鼻内镜经鼻腔-蝶窦入路摘除脑垂体瘤1例

病人，男，62岁，因头痛2年，加重3个月，伴间歇性视力模糊收住院。     

鼻内镜扩大经鼻蝶窦入路切除巨大垂体腺瘤13例

目的:探讨鼻内镜扩大经蝶窦入路切除巨大垂体腺瘤的可行性。方法:回顾性分析2000～2003年 间通过鼻内镜扩大经蝶手术入路治疗的13例巨大垂体腺瘤的临床资料。结果:所有患者术中镜下全部切除肿 瘤,术后10例患者给予放射治疗;术后影像学检查显示肿瘤有残余者6例,平均随访12个月肿瘤无复发或继续 生长。术后发生短暂性尿崩症6例,脑脊液鼻漏2例及急性腺垂体功能低下者1例;无死亡及颅内感染,无鼻腔 通气障碍、鼻腔粘连、鼻中隔穿孔等并发症。结论:扩大经蝶手术是治疗巨大垂体腺瘤的一种可行、安全、有效的 方法,但应掌握熟练的经蝶手术技术;术后应给予放射或药物辅助治疗。     

单鼻孔直接蝶窦入路切除垂体腺瘤

目的 报告单鼻孔直接经蝶入路切除垂体腺瘤３２例显微手术的运用经验,并与其它经蝶入路进行比较。方法 将扩张器插入手术侧鼻孔（通常采用右侧）直抵蝶窦前壁进行扩张,显露蝶窦开口,开前壁,进行手术。结果 ３１例肿瘤近全切除,１例大部切除。１例术后脑脊液鼻漏。结论 此入路与其它经蝶切除鞍区病变的术式相比,对鼻组织损伤小,不必分离鼻中隔和两侧粘膜,省时,简单,并发症少,值得临床推广。     

经鼻入路治疗孤立性蝶窦病变

目的 探讨孤立性蝶窦较为微创的治疗方法。方法 对17例孤立性蝶窦病变行鼻内镜下经鼻入路开放窦口，清除病变。结果 术后随访6～24个月，痊愈13例（76.5％），好转2例（11.8％），总有效率88.2％。结论 鼻内镜下经鼻腔入路是治疗孤立性蝶窦病变的首选术式。     

鼻内镜下经鼻行蝶窦及垂体手术

鼻内镜手术的广泛开展和影像技术的进步,鼻内镜下手术治疗蝶窦及中颅窝病变逐渐增多。蝶窦及垂体病变经鼻进路手术,既往多采用经鼻中隔或经筛窦开放蝶窦,虽然手术视野能满足需要,但仍然存在创伤大。出血多,破坏鼻腔正常结构的缺点。2000年1月～2004年1月我们采用鼻内镜下经鼻腔直接入路行蝶窦及垂体手术,效果良好,现报告如下。     

经单鼻孔蝶窦入路显微镜下切除垂体腺瘤

目的探讨经单鼻孔蝶窦入路显微镜下切除垂体腺瘤的手术方法和疗效。方法对28例垂体腺瘤的病人采用经单鼻孔蝶窦入路行显微镜下垂体腺瘤摘除术,其中微腺瘤18例,大腺瘤10例;功能腺瘤20例,其中催乳素瘤10例、生长激素腺瘤5例、促肾上腺皮质激素腺瘤3例、促性腺激素腺瘤2例;无功能腺瘤8例。结果显微镜下全切除肿瘤20例,次全切除5例,大部分切除3例;术后无1例死亡,无脑水肿、视神经损伤、鼻中隔穿孔以及鼻腔粘连等并发症;术后所有病人血清激素水平均较术前有明显下降,随访3～6个月,未见影像学下的肿瘤复发。结论显微镜下经单鼻孔蝶窦入路切除垂体瘤具有鼻腔结构损伤小、术后并发症少、病人恢复快等优点。     

鼻内窥镜下鼻腔蝶窦径路垂体肿瘤切除术

目的 探讨在鼻内窥下经鼻腔蝶窦垂体肿瘤切除术的术式改进方法及麻醉方法。方法 用鼻窦内窥镜经鼻腔蝶窦入路切除垂体肿瘤４２例,其中局部麻醉加基础麻醉３７例,并作了如下改进：剥离梨骨翼及后鼻孔上缘区域的粘骨膜瓣和切除梨骨翼及蝶嘴,避免了损伤鼻中隔后动脉的可能,也增加手术操作的空间。结果 术中出血少,手术顺利,４２例均无并发症发生。术后随访６～３５个月,均有不同程度的症状改善。结论 用局部麻醉在鼻内窥镜下     

鼻内镜下单鼻腔蝶窦入路垂体腺瘤切除术(附6例报告)

