经鼻内镜额窦脑脊液鼻漏修补术初探

目的探索额窦脑脊液鼻漏修补术的进路、修补方法和手术技巧。方法对9例额窦后壁和4例额隐窝后外侧壁脑脊液鼻漏患者进行手术修补，其中首次手术行鼻内镜下修补术12例，联合进路1例；术后观察手术疗效及并发症情况。结果13例患者中12例一次修补成功，1例二次修补成功。出现并发症2例，其中1例为术后颅内感染，行鼻外引流、额窦填塞术治愈；另1例为阻塞性额窦囊肿，行鼻内镜下额窦开放术治愈。结论经鼻内镜可以成功修补可视的额窦后壁脑脊液鼻漏，但要注意额窦口及漏口大小，防止术后额窦阻塞，诱发阻塞性额窦囊肿、额窦炎和颅内感染；对于额窦内不可视的脑脊液鼻漏和额窦口扩大困难的病例，建议行联合进路修补术。     

Transnasal endoscopic treatment of choanal atresia without prolonged stenting

OBJECTIVE: To analyze the outcome of transnasal endoscopic repair of choanal atresia (CA) in children without prolonged nasal stenting after surgery. DESIGN: Retrospective study. SETTING: Academic tertiary care children's hospital. PATIENTS: Forty children aged 3 days to 15 years (mean age, 41 months) who presented with unilateral (n = 26) or bilateral (n = 14) CA and underwent surgery between August 1996 and December 1999. INTERVENTION: All children underwent transnasal endoscopy with telescopes, endoscopic instruments, and a microdebrider. Nasal tubes in neonates or infants and nasal packing in older children were always removed after 2 days. Systematic revision endoscopy was performed with the patients under local or general anesthesia on days 6 to 10. All patients were then clinically and endoscopically monitored for nasal obstruction and healing during a mean follow-up period of 18 months. RESULTS: There were 16 patients with associated malformations, including 6 cases of CHARGE association (a malformative syndrome that includes coloboma, heart disease, CA, retarded development, genital hypoplasia, and ear anomalies, including hypoplasia of the external ear and hearing loss), and 14 patients (9 with bilateral CA) with a history of previous choanal surgery (4 transnasal, 4 laser, and 6 transpalatine). Postoperatively, 32 patients (80%) had normal nasal patency and a satisfactory choanal diameter, and 8 (20%) had restenosis or complete choanal closure. Six underwent a second procedure, with success. The results in all children who had been previously treated with laser or transpalatine surgery were successful. The last patient, who presented with severe Treacher Collins syndrome, is still tracheotomized. There were no significant postoperative complications. One patient died of congenital cardiopathy 6 months after surgery. CONCLUSIONS: Transnasal endoscopic repair of CA is a safe and successful technique. The use of powered instrumentation and routine postoperative revision endoscopy seems to avoid prolonged nasal stenting.     

Transnasal endoscopic treatment of bilateral choanal atresia in newborns using balloon dilatation: Own results and review of literature

Objectives

Congenital choanal atresia is a complete obliteration of the posterior nasal aperture leading to life-threatening airway emergencies. Several surgical options including sublabial, transpalatal, transseptal or external approaches have been developed for the repair of choanal atresia. So far, no gold standard has been established, but transnasal endoscopic approaches have been favored by many surgeons in recent years.

Methods

Since 2008 a standard procedure for bilateral choanal atresia repair in neonates using an endoscopic transnasal approach supported by balloon dilatation has been established at the Department of Otorhinolaryngology at Ulm University Medical Center. During the last five years, six cases of bilateral choanal atresia were diagnosed and treated, including two male and four female patients aged between three days and two months, at the date of surgery. All interventions were performed in transnasal endoscopic technique. In all patients the abnormally thick posterior vomer and the atretic bony plate were resected and the mucosa was perforated. A balloon dilator was used to dilate the neochoanae and prevent restenosis. All six patients were intraoperatively stented for at least six weeks.

