鼻内镜入路治疗岩尖胆固醇肉芽肿

岩尖胆固醇肉芽肿是一种罕见疾病,其手术入路有多种方式.本文通过分析近年来有关岩尖胆固醇肉芽肿及其治疗的文献报道,对鼻内镜入路治疗岩尖胆同醇肉芽肿这一手术方式做一综述.     

颅底外科中应用立体定向导航系统

蝶鞍区、岩尖等部位病变在临床上难于处理,传统手术径路复杂,手术时间长,死亡率高。该作者共观察7例患者,2例垂体腺瘤,2例岩尖部脑膜瘤,3例岩尖部胆固醇肉芽肿。采用无框架结构立体定向影像导航系统,经蝶入路,去除病变。术前在患者头部确定至少5     

内镜经鼻岩尖区手术的解剖及临床

常见岩尖病变有胆脂瘤、胆固醇肉芽肿、神经纤维瘤、脑膜瘤、脊索瘤、转移瘤和真菌性炎症,其治疗方法目前主要是外科治疗.以往处理此区域的手术入路包括眶颧入路、Kawas入路、经迷路人路、经耳蜗人路、乙状窦后入路和岩骨下入路等.然而由于岩尖区位置深在、解剖关系复杂、手术处理该区病变时会涉及到岩骨段颈内动脉、海绵窦和第Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ组颅神经,故手术难度大、外科创伤大、并发症多.以往这些显微人路,常会造成患侧永久性听力丧失、面神经麻痹等颅神经损伤、颅内外血管性损伤、脑脊液漏等并发症.随着内镜外科技术的进步,国内外学者开始尝试将内镜经鼻入路作为处理岩尖病变的一种可选择人路.本文综述了内镜经鼻岩尖手术的解剖及临床研究进展,以期为该区域开展手术提供参考.     

鼻内镜手术治疗上颌窦良性病变的临床研究

目的对比评价"鼻内镜下经泪前隐窝入路手术组(治疗组)"和"鼻内镜下经鼻内入路手术组(对照组)"治疗上颌窦良性病变的临床疗效。方法通过收集"鼻内镜下经泪前隐窝入路手术组(治疗组)"和"鼻内镜下经鼻内入路手术组(对照组)"治疗上颌窦良性病变的临床资料,对比两种术式的临床疗效。结果鼻内镜下经泪前隐窝入路及经鼻内入路手术治疗上颌窦良性病变的术后鼻部疼痛、术后溢泪、术后住院时间及手术费用情况无明显差异,两组均无发生术后面部肿胀麻木、眶周瘀紫、视物模糊,鼻内镜下经泪前隐窝入路组的手术时间较经鼻内入路手术组短,术后随访半年以上,鼻内镜下经泪前隐窝入路手术组无复发病例,鼻内镜下经鼻内入路手术组术后复发1例。结论鼻内镜下经泪前隐窝人路和经鼻腔入路手术均是治疗上颌窦良性病变的有效方法,两者的术后鼻部疼痛、术后溢泪、术后住院时间及手术费用情况相当,前者手术时间较短,手术野更清晰,清除病变组织更彻底,而且不破坏鼻腔的正常生理结构和功能需要,疗效好,值得临床推广应用。     

鼻内镜下泪前隐窝入路治疗上颌窦内翻性乳头状瘤的疗效分析

目的 探讨鼻内镜下经泪前隐窝入路(即鼻腔外侧壁入路)手术治疗上颌窦内翻性乳头状瘤的疗效及并发症。 方法 回顾性分析2014年9月至2016年3月收治的21例内翻性乳头状瘤的临床资料。 结果 21例患者通过鼻内镜经泪前隐窝入路手术治疗上颌窦病变,术中均完全清除窦内病变,且术中、术后病理证实为内翻性乳头状瘤。术后愈合良好,无严重并发症。1例患者术后6个月局部复发,再次手术切除,现随访12个月无复发。 结论 经泪前隐窝入路进入上颌窦切除病变是一种微创、安全、有效的处理内翻性乳头状瘤的手术方式。     

内镜经鼻经翼突手术入路研究进展

内镜经鼻经翼突（pterygoid process，PP）入路是颅底手术入路中的基本入路，可以单独或联合其他手术入路处理蝶窦外侧隐窝（lateral recess of sphenoid sinus）、翼腭窝（pterygopalatine fossa,PPF）、海绵窦（cavernous sinus，CS）、眶尖（obital apex）、Meckel’s腔（Meckel’s cavity）、中颅窝（middle cranial fossa）、颞下窝（Infratemporal fossa，ITF）、岩尖（petrous apex）以及岩斜区的病变。由于上述结构复杂，经翼突入路到达上述结构的研究成为近年来颅底外科热点。以往的研究局限于该入路与翼腭窝、颞下窝等靶区的关系。本文主要对经翼突至翼腭窝、颞下窝、颅中窝、海绵窦、Meckel’s腔、岩尖等区域的手术入路及其研究进展作一个综述。     

