经前额入路硬脑膜外手术修补脑脊液鼻漏并脑膜脑膨出

目的：探讨脑脊液鼻漏并脑膜脑膨出的外科治疗方法。材料与方法：３例脑脊液鼻漏并脑膜脑膨出的病人接受经前额入路硬脑膜外手术修补。结果：３例病人全部一次手术成功,脑脊液鼻漏停止,脑膜脑膨出得到妥善处理,除１例病人术后嗅觉丧失外,未见其他手术并发症。结论：经前额入路硬脑膜外手术修补是治疗脑脊液鼻漏并脑膜脑膨出安全有效的手段     

经前额入路硬脑膜外手术修补脑脊液鼻漏并脑膜脑膨出

目的：探讨脑脊液鼻漏并脑膜膨出的外科治疗方法。材料与方法;３例脑脊液鼻漏并脑膜脑膨出的病人接受经前额入路硬脑膜外手术修补。结果;３例病人全部一次手术成功,脑脊液鼻漏停止,脑膜脑膨出得到妥善处理,除１例病人后嗅觉丧失外,未见其他手术并发症。结论;经前额入路脑膜外手术修补是治疗脑脊液鼻漏并脑膜脑膨出安全有效的手段。     

经鼻内镜修补脑脊液鼻漏

脑脊液鼻漏(CSFR)是鼻颅底外科的常见病症,传统的修补方法有经颅内修补和经颅外修补2种进路.颅外进路又分为鼻外入路和鼻内入路,鼻内入路可以经显微镜或鼻内镜修复.     

鼻内硬脑膜成形的长期研究和文献复习

195 2年 Hirsch报告了经鼻内进路修补蝶窦的硬脑膜缺损 ,196 4年 Vrabec和 Hallberg介绍了采用鼻内手术修补筛板的脑脊液漏 ,尽管有鼻内硬脑膜成形的经验 ,因鼻内进路不能充分暴露前颅底 ,许多耳鼻喉医生仍采用颅外进路。随着显微镜和鼻内窥镜技术的应用 ,经鼻可很好地看清前颅底。近年有较多的报道经鼻内硬脑膜成形治疗硬脑膜缺损所致的 CSF漏 ,从1980年 7月～ 1998年 5月 ,对 12 6例 CSF漏的病人采用鼻内进路方法施行 136次硬脑膜成形术 ,其中 6 6例次是在慢性鼻窦炎的鼻窦手术过程中损伤了硬脑膜发生 CSF漏 ,33例次 CSF漏因外伤引…     

经蝶窦显微手术治疗蝶窦性脑脊液鼻漏（附7例报告）

７例蝶窦性脑脊液鼻漏患者，经４周保守治疗无效后，行经蝶窦入路颅外修补术，术后无１例复发。这种颅外修补术具有创伤小、并发症少、成功率高的优点，并可同时处理鞍内病变，是修补蝶窦性脑脊液鼻漏的最佳入路。     

外伤性脑脊液鼻漏的术前定位及手术治疗

目的：探讨外伤性脑脊液鼻漏的术前定位和手术治疗。方法：回顾性分析1996年1月～2002年6月，12例外伤性脑脊液鼻漏病人的临床资料，术前行CT或CT脑池造影确定骨折部位及漏口，经额硬脑膜下或硬脑膜外入路寻找漏口，采用自体肌片或带蒂额肌腱膜修补漏口，耳脑胶固定。结果：根据CT或CT脑池造影，术前可确定骨折部位及漏口，与术中相符，12例病人除1例复发外，其余11例均获得治愈。结论：CT扫描及CT脑池造影是术前确定骨折部位的有效途径，经额硬脑膜下入路，采用自体肌片或带蒂额肌腱膜是修补脑脊液鼻漏的有效方法。     

脑脊液鼻漏修补术的手术入路及修补材料选择(附54例报告)

目的：探讨脑脊液鼻漏的各种手术进路及各种修补材料特点,选取最佳的手术径路及修补材料。方法：回顾性分析1983年3月-2001年6月间收治的54例持续性脑脊液鼻漏经各种入路进行修补治愈的临床资料。结果：鼻内镜成功率最高（93．3％）,前颅窝入路最低（20．0％）,颅外法与颅内法比较差异有统计学意义。带血管蒂帽状腱膜瓣及阔筋膜常用于术中修补瘘口。结论：鼻内镜入路是最佳入路,对颅底较大缺损的修补可采用额鼻联合入路及带血管蒂帽状腱膜瓣修补缺损。根据具体情况选择合适的径路及修补材料。     