Results

All six neonates with bilateral choanal atresia, who were operated in endoscopic transnasal technique had patent neo-choanae on both sides. No severe postoperative complications were found. The number of revisions depends on the age at primary surgery.

Conclusions

Endonasal endoscopic approach and balloon dilatation is a safe, reproducible technique for surgical repair of choanal atresia. We recommend the use of bilateral stents, especially in very young patients, as a prerequisite to prevent early restenosis.     

Retrograde nasal intubation via the cleft in Pierre-Robin Sequence neonates: A case series

Pierre-Robin Sequence, the triad of glossoptosis, micrognathia and cleft palate, provides a challenge in airway management both in and out of the operating room. Transnasal intubation is greatly preferred during its surgical intervention for maximum oral exposure in these very small patients without the added encumbrance of an oral endotracheal tube. From 2001 to 2009, three neonates with Pierre-Robin Sequence who underwent surgery to improve their airway had a novel method of securing a transnasal airway performed in the operating theater. After successful placement of a laryngeal mask airway (LMA) and subsequent endotracheal intubation via the LMA, this technique was used to convert from an oral to a nasal intubation. After the LMA is removed, a smaller endotracheal tube is placed into the nose and out of the mouth via the cleft in each of these patients. This smaller tube is then telescoped into the larger one and secured with suture. Both tubes are subsequently backed out of the nose in a retrograde fashion and disarticulated so that the now transnasal endotracheal tube can be re-connected to the anesthesia circuit. This case series highlights a rapid technique utilizing the patient's congenital defect for securing a transnasal airway alternative to that of transnasal fiberoptic intubation in Pierre-Robin Sequence neonates.     

Transnasal endoscopic resection of lesions of the clivus: a preliminary report

OBJECTIVE: To review our experience with transnasal endoscopic resection of clival lesions. BACKGROUND: Because of the surrounding vital structures and the difficulties in achieving wide surgical exposure, the treatment of clival lesions is challenging. In an effort to overcome these obstacles, many centers use facial incisions and osteotomies to approach clival lesions. Minimally invasive endoscopic techniques have the potential to minimize morbidity while yielding similar surgical results. STUDY DESIGN: Retrospective chart analysis. MATERIALS AND METHODS: Patients with tumors involving the clivus that underwent endoscopic resection between 2000 and 2004 were identified. Charts were reviewed for clinical characteristics, previous therapies, diagnosis, tumor extent, management modalities, length of hospital stay, complications, and outcome. RESULTS: A total of six patients were identified. There were four males and two females with a mean age of 50 years, ranging from 29 to 66 years. The most common presenting symptoms were visual disturbances. Three patients had prior craniotomy with subtotal tumor resection. The pathology included three clival chordomas, and one each of meningioma, adenoid cystic carcinoma, and sinonasal undifferentiated carcinoma. All patients were managed with computer-aided transnasal endoscopic tumor resection with neurosurgical standby or involvement. None of the patients required additional craniotomies. The mean follow-up was 13 (range, 8-24) months. Intensity-modulated radiation therapy was used in three patients, and two patients are currently undergoing proton beam radiation therapy (PBRT). The average length of hospital stay was 2 (range, 2-3) days. There were no major postoperative complications. At the last follow-up, five patients were alive with two patients being free of disease. Two patients with residual disease are currently undergoing PBRT, and one patient developed distant metastasis. One patient died of unrelated causes. CONCLUSIONS: This preliminary report suggests that transnasal endoscopic management of clival lesions is a viable option to traditional open approaches with acceptable morbidity and mortality. The use of computer-aided surgery further minimizes surgical risks while maximizing tumor resection.     