目的总结鼻内镜下单鼻腔蝶窦入路垂体腺瘤切除的经验. 方法回顾分析2003～2004年间通过鼻内镜单鼻腔蝶窦入路治疗的6例垂体腺瘤的临床资料,总结经验. 结果按Hardy-wilson分级,Ⅱ级者1例,全切除瘤体;Ⅲ级者5例,全切除3例,大部分切除1例,另1例因出血多,改变手术方式,而完成治疗.5例患者术后均予放疗.所有患者均无严重并发症发生.随访12个月,无复发或瘤体增大现象. 结论鼻内镜下单鼻腔蝶窦入路切除垂体腺瘤是一种微创、安全、有效的方法,但应有熟练的鼻内镜手术技术.     

内镜经鼻入路个体化切除侵袭海绵窦垂体腺瘤

目的 初步探讨侵袭海绵窦垂体腺瘤的内镜手术策略,以提高手术安全性和肿瘤切除率。方法 回顾性分析连续收治的32例侵袭海绵窦垂体腺瘤患者的临床资料,结合患者手术前后影像学特点及术中情况,提出侵袭海绵窦垂体腺瘤的临床分型,并针对不同侵袭类型采取的手术策略及手术要点进行归纳总结。结果 32例患者术前均诊断为侵袭性垂体腺瘤,初发肿瘤21例、复发肿瘤11例,既往有放疗史6例;术前均行头颅MRI平扫+增强、导航序列、头颅三维脑窗+骨窗CT检查。根据肿瘤与颈内动脉(ICA)在海绵窦内走形的相对位置关系,将32例患者分为ICA外上型(10例)、ICA外下型(6例)和ICA外侧型(16例)3种类型。所有患者均行内镜经鼻入路手术治疗,其中全切5例(15.6%),均为ICA外下型;近全切除23例(71.9%);大部分切除4例(12.5%),均为ICA外侧型。术中见肿瘤质软21例、质地中等9例、质韧2例;肿瘤内存在纤维分隔11例。术中发生脑脊液漏10例,术后均未发生脑脊液鼻漏。术后腰大池置管6例,颅内感染2例,无死亡病例。术前19例视力下降、视野缺损患者术后均有不同程度好转,术前1例眼睑下垂患者术后症状消失;术后新增复视及外展麻痹10例,1周至1个月逐渐恢复。结论 ICA外上型、ICA外下型和ICA外侧型是侵袭海绵窦的垂体腺肿瘤常见的3种侵袭类型,针对此3种类型的不同特点,由内而外、循“肿瘤通道”按需切开海绵窦壁及瘤内分隔,沿ICA走形切除肿瘤有利于提高手术安全性和肿瘤切除率。     

经鼻内窥镜垂体腺瘤切除术

目的探讨鼻内窥镜在垂体腺瘤手术中的应用价值和适应证。方法开展了２４例经鼻内窥镜垂体腺瘤切除手术。２４例垂体腺瘤患者中２０例为经鼻蝶窦进路，４例为经鼻中隔蝶窦进路。结果２０例经鼻蝶窦进路瘤组织得到了完全切除，手术所需时间较经鼻中隔蝶窦进路显微外科手术明显缩短。４例经鼻中隔蝶窦进路中３例瘤组织完全切除，１例非分泌性腺瘤（Ⅴ期）患者因瘤组织侵犯鞍旁及海绵窦，仅行大部分切除。所有患者术后头痛、视力障碍和闭经泌乳等症状均有改善。１６例次术前血清泌乳素（ＰＲＬ）水平异常（２３．０～１２５．０μｇ／Ｌ，平均６４．９±４３．７μｇ／Ｌ）的患者，术后血清ＰＲＬ水平恢复正常。９例次术前血清生长激素（ＧＨ）水平异常（５０．０～７２．０μｇ／Ｌ，平均６２．１±１１．４μｇ／Ｌ）的患者，术后血清ＧＨ水平低于５．０μｇ／Ｌ。上述患者术后随访２～７２个月（平均１８±２１个月）无复发。术后均未见颅内出血、视神经损伤、脑脊液鼻漏、脑膜炎及垂体功能低下等并发症。结论经鼻内窥镜垂体腺瘤切除术是一个简便、安全、有价值的外科技术，只要正确地掌握好此类手术的适应证，可以获得满意的治疗效果。     

Long-term olfactory function outcomes after pituitary surgery by endoscopic endonasal transsphenoidal approach

