头皮冠状切口在耳鼻喉科前颅底手术中的应用

对鼻腔、鼻窦肿瘤侵及颅底的7例（恶性4例，良性3例）采用头皮冠状切口施行前颅底手术，除1例巨大骨化纤维瘤未予完全切除外，余6例均完全切除病灶。4例恶性肿瘤中2例硬脑膜因肿瘤侵犯予以切除，3例良性肿瘤因硬脑膜变薄致术中撕裂，缺损的硬脑膜及颅底骨板均用帽状腱膜下层一颅骨膜瓣、颞肌筋膜瓣修补，大的颅底缺损用额肌肌皮瓣加固。良性肿瘤3例中，未完全切除的1例随访1年半病情稳定，另2例随访8年和6年无复发。4例恶性肿瘤中，3例分别随访6年、4年、17月无复发，1例术后18个月颅内复发死亡。所有病例未发生术后并发症。文中对该术式的优缺点以及颅底、硬脑膜的切除和修复问题进行了讨论。     

Use of reconstructed sagittal computed tomography images to plan middle cranial fossa surgery.

OBJECTIVE: To facilitate planning in temporal bone surgery for the middle cranial fossa approach by using sagittal reconstructed temporal bone computed tomography images. STUDY DESIGN: Comparison of anatomic measurements on random high-resolution, reformatted computed tomography scans of the temporal bone. METHODS: High-resolution computed tomography of 10 normal temporal bones in the axial and coronal planes was obtained, and two-dimensional sagittal reconstructions were performed using a commercial software program. Eight anatomical relationships between neural and/or vascular structures were measured. Representative images were inverted to recreate the plane of the middle cranial fossa approach. RESULTS: Anatomical relationships among the vestibule, superior semicircular canal, internal auditory canal, internal carotid artery, and middle cranial fossa exhibited a high SD in the 10 subjects. The sample size and the large range for the eight anatomical relationships precluded the detection of a significant difference between right and left temporal bones or sex and age of the patient. CONCLUSION: The present report presents a novel, practical measurement protocol for rapidly evaluating important individual anatomical differences in patients before middle cranial fossa surgery. Inverted sagittal reconstructions facilitate presurgical planning for the middle cranial fossa approach by 1) assessing critical anatomical relationships before surgery and 2) providing customized measurements between vital landmarks and the first in vivo measurements. This decreases the likelihood of surgical mishaps and improves teaching by providing the first in vivo measurements of practical anatomical relationships in the sagittal plane.     

Asymmetry of the ethmoid roof: analysis using coronal computed tomography.

OBJECTIVES/HYPOTHESIS: To determine the incidence and degree of asymmetry in the height and contour of the ethmoid roof. STUDY DESIGN: Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans. METHODS: Retrospective review of 200 consecutive direct coronal sinus CT scans done at New York University Medical Center from July 25, 2000 to October 11, 2000. The height and contour of the fovea ethmoidalis were examined for symmetry between the right and left sides. When an asymmetry in the height of the fovea ethmoidalis existed, this difference was quantified. RESULTS: In 19 scans (9.5%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left sides. Of these 19, 12 (63.2%) were lower on the right side, whereas 7 (36.8%) were lower on the left. Ninety-six patients (48.0%) demonstrated a contour asymmetry with "flattening" of the ethmoid roof on one side, 46 on the right and 50 on the left. One patient demonstrated both height and contour asymmetry. The fovea ethmoidalis on the remaining 86 scans (43.0%) was symmetric. CONCLUSIONS: In a patient population with sinus and nasal symptoms, the height and contour of the right and left fovea ethmoidalis were symmetric in less than 50% of individuals. The asymmetry was most often the result of a difference in contour with flattening of the fovea on one side. This underscores the importance of careful preoperative and intraoperative review of paranasal sinus CT scans in patients undergoing endoscopic sinus surgery.     

The radiological anatomy of the anterior skull base

Two complications dominate the thoughts of any surgeon undertaking functional endoscopic sinus surgery (FESS), namely damage to orbital structures and fractures of the fovea ethmoidalis. To avoid these complications, a detailed knowledge of the paranasal sinus anatomy of the patient is essential. This is usually assessed using preoperative computerized tomography (CT) scans of the paranasal sinuses. Analysis of 151 CT scans, measuring the height of cribriform plate below a supraorbital horizontal and above the hard palate was performed. Variation of shape and take-off angle of the fovea ethmoidalis was also measured. Comparison between left and right sides, and between scans showing radiological features of sinonasal disease and normal scans, was undertaken. Five patterns of fovea ethmoidalis were identified. No statistically significant difference between left and right sides was demonstrable for any parameter, irrespective of pathological status.     

Complementary use of computed tomography and magnetic resonance imaging in assessing skull base lesions.