Predictive factors for success after transnasal endoscopic treatment of choanal atresia

OBJECTIVE: To analyze the different factors affecting the outcome of transnasal endoscopic repair of choanal atresia (CA) in children. DESIGN: Retrospective study. SETTING: Academic tertiary care children's hospital. PATIENTS: Eighty patients (48 girls and 32 boys) aged 3 days to 17 years (mean age, 3 years 8 months) who presented with unilateral (n = 53: 37 right, 16 left) or bilateral (n = 27) CA and underwent surgery between September 1996 and December 2005. INTERVENTION: All patients underwent transnasal endoscopic surgery with telescopes and a microdebrider. Nasal tubes in neonates and nasal packing in older children were removed after 48 hours. Systematic endoscopic revision was performed under local or general anesthesia a week after surgery. Patients were then clinically and endoscopically monitored for nasal obstruction and healing for a mean follow-up of 43 months. RESULTS: A total of 30 patients presented with associated malformations: 9 with CHARGE (coloboma, heart disease, choanal atresia, retardation of postnatal growth()and mental development, genital hypoplasia, and ear anomalies), 1 with Treacher-Collins syndrome, 1 with Kabuki syndrome, 1 with facial cleft, 1 with Down syndrome, 12 with nonsyndromic malformations, and 2 with 22q11 microdeletion. Three children had heart malformations not related to CHARGE association. One child had a congenital nasal piriform aperture stenosis. Twenty-four children had undergone previous surgery; 10 underwent a second procedure with success. Gastroesophageal reflux disease (GERD) was systematically treated in cases of restenosis. Topical mitomycin C was used in 3 patients with relapse. Two patients underwent laser treatment to reduce stenotic scarring. Of the 10 patients who needed revision surgery, 6 had bilateral CA, and 4 had unilateral CA. Age younger than 10 days and presence of GERD increased the chances of restenosis (P = .03). Postoperative stenting negatively affected the outcome. Associated anomalies and previous surgery had no effect on outcome. The bony nature of the CA and bilaterality were not significant (P = .08). However, surgeon learning curve was an important element positively influencing the results (P = .04). CONCLUSIONS: Transnasal endoscopic repair of CA is a safe and successful technique. Predictive factors of restenosis are the presence of GERD, age younger than 10 days at the time of surgery, and insufficient postoperative endoscopic revision. However, previous surgery and associated malformations are not predictive of a poor surgical outcome.     

Endoscopic transnasal transsphenoidal surgery for pituitary tumors--intranasal procedures

We have been performing intranasal procedures and postoperative nasal treatments in patients undergoing microscopic transseptal pituitary surgery for the past twenty years. This surgery is safe and minimally invasive and has become the standard procedure for removing pituitary adenomas. Recent advances in optical technology have increased the use of endoscopy in endonasal sinus surgery. Several methods for endoscopic transnasal pituitary surgery have been reported. Here, we report the results for 31 patients (34 operations) who were treated with endoscopic transnasal pituitary surgery. This technique enables the area of surgery to be visualized without requiring a sublabial incision or septal ablation to be performed. Five of the cases were for recurrences after microscopic surgery. A transsphenoidal surgical approach via a unilateral nasal cavity was used in 32 cases. For the remaining two cases, a transsphenoidal surgical approach via bilateral nasal cavities was used in 1 case, and a transethmoidal-transsphenoidal surgical approach via a unilateral nasal cavity was used in 1 case. Excellent results comparable to those of microscopic transseptal surgery were obtained. Endoscopic transnasal transsphenoidal surgery was found to have the following advantages: low-invasiveness, a wide and clear surgical view, and a relatively short operating time in the nose and sinus, especially for recurrent cases. This endoscopic procedure should therefore be considered as the first choice for pituitary surgery.     