ObjectivesTo evaluate long-term olfactory outcomes in patients who underwent pituitary surgery through the endoscopic endonasal transsphenoidal approach (EETSA) by T&T olfactometer.MethodsWe retrospectively reviewed 26 patients who underwent pituitary surgery via EETSA. Olfactory function was assessed by T&T olfactometer before and 6 months after surgery. The mean of recognition thresholds for five different odorants was used. The change in the mean recognition threshold values was evaluated in the entire cohort and the subgroup analysis was performed according to the age, sex, past history of pituitary surgery (primary surgery or revision surgery), histopathology (non-functioning adenoma (NFA) or functioning adenoma (FA)), reconstruction procedure (rescue flap or nasoseptal flap), and superior turbinate management (preserved or resected).ResultsOf the 26 patients (12 men and 14 women, median age 53 years), 21 patients were newly diagnosed with pituitary gland tumor (16 NFAs, 5 FAs) and the remaining 5 were diagnosed with recurrent pituitary gland tumor (4 NFAs and 1 FA). In the whole cohort, the mean recognition threshold values of T&T olfactometer significantly improved after surgery (P = 0.01). Thirteen out of 26 patients (50%) showed olfactory improvement, whereas only 3 (12%) showed deterioration. In the subgroup analysis, olfactory function outcomes were not significantly different between the subgroups with respect to the age, sex, past history of pituitary surgery, histopathology, reconstruction procedure, or superior turbinate management. The olfactory function tended to worsen in the revision surgery group compared to that in the primary surgery group, but not significantly (P = 0.06).ConclusionsThe olfactory function was improved or maintained after pituitary surgery via EETSA in 88% of patients, indicating the benefits of low invasiveness of our surgical treatment. On the other hand, three patients (12%) demonstrated deterioration of olfactory function, suggesting that the risk of postoperative olfactory dysfunction should be informed to patients.     

内镜经鼻蝶扩大入路手术治疗鞍结节脑膜瘤

目的探讨内镜下经鼻蝶扩大入路切除鞍结节脑膜瘤的可行性、手术技巧及并发症的防治。方法回顾性分析19例内镜下经鼻蝶扩大入路鞍结节脑膜瘤切除患者临床资料、手术疗效、并发症、长期随访结果。结果19例中9例实现Simposon I级切除,8例II级切除,2例III级切除。6例头痛均好转,16例视力视野损害患者术后改善14例,2例发生脑脊液漏,其中1例并发颅内感染,12例出现嗅觉损害。随访4~31个月无迟发型脑脊液漏、癫痫、尿量改变、垂体功能减退等并发症。10例嗅觉损害患者术后随访12个月时均得到部分恢复。结论内镜下经鼻蝶扩大入路切除鞍结节脑膜瘤是可选的理想手术入路。     

扩大经蝶入路显微手术治疗蝶斜区肿瘤

目的探讨采用扩大经蝶窦入路切除蝶斜区肿瘤的方法。方法1999～2005年采用扩大经蝶入路切除蝶斜区肿瘤25例,肿瘤直径1.9～4.2cm;采用标准经鼻中隔蝶窦入路,先行切除经蝶入路视野内的肿瘤,而后调整Hardy扩张器方向指向斜坡方向,进行手术入路的扩大。根据术前影像学资料、术中"C"型臂监测、神经导航、神经内镜以及术者的经验决定斜坡骨质磨除或咬除的范围,直至显露正常骨质和硬脑膜。结果全切21例(84%),次全切除3例(12%),部分切除1例(4%)。结论采用扩大经蝶窦入路切除蝶斜区肿瘤,肿瘤显露满意,肿瘤全切除率高,无明显手术并发症。神经导航及内镜的辅助使得扩大经蝶入路更为安全、有效。     

Endoscopic transnasal transseptal pituitary surgery

Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic transseptal approach via a sublabial mucosal incision or a nasal mucosal incision has also been extensively used. An endoscopic transnasal approach was first described in the 1990's, followed by the concept of a microscopic transseptal approach and an endoscopic strictly endonasal approach. We use an entirely endoscopic transseptal transsphenoidal approach via an incision in the nasal mucosa for both access and tumour resection. This procedure has a number of advantages: strictly midline approach to the sella turcica, large operative field, no interference between instruments and a low rate of nasal complications.     

内镜下单鼻孔蝶窦入路切除鞍内病变

目的总结内镜下经单鼻孔蝶窦入路切除鞍内病变的疗效与手术经验。方法回顾性分析136例鞍区病变患者的临床资料及手术方法,其中垂体腺瘤116例,Rathke囊肿16例,颅咽管瘤4例,均采用神经内镜下经单鼻孔蝶窦入路鞍内切除病变。结果垂体腺瘤116例,肿瘤全切90例（77．6％）,次全切26例（22．4％）;Rathke囊肿16例,均全切16例（100％）;颅咽管瘤4例,全切1例（25％）,次切3例（75％）。术后视力及视野改善83例,内分泌指标恢复正常95例。脑脊液鼻漏7例,2周后自愈;一过性尿崩25例。本组无死亡病例,无颅内出血等其他并发症。结论神经内镜下经单鼻孔蝶窦入路手术切除鞍内病变具有安全、视野清晰、术时短、肿瘤切除更为彻底及术后并发症少等优点,是较理想的经蝶手术术式。     

Endoscopic transsphenoidal approach versus microscopic approach in children

Objectives

To confirm the efficacy and safeness of the endoscopic endonasal transsphenoidal (ETS) approach in the treatment of sellar and parasellar lesions in children compared with the conventional microscopic transsphenoidal approach (CTS).

