鼻内镜下经鼻蝶窦入路垂体腺瘤切除的手术配合

总结 16例鼻内镜下经鼻蝶窦入路垂体腺瘤切除的手术配合及护理,提出术前加强心理护理,术中严格无菌操作及熟练的手术配合,是确保手术成功、减少并发症、控制感染的必要手段.     

内镜辅助经鼻蝶入路至斜坡区的显微解剖研究

目的研究内镜辅助经鼻蝶入路至斜坡区的显微解剖和显露范围，为临床提供解剖学参数。方法测量40例颅骨干标本的骨性结构，10例福尔马林固定的成人尸头标本模拟手术入路，用内镜和显微镜观察斜坡区显露范围，并进行解剖测量。结果前鼻棘至蝶窦口、鞍底、鞍结节中心、鞍背中点、枕骨大孔前端的距离分别为（55．62±4．23）mm、（71．50±6．21）mm、（79．02±4．97）mm、（81．04±8．02）mm、（91．08±5．20）mm；视神经管、颈内动脉隆起、颈动脉管外口、舌下神经管外口离正中线的距离分别为（5．78±1．94）mm、（5．44±2．02）mm、（25．07±2．77）mm、（16．98±1．99）mm；斜坡的长、高分别为（32．43±5．46）mm、（35．01±4．12）mm；上、中、下部的厚度分别为（17．23±3．12）mm、（9．96±3．10）mm、（6．35±2．95）mm。在内镜辅助下，经鼻蝶入路可以通过适当去除相应结构增加显露鞍后．斜坡区的解剖结构。结论内镜辅助经蝶入路可以通过良好的视角显露鞍后．斜坡等显微解剖结构，适用于鞍后．斜坡等颅底中央区病变的手术治疗。     

经鼻前庭鼻中隔蝶窦入路切除垂体腺瘤18例报告

<正> 垂体腺瘤是颅内常见肿瘤,占全部颅内肿瘤的10～14％。我科于1997年3月～2002年2月经鼻前庭鼻中隔蝶窦入路治疗垂体腺瘤18例,疗效满意,现报告如下。 1 临床资料 1.1 一般资料:本组18例,男8例,女10例,年龄19～63岁,平均41岁。本组视力改变8例,闭经泌乳6例,肢端肥大4     

鼻内镜下经鼻蝶入路垂体瘤切除术的护理体会

目的探讨鼻内镜下经鼻蝶入路垂体瘤切除术的护理配合方法。方法对41例接受鼻内镜下经鼻蝶入路垂体瘤切除术患者的临床护理资料进行回顾性分析。结果患者均顺利完成手术,发生并发症2例(4.9%),经对症治疗后治愈,患者均顺利出院。结论积极做好鼻内镜下经鼻蝶入路垂体瘤切除术围术期各项护理措施,可降低并发症发生率,提高手术治疗效果。     

神经内窥镜在经鼻蝶入路垂体瘤手术中的应用

本文对神经内窥镜在鼻蝶入路垂体瘤手术中的应用作一综述。     

全神经内镜下经鼻蝶入路手术治疗垂体腺瘤72例临床分析

目的 探讨和评价全神经内镜下经鼻蝶入路切除垂体瘤的手术技巧及临床应用价值.方法 2009年1月至2012年3月,完成72例单纯神经内镜经鼻-蝶垂体瘤切除术,回顾性分析患者术前、术后症状及激素水平变化、影像学资料、手术资料、并发症、随访资料等. 结果 72例病例中非功能性腺瘤22例(30.6％),泌乳素腺瘤24例(33.3％),生长激素腺瘤7例(9.7％),促肾上腺皮质激素腺瘤5例(6.9％),促甲状腺激素腺瘤1例(1.4％),多分泌性腺瘤13例(18.1％);肿瘤全切除56例(77.8％),次全切除13例(18.0％),部分切除3例(4.2％);并发脑脊液漏5例,出现短暂性尿崩6例.术后随访3 ～ 24个月,大部分功能性腺瘤术后激素基本恢复正常水平,术后1例视力变差,其余患者症状亦基本恢复正常. 结论 全神经内镜经鼻蝶手术切除垂体腺瘤是一项安全、微创、有效的方法,具有全程直视下切除肿瘤的优点,但系统、专业的训练及相应的设备是必不可少的.     

