婴幼儿先天性基底型脑膜脑膨出的诊断及鼻内镜手术治疗

目的 探讨婴幼儿先天性基底型脑膜脑膨出的诊断及鼻内镜手术治疗的安全性和有效性.方法 回顾性分析8例婴幼儿先天性基底型脑膜脑膨出的临床资料.术前进行鼻窦CT和MRI检查,全部病例经鼻内镜下脑膜脑膨出切除术及颅底修复重建术,术后随访手术疗效.结果 8例病例包括经筛型6例、蝶咽型2例.手术均一次性成功,无并发症出现.术后随访...     

Mucocele after transnasal endoscopic repair of traumatic anterior skull base fistula in children

Objectives

To report the long-term sinonasal complications after endoscopic repair of anterior skull base fractures in children. This study describes mucocele formation in 6 patients treated endoscopically for posttraumatic CSF fistulae. We aim to address possible etiologic factors, specific treatments and follow-up modalities.

Patients and methods

12 children, mean age 5.8 years (3-10), treated endoscopically at our institution between 2004 and 2010 for an anterior cranial base fracture complicated by a CSF fistula. An iatrogenic mucocele was observed in 6 cases. A retrospective review of the files of these 6 patients was carried out demonstrating demographic characteristics, presenting signs/symptoms, site of skull base defect, repair technique, timing and onset of the mucoceles, their presentation and management. A systematic CT-scan and/or MRI was carried out at 3 months, 1 year and then annually.

Results

3 patients presented after cranial trauma with persistent CSF nasal leak, and 4 with meningitis. Posttraumatic defects reached the posterior wall of the frontal sinus and the junction of ethmoid and frontal bone in 3 cases, and the cribriform plate in 3 cases. Endoscopic closure was performed in all cases, with the middle turbinate as an overlay patch. No recurrence of a CSF leak was observed. After a mean period of 16 months, a single iatrogenic mucocele was observed in 4 patients (radiological detection only), and multiple mucoceles in 2 patients. Surgical treatment was advocated in cases of proptosis, quick expansion of the mucocele leading to sinus bony wall remodelling or erosion (2 cases), and meningitis related to an erosion of the cribriform plate by the mucocele. Three mucoceles were successfully treated endoscopically, and 1 required an external approach.

Conclusion

Mucocele incidence after endoscopic repair of skull base fractures in children is not insignificant (50% in our 12 patients series). Paediatric anatomical features, cranial trauma, and the transethmoidal approach may play a role in mucocele pathogenesis. Long-term clinical and radiological follow-up is therefore recommended. These mucoceles may be managed endoscopically with good outcomes.     

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.     

伴高血压的鼻部阻塞性疾病患者术后血压观察

目的：探讨伴高血压的鼻部阻塞性患者手术治疗后血压的变化。方法：鼻内窥镜下手术治疗伴高血压的鼻部阻塞性疾病患者58例,观察术前及术后2周、6个月血压的变化。结果：58例术前、术后2周和术后6个月收缩压为（164.5±63.1）mmHg、（143.0±51.6）mmHg和（141.0±59.8）mmHg;舒张压为（96.0±52.3）mmHg、（82.2±38.4）mmHg和（80.4±41.5 ）mmHg;术前收缩压和舒张压均比术后2周、6个月下降（P＜0.01）。结论：经适当的术前准备,选择鼻内窥镜下解除鼻腔阻塞手术,可帮助伴高血压的鼻部阻塞性患者更好地控制血压。     

Actinomycosis of the middle turbinate: an unusual cause of nasal obstruction

Actinomycosis is a rare chronic infectious disease caused by Actinomyces israelii, which is an anaerobic filamentous, gram-positive saprophyte organism of the oral cavity. Historically, these bacteria were known as fungi because of their light microscopic appearance. Actinomycosis consists of three different forms: cervico-facial (the most common form), abdominal and pulmonothoracic. It commonly involves the head and neck region including the mandible, paranasal sinuses, lacrimal gland, parotid gland and orbit. Poor oral hygiene and dental diseases have been known to be the source of actinomycosis. Actinomycosis is diagnosed with positive culture or detecting actinomyces colonies and sulfur granules in histopathologic specimens. The treatment of choice is surgical excision of the lesion and long-term penicillin therapy. Actinomycosis of the internal nose is extremely rare. There was only one nasal septum actinomycosis reported in the English literature, but there was no lateral nasal wall actiomycosis regarding the turbinate. Therefore, actinomycosis should not be overlooked for the differential diagnosis of intra-nasal lesions for the initiation of appropriate and early treatment.     