Comparison of techniques for transsphenoidal pituitary surgery

BACKGROUND: The aim of this study was to compare three different techniques for transsphenoidal pituitary surgery: (1) sublabial transseptal approach with microscopic resection, (2) transnasal transseptal approach with endoscopic resection, and (3) endoscopic approach with endoscopic resection. METHODS: We performed a retrospective review of 50 pituitary surgeries performed by the same neurosurgeon. Demographic, radiographic, and clinical data were collected. RESULTS: Fifteen patients underwent sublabial approach with microscopic tumor resection, 21 patients underwent the transnasal approach with endoscopic resection, and 14 patients underwent the completely endoscopic technique. There were a total of 20 complications in the sublabial group, 13 transnasal complications, and 6 endoscopic complications. Cerebrospinal fluid leak incidence was 53% in the sublabial approaches, 47% transnasal, and 28% in the endoscopic patients. Diabetes insipidus was encountered in 33% of sublabial approaches, 5% of transnasal approaches, and 7% of endoscopic approaches. Lumbar drains were required in 40% of sublabial approaches, 38% of transnasal approaches, and 7% of endoscopic approaches. Nasal packing was used in 100% of sublabial and transnasal approaches and 0% of endoscopic approaches. Mean recurrence rate and follow-up was sublabial in 6.6% (50 months), transnasal in 9.5% (11 months), and endoscopic in 0% (7 months). Average hospital stay for sublabial approaches, transnasal approaches, and endoscopic approaches was 8.3, 6.2, and 3.4 days, respectively (p < 0.05). CONCLUSION: Transsphenoidal pituitary surgery has evolved over the past several decades, because advances in technology have been the catalyst for minimally invasive surgeries. Less invasive approaches, such as the transnasal approach with endoscopic resection of tumor and the completely endoscopic .technique have less morbidity and a shorter hospital stay than traditional sublabial approaches. Continued follow-up is needed to confirm long-term benefits and similar recurrence rates.     

鼻内镜下经鼻前颅底手术的探讨

目的：探讨经鼻内镜行前颅底手术的可行性及适应证范围。方法：收集并分析我科近年来在鼻内镜下治疗的前颅底疾病6例，包括脑膜脑膨出3例，脑脊液鼻漏2例，左球后肿瘤1例。6例均在全身麻醉下手术。结果：6例手术均一次性成功，无并发症出现。结论：在鼻内镜下行部分鼻前颅底手术具有创伤小、术后恢复快、并发症少等优点，但手术适应证应该严格掌握，术者必须具备熟练的解剖学知识、手术技巧和经验，必须配备先进的手术设备。     

内窥镜鼻内翻性乳头状瘤切除术

目的 探讨和完善鼻内窥镜下彻底切除鼻内翻性乳头状，降低术后复发率的手术方法及其适应证。方法 1994年1月－1999年6月住院的临床及病理诊断为鼻内翻性乳头状瘤的患者47例，其中24例有1－3次前期经鼻或鼻侧切开术手术史。经CT、前鼻镜和内窥镜检查，肿瘤侵及中鼻道、上颌窦口和部分或全部筛窦者29例，同时侵及蝶窦者7例，2例肿瘤原发于鼻中隔，肿瘤侵及嗅裂下部、中鼻甲、中鼻道和部分筛窦；9例患者肿瘤除侵及中鼻道、上颌窦口和部分或全部筛窦外，同时广泛侵及上颌窦内。前者采用鼻内窥镜经鼻肿瘤切除术；后者要用鼻内窥镜经鼻肿瘤切除，同时在内窥镜下经上颌窦前壁（Caldwell-Luc术式）或下鼻道开窗联合径路肿瘤切除术。术前、中、后用电刀电凝肿瘤基部以YAG激光光导纤维插入肿瘤根部和瘤体，术中应用吸切器（shaver system）切 除瘤体，于肿瘤基部周围骨膜下剥离，局部骨骼化，注意将肿瘤及其基部粘骨膜一并切除。手术创腔痊愈后1、3、6个月复查，以后随访。全部病例随访12－40个月（平均24．6个月）。结果 47例中2例术后复发，45例未复发，治愈率95．7％。6例（12．7％）术后清理、换药期间发现术腔局部出现瘤样组织，病理检查证实内翻性乳头状瘤，内窥镜下 除并以电力、YAG激光处理局部创面。随诊1年此6例未再发现有瘤样组织。结论 辅以电刀或激光处理术野的内窥镜鼻内翻性乳头状瘤切除术，有利于彻底切除肿瘤。对肿瘤已广泛侵入上颌窦内人者采用联合径路手术。     

Surgery for correction of bilateral choanal atresia

A transnasal approach was employed in 28 neonates (26 blacks and 2 whites) with bilateral choanal atresia. In each patient the atresia was perforated microsurgically with the drill, followed by insertion of a Portex endotracheal tube for a period of three months. By this method a satisfactory nasal respiration was established immediately. Removal of the posterior part of the vomer is crucial to the successful result. During the follow-up, one death was recorded in a microcephalic neonate, unrelated to the operation and another four patients required repositioning of the tube under general anesthesia. We feel that the above technique is simple and definitive with negligible complications.     

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.     

Transnasal treatment of congenital choanal atresia with the KTP laser

This retrospective analysis presents a minimally invasive method for a transnasal approach to treat bilateral and unilateral choanal atresia and stenosis in infants and children. We describe an advanced surgical technique that applies the use of a KTP laser and give recommendations for preoperative diagnosis and postoperative assessment. We report 13 cases of bilateral and unilateral choanal atresia or stenosis treated over a 3 1/2-year period. We used a transnasal approach and endoscopic control. For bilateral choanal atresia, the operation was performed within the first few days of birth. For unilateral choanal atresia or stenosis, surgery was performed several weeks after birth. In all cases, an intranasal stent was inserted. Our findings demonstrate that this transnasal approach provides significant benefits. A primary advantage is the diminished risk of intraoperative or postoperative complications. Additional benefits include lower rates of re-obstruction and a decreased incidence of subsequent disease, including chronic secretory otitis media.     

Endoscopic and microscopic paraseptal transsphenoidal approach to the sella turcica

OBJECTIVES: To establish the feasibility of the paraseptal approach to the sella and to demonstrate the superiority of the endoscopic over the microscopic vision during pituitary surgery. STUDY DESIGN: Prospective monocentric study. METHODS: Nine consecutive patients with a pituitary tumour were operated since November 2002. The surgical procedure consisted of a paraseptal approach of the sella with use of a rigid endoscope. Pre- and postoperative (3 months after surgery) symptoms, Magnetic Resonance Imaging (MRI) findings, endocrine and ophthalmic assessment, and intraoperative findings were recorded. RESULTS: One patient presented a CSF leak with a successful peroperative repair. Regarding symptom resolution, headache disappeared during the early postoperative period in case of pituitary apoplexy. All cases of preoperative hemianopsia and diplopia but one improved significantly. Two patients recovered preoperative deficient hormonal functions and six patients did not require substitution therapy any more. No nasal packing was needed except in one case. Considering the healing course, the mucosa repair inside the sphenoid sinus was quicker with Surgicel removal at week 4. Postoperative MRI demonstrated a residual parasellar nodule in 3 out of 6 cases of macroadenoma. Only one required radiation therapy. These results are commented through comparison with the transseptal approach and with surgery exclusively using the microscope. CONCLUSIONS: The paraseptal transsphenoidal approach to the sella turcica using the telescope is at least as effective as the conventional transseptal approach using the operating microscope only. It provides a wide access to the pituitary fossa and an optimal vision of the critical areas. The absence of postoperative nasal packing improves significantly the comfort of the patient during the first postoperative hours.     