外伤性迟发性脑脊液鼻漏的诊断和治疗

目的 探讨外伤性迟发性脑脊液鼻漏的发病原因及临床诊治特点.方法 回顾性分析中山大学附属第一医院院2000-2008年收治的13例外伤≥3个月后出现脑脊液鼻漏患者的临床资料,重点分析术前CT及MRI扫描的结果 ,结合术中所见,分析两者之间的关系.结果 13例患者颅底均有陈旧性骨折,MRI扫描显示其中11例有软组织自颅底缺损处疝入鼻窦.术中鼻内镜检查见骨质缺损最小约为0.1 cm×0.2 cm;最大约为1.2 cm×1.5 cm,漏口部位与CT检查结果 一致,其中11例漏口处可见暴露的硬脑膜及坏死组织.所有病例均采用经鼻内镜下脑脊液鼻漏修补术,术后随访12～36个月,未见复发.结论 脑膜组织经颅底缺损疝入鼻窦为外伤后脑脊液鼻漏迟发的关键因素,CT、MRI检查有助于明确漏口位置,其治疗宜采用鼻内镜下脑脊液鼻漏修补术.     

颅底术后骨质缺损的钛网重建

目的探讨钛网在颅底重建中的可行性和外科技术。方法回顾性分析2002年11月至2004年11月采用钛网修复的11例颅底缺损患者的临床资料及随访结果。结果11例患者中颅底肿瘤6例，颅底骨纤维异常增生症3例，脑膜脑膨出2例。手术人路：经颅面联合入路手术7例，经额入路及扩大经额入路3例，经面中部掀翻入路1例。修补中、侧颅底2例，前、中颅底及蝶鞍6例，前颅底及眶板3例。术后短期内3例患者有少量无症状性颅内积气，未经治疗而自愈；1例患者发生短暂性脑脊液鼻漏，局部明胶海绵填塞及碘纺纱条压迫后自愈。术后平均随访14．4个月，无钛网移位和颅内感染等并发症。结论钛网用于颅底大型骨质缺损修复是安全的、可行的。     

颅底缺损的修复

目的：探讨颅底缺损的修复技术。方法：回顾性研究30例颅底缺损修复者的临床资料。颅底骨质缺损修补术20例，其中钛网修补12例，自体髂骨修补2例，裂层额骨修补2例，单纯颅骨外膜修补4例；硬脑膜缺损修补6例，其中带蒂颅骨外膜修补3例，带蒂颞肌筋膜修补2例，游离颞肌筋膜修补1例；颞下窝软组织缺损修补8例，其中带蒂颞肌修复颞下窝5例，带蒂颞肌及胸锁乳突肌联合修复颞下窝3例。结果：术后短暂性脑脊液鼻漏3例，无症状性颅内积气3例，少量硬脑膜外血肿及脑膜炎各1例。结论：颅底手术中采用适宜的外科技术和修复材料进行一期颅底修补，对于减少术后感染、脑脊液鼻漏等并发症有重要意义。     

内镜下带血管蒂鼻中隔黏骨膜瓣修复颅底缺损

目的 探讨内镜下应用带血管蒂的鼻中隔黏骨膜瓣修复颅底硬膜缺损的方法及疗效.方法 回顾性分析2008年7月至2010年3月间收治的8例应用带血管蒂的鼻中隔黏骨膜瓣鼻内镜下修复术后颅底硬膜缺损及创伤性脑脊液鼻漏患者的临床资料及随访结果.8例患者均为男性,年龄28～60岁,平均年龄41岁.其中前颅底血管外皮瘤1例、嗅神经母细胞瘤1例(Kadish C型)、筛窦癌1例、鼻咽癌放疗后局部复发3例、颅底类癌1例、脑脊液鼻漏伴反复颅内感染1例.其中前颅底缺损6例,中颅底缺损2例.手术采用内镜经鼻入路,直视下获取以鼻后动脉为蒂的一侧鼻中隔黏骨膜瓣.组织瓣覆盖硬膜缺损后,周缘敷以明胶海绵,并用生物蛋白胶固定,鼻内以碘仿纱条、水囊及膨胀海绵支撑.术后5～7 d撤除全部鼻内支撑物.结果 1例鼻中隔瓣部分坏死,其余7例鼻中隔瓣全部成活.1例术后7 d有脑脊液鼻漏,再次手术探查以腹部脂肪封堵漏口成功,术后随访6～24个月,颅底组织愈合良好,无延迟性脑脊液漏及颅内感染发生.结论 内镜经鼻入路采用带血管蒂鼻中隔黏骨膜瓣修复颅底硬膜缺损是一种可靠的颅底重建方法.