Twenty-six patients underwent computed tomography (CT) and magnetic resonance imaging (MRI) of skull base lesions at the Cleveland Clinic Foundation. CT provided improved bone detail, documenting invasion of the lamina papyracea, orbital floor, fovea ethmoidalis, cribriform plate, pterygoid plates, hard palate, and skull base. MRI defined invasion of the orbit, dura, brain, and cavernous sinus. Improved soft-tissue-tumor interface was evident on MRI. MRI was superior to CT in determining carotid artery involvement. MRI distinguished between tumor and retained secretions in the paranasal sinuses. Combining radiographic tumor staging reliably predicted surgical findings; however, MRI consistently yielded sufficient diagnostic information and the additional expense of performing two imaging procedures may not be justified.     

Spiral computed contrast tomography in diagnosis of juvenile angiofibroma of the base of the skull

The authors present their experience in surgical and combined treatment of juvenile angiofibroma of the base of the skull (JABS). A total of 180 children were treated, 93.8% of them had advanced tumor and were operated through external approach by Moore. Computed and MR tomographies were made preoperatively and postoperatively in all the patients. Benefits and drawbacks of the above tomographies are analysed. A technique of spiral computed contrast tomography in JABS is described. This tomography has the following advantages: volume visualization of the studied area without artefacts induced by movements; sharper visualization of the vessels; possibility of retrospective reconstruction of the sections with varying interval after the end of the procedure; improved quality of multi-plane reconstructions; reduced radiation dose and time of exposure.     

The pericranial flap for reconstruction of anterior skull base defects

In 1981, the senior author first reported the use of the pericranial flap for support of the brain following resection of the anterior skull base. Since the initial report, considerable experience has been gained with this flap. It is currently deployed via a bifrontal craniotomy and is placed primarily as a support beneath the frontal lobes. The pericranial flap may also be used to repair dural laceration and defects. The sinonasal surface is routinely grafted with split-thickness skin or dermis. This technique provides an excellent barrier between the sinonasal cavity and the cerebrospinal fluid, establishing a tough, fibrous platform. Herniation of intracranial contents has not occurred. One major complication has been reported in which radiation necrosis occurred during postoperative therapy, leading to progressive devitalization of the pericranial flap. Ultimately, dural repair and closure with a latissimus dorsi free flap was required. The pericranial flap repair of anterior skull base defects has a 90% complication-free and 95% overall success rate. It is simple and extremely effective. Bone grafting has not been necessary in our experience.     

The bath-plug closure of anterior skull base cerebrospinal fluid leaks

BACKGROUND: This study presents the technique and results of cerebrospinal fluid (CSF) leak closure by placement of a fat plug on the intracranial surface of the dura. A prospective cohort study of all consecutive patients undergoing endoscopic closure of an anterior skull base CSF leak using the bath-plug technique was performed at a tertiary care center. METHODS: Thirty-three patients presented with CSF leaks: 6 were traumatic, 7 were spontaneous, 9 were iatrogenic, and 10 were associated with a meningoencephalocele. The average age of the patients was 40 years and the male-to-female ratio was 1.2:1. All patients underwent the bath-plug technique for closure of CSF leaks. The surgical technique was presented. RESULTS: Thirty-one of the 33 patients had a successful primary closure of their CSF leak with 2 patients requiring a repeat procedure. After an average of 28 months follow-up, there were no recurrent leaks in any of the patients. This gives a primary closure success rate of 94% and a secondary closure rate of 100%. CONCLUSION: The bath-plug technique for closure of anterior skull base CSF leaks was a reliable technique for a large variety of causes.     

Digital volume tomography (DVT) as a diagnostic modality of the anterior skull base

Conclusion. Because of high resolution and the relatively lower costs in comparison with modern helical CT scanners, digital volume tomography (DVT) can be recommended in the diagnosis of the nasal cavity and paranasal sinuses. Objectives. DVT is an advancement of panoramic tomography and is based on the principles of rotational tomography. It enables high resolution visualization of osseous structures. The slices can be displayed in three orthogonal planes that can be changed in angle arbitrarily. Data volumes of up to 12×17 cm can be examined with a new generation of the DVT. The aim of this study was to point out the potential of DVT in the anterior skull base. Subjects and methods. DVT scans with a cylindrical size of 10 cm in diameter and 10 cm in height were performed in 23 patients. The identification of surgical key landmarks (uncinate process, middle turbinate, ethmoidal bulla, agger nasi cells, Haller cells, frontal recess, anterior ethmoidal artery in its relationship to the skull base, the cribiform plate of the sphenoidal sinus in relation to the optic nerve, and the internal carotid artery) was evaluated. Results. Display of the essential surgical key landmarks was possible in all patients     

The different concepts of surgical managements between anterior and lateral skull base reconstructions based on surgical purposes