内镜下经鼻泪前隐窝入路切除翼腭窝及颞下窝神经鞘瘤

目的 分析和讨论经鼻内镜下泪前隐窝入路,经上颌窦后外侧壁切除累及翼腭窝及颢下窝神经鞘瘤手术结果,探讨手术方法及适应证.方法 病例资料来自2004年至2011年住院接受经鼻内镜下泪前隐窝入路翼腭窝和颞下窝神经鞘瘤切除手术患者6例,其中男性和女性各3例,年龄29 ～ 59岁.手术前主要接受鼻窦CT扫描和MRI检查.采用全身麻醉下经鼻内镜下泪前隐窝入路进入翼腭窝和颞下窝.手术后组织病理学确认为神经鞘瘤.术后定期CT或MRI检查随访观察.结果 6例患者实现手术完整切除.平均随访19.3个月无复发,有3例在术后第1～2周出现面部上颌神经分布区域较明显麻木感,随后逐渐减轻,仅1例随访终期遗留术侧口角轻度麻木.结论 内镜下经鼻开放泪前隐窝入路切除翼腭窝和颞下窝神经鞘瘤,完整保留鼻腔外侧壁,损伤小,并发症少,为经鼻进入翼腭窝和颞下窝的创新微创入路.     

鼻内镜下泪前隐窝入路治疗上颌窦良性病变

目的经鼻内镜下泪前隐窝入路治疗上颌窦良性病变,并探讨其适应证、并发症及手术方式。方法回顾性分析43例经鼻内镜下泪前隐窝入路治疗上颌窦良性病变的病例,其中术前及术后病理确诊的上颌窦内翻性乳头状瘤15例,窦内病变镜下检出菌丝或孢子的真菌性上颌窦炎8例,上颌窦囊肿12例,上颌窦后鼻孔息肉6例,上颌窦异物2例。所有病例手术前均行鼻窦冠状位或水平位CT扫描。患者在局麻下以下鼻甲前缘为中心切口,解剖内移鼻泪管-下鼻甲瓣经泪前隐窝进入上颌窦腔处理上颌窦内病变,复位鼻泪管-下鼻甲瓣,缝合手术切口并行下鼻道开窗。结果 43例患者术中均完全清除窦内病变,术后随访6～24个月,下鼻甲形态愈合良好,术腔上皮化,无溢泪、面部麻木等并发症。2例上颌窦内翻性乳头状瘤术后6个月局部复发,原手术入路切除,随访1 8个月无复发。3例术后鼻腔粘连,局部分离,随访12个月无复发。结论经鼻内镜下泪前隐窝入路进入上颌窦是一种微创、安全、有效的处理上颌窦良性病变的手术方式,可作为鼻内镜下经中鼻道行上颌窦自然口开窗无法彻底切除窦内病变组织的首选治疗方法。     

耳内镜辅助下迷路上入路治疗岩尖胆脂瘤的初探

目的通过对一例岩尖型胆脂瘤的手术治疗过程分析和相关文献复习,为岩尖型胆脂瘤的治疗提供新的术式参考。方法结合文献复习对一例明确诊断的岩尖型胆脂瘤患者的治疗方案及预后进行分析。结果应用耳内镜辅助下迷路上入路的手术方式成功清除了病变,同时保存了内耳功能和避免了开颅。结论耳内镜辅助下迷路上入路的手术方式对于治疗岩尖型胆脂瘤是一种行之有效的治疗方式,避免了去除周围正常结构,减少了不必要的并发症,提高了患者术后生存质量,同时为岩尖的其他类型病变的治疗提供一种新的选择。     

内镜下中鼻道联合泪前隐窝入路治疗眶壁骨折

目的:探讨内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁双壁骨折的手术方法和疗效。方法:回顾性分析我科收治的3例实施鼻内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁骨折患者的临床资料,分析其疗效和手术并发症的发生情况。结果:术后随访6个月~1年,3例患者复视症状消失,眼球内陷完全矫正,无手术并发症。结论:采用内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁的眼眶双壁骨折,具有组织损伤小、费用低、并发症少等优点,疗效满意,值得临床推广。     

Petrous apex cholesterol granuloma: transsphenoid endoscopic approach

The transsphenoid approach to the petrous apex, a surgical procedure described for the first time by Montgomery in 1977, is a rarely performed approach for the drainage and ventilation of cholesterol granuloma. We consider this approach to be the technique of choice when the cholesterol granuloma is located in the medial section of the petrous apex abutting and/or prolapsing into the posterior wall of the sphenoid sinus. The transsphenoid approach, unlike other lateral approaches to the petrous apex, is highly conservative and spares cochlear and vestibular function; moreover, it allows simple and adequate post-operative endoscopic follow up as an out-patient, with easier treatment in the case of recurrence.     

