经鼻内镜切除良性鼻-颅底肿瘤（附11例报告）

目的探讨鼻内镜下切除良性鼻-颅底肿瘤的疗效。方法 2004年3月～2009年11月对11例良性鼻-颅底肿瘤,鼻内镜下先切除鼻腔鼻窦肿瘤,逐渐接近颅底,仔细辨认颈内动脉等重要解剖结构,然后分块切除肿瘤,最后修复颅底缺损。结果 11例鼻-颅底肿瘤鼻内镜下全部切除,术中出血量100～450 ml,平均175 ml;手术时间105～210 min,平均146 min。术后未出现脑脊液鼻漏、细菌性脑膜炎等并发症。病理类型：巨大筛额窦囊肿2例,鼻咽纤维血管瘤3例,上颌窦内翻性乳头状瘤3例,蝶窦骨化纤维瘤1例,翼腭窝神经鞘瘤1例,侧颅底炎性肌母细胞瘤1例。11例随访6～58个月,平均41个月,鼻窦CT扫描和鼻内镜复查无肿瘤局部复发。结论鼻内镜手术利于辨别颅底重要的解剖结构和肿瘤的彻底切除,是治疗鼻-颅底良性肿瘤的理想方法。     

鼻内镜治疗101例颅底疾病研究

目的探讨鼻内镜径路治疗颅底疾病的价值。方法选择2009年11月～2011年2月笔者所在医院收治的101例颅底疾病行鼻内镜径路手术患者,观察术后疗效。结果各种颅底疾病手术时间、手术出血量、随访时间,复发情况及并发症发生略有不同。其中脑脊液鼻漏复发均为采取第1次手术未修补成功而复发,采取第2次手术修补均成功,随访期间未见复发。结论鼻内镜径路可以处理多种颅底疾病,是一种安全、有效、微创的手术方式,但仍需严格掌握手术适应证,特别是恶性肿瘤。     

鼻腔及鼻窦内翻性乳头状瘤不同手术方式的选择

目的探讨鼻腔及鼻窦内翻性乳头状瘤手术方式的选择。方法 2005年10月~2012年9月104例鼻腔及鼻窦内翻性乳头状瘤根据病变范围和分期情况,分别采用中鼻道径路鼻内镜手术、联合尖牙窝径路鼻内镜手术及联合柯陆径路鼻内镜手术3种手术方法。结果中鼻道径路鼻内镜手术时间(68±8)min,出血量(93±17)ml;联合尖牙窝径路手术时间(89±19)min,出血量(162±28)ml;联合柯陆径路手术时间(112±18)min,出血量(206±36)ml。3种术式术中均彻底切除肿瘤,无并发症发生。104例术后随访16~36个月,平均24个月,中鼻道径路复发4例,联合尖牙窝径路复发2例,联合柯陆径路复发2例,总复发率7.7%(8/104)。结论鼻内镜手术是治疗鼻腔及鼻窦内翻性乳头状瘤安全、有效的方法。     

鼻内翻性乳头状瘤手术径路的选择与疗效

目的探讨鼻内镜及鼻内镜联合径路治疗鼻内翻性乳突状瘤的疗效。方法回顾性分析我科2002年1月～2010年9月有随访资料的鼻内翻性乳头状瘤45例,按Krause分期T1期2例和他期32例采用单纯鼻内镜术,T3期10例采用鼻内镜联合柯-陆氏术式,T3期1例采用鼻内镜联合鼻侧切开术。结果45例平均随访3．5年（6个月-9年）,5例术后复发,复发率为11．1％。结论鼻内镜术治疗鼻内翻性乳头状瘤是一种有效的方法。Krause T1、T2期肿瘤可采用单纯鼻内镜术,Krause T3期肿瘤可采用鼻内铺联合传统手术径路。     