ObjectiveAnterior and middle cranial fossa defects require different strategies, depending on their anatomical location. The aim of this study was to elucidate the surgical managements for the defects based on surgical purposes and to clarify the conceptional differences relating to anterior and lateral skull base reconstructions.MethodsThis study included patients who had undergone reconstructive surgery for anterior or middle cranial fossa defects in our institution between July 2008 and June 2019. It consisted of 66 patients who had been subject to anterior skull base reconstructions, and 84 patients who had experienced lateral skull base reconstructions. The medical records were examined retrospectively, and the surgical purposes and procedures performed were reviewed. The surgical purposes were divided into four groups: Separation, Restoration, Augmentation, and Coverage.ResultsRegarding anterior skull base reconstructions, the Separation group included 65 patients, who represented 98% of this category. There were 26 cases in the Separation-only group, 20 of which were reconstructed with locoregional flaps, and 6 of which with free tissue transfers. A Combination group, which consisted of Separation and Other purposes, consisted of 40 cases. Within this group, 5 cases were reconstructed with locoregional flaps, and 35 with free tissue transfers. Regarding lateral skull base reconstructions, the Separation group included 34 patients, who represented 40% of this category. The rate of the Other purposes represented the majority. In the Separation-only group of 24 patients, 16 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In the Combination group of 10 patients, 2 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In groups other than the Separation group, 27 cases were reconstructed with locoregional flaps and 23 cases with free tissue transfers.ConclusionIn most anterior cranial fossa defect cases, the surgical purpose is separation. In middle cranial fossa defect cases, there are many cases in which the surgical purpose is not separation. In the Separation groups, relating to both anterior and lateral skull base reconstructions, the use of locoregional flaps was an effective measure. Free tissue transfers were required in many cases of the Combination group. Outside of the Separation group associated with lateral skull base reconstructions, the use of locoregional flaps and free tissue transfers were almost equal in proportion, and the selection of reconstructive procedures tended to change from locoregional flaps to large free flaps with increase in the numbers of surgical purposes.     

不同手术入路治疗前颅底沟通性肿瘤23例

目的 总结前颅底沟通性肿瘤的3种手术切除与修复方法.方法 采用颅面联合径路对16例鼻腔鼻窦颅沟通性肿瘤、鼻-眶-颅沟通性肿瘤切除,并同期行带蒂额肌帽状腱膜裂层颅骨瓣修复;3例眶颅沟通性肿瘤行额下进路手术切除,并行颞肌筋膜修补;4例经翼点入路,颞肌筋膜修补.结果 术后2例发生脑脊液漏,经对症治疗好转,未发生颅内感染.2年生存16例,3年生存7例,5年以上存活4例.结论 颅面联合径路、额下径路、翼点入路进行前颅底沟通性肿瘤切除,加以带蒂额肌帽状腱膜裂层颅骨瓣、颞肌筋膜瓣修复,切除范围安全、彻底,修复方便、可靠,是一种较为理想的手术切除及修复方法.     

Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies

Technical and technological innovations have spearheaded the expansion of the indications for the use of endoscopic endonasal approaches to extirpate malignancies of the sinonasal tract and adjacent skull base.ObjectiveCritical review of the available literature regarding the use of endoscopic endonasal approaches including indications, limitations, surgical techniques, oncologic outcome, and quality of life.MethodVarious endoscopic endonasal techniques are reviewed according to the origin and local extension of sinonasal and skull base malignancies including anterior cranial base, nasopharynx, clivus, and infratemporal fossa. In addition, the available literature is reviewed to assess outcomes.ConclusionEndoscopic endonasal approaches are an integral part of the armamentarium for the treatment of the sinonasal tract malignancies and skull base. In properly selected cases, it affords similar oncologic outcomes with lower morbidity than traditional open approaches. Nonetheless, these minimal access approaches should be considered a complement to well-established open approaches, which are still necessary in most advanced tumors.     

Low-grade fibrosarcoma of the anterior skull base: endoscopic resection and repair

BACKGROUND: Fibrosarcomas of the paranasal sinuses and skull base are uncommon tumors. Traditionally, "open approach" surgery remains the mainstay for treatment of choice for these tumors. METHODS: A 49-year-old man underwent resection of a right anterior skull base fibrosarcoma using the endoscopic approach. RESULTS: Close follow-up using both endoscopic and imaging methods over a period of four years has revealed a well-healed skull base with no evidence of recurrence. CONCLUSION: Significant resistance exists at present for such a technique to deal with malignant diseases of the head and neck but results from advanced centers continue to prove that this may be a technique worth mastering and improving on.     

Free tissue reconstruction of the anterior skull base: A review

ObjectiveThere has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation. However, when open resection is required, free flap reconstruction is often necessary to provide sufficient well-vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis. This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction.MethodsThis is a state-of-the-art review based on expert opinion and previously published reviews and journal articles, queried using PubMed and Google Scholar.Results & conclusionAnterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing, particularly with large defects, post-radiation, and in at-risk patients. The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease. This review offers insight into the numerous reconstructive options for the free flap surgeon.