头颈外科

890001 经鼻口蝶窦垂体肿瘤手术/赵伟…∥北京医科大学学报.-1988,20(1).-59～60 报道经蝶窦垂体瘤手术14例,其中10例采用鼻口蝶窦入路。介绍术中对鞍内及蝶窦的处理:3例无脑脊液漏者采用中隔带蒂粘膜瓣复盖,其余11例(包括6例有脑脊液漏者)采用筋膜、肌肉和脂肪充填。强调鼻腔正确充填的重要性,并对术后并发症进行了讨论。参4(原提要)     

经蝶窦鼻内镜下垂体腺瘤切除术28例临床分析

目的：探讨垂体腺瘤经蝶窦鼻内镜下切除的可行性及方法。方法：回顾分析1996年4月-2000年4月28例患者接受经蝶窦鼻内镜垂体腺瘤切除手术治疗的治疗效果。全麻下选择肿瘤主体侧及蝶窦发育好的一侧鼻腔进路，将中鼻甲后端1/3切除，沿蝶窦开口扩大蝶窦前壁开口，切开蝶窦粘膜，打开并扩大鞍底，切开硬脑膜，用小刮匙或筛窦钳将肿瘤细心切除。结果：28例中26例得到了全部切除，1例巨大垂体瘤大部切除后，放射治疗，另1例部分切除后用溴鸳停药物治疗，随访1年-4年，症状得到了不同程度的改善。结论：经蝶窦鼻内镜垂体腺瘤切除术方法简便，微创，术中视野清晰，是垂体瘤切除的良好方法之一。     

经蝶窦鼻内镜下垂体腺瘤切除术28例临床分析

目的:探讨垂体腺瘤经蝶窦鼻内镜下切除的可行性及方法。方法:回顾分析１９９６年４月~２０００年４月２８例患者接受经蝶窦鼻内镜垂体腺瘤切除手术治疗的治疗效果。全麻下选择肿瘤主体侧及蝶窦发育好的一侧鼻腔进路,将中鼻甲后端１/３切除,沿蝶窦开口扩大蝶窦前壁开口,切开蝶窦粘膜,打开并扩大鞍底,切开硬脑膜,用小刮匙或筛窦钳将肿瘤细心切除。结果:２８例中２６例得到了全部切除,１例巨大垂体瘤大部切除后,放射治疗。另１例部分切除后用溴隐停药物治疗。随访１年~４年,症状得到了不同程度的改善。结论:经蝶窦鼻内镜垂体腺瘤切除术方法简便、微创、术中视野清晰,是垂体瘤切除的良好方法之一。     

鼻内镜下蝶窦手术入路及超越蝶窦腔病变的处理

目的：探讨蝶窦及鞍区更直接的手术径路,结合影像学资料对超越蝶窦范围的相关疾病进行适当处理,防止严重并发症的发生。方法：在鼻内镜下,分别采用经前筛-后筛-蝶窦、经上鼻道-后筛-蝶窦、经鼻中隔-蝶窦以及直接以后鼻孔上缘为标志经蝶窦前壁自然口进入蝶窦等途径,对46例蝶窦占位并蝶窦骨壁破坏的病变进行处理。结果：蝶窦囊肿及脓囊肿21例,经上鼻道径路处理后痊愈;蝶窦内血肿机化1例,经上鼻道径路清除;蝶窦内血肿并颈内动脉假性动脉瘤3例,1例术中探查发生致命性大出血,后经血管内介入治疗后痊愈,其余2例仅作鼻内镜检查,经DSA证实并行血管内介入治疗后治愈;蝶窦乳头状瘤4例,均行蝶窦自然开口径路,3例治愈,1例因广泛侵犯蝶窦外侧壁仅部分切除;蝶窦胆脂瘤2例,经上鼻道入路完整切除;蝶窦内脑膜脑膨出1例,经蝶窦前壁自然口打开蝶窦,经穿刺抽出脑脊液,手术停止并加固修补暴露脑膜;蝶窦真菌病1例,经上鼻道径路清除蝶窦内病变并联合抗真菌治疗后痊愈;蝶窦恶性肿瘤3例,经前后筛径路切除蝶窦内大部分肿瘤,后辅以放化疗;鼻咽癌侵入蝶窦5例,病理检查证实后行放化疗;垂体瘤术后蝶窦脑脊液鼻漏并肉芽增生5例,经上鼻道或鼻中隔径路均一次修补成功。结论：鼻内镜下处理蝶窦及蝶窦相关疾病径路多样,适当选择径路可达到直接、安全、微创等目的。术前蝶鞍CT薄层扫描、三维重建以及DSA是防止超越蝶窦范围病变手术并发症发生的有效手段之一。     

经蝶窦进路显微手术适应证的探讨

对２５８例蝶鞍区及其周围的肿瘤患者采用经蝶窦进路显微手术治疗，均获成功，无一例术中死亡；随访１０４例，１９例复发。对此术式的适应证进行讨论，认为，除垂体瘤外，还应包括视神经管外伤性骨折，颅咽管瘤，空蝶鞍综合征，蝶鞍脊索瘤，蝶窦、筛窦低分化鳞癌和转移癌，蝶窦囊肿及海绵窦脓肿等；提出，甲介型蝶窦不应列为本术式的绝对禁忌证。     

孤立性真菌球性蝶窦炎的诊断和治疗

目的 总结孤立性真菌球性蝶窦炎的临床特征及其诊断与治疗经验.方法 回顾性分析12例孤立性真菌球性蝶窦炎的临床资料及鼻内镜手术后的随访结果,总结本病诊断与治疗的临床经验与体会.结果 所有病例中,表现头痛或眼部疼痛者9例(75％),涕中带血3例(25％).CT扫描均表现为窦腔高密度影,窦内有斑点状或条块状钙化影者10例(83％).12例均在鼻内镜下手术治疗.术后随访6～24个月,术腔黏膜康复良好,无病变复发.结论 孤立性真菌球性蝶窦炎临床症状无诊断特异性,CT扫描是诊断本病的主要影像学方法,鼻内镜下经蝶窦前壁自然口的术式应为首选手术方法.     

孤立性真菌性蝶窦炎的影像学特征与鼻内镜手术治疗

目的：探讨孤立性真菌性蝶窦炎的影像学特征和鼻内镜手术效果。方法：16例患者术前行CT检查,均提示窦腔内有片状破棉絮样或充满型或肿块状软组织阴影,软组织阴影中有斑点状高密度影;以鼻内镜手术扩大蝶窦口,彻底清理蝶窦腔内病灶。结果：16例手术经过均顺利,术中平均每例出血15～30ml,11例术后症状立即缓解;未出现明显的手术并发症。随访3～9个月,治愈15例,蝶窦前壁开放通畅,窦腔各壁光滑,无异常分泌物。好转1例,窦腔内有少量分泌物潴留,窦口黏膜水肿,经蝶窦腔冲洗及辅舒良喷鼻后好转。结论：CT对真菌性蝶窦炎的确诊有独特的价值,鼻内镜手术治疗本病,可直接开放蝶窦腔,直达病变区处理病灶,具有手术距离短、创伤小、出血少等优点。     

188例垂体瘤手术治疗分析

自从1907年Schoffer氏第一次经蝶窦进路成功地摘除一例垂体腺瘤之后,在较长的一段时间内垂体瘤的手术进路一直是按照Cushing氏所倡导的低位鼻蝶窦进路或Olivecrona的颅内额下进路。近年来由于光镜与电镜的进展,内分泌学与生物学检验的日趋完善,CT的应用,使垂体瘤的诊断准确性大大提高。又由于手术所需设备的更新及手术技术的改进,鼻蝶窦进路垂体瘤手术遂被广泛采用。本文系对经治的188例患者的系统分析报道。【临床分析】一、发病情况:188例中,女性122例(64.8%),男性66例(35.2%)。女性多见系因近5年来催乳腺瘤能早期诊断之故。患者年龄最小者15岁,最长者60岁,平均为42岁半。二、视觉症状:出现视觉症状者共119例(63.3%),其中90人次有视野缺损(一侧或双     

侵入鞍上区的巨大垂体瘤经蝶窦手术致死二例

侵入鞍上区的巨大垂体瘤经蝶窦手术致死二例姜加维，林武延，张萍，赵燕我科自１９８４～１９９３年经鼻中隔蝶窦行垂体肿瘤切除术共３４例，其中２例巨大垂体瘤术后２～３天内死亡，作为教训报道如下。例１女，５０岁。５年前开始视力减退，头痛，近１年来加重，有时伴恶...     

