筛泡前径路额窦开放术的鼻内镜解剖

目的研究鼻内镜下额窦开口及周围解剖结构,为筛泡前径路额窦开放术式提供应用解剖依据。方法鼻内镜下按照筛泡前径路额窦开放的手术步骤,解剖12例24侧外观无异常,经10%福尔马林固定的成人尸头(男8例,女4例)标本,观察额窦开口的解剖特征以及与周围结构的关系。结果①星状裂及其周围结构是识别额窦开口的重要解剖标记。②星状裂由筛泡、钩突和中鼻甲的顶端共同汇合形成。③额窦开口始终位于星状裂的中心,钩突基板的后方,后鼻道气房或筛泡基板的前方,周围有后鼻道气房和前鼻道气房围绕。④筛泡及伸出的前、后角是星状裂的后界限。⑤筛泡前入路开放额窦可以避开筛前动脉和筛顶。结论通过鼻内镜对额窦开口及周围解剖结构的观察,认为星状裂作为恒定的解剖标志是识别额窦开口的关键区域。筛泡前径路是鼻内镜下额窦开放的安全入路,能避免其他径路存在的某些风险。     

以星状裂解剖标志定位经筛泡前径路行额窦开放术

目的实施以星状裂解剖标志定位经筛泡前径路行额窦开放术,评价该术式的有效性及安全性。方法对225例（407侧）慢性额窦炎患者行星状裂解剖标志定位的筛泡前径路额窦开放术。术前常规鼻窦CT扫描,确定额窦自然开口与钩突及筛泡的关系。术中保留筛泡,依据星状裂解剖标志定位额窦开口行额窦开放手术。结果220例患者按该手术步骤开放了额窦自然开口;5例（8侧）术中暴露额窦开口困难,通过经皮额窦穿刺,注水时在内镜下观察,确定额窦自然开口位置后继续手术获得成功。无一例出现筛前动脉破裂出血和前颅底骨折等术中并发症,2例患者纸样板损伤出现眶周血肿。术后随访6～12个月,293侧（72％）可见额窦窦口开放良好,完全上皮化。201例患者（89％）主观感觉症状缓解。结论以星状裂为解剖标志定位经筛泡前径路行额窦开放术术中能较准确地寻找额窦开口,提高了额窦手术成功率,可减少手术并发症的发生。     

鼻内镜下筛泡前径路额窦开放手术

目的探讨经鼻内镜筛泡前径路额窦开放术的技术路线,讨论该术式在额窦开放中的疗效和安全性。方法选取23例(36侧)确诊为慢性额窦炎的成人病例,采用经鼻内镜筛泡前径路术式开放额窦。术后随访观察评估其安全性及疗效。结果20例经该径路开放成功,3例经额钉补充定位后开放成功。全部病例均无严重并发症出现,术后随访12～39个月,术前症状均消失,无复发。经鼻内镜检查额窦口开放良好。结论经鼻内镜筛泡前径路额窦开放手术是一种解剖标志易辨认、技术路线安全、疗效肯定的术式。     

鼻内镜下经上颌骨额突-鼻丘径路的额窦手术

目的改进鼻内镜下的额窦开放手术,提高额窦炎的治愈率。方法显微镜下观察10例解剖标本的钩突位置,并测量鼻丘的大小,结合39例(61侧)复发性慢性额窦炎患者鼻窦CT扫描结果进行分析,采用鼻内镜下经上颌骨额突-鼻丘径路额窦开放术式,对上述患者进行额窦开放术。结果10例(18侧)标本鼻丘气房的前后径、左右径和高度分别为(5.6±1.3)mm、(4.1±1.1)mm和(6.2±2.5)mm,所有钩突均附着于上颌骨额突及中鼻甲骨与额突的交界处,上端单纯附着于眶纸板14侧(70%),单纯附着于颅底3侧(15%),交叉附着于眶、颅底或中鼻甲3侧(15%)。CT扫描结果显示,慢性额窦炎复发与鼻丘气房未完全切除相关(P<0.001)。39例患者经改进的术式治疗后,治愈率为90.2%。结论额窦开口周围的钩突和鼻丘气房变异大,鼻丘气房清除不彻底可能是慢性额窦炎复发的主要原因,鼻内镜下经上颌骨额突-鼻丘径路额窦开放是治疗复发性慢性额窦炎的有效方法。     

