经鼻内镜切除嗅神经母细胞瘤疗效观察

目的探讨经鼻内镜切除嗅神经母细胞瘤的疗效及辅助放射治疗的意义。方法对2001年8月至2005年9月经鼻内镜手术治疗的6例鼻腔鼻窦嗅神经母细胞瘤患者的临床特征、治疗效果及失败的原因进行回顾性分析。其中男4例，女2例；1例儿童，5例成人，年龄9—68岁；KadishB期2例，C期4例。所有病例随访14—63个月。结果6例鼻腔鼻窦嗅神经母细胞瘤患者，5例肿瘤完全切除，包括1例先开颅手术，1例颅内侵犯经鼻内镜切除肿瘤并进行颅底修复，1例颈淋巴清扫术，1例次全切除。5例首次术后辅助放疗，均无瘤生存，1例未加放疗手术后复发带瘤生存至31个月死亡，中位生存期44．5个月。结论内镜手术具有手术进路简便，视野清晰，损伤小，术后恢复快，面部不留瘢痕，易为患者接受的优点。初步结果显示该术式是治疗鼻腔鼻窦嗅神经母细胞瘤的有效方法，但术后必须结合放射治疗方可获得满意效果。     

Esthesioneuroblastoma: reflections of a 21-year experience.

OBJECTIVES: To evaluate the results of standardized treatment of esthesioneuroblastoma at a single institution during a 21-year period and calculate pertinent parameters, i.e., metastatic disease (local, regional, distant), disease-free survival, and complications of treatment. STUDY DESIGN: A retrospective review was conducted of all patients treated at a single institution from September 1976 through May 1998. METHODS: Only those patients who received their complete evaluation and treatment at our institution were included in this analysis. Thirty-five patients met this criterion. In addition, results of epidemiological, pathological, and molecular analyses were evaluated to seek accurate indicators for clinical outcomes. RESULTS: Six percent of patients presented with cervical metastatic disease, but ultimately 25.7% developed at least one episode of cervical metastases; 14.3% of patients developed a local recurrence an average of 6 years after diagnosis; and 37% of the patients ultimately developed at least one episode of metastatic disease. The disease-free survival for this cohort of 35 patients was 80.4% at 8 years. CNS complications occurred in 25.7% of the patients, 22.9% had orbital complications, 20% had systemic posttreatment problems, 18.2% had chemotoxic sequelae, 8.6% had infectious complications, and 14.3% had cosmetic sequelae. No epidemiological, pathological, or molecular factors appeared to be more accurate clinical indicators than the Kadish staging system. CONCLUSIONS: This series of esthesioneuroblastoma patients (N=35) reflects an 8-year disease-free survival of 80.4%, representing a significant number of patients treated and followed at one institution for an extended period of time. No valuable pathological or molecular indicators to predict aggressive clinical behavior were found. The average time interval before recurrent disease developed was more than 6 years, far greater than that expected for other sinonasal malignancies. Therefore, extended follow-up is necessary for this patient group.     

Esthesioneuroblastoma: A case report and review of the literature

Esthesioneuroblastoma (ENB) is an extremely rare malignant neoplasm of the nasal cavity. We report the case of a middle aged man who presented with a 6-months history of progressive nasal obstruction, watering of the eye, headache and occasional epistaxis. A diagnosis of esthesioneuroblastoma was established by histopathology and confirmed by immunohistochemistry. On staging the mass was classified as a kadish stage C tumor. The mass was excised via a craniofacial resection through a bi-coronal approach and the tumor mass was peeled away completely from the frontal lobe dura. The patient underwent postoperative radiation, and he was free of recurrence at follow-up 3 months later.     

Endonasal endoscopic oncologic resection and reconstruction of the anterior skull base in the elderly: A single-center retrospective study

IntroductionIn old and frail patients, oncologic anterior skull-base surgery through an endonasal endoscopic approach avoids the morbidity incurred by transfacial and transcranial approaches, sometimes considered unreasonable, although surgery remains the gold standard treatment for sinonasal cancer.ObjectivesTo assess the functional and oncologic results of this surgery in over-70 year-olds.Material and methodsA single-center retrospective study included all patients aged over 70 years at surgery, who underwent endonasal endoscopic oncologic resection and reconstruction of the anterior skull base, between October 2008 and October 2018.ResultsFifteen procedures in 13 patients met the inclusion criteria. Mean hospital stay was 7 days. All resections were considered R0, apart from one case with positive dura-mater margins (6.7%). All patients had complete radio-surgical treatment, in accordance with the REFCOR recommendations. Two cases of meningitis were reported (13.3%). At a median follow-up of 27 months, 4 patients presented local recurrence, 1 of whom also had lung metastases. Two patients died of disease-related or treatment-related causes.ConclusionThis technique is a feasible treatment in patients aged over 70 years, providing good functional results, and acceptable oncologic outcome.     