鼻内镜下修补垂体瘤术后迟发性脑脊液鼻漏

目的 总结经蝶窦入路垂体瘤术后并发迟发性脑脊液鼻漏的原因,探讨鼻内镜下经蝶窦人路脑脊液鼻漏的修补方法.方法 回顾性分析11例经蝶窦入路垂体瘤术后并发迟发性脑脊液鼻漏患者临床资料,分析术后并发脑脊液鼻漏的原因、部位和鼻内镜手术修补情况.结果 11例患者中,7例予自体脂肪、肌肉、游离中鼻甲黏膜瓣分别修补成功;4例予自体肌肉...     

计算机辅助内镜鼻窦手术：一项回顾性对照研究

内镜鼻窦手术是慢性鼻．鼻窦炎患者首选治疗方法,并且在其他鼻窦、眼眶及颅底疾病的处理上正发挥越来越大的作用。尽管先进的鼻内镜和高分辨率的术前CT的应用,但是严重的并发症诸如失明,中枢神经系统的损伤,甚至死亡仍有发生,这是因为内镜鼻窦手术可能受限于解剖结构的复杂性或术中的出血。最近,计算机辅助手术技术已经实现术中解剖结构和术前影像学资料直接对比。在记录和校准之后,术者可以在计算机辅助手术设备支持下指向特定的结构,然后锁定CT影像上该设备顶端的位置。这种计算机辅助手术系统可以获得更精准的手术切除和更高的鼻窦通畅率以及更少的并发症出现的效果雄。笔者把使用计算机辅助手术的经验应用到术中导航中,并且就手术的安全性、持续时间、并发症以及手术结果几方面将它同无导航的手术进行了比较。     

蝶窦外侧隐窝真菌球的临床特征及手术治疗

目的探讨蝶窦外侧隐窝真菌球的临床特征及经鼻内镜下手术的疗效。方法回顾性分析2005年2月～2011年2月收治的21例蝶窦外侧隐窝真菌球患者的临床资料及手术后的随访结果。所有蝶窦外侧隐窝真菌球患者中,颞部头痛或眼外侧胀痛患者14例;涕中带血5例、视力下降2例。均行鼻内镜蝶窦开放手术,其中12例经嗅裂蝶窦开口处入路,5例经蝶窦前下壁开窗人路,4例经翼突根部入路。结果术中及术后所有患者均无并发症发生。术后随访12～24个月,21例患者临床症状均消失,术腔黏膜生长良好,蝶窦口开放良好,无复发病例。结论鼻窦CT检查有助于蝶窦外侧隐窝真菌球的诊断,鼻内镜手术具有微创和病灶获得彻底清除的优点,对于防止术后复发具有重要的意义。     

Approaches to sella turcica in endoscopic pituitary surgery

Recent advances in endoscopic sinus surgery suggested the potential for its surgical application to pituitary surgery. A number of institutions have reported the advantage of endoscope use in pituitary surgery, which is now widely accepted, but approaches to the sella vary in the literature. We retrospectively studied sella approaches in endoscopic pituitary surgery as rhinologists. Subjects included 6 cases of pituitary adenoma and 2 cases of Rathke's cleft cyst. A both-nostril transnasal transsphenoidal approach, our standard technique, was used in 6 cases. This approach consisted of elevation of mucoperiosteal flaps, resection of the vomer and sphenoid anterior wall, and opening of the sellar floor. Elevated mucoperiosteal flaps were used to close of the sella after tumor resection. All tumors were removed and no significant postoperative complications occurred. We found the both-nostril transnasal approach to be easy and time-saving and provided surgeon with a broad surgical field necessary to treat large tumors and accidental cases. Postoperative observation of the sella was easy for wide opening of the anterior wall of the sphenoid sinus. In our experience with reoperation, we quickly accessed the sella and easily removed tumors in the second operation. Our technique therefore has an advance in treatment of recurrence. The both-nostril transnasal approach involves the same procedures as median drainage of the sphenoid sinus, so our technique may have advantages in preventing mucocele of the sphenoid sinus as a late complication of transsphenoidal surgery. The transnasal transsphenoidal approach via both nostrils is preferable rhinologically.     

