医源性脑脊液鼻漏的成因及鼻内镜下手术修补术

目的 分析医源性脑脊液鼻漏（ICFR）发生的相关原因以及提高鼻内镜下修补术成功率的手术技巧。方法 回顾性分析1992年4月—2012年12月医治的53例ICFR患者的临床资料,其中40例用腹壁脂肪制成哑铃球状修补,4例加用中鼻甲黏膜瓣转移修复,9例加用鼻中隔黏骨膜瓣转移修复,脑脊液鼻漏修补手术均在鼻内镜下完成;对53例ICFR发生原因进行总结分析。结果 53例患者ICFR的原因分别为：术者术前局部解剖结构了解不充分19例、手术操作不当20例、取瘤时操作不当12例、术中发现脑脊液漏而修补不完全者49例。本组53例中,50例一次修补成功,3例二次修补成功,治愈率为100％。结论 经鼻内镜下脑脊液鼻漏修补术是ICFR修补的首选进路。术者术前对局部解剖结构了解不充分、手术操作不当、取瘤时操作不当、术中发现脑脊液漏修补不完全是造成ICFR的主要原因。     

鼻内镜下成形术矫正鼻中隔偏曲临床分析

目的：探索以提高鼻中隔偏曲矫正的治疗效果、减少并发症为主的手术方法。方法：将98例鼻中隔偏曲患者随机分为两组，内镜组46例采用鼻内镜下塑形方式成形治疗，对照组52例采用传统额镜下手术矫正，并观察术后疗效，并发症情况。结果：鼻内镜组46例均获得完全矫正，无1例出现并发症；对照组52例患者中，43例获得完全矫正，9例部分矫正，术后并发鼻中隔穿孔4例，塌鼻1例。结论：鼻内镜下鼻中隔偏曲成形术，具有视野广、亮度强、微创、精细、安全有效等优点，值得临床推广应用。     

经鼻内窥镜选择性鼻中隔粘膜下切除术

目的：探讨经鼻内窥镜选择性鼻中隔粘膜下切除术的意义及手术方法。方法：根据不同的手术目的对204例需要行鼻中隔手术的病人，经鼻内窥镜实施选择性鼻中隔粘膜下切除术。结果：采用该技术对单纯性鼻中隔偏曲患者手术临床治愈率100％，其手术有效治愈头痛、鼻阻及鼻出血等鼻中隔偏曲临床症状，达到临床治疗目的。未出现鼻腔粘连、鼻中隔穿孔等并发症。有2例形成鼻中隔血肿，经放置引流管处理后治愈。对于解除高位鼻中隔偏曲解剖异常引发的鼻窦炎，手术后效果良好。取鼻中隔软骨做为修补材料手术效果满意。结论：经鼻内镜选择性鼻中隔粘膜下切除术目的性强、方法灵活、创伤小、并发症少、手术效果确切。     

鼻窦炎合并鼻中隔偏曲鼻内镜下联合手术治疗的临床体会

目的总结慢性鼻窦炎合并鼻中隔偏曲鼻内镜下联合手术治疗的优点疗效及安全性。方法对42例慢性鼻窦炎合并鼻中隔偏曲的患者行鼻窦手术联合鼻中隔矫正术。结果术后随访3~6个月,观察其疗效及并发症。所有手术患者术腔粘膜上皮化良好,鼻中隔矫正后未出现穿孔,血肿及脓肿,脑脊液鼻漏等严重并发症。结论鼻内镜手术过程中同时处理鼻窦炎及鼻中隔偏曲有效减少鼻窦炎复发。     

转位鼻中隔软骨瓣的应用解剖

目的:探讨鼻中隔软骨瓣转位应用的可能性.方法:在30例成人湿性尸头标本上对鼻中隔软骨瓣进行解剖学测量.结果:鼻中隔软骨膜瓣上边长(44.19±5.82)mm,鼻中隔软骨膜瓣下边长(56.83±6.65)mm,鼻中隔软骨上下径(27.93±3.48)mm,鼻中隔软骨前后径(20.83±2.12)mm.鼻中隔软骨膜瓣转位到鼻颅底可修复范围为(27.22±4.91)mm×(13.03±3.44)mm.鼻中隔软骨膜瓣转位到眶内侧壁可修复范围为(28.19±3.27)mm×(27.93±3.48)mm.结论:鼻中隔软骨瓣转位可用于鼻内镜下修复鼻颅底和眶内侧壁的缺损.     