Frontal sinus complications after frontal craniotomy

OBJECTIVES: To review frontal sinus complications following frontal craniotomy and to describe management strategies. STUDY DESIGN: Retrospective review. METHODS: Retrospective review was made of six patients who had undergone frontal craniotomy and subsequently developed frontal sinus complications. Demographic data, indication for craniotomy, type of reconstruction, average time to development of complications, presenting symptoms, diagnosis, surgical management, follow-up, and outcomes were reported. RESULTS: Complications included unilateral frontal sinus mucoceles in four patients, bilateral frontal sinus mucoceles in one patient, and bilateral frontal sinus mucopyoceles with upper-eyelid abscess in one patient. The average time to presentation of symptoms and development of complications following frontal craniotomy was 14.8 years (range, 1-39 y). Headaches were the most common presenting complaint. All patients underwent endoscopic mucocele marsupialization as part of their management. After an average follow-up period of 9 months, no recurrences were found and no complications occurred. CONCLUSION: A small number of patients develop otolaryngological complications, most commonly, frontal mucoceles, following frontal craniotomy. A high level of suspicion and long-term surveillance are needed to monitor for their occurrence. Endoscopic marsupialization may provide an effective, safe means for management.     

The effect of functional endoscopic sinus surgery on nasal resonance

Background and objectiveFunctional endoscopic sinus surgery (FESS) increases the nasal volume, and thereby it can alter the nasal resonance. The objectives were to measure the percentage of nasal resonance following FESS and compare it with healthy individuals with normal nasal findings.MethodsThe nasometric analysis of voice was done using n/p/m consonant sounds in 72 individuals with healthy post FESS cavities (group 1) and 72 healthy individuals with normal nasal findings without any nasal pathology (group 2). The scores of nasal resonances were expressed in percentages and were compared between the two groups. Both in group 1 and group 2, 32 (44.4%) were females, and 40(55.6%) were males. In group 1, 51 participants had bilateral FESS cavities, and 21 had unilateral FESS cavities. Kannada was the mother tongue in 30 (41.7%) participants in group 1 and 36 (50.0%) in group 2. Malayalam was the mother tongue in 42(58.3%) participants in group 1 and 36 (50.0%) in group 2.ResultsIn both cases and control groups, more than 80% of the participants were showing less than 20% of nasal resonance. In group 1, the mean values of/n/p/m sounds were 11.23%, 10.23% and 11.42% respectively, and in group 2 the mean values were 8.27%, 8.58% and 8.58% respectively. But the P value was not statistically significant. Individuals with unilateral FESS cavities had more nasal resonance values compared to bilateral FESS cavities. Similarly, Kannada speaking people had more values compared to Malayam speaking individua.ConclusionChanges in nasal resonance after FESS is minimal, and it is unnoticed. But it may affect the speech quality in professional voice users, depending on their language. Though the nasometer is considered as the most validated instrument to record nasal resonance, we feel that further standardization is needed to evaluate the nasalance.     

