性6例,外伤性5例,医源性5例。采用的修补材料有颞肌、颞肌筋膜、中鼻甲黏膜、中鼻甲骨、鼻中隔黏膜、下鼻甲黏膜、阔筋膜、腹部脂肪、钩突黏膜等,均为自体材料。 结果 16例患者中,一次修补成功15例, 二次手术修补成功1例。术中及术后均未发生严重并发症。 结论 鼻内镜下自体材料脑脊液鼻漏修补术是一种安全、有效和微创的手术方式,成功率高。术前准确的漏口定位、选择合适的手术入路和适宜的修补材料是手术成功的关键。     

经鼻内镜修补复发性脑脊液鼻漏及颅底缺损

目的：探讨脑脊液鼻漏修补失败的原因及鼻内镜手术修补的方法。方法：经鼻内镜修补18例脑脊液鼻漏手术修补后复发患者。结果：经鼻内镜1次修补成功13例,2次修补成功3例,2例患者2次手术失败后失访。结论：鼻内镜修补复发性脑脊液鼻漏有效。影响手术成功的因素有：漏口位置、修补材料及放置技术、颅骨缺损的面积及漏口定位是否准确等。     

Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience

INTRODUCTION: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. METHODS: A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. RESULTS: Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). DISCUSSION: Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.     

The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus

OBJECTIVES/HYPOTHESIS: The transnasal endoscopic approach has become the preferred technique for the surgical management of patients with cerebrospinal fluid (CSF) leaks of the anterior, sellar, and parasellar skull base. The literature has reported an 85% to 100% success rate for the endoscopic repair of CSF leaks, which compares favorably with that reported after transcranial repair. Despite an adequate repair, a subpopulation of patients remain at high risk for recurrence of the CSF leak attributable to undiagnosed high-pressure hydrocephalus. Patients at high risk for high-pressure hydrocephalus include those who have had a subarachnoid hemorrhage as a result of trauma (accidental or surgical) or stroke and those with spontaneous CSF leaks. STUDY DESIGN: With the goal of reducing the risk of recurrence, the authors developed a protocol for the identification and management of patients with CSF leaks who are at risk for high-pressure hydrocephalus. METHODS: The protocol includes endoscopic repair, temporary CSF diversion, measurement of CSF pressure after the repair, and immediate ventriculoperitoneal shunting if necessary. RESULTS: During the period of September 1999 to April 2002, the authors repaired 25 CSF leaks through an endonasal endoscopic approach. Nineteen patients were considered at high risk for high-pressure hydrocephalus. Using the protocol described, the authors identified six patients (31%) with CSF leaks that could be associated with undiagnosed high-pressure hydrocephalus. All CSF leaks were successfully repaired using a transnasal endoscopic repair. Six patients with high-pressure hydrocephalus underwent ventriculoperitoneal shunting after repair of the CSF Leak. No recurrence has been observed at a follow-up ranging from 24 to 84 months (median period, 30 mo). CONCLUSION: Patients with high-pressure hydrocephalus may be identified in a prospective fashion to prevent recurrence or persistence of the CSF leaks. The presence or absence of high-pressure CSF may be established by means of direct CSF pressure measurement through lumbar puncture postoperatively. This allows early intervention and prevention of recurrence.     

Endoscopic repair of traumatic CSF rhinorrhea in a pediatric patient

Cerebrospinal fluid (CSF) rhinorrhea typically results from trauma to the skull base, producing leaks through either the cribiform plate region or the sphenoid bone. Traditional approaches to the repair of such leaks include a frontal craniotomy or external ethmoidectomy. An endoscopic approach through the nose has also proven to be successful. A 7-year-old male suffered traumatic CSF rhinorrhea and development of a meningocele in the region of the cribiform plate. After demonstrating the site of the leak with fluorescein dye, the defect was repaired via a transnasal endoscopic approach. The evaluation of the child with CSF rhinorrhea, including the presenting symptoms and signs and the radiographic assessment, is presented. The variety of approaches, types of repair and post-operative care are also discussed.     

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。