鼻内镜下真菌性蝶窦炎手术治疗分析

目的探讨真菌性蝶窦炎的治疗方式及预防复发的方法。方法对19例真菌性蝶窦炎患者在鼻窦内窥镜下行蝶窦开放及引流术。术后鼻内镜下清理术腔,定期复查随访。结果 19例真菌性蝶窦炎患者术后随访12个月,其中18例痊愈,I期治愈率94.73%。复发1例,行全麻鼻内镜下再次手术后治愈。未发生其他术后并发症。结论真菌性蝶窦炎鼻内镜下术中充分扩大开放自然口,彻底清除窦口及窦腔病变物,保留正常窦腔黏膜,定期复查换药随访,有利于抑制复发,提高临床治愈率。     

鼻内镜下切除鼻腔鼻窦内翻性乳头状瘤的临床分析

目的探讨经鼻内镜手术切除鼻腔鼻窦内翻性乳头状瘤的疗效。方法对2002年6月～2007年6月笔者所在医院在鼻内镜下切除鼻腔鼻窦内翻性乳头状瘤11例患者和同期行鼻侧切开术治疗鼻腔鼻窦内翻性乳头状瘤11例患者进行回顾性比较研究。所有患者系Ⅰ期和Ⅱ期病例。结果在鼻内镜下治疗的11例患者中,10例一次性手术完全切除,1例15个月复发再手术治愈。在鼻侧切开术下治疗的11例患者中1例恶变,6例一次性手术完全切除,2例术后发现残留,予以微波处理,2例分别手术后6个月和12个月复发,均再手术治愈。所有病例均随访3年,均未再复发。结论内镜下切除鼻腔鼻窦内翻性乳头状瘤,具有视野清晰、损伤小、面部无瘢痕、患者康复快,术后换药方便等特点。     

鼻内镜下鼻腔蝶窦径路垂体腺瘤切除术

目的探讨鼻内镜下经鼻腔蝶窦径路切除垂体腺瘤的疗效。方法 2002年9月～2008年9月,22例垂体腺瘤在鼻内镜下经扩大的嗅裂暴露蝶窦前壁,打开并扩大蝶窦开口,再行鞍底开窗,切开硬脑膜暴露肿瘤后用刮匙及取瘤钳逐块切除肿瘤。结果完全切除肿瘤19例(86.4%),次全切除(90%切除)3例(13.6%)。术中2例出现轻度脑脊液鼻漏,同期修补术后恢复良好;术后2例出现尿崩,经保守治疗1周内痊愈。22例术后随访6～60个月,平均21.6月,术后头痛、闭经泌乳和视力障碍等临床症状均有不同程度缓解,复发1例,复发率4.5%(1/22),再次手术后未再复发。结论鼻内镜下经鼻腔蝶窦径路具有良好的术野,该方法切除垂体腺瘤安全有效。     

鼻腔鼻窦内翻性乳头状瘤患者鼻内镜术后复发的危险因素分析

目的 探讨并分析鼻腔鼻窦内翻性乳头状瘤患者鼻内镜术后复发的危险因素。方法 选择本院2018年11月至2022年11月62例鼻腔鼻窦内翻性乳头状瘤术后患者作为研究对象,将术后1年复发的15例作为复发组,将未复发的47例作为未复发组。比较两组患者的年龄、性别、吸烟、饮酒、鼻部手术史、肿瘤发生部位、病程、Krouse分期情况,并采用逻辑（Logistic）回归分析影响鼻腔鼻窦内翻性乳头状瘤患者鼻内镜术后复发的危险因素。结果 两组患者的年龄、性别、饮酒、病程比较,差异无统计学意义（P>0.05）;鼻腔鼻窦内翻性乳头状瘤患者鼻内镜术后复发与吸烟、鼻部手术史、肿瘤发生部位、Krouse分期有关（P<0.05）;经Logistic回归分析结果显示,吸烟、鼻部手术史、肿瘤发生部位、Krouse分期均是影响鼻腔鼻窦内翻性乳头状瘤患者鼻内镜术后复发的危险因素（P<0.05）。结论 鼻内镜术后,吸烟、手术史、肿瘤位置及Krouse分期是鼻腔鼻窦内翻性乳头状瘤复发的危险因素,需要对这些危险因素进行临床干预,以减少术后复发。     