鼻内镜下额隐窝解剖特征与额窦开放手术

目的 通过术中鼻内镜下解剖额隐窝，总结与内镜额窦手术相关的镜下额窦引流通道解剖特征，探讨额窦鼻内镜手术相关问题。方法 病例资料为慢性鼻窦炎、鼻息肉患者301例(562侧)，有前期手术史者除外。术前鼻窦CT扫描证实合并额窦炎者280例(479侧)，术前根据CT扫描判定额窦引流方式；术中以钩突为参考标志，250例(421侧)行鼻内镜下额窦开放手术，并对鼻内镜下额隐窝解剖结构特征进行分型。结果 冠状CT扫描提示额窦开口于钩突与中鼻甲之间为203侧(48．2％)；额窦开口于钩突和眶纸板之间218侧(51．8％)。对应上述规律的鼻内镜下额隐窝解剖特征分型：前者属Ⅰ型203侧(48．2％)，后者属Ⅱ型218侧(51．8％)。结论 以额窦口为中心的额隐窝鼻内镜下解剖特征及分型，对额窦开放手术有重要意义；钩突上部为CT扫描和术中定位额窦口解剖参考标志。     

鼻内镜下额窦病变处理的临床观察

目的探讨在鼻内镜手术中,额窦病变处理的径路、安全性及疗效。方法 78例128侧诊断明确的病例,术前进行CT冠状位、水平位扫描,矢状位重建为基础,根据检查结果选择手术径路(钩突路径或鼻丘路径):鼻内镜下以鼻丘气房、钩突附着上缘及筛泡前上缘为标记开放额隐窝及额窦。结果 78例全部开放成功。除3侧眶周青紫外,无并发症发生。鼻内镜检查额窦口引流良好。术后随访6个月,78例额窦炎症状全部消失,10例明显改善,3例无明显改善。两组患者临床治疗的效果经统计学分析比较差异不具有统计学意义(P0.05)。结论鼻丘径路和筛泡基板前径路的鼻内镜下额窦开放术皆可有效地治疗慢性额窦炎,根据术前CT扫描选择不同径路可能更好按术前设计地完成手术并降低手术并发症可获得满意疗效。     

鼻内镜下额隐窝解剖特征与额窦开放手术

目的　通过术中鼻内镜下解剖额隐窝 ,总结与内镜额窦手术相关的镜下额窦引流通道解剖特征 ,探讨额窦鼻内镜手术相关问题。方法　病例资料为慢性鼻窦炎、鼻息肉患者 30 1例 ( 5 6 2侧 ) ,有前期手术史者除外。术前鼻窦CT扫描证实合并额窦炎者 2 80例 ( 4 79侧 ) ,术前根据CT扫描判定额窦引流方式 ;术中以钩突为参考标志 ,2 5 0例 ( 4 2 1侧 )行鼻内镜下额窦开放手术 ,并对鼻内镜下额隐窝解剖结构特征进行分型。结果　冠状CT扫描提示额窦开口于钩突与中鼻甲之间为 2 0 3侧( 4 8 2 % ) ;额窦开口于钩突和眶纸板之间 2 18侧 ( 5 1 8% )。对应上述规律的鼻内镜下额隐窝解剖特征分型 :前者属Ⅰ型 2 0 3侧 ( 4 8 2 % ) ,后者属Ⅱ型 2 18侧 ( 5 1 8% )。结论　以额窦口为中心的额隐窝鼻内镜下解剖特征及分型 ,对额窦开放手术有重要意义 ;钩突上部为CT扫描和术中定位额窦口解剖参考标志     