Origin of nasal polyps: an endoscopic autopsy study

OBJECTIVES/HYPOTHESIS: To further elucidate the natural history, etiology, and pathogenesis of nasal polyps, the present study of their anatomical site of origin was undertaken. The possibility for preferred areas or certain patterns in the places of origin was also considered. STUDY DESIGN: Autopsies were examined consecutively. METHODS: Endoscopic examination of the nasal cavity and paranasal sinuses, including endoscopic sinus surgery, was performed in 69 autopsies. The place of origin and attachment of each polyp was meticulously described. Polyps were photographically documented in situ and removed, together with the corresponding mucosa, for later histological examination. The cause of death of the patients was either cardiopulmonary disease or malignant diseases. Median age was 73 years (age range, 47-94 y). RESULTS: Nasal polyps were found in 22 of the 69 autopsies, corresponding to a frequency of 32%. In all, 54 polyps were found. Thirty-nine polyps were small (length, 2-5 mm), 10 were medium-sized, and 5 were large. No complaints of symptoms from the nasal polyps were registered. Most of the polyps (40 of 54 [74%]) originated in relation to sinus outlets. Most of these (34 of 54 [63%]) were found in the middle or superior meatus (13 of 54 [24%]). CONCLUSION: The results seemed to indicate that the frequency of nasal polyps is high and that most of the polyps originate from the mucosa of the ostia, clefts, and recesses in the ostiomeatal complex where the initial stage of sinonasal polyposis seems to take place. Continuous postmortem studies in autopsy materials and systematic endoscopic examinations for "silent," asymptomatic nasal polyps in various groups of patients will lead to a better understanding of the natural history of nasal polyps.     

低温等离子射频辅助下功能性内镜鼻窦手术初步临床观察

目的:通过对低温等离子辅助下的功能性内镜鼻窦手术(CAFESS)患者的术前、术后的临床观察,探讨CAFESS的临床疗效。方法:选取行CAFESS的慢性鼻-鼻窦炎伴或不伴鼻息肉患者30例作为研究对象。术后对患者的主观症状及局部变化过程进行6～9个月的随访观察。结果:术后患者鼻塞、头面部胀痛、流脓涕、鼻涕倒流、头痛等症状明显缓解,并有其他症状的缓解。SNOT-20评分由术前的(22.53±6.26)分减少为术后6个月的(7.80±3.63)分,差异有统计学意义(t=16.741,P<0.05)。Lund-Kennedy评分由术前的(4.30±1.15)分降低为术后6个月的(1.17±0.83)分,差异有统计学意义(t=19.947,P<0.05)。鼻内镜检查:术后第6周,部分患者鼻腔黏膜开始上皮化,直至第12周所有患者鼻腔黏膜完成上皮化。结论:CAFESS是继功能性内镜鼻窦手术后治疗慢性鼻窦炎、鼻息肉的一项新技术,术后临床疗效满意。     

Paranasal sinus exostoses: Possible correlation with cold temperature nasal irrigation after endoscopic sinus surgery

Exostoses of the external auditory canal (EEAC) are a commonly encountered clinical exam finding; however, exostoses in other locations are vanishingly rare. The postoperative paranasal sinuses are penetrated with cold water solutions, the reputed etiological agent for EEAC, and development of exostoses in this unexpected location may be observed endoscopically. The surprising appearance of these protuberant lesions within the sinuses could be mistaken for more ominous processes, subjecting the patient to biopsy, surgery, or unnecessary medical therapy. The radiologic appearance of exostoses within the paranasal sinuses is herein reported for the first time, and care is taken to distinguish these bony lesions from the osteoneogenesis of chronic inflammation. Laryngoscope, 2013     

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.     

鼻内镜技术在鼻腔鼻窦前颅底恶性肿瘤手术中的应用

在切除鼻腔鼻窦前颅底恶性肿瘤的实践中,鼻内镜技术取得了不低于开放手术的近期疗效,其创伤小,减少了手术并发症,提高了患者的生存质量。鼻内镜手术范围和适应证逐渐扩大,但现有研究证据级别低。鼻内镜手术缺乏统一的适应证和方法,其疗效也需进一步证实。     

Outcomes for endoscopic resection of sinonasal squamous cell carcinoma

OBJECTIVES: Preliminary data suggest efficacy for the endoscopic approach for sinonasal malignancy. The purpose of this study is to evaluate the effectiveness of the endoscopic approach for the resection of sinonasal squamous cell carcinoma (SCC). STUDY DESIGN: Retrospective analysis of patients undergoing endoscopic resection of sinonasal SCC from August 1996 to May 2004. METHODS: Eleven patients were treated with curative intent. Demographic data, histopathology, extent of tumor involvement, and need for adjunctive radiation or chemotherapy were determined. Local recurrence (LR), distant metastasis, overall survival (OS), and disease-free survival (DFS) rates were calculated. RESULTS: The mean age for the patient population was 62.5 (52-85) years with a male:female ratio of 8:3. Multimodality therapy including radiation or chemotherapy was used in 8 of 11 (73%) patients. Seven patients were resected using strictly an endoscopic approach, whereas four required combined endoscopic and neurosurgical resection. LR and distant metastatic rates were 20% and 0%, respectively. OS and DFS were both 91%, with mean follow-up of 31.5 (range 6-88) months. CONCLUSIONS: Endoscopic resection in combination with multimodality therapy is an effective method for curative resection of sinonasal SCC. In this preliminary study, it facilitated complete resection with acceptable LR and DFS rates.     