鼻内窥镜下鼻中隔偏曲矫正术方法的探讨

目的探讨鼻内窥镜下鼻中隔偏曲矫正的手术方法和注意事项。方法回顾分析我院2003年8月-2007年12月间鼻内窥镜下鼻中隔偏曲矫正术病例150例的临床资料。结果术后复诊3-6个月,全部病例鼻中隔偏曲矫正满意,无1例出现鼻中隔穿孔。结论鼻内窥镜下鼻中隔偏曲矫正手术具有视野清晰、不受手术深度限制、操作准确等优点,大大降低了鼻中隔穿孔等并发症的发生,鼻中隔偏曲矫正术常常作为鼻内窥镜其它手术的同期前置手术,已成为鼻内窥镜手术中的一项重要内容。     

在鼻内镜辅助下经鼻腔-蝶窦径路垂体肿瘤切除术

目的探讨在鼻内镜辅助下经鼻腔-蝶窦径路行垂体肿瘤切除术的手术方法及优点。方法在现有文献眼1～5演报道几种手术方法的基础上,进行了改进。采用4mm0°、30°硬性鼻内镜及在配套摄录系统监测下,经右侧鼻腔,用双极电凝烧灼过大之右中鼻甲中后段。于蝶窦前壁前方约1cm处与前壁平行切开鼻中隔右侧黏骨膜,于黏骨膜下向后分离达蝶窦前壁。于黏骨膜切口稍后方切开筛骨垂直板及部分梨骨,经骨性切口向后分离左侧黏骨膜。经右侧鼻腔置入专用撑开器,充分暴露两侧蝶窦前壁、蝶窦开口、蝶嵴及蝶嘴。在显微镜下去除蝶骨嵴、蝶嘴及蝶窦前壁。双极电凝去除蝶窦前壁黏膜,咬除蝶窦间隔及鞍底骨质。电灼硬脑膜并“十”字切开,将肿瘤分次切除。结果16例肿瘤全部切除,症状均有不同程度的改善。术后一过性脑脊液鼻漏2例,多尿2例,无其他并发症。结论在鼻内镜下经鼻腔-蝶窦径路垂体腺瘤切除术方法简便,进入蝶窦腔后在显微镜下双手操作便利,立体感强,准确性高,鼻腔结构损伤小,术中视野清晰,危险性小,并发症少,肿瘤切除彻底;是一种安全有效的垂体肿瘤切除术的径路和方法。     

鼻内镜下鼻中隔粘膜部分切除治疗鼻出血

目的 介绍鼻中隔粘膜出血鼻内经学校粘膜部分切除治疗的方法.方法 对60例鼻中隔粘膜出血采用鼻内镜下鼻中隔粘膜部分切除治疗鼻出血.结果 本组60例行鼻内镜下鼻中隔粘膜部分切除治疗,均一次性治愈.结论 鼻内镜下鼻中隔粘膜部分切除治疗,适用于鼻中隔粘膜表面各种类型鼻出血,手术损伤小,创面修复快,远期效果好.     

鼻内镜下应用鼻内自体材料治疗脑脊液鼻漏的临床效果观察

目的 探讨鼻内镜下应用鼻内自体材料治疗脑脊液鼻漏的效果和安全性。方法 回顾性研究。纳入蚌埠医学院第一附属医院耳鼻咽喉头颈外科2014年1月—2017年12月收治的10例脑脊液鼻漏患者,其中男7例、女3例,年龄23~52(41.6±12.5)岁。缺损部位位于筛窦顶壁4例、筛板3例,位于额窦顶、蝶窦顶、额隐窝各1 例。颅底骨质缺损周径小于10 mm者6例、10~20 mm者4 例。通过详细的术前检查初步判断颅底缺损部位,按照不同部位颅底缺损的大小及脑脊液鼻漏的严重程度,采用鼻内镜下不同的鼻内自体材料重建鼻颅底缺损,其中6例应用自体鼻中隔黏软骨膜-软骨瓣,4例应用自体中鼻甲黏膜瓣。术后定期行神经系统检查,脑脊液生化检查糖定量,随访观察有无复发。结果 本组10例患者手术时间1~2.5 h,术中出血20~50 mL,住院时间7~14 d。术后患者生命体征平稳,神经系统病理征均阴性,脑脊液生化检查糖定量均低于1.7 mmol/L,术前头痛症状消失。出院前鼻内镜检查术区,无一例修补材料坏死、脱落。出院后6 个月随访,均无脑脊液鼻漏复发。结论 鼻内镜下利用鼻内自体材料重建鼻颅底缺损治疗脑脊液鼻漏安全、可行,术中取材方便、创伤小、手术成功率高、术后复发率低,值得临床推广应用。     

鼻内镜下脑膜脑膨出的治疗体会

目的 探讨鼻内型脑膜脑膨出的影像学表现特征、鼻内镜下手术径路选择及修补方法,以提高该病的临床诊治水平。方法 回顾性分析2009年1月—2017年12月安徽医科大学第一附属医院耳鼻咽喉头颈外科23例鼻内型脑膜脑膨出患者的临床资料。其中男5例、女18例,年龄17~61岁,中位年龄42.3岁。所有患者行鼻窦高分辨率CT(HRCT)和MRI扫描,明确诊断并定位膨出及缺损位置,根据膨出位置不同选择相应手术径路,在鼻内镜下或辅助鼻外小切口鼻内镜下切除膨出脑组织、采用自体组织多层次软修复颅底缺损。重点分析其影像学特点、手术相关资料及预后情况。结果 23例患者MR T₂WI均显示脑膜脑膨出部位,其中18例HRCT发现颅底骨质缺损。所有患者在鼻内镜下Ⅰ期切除膨出脑组织、颅底缺损修补成功。术后随访12~24个月。1例术后出现面部麻木感,半年后自愈;1例良性颅高压患者术后18个月脑脊液鼻漏复发,再次行鼻内镜下脑脊液鼻漏修补术治愈;其余患者术后恢复良好,未见其他并发症发生。结论 鼻窦HRCT和MRI检查有助于脑膜脑膨出的定位诊断;根据脑膜膨出部位不同选择合适的手术径路行鼻内镜手术,切除膨出脑组织、采用自体材料多层次软修复颅底缺损,可获得满意的临床疗效。     

CT findings of the nose and paranasal sinuses in chromium intoxication

We performed computed tomography (CT) of the nose and paranasal sinuses in 21 patients with chromium induced septal perforation or thinning. Twenty patients showed various magnitudes of septal perforation. Twelve of 20 had perforation at the mid portion of the cartilaginous nasal septum. One patient had a sheet-like thinning of septal cartilage. Sixteen patients had mucosal thinning of the nasal conchas. In most cases, unilateral involvement of the inferior concha was seen. Eleven of 21 cases showed paranasal sinus mucosal thickening and one patient had a cyst or polyp in the sinus cavity. The main finding was nodular thickening of mucosa. Septal perforation by inhalation of chromic acid was located in the cartilaginous septum and there was no destruction of the bony septum and wall of the sinuses.     

Transplantation of adipose-derived stem cells combined with decellularized cartilage ECM: A novel approach to nasal septum perforation repair

Nasal septal perforation, a defect of the nasal mucoperichondrium and cartilage, may induce epistaxis, persistent rhinorrhea and nasal obstruction. Cell-based tissue engineering is a promising therapeutic method for the treatment of nasal septal perforation. However, lack of an adequate source of cells and unsuitable biomaterials greatly hinder the development of cell-based therapy. In this paper, we proposed the application of adipose-derived stem cells combined with decellularized cartilage ECM as a potential graft for the damaged nasal septum, which could help to repair the mucosal and cartilage tissues in the treatment of nasal septal perforation. This new technology could play a novel role in the repair of nasal septal perforation, and in regeneration of damaged nasal cartilage.     