Abstract：

Objective To introduce a method and the clinical effects of repairing skull base defects and dural defects using vascular pedicled nasoseptal mucoperiosteal flaps through an endoscopic endonasal approach. Methods The clinical and follow-up data for 8 patients who underwent endoscopic endonasal reconstruction of skull base defects and cerebrospinal fluid rhinorrhea with a vascular pedicled nasoseptal mucoperiosteal flap between July 2008 and March 2010 were retrospectively reviewed. All patients were male. The age of these patients ranged from 28 to 60 years (average 41 years). The diagnosis for these patients included one hemoangiopericytoma of the anterior skull base one olfactory neuroblastoma (type of Kadish C) , one ethmoid sinus cancer, three local recurrent cancers of the nasopharynx after radiotherapy,one carcinoid of skull base and one traumatic cerebrospinal fluid rhinorrhea with recurrent intracranial infection. There were six anterior skull base defects and two middle cranial fossa defects. An endoscopic endonasal surgical approach was used for the repair. A pedicled flap using the nasal septal mucoperiosteum based on the posterior nasal artery was harvested from the ipsilateral side. The tissue flap was used to cover the dural defects. The margin was covered with gelatin sponge and fixed with fibrin glue. The nasal cavity was packed with iodoform gauze, a Foley catheter balloon and Merocel in this sequence to secure the flap in place. Nasal packing was removed 5 to 7 days postoperatively. Results Partial septal flap necrosis was found in one case, but the flaps in the other 7 cases survived. A postoperative cerebrospinal fluid leak occurred in one case 7 days after surgery. This was re-explored and successfully repaired with abdominal fat.All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 6 to 24 months follow-up period. Conclusion The vascular pedicled nasoseptal mucoperiosteal flap is a reliable choice for endoscopic endonasal skull base reconstruction.     

Endoscopic reconstruction of the anterior skull base in cerebrospinal rhinorrhea

Cerebrospinal rhinorrhea is a discharge of cerebrospinal fluid caused by the break continuity in dura mater and by bone defect in the base of anterior skull base. The pathological connections appear mainly in the regions of the skull base with the weaker bone structure (the roof of the frontal, ethmoid, sphenoid sinus and cribriform plate). The aim of the study was presenting the possibility of the endoscopic-surgical closing the fistula within the ethmoid roof. The E.N.T Department in Poznań treated 5 patients with cerebrospinal rhinorrhea. In four cases, cerebrospinal rhinorrhea was caused by operative trauma. In one case the rhinorrhea could not be established. All patients with traumatic rhinorrhea underwent operation treatment based on covering of the loss in dura mater with a piece of mucous membrane together with perichondrium of nasal septum or lyophilised dura. The material used for the plastic operation was sealed by tissue adhesive. In 2 cases rhinorrhea recurred. Using the endoscopic technique, after the identification the leak of the cerebrospinal fluid within ethmoid roof, the fistula has been reconstructed with use of the adipose tissue and temporal muscle fascia. Both cases led to complete recovery. Easy access, precision and accuracy of performance the surgery, the approach without external incision of the patient, makes the endoscopic technique very valuable method in treating rhinorrhea caused by the loss in ethmoid roof and cribriform plate.     