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study.

BACKGROUND: The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access. METHODS: Cadaveric dissections were performed on five heads. Pre-dissection computed tomography scans were used, with the BrainLab navigation system, to verify entry into the petrous apex. Surgical landmarks were characterised in relation to fixed sphenoid sinus structures, and surgical access before and after drilling the sphenoid sinus rostrum was quantitatively compared. RESULTS: The landmark for entry into the petrous apex was the intersection of a vertical line halfway between the medial surface of the internal carotid artery and the midline, with a horizontal line one-third of the way up from the postero-inferior floor of the sphenoid sinus. The dimensions of the postero-superior sphenoid sinus were characterised by the inter-carotid distance, pituitary-to-sphenoid-floor distance and the width of the sphenoid sinus floor, which were 15 +/- 3 mm, 16 +/- 3 mm and 26 +/- 1.6 mm respectively. The surface area of surgical access was 193 +/- 28 mm(2), increasing to 316 +/- 39 mm(2) after drilling of the sphenoid rostrum (P < 0.001; paired t-test). CONCLUSIONS: Endoscopic approach to the petrous apex is anatomically feasible, and, aided by image navigation, could extend the scope of endonasal surgery to access highly-selected lesions in the middle cranial fossa.     

Radiographic diagnosis, surgical treatment, and long-term follow-up of cholesterol granulomas of the petrous apex

Cholesterol granuloma is an unusual lesion of the petrous apex. Accurate preoperative differentiation of the various lesions of the petrous apex by computed tomography scanning only has been difficult. We reviewed the clinical findings, computed tomography and magnetic resonance imaging scans, surgical approaches, and long-term follow-up in 10 patients with cholesterol granuloma of the petrous apex who were seen between 1971 and 1988. Headache and deficits of the 5th, 6th, 7th, and 8th cranial nerves were common presenting symptoms. Magnetic resonance imaging with special imaging techniques was accurate in diagnosing cholesterol granuloma in four patients preoperatively and three patients prior to revision surgery. The optimal surgical approach was chosen on the basis of clinical and radiographic findings and included the transsphenoidal, infralabyrinthine, transcochlear, and suboccipital routes. Our review reveals that magnetic resonance imaging is more specific than computed tomography in establishing a preoperative diagnosis and is also the technique of choice in follow-up. The long-term results are discussed.     

Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child

Cholesterol granulomas of the petrous apex are well-described lesions that originate from chronic obstruction of the air cells in the petrous pyramid. Intracranial surgery, associated with multiple potential complications, has been the salutary action to treat this entity with only two reports of endoscopic drainage of a cholesterol granuloma of the paranasal sinuses. We present the first pediatric patient to be treated by not only endoscopic drainage, but also by the incorporation of computer-assisted image-guided surgery to minimize risk of injury to structures adjacent to the posterior wall of the sphenoid sinus.     

经鼻内镜蝶窦进路岩尖胆脂瘤切除

目的 探讨经鼻内镜蝶窦进路岩尖部胆脂瘤囊内切除术的可行性及疗效.方法 回顾性分析2001-2006年经鼻内镜蝶窦进路切除鞍旁、岩尖部胆脂瘤患者3例的临床资料.3例患者均在全麻下经鼻内镜全筛窦、蝶窦开放,于蝶窦外侧壁、颈内动脉前方磨开颅底骨板进入岩尖部,切开并扩大胆脂瘤囊壁后,采用吸引、刮除和冲洗的方法将胆脂瘤进行囊内清除.结果 3例岩尖胆脂瘤经囊内切除手术,均一次清除干净,手术前伴有头痛和眶尖综合征的2例患者于术后当天即有症状改善,术后1～4周症状完全恢复,全部患者未发生手术并发症.术后随访3～7年,全部患者症状未再发,影像学检查胆脂瘤无复发.结论 靠近鞍旁区域的岩尖胆脂瘤可以采用经鼻内镜蝶窦进路行囊内切除手术,远期疗效可靠.     