额钻辅助定位在经鼻内镜额窦修正手术中的评价

目的:评价额钻辅助定位在经鼻内镜额窦修正手术中的应用及意义。方法:回顾性分析11例(18侧)因复发性额窦炎行经鼻内镜额窦修正手术患者的资料,11例患者术中均不能辨认额窦开口,以额钻辅助定位额窦开口,术后随访观察评估疗效。结果:11例(18侧)额窦炎患者均在额钻辅助定位的帮助下,成功开放额窦,除1例(1侧)术中损伤筛前动脉引起出血外,余10例(17侧)未发生严重并发症。术后随访7～35个月,术前症状均消失,经鼻内镜检查额窦口开放良好。结论:在经鼻内镜额窦修正手术中以额钻辅助定位额窦开口是一种简单、易行、安全、可靠的方法。     

额隐窝的CT检查

目的:利用高速螺旋CT三维重建检查额隐窝,为鼻内镜额窦开放术提供术前参考。方法:利用16排高速螺旋CT对51例(102侧)临床资料进行额隐窝的三维重建,其中包括58侧慢性额窦炎,44侧非鼻窦炎。对钩突附着方式和鼻丘、筛泡进行辨认和统计,测量额隐窝相关参数,再分别统计和比较慢性鼻窦炎组和非鼻窦炎组的各项数据。结果:对51例(102侧)鼻窦的CT三维重建均可辨认出额窦、额窦内口及额隐窝,额隐窝的形态个人差异极大。慢性鼻窦炎组与非鼻窦炎组比较,鼻丘气房矢状位最大内径、额窦内口直径间的差异有统计学意义,而额窦内口与前鼻棘间连线的距离、连线与鼻底平面间的夹角、筛泡前壁与前鼻棘间连线距离、连线与鼻底平面间的夹角间差异无统计学意义。结论:钩突、鼻丘不同的形态和大小对额隐窝的形态产生决定性影响。鼻丘气房发生率高,位置恒定,可作为开放额隐窝的解剖标志。额窦内口位置恒定。鼻内镜手术时,以前鼻棘为起点,与鼻底平面成夹角50～60°、以半径100mm左右的扇形区域为手术的相对安全界,绝大多数患者可在此界限内找到并开放鼻丘气房、开放筛泡气房、扩大额窦内口。     

两种鼻内镜额窦手术方式的临床评价

目的对鼻内镜额窦手术Wormald术式与筛泡前径路术式进行临床比较与评价。方法慢性额窦炎行功能性鼻内镜额窦手术患者50例70侧。随机分为2组：A组（Wormald术式）24例32侧;B组（筛泡前径路术式）26例38侧。结果所有患者均随访6-12个月。①Wormald术式组有效率90．63％（29／32）,筛泡前径路术式组有效率84．21％（32／38）,2组比较P〉0．05。②额窦开放术后随访3个月,以额窦口直径〉0．5cm为标准,A组84．38％（27／32）,B组78．95％（30／38）,两组比较P〉0．05。③手术时间为A组平均54．32min,B组平均58．51min。④手术并发症为A组鼻泪管损伤1例;B组筛前动脉损伤1例,术后下眼睑瘀斑2例。结论对于2种手术径路的临床应用,可以依据鼻窦解剖、术者经验和手术器械的不同而定。但就鼻窦解剖特点而言,如鼻丘气房发育良好或钩突上端附着判断困难,则采取Wormald术式较好;如钩突上端附着于眶内壁或鼻丘气房发育小,则采取筛泡前径路术式较好。手术中如能将两者有机结合应用则更好。     

Anterior skull base trauma during endoscopic sinus surgery for nasal polyposis preferred sites for iatrogenic injuries

OBJECTIVE: To determine typical locations for traumatic lesions of the anterior skull base during endoscopic sinus surgery. STUDY DESIGN: In this retrospective study 12 patients were included who had undergone endoscopic sinus surgery for nasal polyposis and were referred to the author for revision surgery after iatrogenic trauma of the anterior skull base during the procedure. Each patient had been operated by a different surgeon, all of the physicians being in an advanced stage of their surgical career and being board certified otolaryngologists. RESULTS: During endoscopically controlled revision surgery, all lesions could be detected, 10 of them being located in the ethmoid roof, while one injury had occurred in the lateral lamella of the cribriform plate and another one in the olfactory groove between the medial turbinate and the nasal septum. CONCLUSION: In contrast to reports in the literature, the preferred site for anterior skull base injuries during endoscopic sinus surgery in our group was not the lateral lamella of the cribriform plate, but the anterior part of the ethmoid roof, just behind the frontal recess. Apparently the course of the ethmoid roof might be misinterpreted during sinus surgery even by surgeons who are familiar with the operative technique.     