内镜下改良切口个性化三线减张鼻中隔成形的疗效分析

目的 探讨鼻内窥镜下鼻中隔成形术术式的改良及手术疗效。方法 采用随机抽样法将2014年1月~2017年7月100例鼻中隔偏曲手术患者,随机分为改良组与对照组,每组50例,改良组采用鼻内镜下改良切口鼻中隔成形术新方法,对照组采用传统鼻中隔黏膜下矫正术手术方法,针对两组患者术后的鼻中隔病变、症状消失率、伤口出血、肿胀,疼痛、愈合情况及术后并发症进行回顾对比分析。结果 观察组手术时间、术中出血量、并发症、治疗效果优于对照组,比较差异均有统计学意义(P＜0.05);随访6个月,观察组无鼻中隔穿孔、鼻腔粘连等并发症发生,鼻塞、头痛等症状改善,改良组患者有效率（96.00%）高于对照组（84.00%）,差异有统计学意义（P<0.05）,整体治疗满意度高。结论 采用鼻内窥镜下改良切口个性化鼻中隔成形术改变了以往传统的手术方式,具有出血少、粘膜张力小、视野广、愈合好、微创、并发症少、疗效确切,更符合鼻腔生理功能,值得临床推广应用。     

鼻中隔矫正联合筛前神经射频消融治疗变应性鼻炎伴鼻中隔偏曲的疗效分析

探讨鼻中隔矫正联合筛前神经射频消融治疗变应性鼻炎伴鼻中隔偏曲的疗效。方法 选取81例就诊于我科的变应性鼻炎伴鼻中隔偏曲患者,随机分为对照组40例和治疗组41例。对照组采用鼻中隔矫正术治疗,治疗组采用鼻中隔矫正联合射频消融治疗。观察两组治疗后3个月、6个月和1年的临床疗效以及并发症情况。结果 两组患者术后3个月治疗总有效率比较,差异无统计学意义（P＞0.05）;治疗组患者术后6个月和术后1年的治疗总有效率分别为85.00%和82.50%,均高于对照组的63.41%和58.54%,差异具有统计学意义（P＜0.05）。手术病例均未见鼻中隔穿孔、鼻腔粘连、下鼻甲萎缩等严重并发症。结论 相对于单纯鼻中隔矫正术,鼻中隔矫正联合筛前神经射频消融治疗变应性鼻炎伴鼻中隔偏曲的远期疗效明显,安全性较高。     

Nasal septal perforation in a patient with allergic bronchopulmonary aspergillosis and rhinitis on long term corticosteroids

A 22-year-old male, referred to us as a case of multi-drug resistant tuberculosis was diagnosed as allergic bronchopulmonary aspergillosis (ABPA) after serological and computed tomography confirmation. He was initiated on oral as well as inhaled corticosteroids along with nasal corticosteroid spray for his nasal complaints. One year subsequently, he developed a nasal septal perforation. Biopsy taken from the site did not reveal any granulomatous or atrophic changes and cultures of the biopsy did not yield any organism. The septal defect, repaired surgically by Hazeltine's method healed completely within 6 weeks. There have been anecdotal reports of septal perforation in patients with rhinitis on intranasal corticosteroids but hitherto not in patients with ABPA. A periodic examination of the nasal septum should be undertaken in patients with ABPA and rhinitis on long term inhaled oral and intranasal corticosteroids along with oral corticosteroids.     