Endoscopic transnasal craniotomy and the resection of craniopharyngioma

Objectives/Hypothesis: To describe the utility of a large transnasal craniotomy and its reconstruction in the surgical management of patients with craniopharyngioma. Study Design: Observational retrospective cohort study. Methods: Retrospective review of patients treated in an academic neurosurgery/rhinology practice between 2000 and 2007. Patient characteristics (age, sex, follow‐up), tumor factors (size, position extension, previous surgery), type of repair (pedicled mucosal flaps, free mucosal grafts), and outcomes (visual, endocrine, and surgical morbidity) were defined and sought in patients who had an entirely endoscopic resection of extensive craniopharyngioma (defined as requiring removal of the planum sphenoidale in addition to sella exposure in the approach). Results: Seven patients had an entirely endoscopic resection of extensive craniopharyngioma during the study period. Mean age was 23.4 years (standard deviation ± 16.3). Mean tumor size was 3.2 cm (standard deviation ± 2.0). The majority of these pathologies had extensive suprasellar disease, and two (28.6%) had ventricular disease. Cerebrospinal fluid leak rate was 29% (2 of 7). These leaks occurred only in reconstructions with free mucosal grafts. There were no cerebrospinal fluid leaks in patients who had vascularized pedicled septal flap repairs. Conclusions: The endoscopic management of large craniopharyngioma emphasizes recent advancements in endoscopic skull base surgery. The ability to provide exposure through a large (4 cm+) transnasal craniotomy, near‐field assessment of neurovascular structures, and the successful reconstruction of a large skull defect have significantly advanced the field in the past decade. The use of a two‐surgeon approach and bilateral pedicled septal mucosal flaps have greatly enhanced the reliability of this approach.     

Esthesioneuroblastoma: the Northwestern University experience

OBJECTIVE: To review our experience with esthesioneuroblastoma, a rare malignancy of the head and neck. STUDY DESIGN: Retrospective review of Tumor Registry data. METHODS: We performed a computerized search of the Northwestern Memorial Hospital Tumor Registry database from 1981 to 2000. RESULTS: Sixteen patients with esthesioneuroblastoma were identified and analyzed. Their mean age was 42 years. Eleven of 16 patients (69%) had Kadish stage C; 8 patients (50%) had brain involvement at presentation. Craniofacial resection was performed in 13 patients (81%). Fourteen patients received either preoperative or postoperative therapy; radiation therapy was employed in 11 cases and chemotherapy in 4. The actuarial 5-year survival was 60%, and the actuarial 5-year disease-free survival was 33%, with a median follow-up of 4.3 years. Recurrences occurred at a median time of 11 months after diagnosis (2.5 mo-18 y). The first site of failure was locoregional alone in 10 of 12 patients who progressed, and in 6 patients involved the brain or the meninges. Two patients were successfully salvaged. Patients with high-grade tumors had a trend toward work survival. CONCLUSIONS: Esthesioneuroblastoma is a rare tumor that is potentially curable by surgical resection and radiation therapy. However, the rate of local failure is high, and late recurrences are not uncommon. The role of chemotherapy warrants further investigation.     

Endonasal endoscopic resection of an ethmoidal solitary fibrous tumor

Solitary fibrous tumor (SFT) is an uncommon spindle cell tumor that typically arises at the level of the pleura in adults. However, SFT has also been reported in various extrapleural sites including orbit, meninges, liver, lung, salivary glands, retroperitoneum, mediastinum. In the head and neck region, SFT has been documented in the external auditory canal, larynx, thyroid, sublingual gland, tongue, parapharyngeal space and the infratemporal fossa. The nose and the paranasal sinuses are a rare site for SFT with only 14 publications in the world literature. We present an additional case of a SFT arising at the level of the right ethmoid sinus successfully removed in one piece endoscopically and review the corresponding literature.     