鼻内镜手术治疗额窦病变

目的 探讨经鼻内镜手术治疗额窦病变的方法及疗效。方法 经CT明确诊断的额窦病变33例(56侧),以CT扫描成像为基础在鼻内镜下以鼻丘气房、钩突附着上缘及筛泡前上缘为标记开放额隐窝及额窦。结果 所有手术最终找到并开放额窦,无严重并发症发生。术后鼻内镜检查,随访3～18个月。27侧痊愈,额窦口开放引流良好,炎症全部消失;21侧有效,症状明显改善;8侧无效。结论 经鼻内镜手术治疗额窦病变应密切参考CT扫描影像,准确定位额窦口。去除额隐窝处病变,充分开放额窦口引流是治疗额窦病变的关键。     

The safe gate to the posterior paranasal sinuses: reassessing the role of the superior turbinate

Surgery of the posterior ethmoid and sphenoid sinuses can be challenging. In 1999, a technique was described for identification of the superior turbinate and utilizing it as a landmark in endoscopic posterior ethmoidectomy and sphenoidotomy. Although this was more than a decade ago, it has not been supported by further studies. In our practice, we have routinely adopted this technique, and have modified it to allow further orientation during endoscopic surgery of the posterior sinuses. To describe a review of our technique, and to prospectively assess the value of the superior turbinate as a useful landmark during endoscopic posterior ethmoidectomy and sphenoidotomy. Fifty patients listed for endoscopic posterior ethmoidectomy with or without sphenoidotomy were included in a prospective study utilising our surgical technique. Data were collated for the success or failure of identification of the landmarks, and for any complications during the surgery. A total of 93 sides of endoscopic posterior ethmoidectomy and 73 sides of endoscopic sphenoidotomy were performed. The superior turbinate was identified in 100% of the cases. The coronal part of the superior turbinate basal lamella was identified in 60.22% of the cases, and the axial part in 88.17% of the cases. The natural sphenoid ostium was identified medial to the posterior part of the superior turbinate in 98.63% of the cases. The axial part of the superior turbinate basal lamella was a constant landmark for the level of the sphenoid ostium. The number of transverse septae between the axial part of the superior turbinate basal lamella and the skull base was studied, and was found never to exceed one septum. No major complications were recorded. One case of small posterior septal perforation was detected with no post-operative effects. Our study represents the first report of identifying the two parts of the superior turbinate basal lamella intra-operatively. It also represents the first report of using the axial basal lamella of the superior turbinate as a landmark for the level of the sphenoid sinus ostium, as well as a landmark for the level of the skull base. The superior turbinate represents a constant landmark for performing a safe posterior ethmoidectomy and sphenoidotomy.     

经鼻内镜两种径路额窦手术的临床分析

目的 分析经鼻内镜鼻丘径路术式与钩突径路术式额窦开放手术的疗效,个性化评估合适的手术径路.方法 35例、51侧诊断为额窦病变,根据术前CT显示鼻丘气房气化程度及钩突上缘附着部位将其纳入两组:鼻丘径路术式16例、22侧,钩突径路术式19例、29侧.结果 ①术中均顺利找到额窦口开放额窦,未出现严重颅底及眼部并发症;②术后随访6个月以上,主观症状均有不同程度改善,两组病例的有效率分别为87.50％(14/16)及89.47％(17/19).术后6个月鼻内镜下检查,术腔愈合分级以额窦口直径＞0.5 cm为标准,两组的有效率分别为81.82％(18/22)及75.86％(22/29),差异无统计学意义(P＞0.05).结论 鼻内镜下额窦开放术经鼻丘径路和钩突筛泡基板前径路皆可有效处理额窦病变.术前CT扫描选择合适径路有利于手术顺利完成,降低手术并发症.术者的经验与窦口区的合理处理有利于术后的恢复.     