内镜辅助经鼻蝶入路至斜坡区的显微手术

目的 探讨内镜辅助经鼻蝶入路至斜坡区的显微手术方法和疗效.方法 根据经鼻蝶入路至鞍区斜坡区显微解剖学研究结果,采用内镜辅助经鼻蝶显微手术治疗该区肿瘤12例(侵袭性垂体腺瘤8例,脊索瘤3例,软骨瘤1例).所有病例均在3个月至6年内获得随访.结果 手术全切8例,次全切除3例,部分切除1例.术后发生短暂性尿崩症6例,脑脊液鼻漏2例,无死亡及颅内感染.随访3个月至6年,除1例脊索瘤残瘤继续生长外,其余患者未见肿瘤复发.结论 采用经蝶入路显微手术切除沿中线生长的鞍区斜坡区肿瘤,入路简便快捷,创伤小,手术显露良好,疗效满意.内镜辅助使得经蝶入路更为安全、有效.     

神经内镜下单鼻孔经蝶切除鞍区Rathke囊肿

目的探讨神经内镜下经鼻蝶治疗鞍区Rathke囊肿的手术疗效、方法和技巧。方法回顾性分析2012年1月～2013年2月10例术后病理证实为鞍区Rathke囊肿的临床资料。临床主要表现为头痛、头晕及视力下降。均采用神经内镜下单鼻孔经蝶入路。结果10例术中均完全清除囊液,大部分切除囊壁,术后患者头痛、头晕症状均消失,视力均较术前提高,未出现明显并发症,术后住院时间3～8d,平均6d。术后随访1—13个月,平均6个月,未见复发。结论神经内镜单鼻孔经蝶切除鞍区Rathke囊肿创伤小,术野清晰,能完全清除囊液,大部分切除囊壁,手术操作简单、安全,术后并发症少,恢复快,是治疗鞍区Rathke囊肿的理想治疗方法。     

神经内镜经鼻蝶窦垂体瘤切除术后颅底重建对病人生活质量的影响

目的观察神经内镜经鼻蝶窦垂体瘤切除术后颅底重建对病人生活质量的影响。方法垂体腺瘤病人90例,均接受神经内镜经鼻蝶窦垂体瘤切除术联合颅底重建治疗,观察并记录病人垂体瘤切除情况、并发症发生情况以及术后1个月症状改善情况;分别于术前和术后1个月测定激素水平;术后随访3个月,应用SNOT-20中文版量表对病人鼻部生活质量进行评分。结果垂体瘤全切率为81. 11%,术后7例病人鼻腔结构发生改变,且月经失调、视力下降、头痛和性功能障碍较术前显著缓解(P 0. 05)。术后泌乳素(PRL)、促肾上腺皮质激素(ACTH)、促甲状腺素(TSH)及生长激素(HGH)异常比例均显著下降,差异有统计学意义(P 0. 05);术后病人鼻生活量表各项评分较术前均显著改善(P 0. 05)。结论神经内镜经鼻蝶窦垂体瘤切除术联合颅底重建,垂体瘤完全切除率较高,术后并发症发生较少,症状缓解率高,可有效提高病人鼻部生活质量。     

神经导航引导下内镜经蝶入路切除鞍上型巨大垂体瘤

目的探讨神经内镜及神经导航用于经鼻蝶入路治疗鞍区肿瘤的临床应用及手术技巧。方法对2007-03—2013-11间收治的32例鞍上型巨大垂体肿瘤实施神经内窥镜结合神经导航技术经鼻蝶手术切除。结果本组肿瘤全切除24倒,近全切除6倒,大部分切除2例。术后患者症状均有不同程度改善。2例患者出现一过性脑脊液漏,5例出现尿崩症,其中1例需长期口服弥凝,无其他严重并发症发生。结论内镜技术经鼻蝶手术治疗垂体肿瘤,具有对鼻腔正常结构损伤小、暴露清楚等特点,特别是对于传统显微镜手术不能暴露的鞍上结构显露满意。结合导航技术能提高肿瘤的全切率及手术的安全性。     