Cerebrospinal fluid rhinorrhea: endoscopic repair based on a combined diagnostic approach

Background  The treatment of cerebrospinal fluid rhinorrhea has evolved since the first recorded instance of this condition by Willis in 1676. The advancements in radiology and endoscopic nasal surgery have provided ways to solve this potentially dangerous condition. But even now quite a few questions remain unanswered while tackling this difficult clinical situation. Laboratory tests for confirming the presence of cerebrospinal fluid in nasal fluid can yield false positive results and radiological evaluation has never been foolproof when it comes to small leaks and multiple leaks. Also the postoperative recurrence needs to be brought within acceptable limits. Objectives  We have tried to evaluate endoscopic repair of CSF rhinorrhea based on a combined diagnostic approach. The methods for diagnosis of CSF rhinorrhea have been reevaluated based on our experience with a view to prevent recurrences and complications. Materials and methods  The study group included twenty patients of CSF rhinorrhea who have been treated by endoscopic repair and spans over a period of five years from January 2001 to December 2005. A combination of retrospective and prospective methods of study has been used. Patients have been subjected to laboratory, radiological and dye studies for confirmation and localization of leak. Endoscopic repair of CSF fistula with composite graft and fibrin glue has been performed. Postoperative management included intracranial pressure reducing measures and control of primary condition in cases of spontaneous leak. Results  Endoscopic repair of CSF rhinorrhea produced a first time success rate of 92%. CT/MR Cisternogram could localize the defect in 85% cases while intrathecal fluorescein aided localization whenever it was used. The use of fibrin glue with composite graft and postoperative intracranial pressure reducing measures could improve the success rate. Conclusion  Management of a suspected CSF leak requires a combined diagnostic approach. Endoscopic repair with composite graft and fibrin glue should be the first line of management in cases of CSF rhinorrhea requiring surgical closure. Intracranial pressure reducing measures play an important role in preventing postoperative recurrence.     

鼻丘气房过度气化对内镜下泪囊鼻内造口术的影响

目的探讨鼻丘气房过度气化在鼻内镜下泪囊鼻内造口术时对造孔的影响。方法18例溢泪患者经泪囊造影CT检查后显示鼻泪管阻塞,且鼻丘气房气化超过泪颌缝,采用经鼻内镜下鼻丘气房泪囊鼻内造口术,回顾性分析该术式及临床疗效。结果18例（20眼）术后随访1年,治愈率9 0%（18/20）;显效5%（1/20）;有效5%（1/20）,总有效率100%。结论通过术前泪囊CT造影检查明确鼻丘气房与泪囊窝的局部解剖关系,对鼻丘气房过度发育者,可行经鼻丘气房泪囊鼻内造口术。     

Endoscopic surgery for congenital basal meningoencephaloceles in children

Conclusions Endoscopic surgery is safe and effective for children with congenital basal meningoencephaloceles (CBMs); it provides an acceptable operative outcome with a short recovery time and fewer complications and may be considered as a primary approach. Objectives To explore the safety and effectiveness of using transnasal or transoral endoscopic surgery on children with CBMs. Methods The clinical data of eight CBMs children who underwent transnasal or transoral endoscopic surgery in a hospital from January 2011 to January 2015 were collected. The presenting symptoms, lesion locations, surgical outcomes, and complications were examined retrospectively. Results Of the eight children, five (62.5%) patients were male, and their ages ranged from 1 year and 6 months to 14 years (median of 9 years). Six patients presented with the transethmoidal sub-type, and two presented with the transsphenoidal sub-type. The average hospital stay of all patients was 8.6?±?2.6 days. There were neither intra-operative nor post-operative complications observed in any of the cases during the follow-ups that occurred between 6–54 months (mean of 15.5 months).     

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.     