内镜经鼻蝶切除伴有蝶窦气化不良的鞍区病变

目的探讨单鼻孔内镜下经鼻蝶切除伴有蝶窦气化不良的鞍区病变的方法。方法 2007年1月～2009年1月,内镜下经鼻蝶切除伴有蝶窦气化不良的15例鞍区病变,其中鞍前型蝶鞍8例,甲介型5例,骨性病变填塞蝶窦2例。结果无手术死亡病例,肿瘤全切12例(80.0%),次全切2例(13.3%),部分切除1例(6.7%)。病理类型包括垂体瘤12例(巨大腺瘤3例,大腺瘤7例,微腺瘤2例),脊索瘤2例,骨纤维结构不良1例。经1～3年随访(平均2.1年),术后复发1例,术后垂体功能低下1例。结论内镜经鼻蝶手术适用于大部分伴有蝶窦气化不良的病例,且效果良好。     

神经内镜辅助下创伤性脑脊液鼻漏的治疗

目的探讨神经内镜辅助下创伤性脑脊液鼻漏修补的手术方法 ,并就相关问题进行讨论。方法神经内镜下经鼻手术修补创伤性脑脊液鼻漏19例,术前根据临床表现、实验室检查、辅助以颅底CT扫描、脑池造影等获得诊断,采用自体阔筋膜片修补颅底缺损。结果 19例患者中18例术后当时均无脑脊液鼻漏,1例术后复发经保守治疗治愈。手术成功率为94.7%。所有患者均无新出现的神经功能缺失。所有病人经随访1~3年均未再次出现脑脊液漏。结论神经内镜下创伤性脑脊液鼻漏修补术创伤小、直观、手术成功率高,可以作为首选手术方法。     

Long-Term Outcome of Endonasal Endoscopic Skull Base Reconstruction with Nasal Turbinate Graft

Objective: To study the long-term outcome of endonasal endoscopic skull base reconstruction with nasal turbinate tissue free graft. Patients and Methods: This study included 55 consecutive patients who underwent endonasal endoscopic skull base reconstruction with nasal turbinate graft and were available for follow-up. They were 30 patients with pituitary adenomas, 20 with cerebrospinal fluid (CSF) rhinorrhea of different etiologies, three with meningoencephalocele, and two with skull base meningiomas. Autologous nasal turbinate tissue materials were used in reconstructing the skull base defect. Clinical follow-up with endoscopic nasal examination was done routinely 1, 3, 6, and 12 months after surgery. Computed tomography and magnetic resonance imaging were performed when indicated. The follow-up period ranged from 6 months to 8 years. Results: There were no major operative or postoperative complications. Nasal turbinate graft was effective in sealing of intraoperative CSF leak, obliteration of dead space, and anatomic reconstruction of the skull base. There was no evidence of graft migration or inflammatory changes. Starting from 3 months after surgery to the rest of the follow-up period, endonasal endoscopic view of the site of duraplasty showed that: with small skull base defect (less than 5 mm), there was neither dural pulsation nor prolapse; with moderate-sized defect (5 to 10 mm), there was dural pulsation without prolapse; with larger defect (>10 mm), there was dural pulsation and prolapse. These finding were constant regardless of the etiology of the lesion and the reconstruction material used. Conclusions: This long-term study demonstrated the efficacy of nasal turbinate graft in sealing of CSF leak without any delayed complications. Other rigid materials may be considered in reconstruction of large skull base defect (more than 10 mm) to prevent dural prolapse and herniation. For any future endonasal procedure for those patients, who had previous endonasal endoscopic duraplasty, the surgeons should be fully aware of the state of duraplasty (e.g., dural prolapse) to avoid any intraoperative complication (e.g., penetration of the prolapsed dura during nasal packing).     