Immunohistochemical distribution patterns of collagen type II,chondroitin 4-sulfate,laminin and fibronectin in human nasal septal cartilage

Collagen type II, chondroitin 4-sulfate, laminin and fibronectin are major components of cartilage matrix. It is important to know their distribution patterns to evaluate relationships between cartilage cells and surrounding cartilage matrix. In the present study, we investigated localization patterns of these macromolecules in human nasal septal cartilage by immunohistochemical methods. Samples of human nasal septal cartilage were obtained from patients with nasal septum deviations who underwent septoplastic operation and were prepared for immunohistochemical examination. Distribution patterns of cartilage matrix macromolecules correlated with those found in other cartilage tissues. Diffuse staining of collagen type II was found in the cartilage matrix, chondroitin 4-sulfate immunostaining was present in the cytoplasm and like a pericellular ring around chondrocytes. Laminin immunostaining was found in the cytoplasm of chondrocytes, and fibronectin was localized in the pericellular matrix and in capsules of human nasal septal cartilage. Moreover, fibronectin was also detected at high levels in the interconnecting segments between adjacent chondrons. In conclusion, similar localisation patterns of the components investigated in human septal cartilage as in other tissues indicate that these macromolecules may play a role in both cell-matrix adhesion and matrix-matrix cohesion in the pericellular microenvironment surrounding nasal septal cartilage chondrocytes as in other cartilage tissues.     

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo’s flap): CT cadaver study

Objective

We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap.

Study design

We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients.

Methods

Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum.

Results

The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients.

Conclusion

The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

     

Surgical treatment using an allograft dermal matrix for nasal septal perforation

PURPOSE: Numerous methods have been utilized to repair nasal septal perforation with varying degrees of success; however, no consensus has been reached on nasoseptal perforation repair. Here, the authors describe a surgical method based on human dermal allograft (Surederm, Hans Biomed Corp. Korea) for the repair of nasal septal perforations. MATERIALS AND METHODS: Eleven patients with a nasal septal perforation were included in this study. The causes of these septal perforations included previous nasal surgery, trauma, foreign body (button battery), and idiopathy. There were several sites of perforation: 9 in the central area, 1 in the posterior-central area, and 1 in the anterior area. An interpositional graft incorporating Surederm was positioned between bilateral mucoperichondrial flaps using an intranasal approach. A silastic sheet was then left in the nasal septum bilaterally until complete healing had occurred through new nasal mucosa, which took a mean duration of 6 weeks. RESULTS: Outcomes in ten of the eleven patients were successful, with complete septal perforation closure. The remaining perforation, which was caused by a button battery, closed incompletely; however, its initial size of 2 cm was reduced to 5 mm. CONCLUSION: The described technique has a high success rate and can be performed under local anesthesia without external scarring. In the absence of donor site morbidity, this technique can also be utilized to repair posterior or multiple septal perforations without difficulty.     

牛心包补片修复心脏间隔缺损的应用

背景：心脏涤纶补片因其质地薄、质量轻、生物相容性好等优点常规用于心脏手术,但最近几年发现,用心脏涤纶补片对心室间隔缺损修补后,一旦发生术后残余漏,较易引起溶血、细菌或真菌感染。 目的：探讨应用牛心包补片修复心脏间隔缺损的疗效。 方法：采用戊二醛固定的牛心包补片修补152例心脏间隔缺损患者,其中房间隔缺损56例,室间隔缺损78例,部分房室间隔缺损18例。术后复查心电图、胸片、心脏超声,观察其术后早期病情、血流动力学和心脏功能。 结果与结论：152例患者均完成修补手术,术后无早期死亡,患者随访2-6个月,牛心包补片在使用过程中及术后早期均未发现漏血、溶血、血栓、感染、排斥反应等并发症。1例患者因合并肺动脉高压,术后第1天出现高血压危象,经过抢救后好转。复查心电图、胸片、心脏超声可见心脏间隔缺损修补完全,无残余分流;肺动脉压力明显下降;活瓣已关闭无分流;心脏功能正常。证实牛心包补片可以有效修复心脏间隔缺损,改善患者的血流动力学和心功能,近期效果满意,是一种良好的心脏间隔缺损修补材料。