单鼻孔经蝶窦入路治疗鞍区囊性垂体病变

目的总结单鼻孔经蝶窦入路显微手术治疗鞍区囊性垂体病变的经验。方法 2006～2010年,显徽镜下单鼻孔经蝶窦入路治疗15例囊性垂体病变,病变直径11～28 mm,其中〉20 mm者6例。将鼻窥器缓慢插入右鼻孔向上经中鼻甲直至蝶窦前壁,横行切开鼻中隔黏膜约1.5 cm,保持窥器尖呈闭合状态向对侧偏移,使鼻中隔骨折移位。然后将窥器张开,可见中线骨性隆起结构蝶嵴及两侧蝶窦开口。凿除蝶窦前壁约1.0～1.5 cm,显露蝶窦腔,咬除蝶窦分隔,剥离电凝蝶窦黏膜,显露凸形鞍底,凿开并扩大至1.2～1.5 cm骨窗即见硬脑膜,电凝硬膜后穿刺,证实病变后＂十＂字切开,显露病变并予钳取和刮除。结果手术过程顺利,病变全切除14例,次全切除1例。病理结果为垂体脓肿4例,Rathke囊肿7例,囊性垂体腺瘤4例。无死亡及病残,术后无脑脊液鼻漏。1例囊性垂体腺瘤次全切除患者术后行伽玛刀治疗,随访10个月未见肿瘤增大。余14例随访8～19个月,平均14个月,无复发。结论鞍区囊性垂体病变术前鉴别诊断虽然较困难,但仍有很多特征可以鉴别;应用单鼻孔经蝶窦入路可取得简捷、安全、高效的治疗效果。     

经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤20例报告

目的探讨采用经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤的可行性。方法经单鼻孔显露蝶窦腹侧壁,蝶窦腹侧壁充分咬除,进入蝶窦,去除蝶窦黏膜和蝶窦隔,显露鞍底,鞍底开窗,放射状切开鞍底硬膜,切除鞍内肿瘤组织后,将牵开器的中心部分指向所侵入的海绵窦方向,咬骨钳咬除或磨钻磨除海绵窦腹侧骨质,显露海绵窦腹侧硬脑膜,自鞍底硬膜切开部分向外侧切开海绵窦腹侧硬脑膜,显露并切除海绵窦内部分肿瘤。结果肿瘤全部切除18例,次全切除2例。术中出现2例脑脊液漏,应用明胶海绵鞍内及蝶窦内填塞,术后无脑脊液漏。术后出现一过性动眼神经麻痹1例,术后3个月恢复正常。术后出现一过性尿崩12例,一过性电解质紊乱6例,均在1周内恢复正常。术后出院半个月后出现2例脑脊液鼻漏,行腰穿置管引流1周治愈。18例随访3～36个月,平均20个月,肿瘤无复发。结论采用经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤显露满意,切除彻底,无明显手术并发症。     

内镜辅助经蝶入路垂体腺瘤手术83例报告

目的探讨内镜辅助经蝶入路垂体腺瘤的手术治疗方法。方法 2004年6月～2012年6月,对83例垂体腺瘤在内镜辅助下经单鼻孔鼻中隔中段入路治疗。先用内镜探明蝶窦开口,显露鞍底,充分扩大鞍底开口,按先后下、再两侧、之后前上的顺序刮除肿瘤。最后内镜鞍内确认有无肿瘤残余。结果 83例均顺利完成手术,无死亡。62例视力视野改变者中,术后视力视野改善55例。内分泌激素2周内恢复正常26例,改善30例。术后3个月磁共振复查肿瘤未见残余49例,肿瘤部分残余（残余〈50%）30例,大部残余（残余〉50%）4例。结论经鼻蝶入路适用于绝大多数垂体腺瘤手术,鞍底骨质切除范围与肿瘤切除次序是经蝶入路垂体腺瘤全切除的要点,内镜辅助下手术有视野清晰、肿瘤切除彻底等优点。     

Endoscopic Endonasal Transsphenoidal Approach to Sellar Lesions: A Detailed Account of Our Mononostril Technique