鼻内镜下鼻颅底相关手术临床体会

目的探讨基层医院开展鼻内镜下颅底外科手术的可行性及手术范围。方法回顾性分析2006年5月-2012年8月收治的41例鼻颅底肿瘤患者临床资料,其中外伤性视神经病7例,脑脊液鼻漏11例,颅底肿瘤12例,蝶窦巨大囊肿8例,翼腭窝肿瘤4例,均在鼻内镜下手术治疗。结果11例脑脊液鼻漏修补获得成功,视神经减压5例有效,2例无效,1例术后出现脑脊液鼻漏,保守治疗愈合;12例颅底肿瘤手术,术中均能很好暴露肿瘤,1例术中损伤海绵窦,经处理后出血得到控制,顺利完成手术,1例术后出现脑脊液鼻漏,保守治疗愈合,所有病例无颅内感染并发症发生。肿瘤患者均随访3年以上,无复发。结论在合理选择适应证的条件下,基层医院开展鼻内镜下颅底手术是安全、可行的。     

Endoscopic management of cerebrospinal fluid rhinorrhea

PURPOSE: Most anterior skull base defects causing cerebrospinal fluid (CSF) rhinorrhea can be readily approached using endoscopic techniques when surgical repair is necessary. We present our data from endoscopic repair of CSF rhinorrhea with long-term follow-up. METHODS: Retrospective data analysis of patients that were diagnosed with anterior skull base CSF rhinorrhea and underwent endoscopic repair at a tertiary institution. Data were analyzed to determine the etiology and location of CSF leaks. Diagnostic techniques, surgical techniques, and surgical outcomes were reviewed. RESULTS: Ninety-two patients were diagnosed with CSF rhinorrhea and underwent endoscopic repair over a 12-year period. Forty-eight were males, and 44 were females. The average age was 49 (range 6-81) years. Average follow-up was 25 months, with a range of 12 to 82 months. The etiology of CSF leak was prior endoscopic sinus surgery in 23 patients (25%), idiopathic in 19 (21%), neurosurgery in 17 (18%), trauma in 18 (20%), and the presence of meningocele/encephalocele in 11 patients (12%). The most common location of the defect was the sphenoid sinus (n = 36, 39%), followed by ethmoid roof (n-27, 29%), and cribriform plate (n = 24, 26%). Endoscopic repair was initially successful in 78 (85%) patients. Seven additional patients underwent successful revision endoscopic repair for an overall success rate of 92% (n = 85). Five (6%) large skull base defects were eventually repaired by neurosurgery using open intracranial techniques. No major complications were encountered. CONCLUSION: The intranasal endoscopic approach is an effective and safe technique in the surgical management of anterior skull base CSF rhinorrhea. Long-term success rate in our patient population was 92%.     

Cerebrospinal fluid leakage after gamma knife radiosurgery for skull base metastasis from renal cell carcinoma: a case report

We report a rare case of cerebrospinal fluid (CSF) leakage after radiosurgery for skull base metastasis from renal cell carcinoma. A mass invading the left petrous bone and sphenoid sinus was treated with gamma knife radiosurgery, and CSF rhinorrhea developed 4 months after the procedure. The CSF leak was successfully controlled by endoscopic sinus surgery. CSF leakage may develop as a rare complication after radiosurgery for skull base lesions, and the endoscopic repair technique is a useful therapeutic method.     

以筛前动脉为蒂的鼻腔外侧壁黏膜瓣在额窦后壁缺损重建中的应用

 目的介绍一种以筛前动脉为血管蒂的鼻腔外侧壁黏膜瓣应用于额窦后壁缺损修复重建的新方法,并总结其疗效和初步应用体会。方法回顾性分析应用带蒂鼻腔外侧壁黏膜瓣修复15例额窦后壁脑脊液鼻漏病例,其中男12例,女3例,年龄12~51岁,平均年龄32岁,均为外伤引起的颅底骨折、术前均经过至少1个月保守治疗无效的脑脊液鼻漏患者。采用内镜下DrafIIB型额窦开放+上方带蒂的鼻腔外侧壁黏膜瓣进行颅底修复。结果所有病例均一次性重建成功,术后1个月拔除填充物后无脑脊液鼻漏发生,随访1~3年,无脑脊液鼻漏和颅内感染发生,额窦及上颌窦均引流通畅,上皮化好。主要副反应为鼻腔干燥结痂。结论以筛前动脉为血管蒂的鼻腔外侧壁黏膜瓣取材方便,应用于额窦后壁颅底缺损修复疗效满意,该术式有创新性。     

Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks

OBJECTIVE: To analyze possible etiological factors of spontaneous cerebrospinal fluid (CSF) rhinorrhea and to assess the outcomes of endonasal endoscopic repair. DESIGN: Retrospective study. SETTING: Academic neurosurgical hospital.Patients Twenty-one consecutive patients who presented with spontaneous CSF leak and underwent endonasal endoscopic surgery from January 1999 through December 2001. INTERVENTION: Preoperative examination included computed tomographic scans; nasal endoscopy; measurement of glucose concentration in the nasal discharge; and, in some cases, cisternographic evaluations via computed tomography and/or magnetic resonance imaging. Telescopes, conventional endoscopic sinus surgery instruments, and a microdebrider were used for all patients who underwent endonasal surgery. A combination of plastic materials, ie, abdominal fat, fascia lata, rotated middle turbinate flaps, and fibrin glue, were used for fistula repair. RESULTS: At the time of surgery, CSF fistulas were found in the cribriform plate (6 patients), in the fovea ethmoidalis (6 patients), and in the sphenoid sinus (9 patients). In 5 of the 6 patients who had an extremely pneumatized sphenoid sinus, the source of the leak was located in the lateral extension of the sinus. A meningocele protruding through the bone defect was the source of the leak in 10 patients. Postoperative follow-up lasted from 9 to 42 months, and 20 patients were considered cured. There was only 1 recurrence, in a patient whose CSF rhinorrhea originated in the deep lateral recess of an overpneumatized sphenoid sinus. Thus, the overall success rate was 95.2%. There were no postoperative complications. CONCLUSIONS: Possible etiological factors of this disease include obesity, congenital malformations of the skull base, an overpneumatized sphenoid sinus (particularly in its lateral extensions), and the empty sella syndrome. Endoscopic endonasal repair of spontaneous CSF rhinorrhea appears to be a safe and successful procedure. However, techniques for endoscopic closure of CSF fistulas in the lateral part of the sphenoid sinus need further perfecting.     

自发性脑脊液鼻漏定位诊断的影像学征象分析

目的 通过总结自发性脑脊液鼻漏患者的影像学直接征象和间接征象,为脑脊液鼻漏修补术前瘘点的影像学定位诊断提供依据。方法 回顾性分析2017年1月—2021年3月中南大学湘雅医院耳鼻咽喉头颈外科诊治的48例患者的临床资料,所有患者术前行鼻窦颅底高分辨CT(HRCT)和核磁共振(MRI)水成像检查。术前分析其影像学直接征象和间接征象,并结合术中情况证实其瘘点位置。结果 48例患者术前经影像学瘘点判断并经手术证实瘘点位于筛板20例(41.7%),蝶窦外侧隐窝16例(33.3%),筛顶8例(16.7%),额窦后壁2例(4.2%),斜坡2例(4.2%)。研究发现不同区域的自发性脑脊液鼻漏直接征象和间接征象存在明显不同,间接征象如左右侧不对称,引流通道水肿,窦腔黏膜增厚和积液征可以用于寻找瘘点。瘘口在影像学上根据直接征象颅底骨质缺损的诊断符合率为66.7%,而联合应用CT与MRI水成像根据直接征象和间接征象联合应用的诊断符合率为100%。结论 自发性脑脊液鼻漏患者影像学的间接征象对于术前准确判断瘘点具有重要价值。     

额眶筛入路切除前中颅底颅鼻眶沟通瘤

目的探讨切除前中颅底、额、筛窦、眶沟通性肿瘤的最佳手术方式,以满足临床需要。方法对13例前中颅底颅鼻眶沟通瘤患者采用额眶筛入路、T型切口,将外鼻下翻,切除部分筛窦、纸板、额骨眶部及额窦后壁,充分暴露肿瘤组织,在手术显微镜下分块或完全切除肿瘤,分离、保护相应解剖部位,如视神经、内动脉、蝶鞍和脑膜等重要解剖结构。将外鼻回复,用钛板钛钉与额骨固定,恢复良好颌面外形。结果13例颅鼻眶沟通瘤手术均获得成功,随访24个月,11例肿瘤无复发,均无脑脊液鼻漏、脑膜脑膨出等并发症。面部外形良好。结论经额眶筛进入、侧下翻鼻骨入路是耳鼻咽喉科切除前中颅底颅鼻眶沟通瘤的一种良好方法。