Sigmoid incision rescue nasoseptal flap technique for endoscopic endonasal skull base surgery

Conclusion The sigmoid-incision (S-I) rescue flap technique has the advantage of both reduced-invasiveness and providing a sufficient surgical corridor for endoscopic endonasal skull base surgery (EESBS). Objective Skull base reconstruction with nasoseptal flap (NSF) is critically important in managing post-operative cerebrospinal fluid (CSF) leakage after tumor removal by EESBS. The NSF needs to be elevated before sphenoidotomy and posterior septectomy to preserve the pedicle. However, most extradural surgery without CSF leakage does not require NSF and, therefore, NSF preparation is often futile. As a result, a rescue flap technique to overcome this problem has been developed, whereby a new S-I rescue flap method is used that enables wide exposure of the sphenoidal rostrum and smooth manipulation of surgical instruments to preserve the NSF pedicle. Materials and methods Starting in April 2014, 19 cases underwent EESBS with S-I rescue flap. Results All patients underwent tumor resection under an adequate operative field with smooth manipulation of surgical instruments. Two complications were experienced. One patient had CSF leak after removal of the nasal packing, but the leakage was successfully closed by conventional NSF. Another patient had epistaxis from the septal wall, but this was controlled by electrocautery.     

A massive adenoid cystic carcinoma of nasal septum progressed into the skull base

Background

Adenoid cystic carcinoma (ACC) is a malignant tumor commonly occurring in the major salivary glands. ACC of the nasal septum is exceeding rare.

Methods

The case of a 42-year-old woman with ACC of the nasal septum is presented. Her chief complaint was nasal obstruction and dysosmia for two month. CT and MRI demonstrated a massive mass occupying the nasal septum infiltrating the palate, vomeronasal, anterior skull base, and dura mater. Combined anterior cranial surgery, endoscopic intranasal surgery, and transpalatal surgery were selected due to the size and location of the tumor. A negative surgical margin was achieved without cosmetic deformity or functional disorder.

Results

She had postoperative radiotherapy with no recurrence or distant metastasis during the follow-up period.

Conclusion

The tumor location and the perineural spread pattern should be considered to determine the treatment plan for septum ACC. Post operative radiation is now generally recommended. ACC has a high incidence of local recurrence and distant metastasis rate; therefore, long-term follow-up is necessary.     

鼻内镜下颅底恶性肿瘤切除的初步探讨

目的探讨鼻内镜下切除侵犯颅底或原发于颅底的鼻腔鼻窦恶性肿瘤的可行性。方法回顾性分析1998年1月～2007年5月我院收治的40例鼻腔鼻窦恶性肿瘤侵犯颅底或原发于颅底恶性肿瘤患者,鼻内镜或鼻内镜辅助下手术切除病灶。结果4例患者术后6个月至2年内症状复发,再次鼻内镜手术效果满意。所有病例随访1年以上,死亡3例,失访7例,其中随访3年以上9例。结论鼻内镜下手术切除鼻腔鼻窦侵犯颅底或颅底原发性恶性肿瘤切实可行,但必须严格选择适应证。     

慢性鼻窦炎鼻息肉鼻内镜术后的康复治疗

目的:分析鼻息肉、慢性鼻窦炎经鼻内镜手术后影响疗效的因素,并探讨其预防措施。 方法:对因鼻息肉、慢性鼻窦炎接受鼻内镜手术、随访3年以上的226例患者从职业、个人生活习 惯、术后是否坚持系统的康复治疗及持续时间、临床转归等方面进行回顾性分析。结果:从事接触 刺激性物质或粉尘的职业(化工、纺织、建筑、装饰、锅炉和厨师等)、具有不良生活习惯(喜食辛辣 食物、嗜烟酒)、术后(尤其是出院后)根本不曾或不能坚持进行系统康复治疗(包括局部用药、全 身用药、鼻腔冲洗、定期鼻内镜下清理术腔等)的患者与不具有前述"特质"的患者鼻息肉、鼻窦炎 复发的可能性明显居高、复发时间亦明显提前;具备前述"特质"类别愈多,复发愈快、愈剧。其中 尤以系统康复治疗对术后转归影响最显著。结论:术后定期、足够疗程的系统康复治疗是提高鼻 息肉、慢性鼻窦炎经鼻内镜手术疗效的有力措施,良好的职业保护和戒除不良生活习惯能有效地 预防和减缓鼻息肉、慢性鼻窦炎经鼻内镜手术后的复发。     

Relationship between nasal septum morphology and nasal obstruction symptom severity: computed tomography study