Chronic sphenoid sinusitis revisited: comparison of multidetector axial sections, multiplanar reconstructions, and virtual sinoscopy with endoscopic sinus surgery

OBJECTIVES: To assess the role of multidetector computed tomography (CT) and CT virtual sinoscopy in the evaluation of chronic sphenoid sinusitis and to compare the imaging findings with functional endoscopic sinus surgery. DESIGN: Prospective study. SETTING: Tertiary care teaching hospital. PATIENTS: Thirty patients with chronic sphenoid sinusitis referred for preoperative CT. INTERVENTIONS: Thin-section helical axial CT was performed using a multidetector CT scanner with multiplanar reformation (MPR) and volume-rendered or virtual sinoscopy images. Sixty sinuses were divided into quadrants for analysis. Extrasinus extension was labeled as the "fifth quadrant." MAIN OUTCOME MEASURES: Imaging findings were compared with those of functional endoscopic sinus surgery, and accuracy of the imaging modality was determined. RESULTS: Multidetector CT (axial CT and MPR) was found to be 100% sensitive, specific, and accurate in the evaluation of extent of sinusitis, status of the sinus septum, integrity of the optic nerve canal in relation to the sinus, and type of sinus pneumatization. Axial CT and MPR images showed sensitivity of 98% and specificity of 92% compared with functional endoscopic sinus surgery in evaluating the ostia. Regarding carotid canal integrity, axial CT and MPRs were 100% sensitive and 98% specific. Virtual sinoscopy showed sensitivity and specificity of 67% and 92%, respectively, for the 22 ostia that could be visualized and evaluated using this modality. CONCLUSIONS: Axial multidetector CT with secondary MPRs provide the necessary preoperative information regarding extent of disease and sphenoid sinus anatomy. Virtual sinoscopy is a navigational aid, an adjunct to endoscopy, and an educational tool for surgeons-in-training.     

鼻内镜下扩大的经鼻腔蝶窦入路治疗鞍周病变的解剖研究和临床应用

目的：通过扩大的经鼻腔蝶窦人路的内镜解剖学研究和初步临床应用,为扩大的经鼻腔蝶窦手术适应证及范围提供理论依据。方法：在4具(8侧)已经染料动脉灌注的成人尸头上模拟扩大经鼻腔蝶窦手术入路,同时测量海绵窦旁重要结构与鞍底的距离。结果：根据蝶窦后壁的骨性结构特征将蝶窦腔分为1个中间腔、2个旁中间腔及2个外侧腔。扩大经蝶手术入路可清晰显示鞍底骨膜、硬脑膜外层、海绵窦内侧壁、海绵窦内颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍隔及视丘下部等解剖结构。临床初步用于治疗1例巨大侵入海绵窦的生长激素型垂体腺瘤患者,取得了较好的手术效果。结论：内镜扩大经鼻腔蝶窦手术入路可清晰显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗,但应熟练掌握内镜鞍周解剖学及熟练的经鼻腔蝶窦手术经验。     

经鼻内镜蝶鞍区手术蝶窦壁的应用解剖

目的研究蝶窦壁相关解剖结构的分区及空间定位，为经鼻内镜蝶鞍区手术提供立体解剖学依据。方法10具去脑颅底骨按九分区法划分蝶窦壁区域，测量蝶窦各壁之间相关的角度和距离参数；在1具新鲜完整尸头上模拟内镜下手术观察。结果视交叉平面-球形鞍底隆起角度为（121±8．52）°，海绵窦平面一鞍底平面角度为（129±9．35）°，斜坡凹陷平面-鞍底平面角度（124±7．54）°，颈内动脉视神经隐窝至鞍底移行处距离为（5．54±1．86）mm，至斜坡后缘的距离为（22．43±1．96）mm，至颈内动脉海绵窦段后曲部的距离为（15．86±2.13）mm；根据测量结果可建立起蝶窦壁九分区法的立体模型。结论蝶窦壁九分区法的立体模型，丰富了鼻内镜下蝶窦壁九分区法的内容，使其更加方便应用于手术。     

Computer-aided image-guided endoscopic sinus surgery in unusual cases of sphenoid disease

The vital neurovascular structures that border the sphenoid sinus make extensive sphenoid sinus surgery hazardous despite the advent of endoscopic sinus surgery (ESS). Computer-aided image-guided endoscopic sinus surgery (CAIGESS) has facilitated safer surgery by providing real-time analysis of complex, three-dimensional anatomic landmarks. We present 6 cases of atypical sphenoid disease, which greatly benefited from the unique superiority of CAIGESS in avoding surgical complications. Two cases of cerebrospinal-fluid (CSF) leak with concomitant meningoencephalocele of the sphenoid sinus were successfully managed with this technique. An inverting papilloma originating from the sphenoid sinus was successfully exenterated using CAIGESS. One patient, who experienced a lateral-rectus muscle palsy from sphenoid sinusitis, underwent successful sinusotomy with CAIGESS. Another patient, who had refractory left-sided sphenoid sinusitis despite 2 ESS procedures, was found to have an obliquely oriented intersinus septum which misled the previous surgeons to enter mistakenly the contralateral sphenoid sinus. CAIGESS allowed accurate identification and removal of the intersinus septum and relief of the sinusitis. Finally, a sphenoid-sinus mucocele that developed after a prior pituitary surgery was safely decompressed with CAIGESS. This surgical approach offers a new and effective adjunct to ESS in selected revision or difficult sinus cases and has proven invaluable in complicated sphenoid cases where the surrounding neurovascular anatomy could otherwise be jeopardized.     