内镜下经鼻入路暴露岩尖的解剖研究

目的通过影像学、内镜手术两种方法对内镜下经鼻入路暴露岩尖这一手术入路进行研究,为临床应用提供依据。方法选取24具国人成人尸头标本,进行轴位、冠状位及矢状位高分辨率CT扫描,观察与内镜下经鼻入路暴露岩尖的相关解剖标志,并测量其距离。选择5例10%甲醛固定、动脉灌注染料的尸头标本,模拟内镜下经鼻入路暴露岩尖（10侧）。记录内镜下解剖图像,描述其相关解剖关系。结果通过影像学资料可了解蝶窦发育情况并测量一系列颅底骨性解剖标志的距离,蝶骨嵴至两侧视神经管眶口直线距离相比较无显著性差异（P〉0.05）。所有标本通过内镜经鼻入路均从颈内动脉内侧到达岩尖,翼管及翼管动脉可作为寻找颈内动脉的重要解剖标志。结论影像学资料应作为内镜下经鼻入路暴露岩尖手术的术前常规参考;蝶骨嵴位于两侧视神经管眶口的中点,为术中可靠的解剖标志。从解剖学角度内镜下经鼻入路暴露岩尖具有可行性,该入路径路短,副损伤小,可作为临床治疗岩尖病变的重要术式之一。     

How to perform microscopic/endoscopic resection of large petrous apex lesions

The endoscope and microscope can be used conjointly in certain sites, such as middle ear cholesteatoma or for resection of cerebellopontine angle tumours. Petrous apex tumours are classically accessed via a lateral otological approach, or, for the most anterior tumours, via an endonasal endoscopic approach. Surgical access via a lateral incision is limited inferiorly by the superior bulb of the internal jugular vein, medially by the labyrinth, facial nerve and internal auditory canal, superiorly by the dura mater, and laterally by the internal carotid artery. Via an anterior endonasal approach, the corridor formed by the internal carotid artery and the paraclival dura limits access to the posterior part of the petrous apex, restricting this approach to certain cholesterol granulomas or small cholesteatomas. None of these approaches, on its own, is sufficient in the case of an extensive petrous apex lesion. The objective of this technical note is to describe the combined microscopic/endoscopic approach comprising sequential use of the microscope and the endoscope via a lateral approach for the management of large petrous apex lesions.     

Cholesterol granulomas

PURPOSE OF REVIEW: This paper reviews the literature relating to the pathogenesis, diagnosis and management of petrous apex cholesterol granulomas. RECENT DEVELOPMENTS: Diagnosis of cholesterol granulomas can be challenging due to the rarity of this surgical condition and similarities to other petrous apex pathology. Recent literature reports novel locations of cholesterol granulomas, provides support for a new theory of pathogenesis, describes additional cases of endoscopic approaches to excision, and evaluates the efficacy of stenting to prevent recurrence of the lesion. SUMMARY: Cholesterol granulomas of the petrous apex are significant due to their similarity to other petrous apex lesions, their adverse effect on cranial nerves and their challenging surgical location. These lesions are now believed to be an inflammatory reaction to the by-products of eroded marrow cavities in the temporal bone. The ideal surgical approach takes into account the hearing status of the patient and lesion location and may include the endoscopic transsphenoid, transmastoid, infralabyrinthine, middle fossa, and transotic approaches. Lesions should be excised, drained, and stented with the largest diameter silicone stent possible.     

Cholesterol granuloma of the petrous apex

The traditional approaches to symptomatic cholesterol granuloma (CG), the most common benign pathologic lesion of the petrous apex, have historically been transotic, including middle fossa, translabyrinthine, retrocochlear, or infra- or retrolabyrinthine approaches. These approaches were often fraught with risk to the vestibular or cochlear apparatus, the need for brain retraction, or lack of a natural drainage pathway after marsupialization of the granuloma. This article reviews the literature on the transnasal approach to petrous apex CGs, including medial, medial with carotid medialization, and transpterygoid approaches. Of the 19 reported CGs treated with endoscopic drainage, only one recurrence was noted.     

Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex

? Surgery for cholesterol granulomas involving the petrous apex has traditionally been performed via a lateral skull base approach. ? We present a case‐series of four cholesterol granulomas treated through the endoscopic–transsphenoid approach over the last 10 years. ? Drainage was successful and symptomatic improvement was obtained in all cases (follow‐up 6 months–10 years). ? Primary ‘sphenoid’ lesions, which can be widely drained and remain marsupialised, should be differentiated from primary ‘petrous’ lesions that can be removed safely through the sphenoid sinus only in case of extension medial to the internal carotid artery (ICA). ? We feel that the endoscopic transsphenoidal approach is a safe and effective way to access cholesterol granulomas of the petrous apex.