经鼻内镜脑脊液鼻漏修补术的方式和方法分析

目的：探讨脑脊液鼻漏的最佳治疗方法。方法：45例经鼻内镜行脑脊液鼻漏修补术患者,42例经鼻进路,3例经鼻及鼻外双进路。采用患者自体游离阔筋膜、捣碎的肌肉,剥去骨质带骨膜的中鼻甲或下鼻甲作为修补移植物,修补采用内贴修补法、堵塞修补法、外贴修补法和充填修补法。结果：1次性手术修补成功44例（97．8％）。术后并发脑膜炎3例,额窦区感染皮瓣下积液1例。45例住院治疗7～30d,平均11d。随访5个月～7年,无复发。结论：对于前颅底小瘘口和鞍底、斜坡处瘘口的脑脊液鼻漏,经鼻内镜脑脊液鼻漏修补具有明显优势。修补方式、方法和修补材料的正确选择是修补成功的关键。     

Visual changes after transnasal endoscopic versus transcaruncular medial orbital wall decompression for dysthyroid optic neuropathy

ObjectiveTo compare postoperative changes in visual acuity between the transnasal endoscopic approach and the transcaruncular approach when comparison of preoperative values used for medial orbital wall decompression in patients with dysthyroid optic neuropathy.MethodsWe included 14 patients (23 sides) and divided them into a transnasal group (11 sides, 8 patients) and a transcaruncular group (12 sides, 6 patients). Visual acuity was examined preoperatively, on postoperative days 1, 3, and 7, and at a final follow-up visit. The differences in postoperative improvement of the logarithm of the minimum angle of resolution (logMAR) visual acuity and critical flicker frequency (CFF) between the two surgical groups at each time point were analyzed using the Mann–Whitney U test.ResultsPostoperative improvement in logMAR visual acuity on postoperative days 1 and 3 and that in CFF on postoperative day 1 were greater in the endonasal group than in the transcaruncular group (P < 0.050). Vision was improved or maintained in all patients in the transnasal group at the final follow-up. One patient in the transcaruncular group had loss of vision on one side and decreased vision on the other side after surgery.ConclusionMedial orbital decompression appears to provide better postoperative vision when performed by the transnasal approach than by the transcaruncular approach in patients with dysthyroid optic neuropathy.     

鼻内镜下经蝶窦入路垂体肿瘤切除术的麻醉选择

目的：探讨在鼻内镜下经鼻腔蝶窦垂体肿瘤切除术的麻醉方法。方法：在鼻内镜下经鼻腔蝶窦入路切除垂体肿瘤56例,其中8例在全身麻醉下完成,48例局部麻醉加基础麻醉下完成。结果：所有患者都顺利完成手术,56例均无手术并发症,其中在局部麻醉加基础麻醉下完成的48例,术中出血量明显减少,生命体征平稳,无呻吟挣扎,手术顺利。结论：局部麻醉加基础麻醉下行鼻内镜下经鼻腔蝶窦垂体肿瘤切除术简单、安全,且效果好。     

鼻内镜下经筛窦眶纸板入路眶内占位病变切除术

目的 探讨鼻内镜下经筛窦眶纸板入路切除眶内占位病变的可行性.方法 回顾性分析2003年6月～2006年8月以突眼为主要症状的9例眶内占位(2例脂肪瘤、2例海绵状血管瘤、2例炎性假瘤和3例血肿)和1例眶内异物患者.除1例海绵状血管瘤外,均在鼻内镜下经筛窦眶纸板进入眼眶,清除眶内病变.结果 眶内异物一次性取出;1例海绵状血管瘤经眶外切开入路切除;突眼和复视症状均完全消除;术前手动视力提高到0.3,光感视力提高到0.1,伤后14天就诊者视力未恢复.随访3个月至2年,炎性假瘤1例治愈,1例复发,再次手术后切除,现随访中;其余8例均一次性治愈,临床症状消失,无复发.结论 鼻内镜下筛窦眶纸板入路眶内占位性病变切除术,具有术野清楚、损伤小、恢复快及面部无瘢痕等优点,可以完整切除占位病变,方法切实可行.