孤立性蝶窦疾病的诊断及其鼻内镜手术治疗

目的：探讨孤立性蝶窦疾病的临床特点、影像学特征和鼻内镜手术的疗效。方法：38例孤立性蝶窦疾病患者,35例行鼻窦CT（其中5例同时行MRI）,3例行单纯鼻窦MRI,1例行脑池CT造影。所有患者均行鼻内镜下蝶窦开放术,其中有33例采用经鼻腔嗅裂径路,5例采用经前筛一后筛径路（即Messerklinger技术）。结果：术后随访6个月以上,34例病情完全控制,4例部分控制。术中和术后均未出现严重并发症。结论：孤立性蝶窦疾病临床症状不典型,无特异性,鼻部检查多无阳性体征,仅有以头痛为主诉的神经系统症状,早期常难以确诊。鼻窦CT和MRI是诊断孤立性蝶窦炎的最佳手段,而鼻内镜手术则是治疗该病的首选方法。     

Analysis of sphenoid sinus in the operative plane of endoscopic transsphenoidal surgery using computed tomography

Recently, the endoscopic transsphenoidal approach for sphenoid sinus or intracranial lesion has gained more popularity and the study of the surgical anatomy and relationships of the sphenoid sinus has gained increased significance. The aim of this study was to clarify the anatomical features of the sphenoid sinus including surrounding structures as seen in the operative view of endoscopic transsphenoidal surgery. The various distances in the sphenoid sinus as well as the relationships between the sphenoid sinus ostium (SO) and important structures such as the optic canal (OC) and carotid artery (CA) according to the presence of Onodi cell (sphenoethmoidal cell; Onodi group vs. non-Onodi group) were assessed using multiplanar and three-dimensional model of CT scans in 100 patients. The SO was more inferior in Onodi group and located superior to the lowest point of the sella. The horizontal distance from the SO to sella was approximately 13 or 14 mm depending on the existence of Onodi cells. Regardless of Onodi cell, the whole course of the OC in the sinus ran superolaterally to inferomedially in the endoscopic view. However, Onodi cell made the angles from the SO to OC larger. In Onodi group, the CA was located from the SO in a superolateral direction, but in non-Onodi group, the CA was located from the SO in the inferolateral direction. This study provides anatomical information about the sphenoid sinus, with important surgical distances between the SO and surrounding structures measured, which is essential to avoid complications during transsphenoidal surgery.     

真菌球型真菌性鼻窦炎的CT特征及诊断

目的探讨真菌球型真菌性鼻窦炎的CT特征及其在临床中的诊断意义。方法选择2006年8月～2008年5月行鼻内镜手术治疗并经组织病理学检查证实为真菌球型真菌性鼻窦炎的25例患者,对其临床资料及影像学资料进行总结,并以组织病理学结果作为标准分析评价CT扫描对真菌球型真菌性鼻窦炎的诊断价值。结果24例（96%）均为单侧单窦病变,1例（4%）为双侧单窦病变;上颌窦占92%,蝶窦占8%。真菌球型真菌性鼻窦炎CT表现：病变鼻窦内全部充满软组织密度影,密度不均匀的软组织影53.8%,密度均匀的软组织影46.2%;钙化斑或点68.0%。病变鼻窦骨质增生硬化100%,病变上颌窦窦口或内侧壁骨质受压吸收破坏72.0%。此外还有上颌窦口阻塞并扩大（72.0%）及液平面、气泡等（32.0%）。鼻窦CT扫描术前诊断的总体准确率为84.0%。结论真菌球在鼻窦CT除表现为特征性的密度不均匀软组织影及钙化斑或点外,还可表现为密度均匀的软组织影,并同时可伴有骨质增生硬化、窦口阻塞并扩大及上颌窦口和（或）内侧壁骨质受压吸收破坏等。CT扫描对真菌球型真菌性鼻窦炎的术前筛选及诊断有着十分重要的作用,但最终确诊仍需依据组织病理学检查。