A new multilayer reconstruction using nasal septal flap combined with fascia graft dural suturing for high-flow cerebrospinal fluid leak after endoscopic endonasal surgery

This study aimed to evaluate the usefulness and reliability of a new endoscopic multilayer reconstruction using nasal septal flap (NSF) to prevent high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. This study was a retrospective review on 97 patients who underwent multilayer reconstructions using NSF combined with fascia graft dural suturing after endoscopic endonasal surgery between July 2012 and March 2014. Patients were divided into two groups, third ventricle opening group and nonopening group, based on the presence of a direct connection between the third ventricle and the paranasal sinus after tumor removal. Furthermore, we compared this procedure with our previous reconstruction after resection of craniopharyngioma. Finally, we checked the patients who had postoperative prolonged discomfort of the nasal cavity for over a year. Postoperative cerebrospinal fluid (CSF) leak occurred in three patients (3.1 %): one from the third ventricle opening group and the remaining two from the nonopening group. External lumbar drain was performed after surgery in only seven patients (7.2 %). The incidence of postoperative CSF leak was similar in both groups, whereas the rate of craniopharyngioma in the third ventricle opening group was significantly higher. The incidence of postoperative CSF leak after resection of craniopharyngioma was not statistically significant but obviously higher in the previous group (12.2 %) compared with that in the present group (2.3 %). Twelve patients (12.4 %) had postoperative nasal discomfort of the nasal cavity for over a year. Multilayer reconstruction using NSF combined with fascia graft dural suturing is a more reliable method for preventing postoperative high-flow CSF leakage after endoscopic endonasal surgery even if there is a direct connection between the third ventricle and the paranasal sinus. However, we should pay close attention especially to prolonged discomfort of the nasal cavity after harvesting NSF.     

Endoscopic Endonasal Transclival Approaches: Case Series and Outcomes for Different Clival Regions

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution''s experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.     

Endonasal endoscopic repair of cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea implies a communication between the subarachnoid space and the upper respiratory tract. Trauma and postoperative defects are the more common causes of CSF rhinorrhea. The authors review their results with endoscopic repair of skull base defects associated with CSF rhinorrhea involving the paranasal sinuses. A total of 10 patients, 7 males and 3 females, were treated under endoscopic vision from 1997 to 2001. The causes of CSF rhinorrhea were traumatic (7), postoperative (2) and spontaneous (1). Four patients had the diagnosis and the site confirmed after intrathecal fluorescein-saline injection. The obliteration of the CSF leak was achieved with fat free, mucoperichondrial, or mucoperiostal free grafts taken from the middle or inferior turbinate and kept in place by fibrin glue. Primary closure was obtained in 10 patients and one patient developed a recurrence 14 months later. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, very effective and is a valid alternative to the cranial approach.     

Unilateral endoscopic approach for repair of frontal sinus cerebrospinal fluid leak

Cerebrospinal fluid (CSF) leak closure remains one of the most difficult surgeries for skull base surgeons, particularly with frontal sinus involvement. Technological advances in endoscopic surgery increasingly allow for less morbid approaches to the frontal sinus. We describe a series of patients who underwent endoscopic frontal sinus CSF leak repair utilizing a unilateral approach, to evaluate the utility and outcomes of this method. We performed a retrospective review of four cases in tertiary care centers. Participants included patients with CSF leak involving the frontal sinus. Main outcome measures included cessation of CSF leak and frontal sinus patency. Three patients were closed on the first surgical attempt; one with a communicating hydrocephalus required a revision procedure. Leak etiologies included prior craniotomy for frontal sinus mucopyocele, spontaneous meningoencephalocele, erosion due to mucormycosis, and prior endoscopic sinus surgery. The frontal sinus remained patent in three of four patients. No patients have evidence of a leak at a minimum of 1 year after surgery. The repair of frontal sinus CSF leaks is possible in specific cases with an endoscopic unilateral approach in leaks with multiple etiologies. Surgeons should consider this approach when selecting the appropriate procedure for repair of frontal sinus CSF leaks.     