Objective The endonasal endoscopic approach is currently under investigation for perisellar tumor surgery. A higher resection rate is to be expected and nasal complications should be minimized. Here, the authors report their technique of transnasal endoscopic neurosurgery after 218 procedures.Methods Between October 2000 and September 2011, 210 patients received 218 endoscopic endonasal transsphenoidal procedures for perisellar lesions. Procedures were video recorded. The surgical technique was carefully analyzed. These cases were prospectively followed.Results Standard technique was mononostril approach with 0-degree optics. 30-degree and—after availability—45-degree optics were used for assessment of radicality. On follow-up, magnetic resonance imaging revealed radical tumor resection in 94 out of 104 cases (90.3%). Recurrent tumor growth was observed in five younger patients (2.2%). There was no mortality and a low complication rate. Three patients (1.4%) complained postoperatively of nasal congestion or reduced nasal air flow; however, no complaints were considered to be severe.Conclusion In comparison with other literature reports, the results are comparable or even better with respect to surgical radicality. The very low rate of nasal complaints is particularly remarkable. The technique has been shown to be safe and successful with a high radicality and only minor complications.     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.     

Analysis of the Bacterial Flora in the Nasal Cavity and the Sphenoid Sinus Mucosa in Patients Operated on with an Endoscopic Endonasal Transsphenoidal Approach

The aim of this study was to analyze the bacterial flora in the nasal cavity and sphenoid sinus and evaluate the sensitivity of these bacteria to antibiotics that can be used to prevent postoperative meningitis. Bacteria of the preoperative nasal cavity and intraoperative sphenoid sinus mucosa were cultured and analyzed in 40 patients (20 men and 20 women; mean age, 52.2 years) who underwent endoscopic transsphenoidal surgery. The sensitivity of these bacteria to cephalosporin, a representative prophylactic antibiotic, was examined. Staphylococcus epidermidis was the most frequently detected species in both spaces; 24 (38.7%) of 62 isolates in the nasal cavity and 26 (37.1%) of 70 isolates in the sphenoid sinus. In contrast, Corynebacterium species were found mainly in the nasal cavity, and anaerobic bacteria were found only in the sphenoid sinus. Bacteria that were resistant to cephalosporin were found in the nasal cavity in 3.2% of patients and in the sphenoid sinus in 20% of patients. In conclusion, the composition of bacterial flora, including bacteria that are resistant to prophylactic antibiotics, differs between the nasal cavity and the sphenoid sinus.     

Transsphenoidal Cephaloceles in Adults. A Report of Two Cases and Review of the Literature

Transsphenoidal cephalocele rarely occurs in adults. We describe two adult cases with transsphenoidal cephaloceles. The first case was a 53-year-old female who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea. Magnetic resonance (MR) imaging demonstrated a transsphenoidal meningocele. Surgical repair was attempted via the transsphenoidal route. Rhinorrhea recurred at one month and also two years later. Transsphenoidal surgical repairs were repeated. There has been no evidence of CSF leakage in the four years of follow-up after the last surgery. Transsphenoidal repair seems to be the most suitable approach in this case. The second case was a 26-year-old female with secondary amenorrhea, diabetes insipidus, bitemporal hemianopsia, and see-saw nystagmus. MR imaging demonstrated a transsphenoidal encephalocele with the optic chiasma and infundibular recesses descending into the meningocele and an agenesis of the corpus callosum. The first operation was performed via the transnasal route and the second by sublabial transmaxillary transsphenoidal approach six months later. Postoperative MR imaging revealed reduction of the encephalocele. There was neither worsening nor noticeable improvement in the neurological or endocrinological function. However, in this type, complete repair is often impossible, and non-radical surgery such as transsphenoidal repair may be indicated as most suitable. They should be selected with careful assessment referring to MR findings and clinical symptoms and signs.     

Transnasal Endoscopic Resection of a Cavernous Sinus Hemangioma: Technical Note and Review of the Literature

Objective/Importance: Hemangiomas of the cavernous sinus are rare lesions. Complete removal through a transcranial route often causes ocular motor palsies. Because the cranial nerves in the cavernous sinus are lateral to the carotid, a medial approach to the cavernous sinus may be less traumatic to the cranial nerves. Clinical Presentation: A 50-year-old man with headaches, dizziness, diplopia, and magnetic resonance imaging that demonstrated a right cavernous sinus mass expanding into the sella and sphenoid sinus. Intervention: A gross total removal of a cavernous sinus hemangioma was performed through an extended endoscopic transsphenoidal approach. Conclusion: This is the first report of a complete removal of a cavernous sinus hemangioma using an endoscopic transnasal approach. The endoscopic transnasal approach to the medial cavernous sinus may be less traumatic than the transcranial route based on the lateral location of the cranial nerves.