Study design

Case series with chart review.

Setting

A. Gemelli - University Hospital - Catholic University of Sacred Heart - Rome.

Subject and methods

We retrospectively evaluate 21 children (mean age 8.3 years) affected by sellar/parasellar lesions: 11 were treated via microscopic sublabial approach between 1995 and 2005 and 10 were treated with ETS approach between 2006 and 2009.

Results

The past series (group A) comprised all sellar/suprasellar lesions and we observed: gross total surgical excision in 81.2% of cases, permanent morbidity in 1/11 patients, CSF fistula in 1/11 patients, mean hospitalization time of 5.8 days and PICU was required. The present series (group B) included 8 sellar/suprasellar and 2 clival lesions and we observed: GTS excision in 80% of the cases, no permanent morbidity, a mean hospitalization time of 4.1 days (P = 0.01), CSF fistula in 2/10 patients and the PICU was not required. 10/11 patient of group A underwent to blood transfusion vs 4/10 of the group B (P = 0.008). The mean pain score of group A was 5.8 ± 1.7 on the contrary in the group B it was 4.1 ± 1.5 (P = 0.006).

Conclusion

The ETS approach to the sellar and parasellar region has proved its reliability and effectiveness in the adults. The minimal invasiveness makes it ideal for the treatment of pediatric lesion of this region, in which it is essential to preserve the integrity of the hypothalamic-pituitary axis and of the naso-facial structures to assure the correct growth of the child.     

Efficacy of controlling rhinosinusitis on the prevention of complications in pituitary surgery with transsphenoidal approach

Objective

The microscopic transcolumellar transseptal transsphenoidal approach (TSA) is the one of the most widely used methods for the surgical treatment of sellar and parasellar lesions. But nasal and paranasal sinus inflammation is the relative contraindications of TSA. This study was performed to investigate the results of pre TSA treatment options according to the degree of nasal and paranasal sinus inflammation on the paranasal sinus computed tomography scan (PNS CT).

Methods

From January 2005 to September 2010, 145 consecutive patients underwent operation of pituitary lesions through the TSA. The preoperative CT images for these patients were reviewed, and 26 patients were identified with sinus opacification on PNS CT. We then analyzed presenting symptoms, physical and endoscopic examination, Lund–Mackay score on PNS CT and preoperative management of the sinus problem retrospectively.

Results

Twenty-six patients had sinus opacification on PNS CT. Eight patients had the symptoms of sinusitis corresponding to PNS CT finding, so they had therapeutic antibiotics, and had TSA after symptomatic improvement. Three patients had the symptoms of sinusitis and sinus opacification with mean Lund–Mackay score of 5.33, so they underwent endoscopic sinus surgery first, and they got TSA a few months after. One patient underwent endoscopic sinus surgery and TSA simultaneously. No patient had a serious complication including intracranial infection.

Conclusion

TSA is a relatively safe technique, but intracranial complication after surgery may be fatal. Therefore rigorous evaluation and management is mandatory. It is especially important to treat rhinosinusitis issues preoperatively. Our preliminary data may be helpful to evaluate and manage the paranasal sinus inflammation before TSA.     

单鼻孔-蝶窦入路切除大型巨大型侵袭性垂体瘤61例

目的探讨大型、巨大型侵袭性垂体瘤经单鼻孔-蝶窦入路切除的手术方法及疗效。方法回顾性分析经单鼻孔-蝶窦入路切除61例大型、巨大型侵袭性垂体腺瘤患者的临床资料。结果全切32例,次全切20例,大部切除9例,无严重并发症及手术死亡病例。术后脑脊液鼻漏1例,卧床1周后痊愈;尿崩22例,均在术后2～3d出现,尿量5000～8000ml/d,1周5例,3～4周16例,最长半年1例,均采用垂体后叶素、尿崩停等治疗痊愈。术后视力视野均得到不同程度的改善,功能恢复。结论经单鼻孔-蝶窦入路手术加γ-刀治疗可作为大型、巨大型侵袭性垂体瘤的治疗方法。     

Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: assessment of technique and postoperative findings of nasal and paranasal cavities

OBJECTIVE: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities. METHODS: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides. RESULTS: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES. CONCLUSION: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella.