鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤

目的： 探讨鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤的安全性、临床效果和术式的选择。方法:回顾性分析15例在鼻内镜下行切除手术治疗的侵及眼眶的良性和早期恶性鼻腔鼻窦肿瘤患者的临床资料、手术方法、并发症及治疗预后。结果:全部病例中,11例单纯经鼻内镜下切除肿瘤,4例经鼻腔和鼻外切口双径路手术治疗,其中 1例侵袭性大B细胞淋巴瘤患者术后出现下睑外翻,经治疗后好转;1例鼻腔鼻窦骨瘤患者于鼻内镜下全切骨瘤,术后出现患侧内眦外移;4例良性骨源性病变患者行鼻内镜下病变部分切除术,其余病例均彻底切除肿瘤而无明显并发症,随访6~36月未见复发。结论:鼻内镜下手术治疗侵及眼眶的鼻腔鼻窦肿瘤有其独特的优势,在鼻内镜下单纯经鼻腔或内镜辅助经鼻腔和鼻外切口双径路手术治疗可以取得比较好的临床预后。     

神经内镜下经鼻蝶窦切除垂体瘤

目的探讨神经内镜下经鼻蝶窦入路切除垂体瘤的手术方法和技巧。方法回顾分析2008年5月至2012年10月南京医科大学第一附属医院收治的神经内镜下经鼻蝶窦入路切除垂体瘤103例。结果神经内镜下经鼻蝶窦人路全切垂体瘤97例（94．2％）。术后平均住院天数5．5天,无手术死亡病例,2例术后脑脊液漏,1例经再行手术修补,1例经腰穿置管平卧治疗后自愈。结论对蝶窦气化较完全的患者,经鼻蝶窦手术入路创伤小、安全有效。     

鼻内镜手术在鼻咽部占位性病变治疗中的应用

目的：探讨鼻内镜下手术治疗鼻咽部占位性病变的适应症、方法及效果。方法：回顾性分析及总结经鼻内镜手术治疗的22例鼻咽部良恶性占位性病变的临床资料、治疗过程及术后效果。结果：22例患者中有9例良性病变,13例恶性病变;1例鼻咽纤维血管瘤患者术后复发,经再次手术后治愈;1例鼻咽部良性淋巴组织增生症患者术后进行心理治疗;1例放线菌病患者术后进行长期抗菌治疗;1例恶性淋巴瘤患者术后未能确诊,随访18月后再次活检确诊,未进行后续治疗;1例横纹肌肉瘤患者术后3月失访;1例恶性黑色素瘤患者术后复发,继续在肿瘤科治疗。结论：对于鼻咽纤维血管瘤及以复发性鼻咽癌等恶性肿瘤,可在鼻内镜下按解剖标志逐步暴露病变边界,彻底切除肿瘤并修复缺损创面。     

Canine fossa approaches in endoscopic sinus surgery - our experience

Objective

To define the role of canine fossa approach when standard endoscopic endonasal sinus surgery technique fails.

Study design

Retrospective review of all endoscopic sinus surgeries performed from 1992 to 2007.

Result

Out of 1612 endoscopic sinus surgeries for various indications, CFA was used in 80 patients (4.96%) and among this 15 had bilateral procedure.The various diseases which required CFA were allergic fungal sinusitis (AFS), Fungal ball, Chronic invasive aspergillosis,antro choanal polyp, inflammatory polyp, Mucocoele and Maxillary cyst,inverted papilloma and Juvenile Nasopharyngeal Angiofibroma (JNA). Eight patients had minor complications (cheek swelling-6, facial pain-2 ) which resolved in 5 days.

Conclusion

Canine fossa approach offers an ancillary approach to failed standard endoscopic endonasal technique thereby avoiding other more invasive procedures.     

Endonasal endoscopic dacryocystorhinostomy: our experience

Objectives

To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.

Methods

Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.

Results

Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.

Conclusion

Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.     

Endoscopic removal of malignant melanoma of the nasal cavity

Mucosal melanoma of the nasal cavity is a rare tumour. With the extended used of nasal endoscopes and advent of CT scan, early diagnosis of nasal melanoma and accurate assessment of its extent is possible. This allows endoscopic excision of tumour, avoiding unnecessary removal of healthy tissue. Here we present a case where endonasal endoscopic excision with postoperative radiotherapy achieved disease free survival till follow up (nearly 2 years).     

神经内镜下再次经蝶窦手术治疗复发性垂体腺瘤

背景与目的：近年来随着内镜光学技术的发展和五官科医生在鼻窦手术中广泛使用内镜．内镜在经蝶窦垂体腺瘤外科中的应用逐渐被熟知。本研究主要探讨神经内镜下再次经蝶窦手术治疗复发垂体腺瘤的安全性及临床疗效。方法：对12例经蝶手术后复发的垂体瘤患者进行了内镜下再次经蝶切除术。观察其安全性、肿瘤切除情况及手术并发症等。结果：内镜下全切除8例。次全切除2例。大部分切除2例。本组术后无死亡及严重并发症,常见并发症为一过性尿崩症、电解质紊乱和脑脊液鼻漏,术后83％（10／12）患者临床症状明显改善．12例随访6个月至5年,疗效满意。结论：神经内镜下再次经蝶窦手术治疗复发性垂体腺瘤是安全有效的．而熟练的内镜技术和可靠的颅底重建是手术成功的关键。     

Endoscopic Endonasal Approach in Clival Chordoma Surgery: Case Series

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25–35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 – 23 days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available.     

神经内镜下经鼻蝶治疗垂体肿瘤的研究进展

神经內镜下垂体肿瘤切除术取代传统显微镜下经鼻蝶垂体瘤切除术,是使用经鼻內镜从正常生理鼻腔空隙直达蝶窦切除肿瘤的手术方法。神经内镜以其创伤小、术程短、术式简洁、术后恢复快等优点,逐渐成为治疗垂体肿瘤的首选手术方式。本文对目前国内外应用神经内镜治疗垂体肿瘤适应症、并发症、手术技巧、新技术的使用等相关临床进展进行综述,旨在能够更好的应用该技术以提高垂体肿瘤的手术治疗效果。      

Endoscopic pituitary surgery - a. beginner’s guide

Endonasal endoscopic surgery is now the preferred technique to tackle pituitary tumours. Our paper describes the stepwise endoscopic approach for surgeons embarking on pituitary surgery. It also highlights the common pitfalls encountered during surgery and the ways to avoid them. One must proceed in a gradual step- wise manner starting from simple exposure of the sphenoid sinus to complete endoscopic tumour removal so us to gain the neurosurgeon’s confidence as well as develop our own skills, confidence and ability to tackle complications. We use the endonasal paraseptal trans- sphenoidal approach. Surgery begins with gentle packing between the middle turbinate and septum to expose the anterior sphenoid wall and expose the sphenoid astium. The ostitum is then widened inferiorly and onto the opposite side to expose both sphenoid sinuses. The inter- sphenoid sinus and necessary mucosa is removed to expose the sella. We then use a bone flap technique or punches to open the sella. After incising the dura, tumour is removed with a suction curette. An endoscope holder facilitates the operation. The bone flap is replaced at the end of surgery to reconstruct the sella. This is especially important if a CSF leak is present. Nasal packing is usually not required.     

神经内镜经单鼻孔-蝶窦入路直视下切除垂体瘤

目的：探讨神经内镜技术经单鼻孔-蝶窦入路切除垂体瘤的临床应用及手术技巧。方法：对12例经CT和MRI诊断的垂体瘤患者在神经内镜经单鼻孔入路直视下予以切除。结果：全切9例,近全切3例。术后2例出现一过性脑脊液漏,尿崩3例。4例内分泌检查正常,7例视力好转,无严重并发症发生。结论：内镜单鼻孔经蝶窦入路切除垂体瘤具有良好的深部照明、微创、全景化视野等优点,手术创伤小,并发症少、病人恢复快。     

Endoscopic endonasal medial maxillectomy: case series

Introduction

A medial maxillectomy (MM) consists of a complete resection of the medial wall of the maxillary sinus. Traditionally the surgery is performed via an open approach. With more familiarity and expertise in endoscopic sinus surgery the endonasal approach is feasible.

Objective

To expose the surgical technique and report the results of endonasal endoscopic MM in a series of 6 consecutive patients.

Materials and methods

Between August 2006 and October 2009, 6 patients were operated with this procedure. All were men. The mean age was 62-year-old (range: 43–83). In 5 cases, the surgery was performed for inverted papillomas confined to the maxillary sinus. In one case it was a primary surgery whereas it was a revision surgery for the others. The sixth patient was operated for a solitary extramedullary plasmocytoma inserted on the intersinonasal wall persistent after an external radiation therapy.

Results

All the patients are free of disease at the time of writing with a mean follow-up of 18,2 months (range: 9–38). This has been confirmed by a nasal endoscopy and CT scans. There were no major per or postoperative complications. Patients suffered from crusting for at least 6 months postoperatively necessitating daily nasal douches. One patient is still complaining of intermittent epiphora when he is exposed to wind.

Conclusion

Endoscopic MM can be successfully performed for the resection of expanding processes involving the maxillary sinus and/or the intersinonasal wall. Compared to open approaches, it seems to be as effective with less postoperative morbidity. An important technical point is to do the anterior osteotomy in front of the nasolacrimal duct in order to expose the prelacrimal recess that is typically an area for possible recurrence. Exact determination of the tumor attachment during the surgery is another key point for success.     

Impact de la chirurgie reconstructrice avec lambeaux et de la chirurgie mini-invasive sur la définition du volume cible anatomoclinique des cancers de la sphère ORL

Advances in the reconstructive surgery and minimally invasive endonasal endoscopic surgery of head and neck is poorly evaluated in terms of their impact on radiotherapy planning and outcomes. These surgical advances have resulted in reduced morbidity with equivalent or better tumor control. In the absence of a recommendation on how to delineate target volumes in patients with flaps or to consider margins after endoscopic endonasal surgery, radiotherapy practices are inevitably heterogeneous. Efforts are needed to increase the therapeutic index of postoperative radiotherapy in these situations. We analysed the rare existing literature and outlined a preliminary basis for a recommendation. Strengthening of multidisciplinarity to accurately define target volumes in these complex and relatively new situations, and “delineation concertation meetings” between radiologists, surgeons and radiation oncologists could probably contribute to improved outcomes.     

Endoscopic transsphenoidal surgery

Background: Endoscopic transsphenoidal surgery was developed under a minimally invasive surgical strategy. This endonasal transsphenoidal endoscopy eliminates a sublabial or transfixional incision, the use of a transsphenoidal retractor and any nasal packing. Materials and method: Reported are 160 patients who had undergone endoscopic transsphenoidal surgery from 1993 to 1999. Seventy were men and ninety women. Age ranged from 14 to 88 years (median 43 years). Among the 160 patients, 128 had pituitary adenomas, 9 had anterior fossa meningiomas, 7 had clival chordomas and 16 patients had other pathologies. Results: Among the 68 patients with hormone-none-secreting adenomas, 53 (78%) patients had gross total removal. Among the 35 patients with prolactinomas, 24 (71%) patients exhibited normalized prolactin levels postoperatively. Eleven (70%) patients among the 16 with Cushing's disease had normal postoperative cortisol levels. Among the 9 patients with acromegaly, 7 (78%) had normalized postoperative IGF-1 levels. Among the 9 patients with anterior cranial fossa meningiomas, 7 had gross total removal and 2 had subtotal removal. Among the 7 patients with clival chordomas, 5 had total removal and 2 had subtotal removal. One patient with a large calcified recurrent pituitary fibrosarcoma died postoperatively. Postoperative morbidities included cerebrospinal fluid (CSF) leak in 6%, meningitis in 1.2%, deterioration of anterior pituitary function in 11%, temporary diabetes insipidus in 4%, permanent diabetes insipidus in 3%, and sinusitis in 1.2%. Outpatient surgery was performed in 2 patients. One hundred and eleven patients (66%) stayed in the hospital only overnight. Postoperative discomfort was minimal. Conclusion: Endoscopic endonasal transsphenoidal surgery in this series resulted with comparable surgical outcomes to conventional microscopic transsphenoidal surgery. Patients' quick recovery, short hospital stays, and minimal postoperative discomfort have been observed.     

Improving the Results of Endonasal Dacryocystorhinostomy with Mitomycin C Application: A Prospective Case–Control Study

Many surgical advancement paved to surgical success in endonasal endoscopic dacryocystorhinostomy. Mitomycin C is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. The objective of the study was to evaluate the advantage of mitomycin C in primary endoscopic endonasal dacryocystorhinostomy without stenting. Randomised case control design. Tertiary academic centre in central India. 112 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups with or without mitomycin C intraoperative application. 112 eyes underwent endoscopic-dacryocystorhinostomy. Additional surgeries were done according to necessity. Mitomycin C was applied in concentration of 0.4 mg/dl for 5 min. Patients were followed up on OPD-basis at the end of 1st week, 1st month, 3rd month and over phone call at end of 1 year. Symptomatic improvement assessed by verbal enquiry and clinically by syringing by ophthalmologist. 8 patients underwent septal surgery in case group and 4 in control group along with 1 concha bullosa correction in the case group (p?<?0.05). Nil intraoperative complications (p?<?0.05) and nil postoperative complication noted (p?<?0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96.5% at 3rd month in case group and 96.4% and 92.9% at 1 month and 3 month respectively in control group. Nasal endoscopy of all surgical failures showed restenosis in both case group and control group except 1 patient with granulation in control group. Eventhough intraoperative mitomycin C application is effective in increasing the success rate of endonasal DCR surgery in standard nasolacrimal duct obstruction, and with no significant complications from its use, the study did not show added benefit in the primary endoscopic endoscopic dacryocystorhinostomy without stenting.     