Frontal skull base surgery combined with endonasal endoscopic sinus surgery

BACKGROUND: Postoperative infection remains a serious complication after radical resection of anterior skull base lesions because intracranial, nasal, and paranasal cavities are opened during surgery. To prevent complications from postoperative infection, we combined endonasal endoscopic sinus surgery (ESS) with the frontal transbasal approach in patients with skull base lesions. METHODS: Patients (n = 16) with anterior skull base lesions extending to the paranasal or nasal cavity underwent surgical resection via the frontal transbasal approach. After removal of the lesion via the transcranial approach, enlargement of the ostium or sinusotomy was performed bilaterally using our endonasal ESS procedure. The main purpose of ESS is the establishment of a wide drainage route to avoid dead space and postoperative infection. Furthermore, we confirmed the absence of residual lesion and leakage of cerebrospinal fluid (CSF), endoscopically. RESULTS: The frontal transbasal approach combined with endonasal ESS was performed in 16 patients with frontal skull base lesions. There were 8 malignant tumors, 6 benign tumors, and 2 mucoceles. Although 11 patients had preoperative active paranasal sinusitis, most frequently at the ethmoid sinus, none experienced postoperative infection. There was no complication related to ESS procedure. Furthermore, leakage of CSF and extracranial residual tumor were not found. CONCLUSION: Endonasal ESS after frontal skull base surgery is a highly useful technique for preventing postoperative infection, especially for the cases with large skull base tumors extending into other regions involving the paranasal sinuses or nasal cavity and with active paranasal sinusitis.     

How to Choose? Endoscopic Skull Base Reconstructive Options and Limitations

As endoscopic skull base resections have advanced, appropriate reconstruction has become paramount. The reconstructive options for the skull base include both avascular and vascular grafts. We review these and provide an algorithm for endoscopic skull base reconstruction. One hundred and sixty-six skull base dural defects, reconstructed with an endonasal vascular flap, were examined. As an adjunct, avascular reconstruction techniques are discussed to illustrate all options for endonasal skull base reconstruction. Cerebrospinal fluid (CSF) leak rates are also discussed. Small CSF leaks may be successfully repaired with various avascular grafting techniques. Endoscopic endonasal approaches (EEAs) to the skull base often have larger dural defects with high-flow CSF leaks. Success rates for some EEA procedures utilizing avascular grafts approach 90%, yet in high-flow leak situations, success rates are much lower (50 to 70%). Defect location and complexity guides vascularized flap choice. When nasoseptal flaps are unavailable, anterior/sellar defects are best managed with an endoscopically harvested pericranial flap, whereas clival/posterior defects may be reconstructed with an inferior turbinate or temporoparietal flap. An endonasal skull base reconstruction algorithm was constructed and points to increased use of various vascularized reconstructions for more complex skull base defects.     

Primary closure of a cerebrospinal fluid fistula by nonpenetrating titanium clips in endoscopic endonasal transsphenoidal surgery: technical note

Postoperative cerebrospinal fluid (CSF) leakage is one of the most common and aggravating complications in transsphenoidal surgery. Although primary closure of the fistula would be the most desirable solution for an intraoperatively encountered CSF leak, it is difficult to achieve in such a deep and narrow operative field. In this article, the authors report endonasal endoscopic applications of no-penetrating titanium clips to repair a CSF fistula following tumor removal. The AnastoClip Vessel Closure System (VCS; LeMaitre Vascular, Boston, MA) was used for closure of a CSF fistula in endonasal transsphenoidal surgery. In all four patients, CSF leakage was successfully obliterated primarily with two to five clips. There was no postoperative CSF rhinorrhea or complications related to the use of the VCS. Metal artifact by the clips on postoperative images was tolerable. Primary closure of the fistula using the VCS was an effective strategy to prevent postoperative CSF leakage in transsphenoidal surgery. Future application can be expanded to reconstruction of the skull base dura via endonasal skull base approaches.     

显微镜下吲哚菁绿荧光造影对带蒂鼻中隔黏膜瓣活性的预测价值

目的:探讨术中显微镜下吲哚菁绿荧光造影(ICGA)技术在内镜颅底重建手术中预测带蒂鼻中隔黏膜瓣活性的价值。方法:选取河南省人民医院2019年1月至2020年6月行内镜经鼻颅底手术且应用带蒂鼻中隔黏膜瓣行颅底重建患者36例,颅底重建时切换为显微镜,对鼻中隔黏膜瓣进行ICGA,记录术中黏膜瓣蒂部和体部显影,将显影程度分为强...     

Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches

Abstract Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.