IntroductionThe impact of the nasal septum morphology on the severity of obstruction symptoms has not been fully explored.ObjectiveThis study aimed to investigate whether the morphology of the deviated nasal septum assessed by computed tomography may explain nasal obstruction severity.MethodsThe study included 386 patients who were referred to the computed tomography examination of the paranasal sinuses. Patient selection criteria were the absence of facial anomalies, facial trauma, nasal surgery, and sinonasal tumors. Computed tomography images were used to estimate deviated nasal septum prevalence, the prevalence of Mladina's seven types of deviated nasal septum, and to measure the deviated nasal septum angle. Nasal obstruction severity was assessed by the nasal obstruction symptom evaluation, NOSE scale. The relationship between NOSE score, deviated nasal septum morphology, and deviated nasal septum angle was performed by a statistical regression model on the reduced sample of 225 patients.ResultsThe prevalence of deviated nasal septum was 92.7%. Type 7 deviated nasal septum was the most frequent (34.2%) followed by type 5 (26.2%) and type 3 (23.6%). The worst NOSE scores were recorded in the type 2 deviated nasal septum (45.00 ± 28.28). The mean deviated nasal septum angle in patients with nasal obstruction was 8.5° ± 3.24. NOSE scores were not significantly associated with deviated nasal septum types and angles.ConclusionPatients with different types of deviated nasal septum have different NOSE scores. Computed tomography morphology of the deviated nasal septum could not fully explain the severity of nasal obstruction.     

Bilateral nasal vestibular stenosis: a case of rhinoscleroma and review of surgical techniques

Vestibular stenosis is an uncommon but debilitating cause of nasal obstruction. It is caused by disruption of the nasal vestibular lining with secondary proliferation of granulation and fibrous tissue. A number of techniques have been described for repair of the stenotic segment. Correction can be difficult because of the tendency of wound contracture and recurrence. We present a surgical technique that employs the concept of excision of the stenotic segment, enlargement of the vestibule and placement of a full thickness skin flap. Its ability to resist contracture obviates the need for post-operative stenting and gives good result.     

Endoscopic endonasal surgery for nasal dermoids

Midline congenital lesions are rare and commonly comprise nasal dermoids (NDs), encephaloceles, and gliomas. This article discusses the epidemiology of NDs. Management is also discussed, as well as prognosis.     

Endonasal endoscopic oncologic resection and reconstruction of the anterior skull base in the elderly: A single-center retrospective study

IntroductionIn old and frail patients, oncologic anterior skull-base surgery through an endonasal endoscopic approach avoids the morbidity incurred by transfacial and transcranial approaches, sometimes considered unreasonable, although surgery remains the gold standard treatment for sinonasal cancer.ObjectivesTo assess the functional and oncologic results of this surgery in over-70 year-olds.Material and methodsA single-center retrospective study included all patients aged over 70 years at surgery, who underwent endonasal endoscopic oncologic resection and reconstruction of the anterior skull base, between October 2008 and October 2018.ResultsFifteen procedures in 13 patients met the inclusion criteria. Mean hospital stay was 7 days. All resections were considered R0, apart from one case with positive dura-mater margins (6.7%). All patients had complete radio-surgical treatment, in accordance with the REFCOR recommendations. Two cases of meningitis were reported (13.3%). At a median follow-up of 27 months, 4 patients presented local recurrence, 1 of whom also had lung metastases. Two patients died of disease-related or treatment-related causes.ConclusionThis technique is a feasible treatment in patients aged over 70 years, providing good functional results, and acceptable oncologic outcome.     

单纯鼻部手术对伴有鼻阻的阻塞性睡眠呼吸暂停低通气综合征患者睡眠的影响

目的 探讨对伴有鼻阻塞的阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者,仅单纯行鼻部手术,术后对患者睡眠质量、结构、体位及紊乱性睡眠呼吸(SDB)的影响。方法 对鼻阻塞OSAHS患者30例鼻部手术前后,进行多导睡眠仪(PSG)监测和Epworth嗜睡量表(ESS)评分,比较手术前后睡眠质量、结构、体位和SDS变化。结果 睡眠效率［(86.4±6.4)% ～ (89.4±6.8)%, P＝0.043］、ESS评分(10.08±3.3 ～ 8.1±3.3, P=0.001)和睡眠R期［(15.5±4.0)%～(18.8±4.7)%, P＝0.006］手术后有明显改变。觉醒指数(ArI)、其他睡眠期、侧卧位占睡眠时间比例、呼吸暂停低通气指数(AHI)、最低血氧饱和度(LSaO2)和鼾声术后差异无统计学意义。结论 单纯鼻腔手术可部分改善睡眠质量和结构,但对体位、鼾声和阻塞性睡眠呼吸暂停无影响。