内镜下复发性鼻咽癌外科治疗创新体系建设

鼻咽癌是我国常见恶性肿瘤,放疗是初发鼻咽癌的首选治疗方案。经过放疗后仍有5%~15%的患者出现疾病复发。再次放疗难以取得满意的疗效,同时发生严重放疗后并发症的风险较高,所以复发性鼻咽癌患者推荐经鼻内镜入路的挽救性手术治疗。相比再次放疗,内镜手术可以更好地延长患者生存时间、改善生活质量、减少治疗后并发症的发生以及患者总体医疗费用,然而鼻咽颅底解剖的复杂性增加了内镜手术切除病变的难度和风险。如何提高患者的生存时间是鼻颅底外科医生面临的重要问题,这需要基于解剖的深入研究、颈内动脉的充分评估、手术分型的积极探索、重建方式的合理应用,以及多学科合作,建立鼻咽癌外科诊疗的创新体系。     

Endonasal Endoscopic Approach in Management of Paediatric CSF Rhinorrhoea Cases

Though endoscopic repair has been the proven to be the gold standard for the repair of cerebrospinal fluid rhinorrhoea in adult patients, the type of approach to be used in paediatric patients especially those below 5 years is still a challenge with no clear cut guidelines. The objective of this study was to evaluate the efficacy of using endonasal endoscopic approach for treating paediatric patients aged less than 5 years diagnosed with cerebrospinal fluid rhinorrhoea. This was a retrospective analysis of five cases of paediatric CSF rhinorrhoea operated in a tertiary health care centre with an age of less than 5 years from October 2002 to September 2010. All the five cases treated by endoscopic approach have no further complaints of CSF leak or meningitis with a follow up period of a minimum period of 6 months. Two cases were further detected to have meningocele and meningoencephalocele which was detected preoperatively and treated by reduction and excision respectively. The good results obtained by endoscopic closure with lack of major complications and the decreased morbidity for the patient suggests that the endoscopic approach should be considered the first line of approach in pediatric population. But we would warrant a careful selection procedure and availability of adequate expertise for this approach to avoid complications.     

内镜经鼻蝶入路手术治疗大型垂体腺瘤

背景与目的：对于大型垂体腺瘤,传统的开颅和经蝶入路手术均难以全切,本文探讨内镜经鼻蝶入路切除大型垂体腺瘤的手术技术。方法：回顾性分析2000年9月-2005年12月间治疗的大型垂体腺瘤患者39例,术前均行头CT、MRI及内分泌学检查,手术采用内镜经鼻蝶入路肿瘤切除术。结果：本组患者无手术死亡,肿瘤全切除23例（60．0％）,近全切除14例（35．9％）,部分切除2例（5．1％）。术后随访6—24个月,症状和内分泌学指标均有所改善,肿瘤复发2例。结论：内镜经鼻蝶手术是治疗大型垂体腺瘤微创、安全的方法。     

Advances in minimally invasive surgery in the treatment of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the USA. Surgery is the primary treatment for most patients with CRC. Over the past 15 years, minimally invasive techniques for colorectal surgery have been developed. There is growing evidence that these techniques have significant advantages in short-term outcomes (e.g., postoperative pain and length of hospital stay) with similar long-term recurrence and overall survival. While transanal local excision has been shown to be inferior to radical resection for early rectal cancer, transanal endoscopic microsurgery (TEM) is a minimally invasive technique that appears to facilitate local excision in appropriate patients. TEM combined with radiotherapy has demonstrated promising early results and is currently being investigated in clinical trials as a potential alternative to radical surgery. We summarize the current literature on these minimally invasive approaches to CRC.     

Primary Endonasal DCR Without Stent: Our Experience and Case Series Analysis

Endonasal dacryocystorhinostomy is widely accepted and effective treatment option for nasolacrimal duct obstruction. It can be done with or without the use of stents. This study was carried out to evaluate the results of endonasal DCR surgery and to access efficacy of this procedure without stenting. This is a prospective clinical study conducted in Departments of ENT and Ophthalmology, L.N. Medical College and J.K. Hospital, Bhopal from October 2008 to April 2012. A total of 90 patients with epiphora as evidenced by nasolacrimal duct blockage on syringing were included in the study. These patients underwent endoscopic DCR without stenting. The cases were followed up to 18 months postoperative. Surgical success was defined as anatomical patency and symptomatic relief at the end of the follow up period. Failure was defined as no symptomatic relief, and/or acute dacryocystitis, and/or non patent lacrimal drainage system. Surgical success was observed in 80 of 90 (88.89 %) patients. Incidence of complication was low as only 6 patients had minor complication of bleeding, synechie and granulation tissue formation. It was concluded that high success rates could be achieved in case of nasolacrimal duct obstruction by endoscopic DCR. Thus, we can minimize complications, discomfort, the cost of stenting and follow up visits after endonasal DCR surgery.