Preoperative sagittal CT evaluation of the frontal recess

Endoscopic surgical approaches for chronic frontal sinusitis require the reestablishment of adequate frontal sinus ventilation and drainage for relief of symptoms. After the resection of anterior ethmoid mucosal disease and cellular structure, the anterior to posterior depth of the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla (frontal sinus ostium) often represents a critical margin for functional success. However, little information concerning this dimension is available. Depending on intraoperative surgical judgment of this distance, extended endoscopic surgical procedures involving additional bone resection may be indicated. These approaches may be hazardous due to the proximity of the cranial cavity and orbit. In addition, secondary stenosis can result from the subsequent inflammatory response. Improved CT imaging, high resolution sagittal reformatting, and computer workstations provide the ability to obtain direct preoperative measurements of the frontal recess. We used a paramedian sagittal section and recorded the maximal anterior to posterior depth from the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla in 20 patients, 31 sides, undergoing primary endoscopic frontoethmoidectomy. In addition, we found a positive correlation between this distance and agger nasi air cell size measured in the same 31 sides.     

The analysis of anterior skull base from two different perspectives: coronal and reconstructed sagittal computed tomography

The aim of the study was to determine the heights of the anterior skull base and the distances between the anterior nasal spine and the skull base at three levels by means of coronal and reformatted sagittal images of computed tomography. The present study was performed on coronal and reformatted sagittal CT scans of 30 patients with sinonasal complaints. On the coronal view, the heights of the cribriform plate, the roof of ethmoid, and lateral lamella and the medial take-off angle between the ethmoid roof and cribriform plate were measured at different levels. On the reformatted sagittal images the distances from the nasal spine to the anterior cranial base at three different levels were measured. Then, the side-to-side variability of these measurements was statistically compared. The variations with normal distribution and abnormal distribution were analysed by paired t test and Wilcoxon paired-signed rank test, respectively. A statistically significant difference was detected only between the right and left sides in the height of the lateral lamella at the crista galli level (p < 0.05). The lateral lamella at the crista galli level on the left side was higher than on the right side. No statistically significant differences between the left and the right sides were noted in the heights and the distances of other data (p > 0.05). The normal anatomy of the anterior skull base has been described in detail on coronal and reconstructed sagittal computed tomography. These measurements may be helpful in the presurgical evaluation of patients undergoing endoscopic sinus surgery to optimize surgical safety.     

The relationship between pneumatized middle turbinate and the anterior ethmoid roof dimensions: a radiologic study

The development of pneumatized middle turbinate may affect anterior ethmoid roof formation. The aim of this study was to investigate the relationship between the pneumatized middle turbinate and the dimensions of the anterior skull base structures using computed tomography scans. The coronal reconstructed images of the computed tomography scans were evaluated retrospectively. The lateral and medial ethmoid roof points, the width of the cribriform plate (CP), and the anterior ethmoid roof were identified at the first coronal cut, which was determined by the infraorbital nerve. The pneumatized middle turbinates were measured on the axial, vertical, and sagittal planes. The images of 101 patients were evaluated. The mean axial diameters of the pneumatized middle turbinate on the right and left sides were between 6.93 and 4.95 mm, respectively. The correlation between the axial diameters of the pneumatized middle turbinate and the width of the anterior ethmoid roof (termed AER width) was significant for both sides and gender (p < 0.05). There was a higher correlation on the right side where the pneumatized middle turbinate was observed more frequently (r = 0.357). The relationship between CP width and the diameters of the pneumatized middle turbinate was not significant (p > 0.05) for both sides. Iatrogenic lesions of the skull base occur predominantly in the lateral lamella of the CP. The risk of this complication may decrease with increasing of the AER width. Pneumatized middle turbinate may cause an increase in the width of the anterior ethmoid roof and provide more reliable endoscopic intervention of the anterior skull base and frontal sinus.