KTP‐532 laser‐assisted endoscopic nasal sinus surgery

KTP‐532 laser‐assisted endoscopic nasal sinus surgery The present study is meant to give an overview of the application of KTP lasers in endoscopic sinus surgery and to give an account of the experience gained in the course of 24 operations. Laser‐assisted FESS was performed in 24 patients (13 on the right side and 11 on the left side). Sixteen men and eight women were treated for chronic maxillary sinusitis. Diagnostic criteria of chronic maxillary sinusitis included at least 3 months history of intermittent or persistent facial pain, intermittent or persistent fever, tenderness or headache over the areas of the maxillary, ethmoid or frontal sinuses, purulent discharge from nasal passages or nasopharynx, and radiographic evidence of opacification on CT scans. Traditional FESS surgery was performed on the one side and KTP laser‐assisted surgery on the other side. CT was performed in each case. The operations were carried out under local anaesthesia. The KTP laser was delivered via an optical fibre (0.6 mm) and was used for bone ablation, incision, vaporization and coagulation. Patient symptoms were recorded using a self‐administered questionnaire preoperatively, and postoperatively on weeks 1, 4, 12 and 24. Blood loss on the laser‐assisted operations' side was minimal. The improvement of the symptoms (pain, sensation of fullness, discharge) during weeks 1 and 4 proved to be significant (P < 0.05) in the case of both techniques. The cumulated average of the point scores on the laser‐assisted side was higher: especially postoperative week 1. Of the parameters assessed in the course of healing, oedema prevailed on the laser‐assisted side, while crusting was characteristic in the traditional operation site. We conclude that laser‐assisted FESS surgery is as effective as traditional endonasal sinus surgery. Its advantage is that it offers excellent haemostasis, as the use of ‘star pulse’ mode allows accurate bone work. No complications were observed. The disadvantage of the laser‐assisted procedure is that the instrument is expensive and it is time consuming.     

囊泡分子免疫病理学改变对鼻内镜术后鼻腔黏膜上皮预后转归的影响

目的:探讨囊泡分子免疫病理学改变对鼻内镜术后鼻腔黏膜上皮预后转归的影响。方法:依EPOS标准选取40例(80侧)慢性鼻窦炎、鼻息肉患者为研究对象,根据术后对囊泡处理方式的不同分为囊泡刮除(右侧)和不刮除(左侧);依据囊泡数量及大小分为轻度组(44侧,单侧术腔囊泡数目≤5个且囊泡直径均≤5mm)及中重度组(36侧,单侧术腔囊泡数目>5个或囊泡数目≤5个而囊泡直径>5mm)。鼻内镜下比较轻度组、中重度组术后鼻黏膜上皮化情况;用苏木精-伊红染色及透射电镜观察囊泡的病理形态学变化;免疫组织化学法比较术后不同时间各组(术后1～3周、6～8周及11～14周)和对照组(下鼻甲黏膜、鼻息肉)转化生长因子β1(TGFβ1)、血管内皮生长因子(VEGF)表达的变化。结果:病理学观察发现,囊泡上皮基膜不连续、间质水肿、炎细胞浸润、病理性腺体增多;超微结构显示,囊泡微管结构出现异常,线粒体减少;分子免疫学结果显示,在术后1～3周、6～8周及鼻息肉组织中TGFβ1的表达明显高于术后11～14周及下鼻甲黏膜组织(P<0.05);术后6～8周及鼻息肉组织囊泡中VEGF的表达明显高于术后1～3周、11～14周及下鼻甲黏膜组织(P<0.05)。中重度组囊泡刮除较不刮除鼻黏膜更快上皮化,与轻度组比较平均时间缩短1.5周(P<0.05),轻度组囊泡刮除和不刮除对术腔黏膜上皮化的影响差异无统计学意义(P>0.05)。结论:囊泡是鼻内镜术后有可能经历的阶段,其出现可能提示是鼻腔黏膜术后对炎症存在的反映,存在病理形态学改变及VEGF、TGFβ1的高表达,VEGF、TGFβ1术后的动态变化可以成为鼻内镜术后鼻腔黏膜预后转归的监测指标之一。术后对中重度囊泡进行清除有利于鼻腔黏膜的恢复和愈合。     

Maxillary sinus mucoceles: clinical presentation and long-term results of endoscopic surgical treatment.

OBJECTIVE: To describe the clinical presentation of maxillary sinus mucoceles, understand their pathogenesis, and determine the long-term efficacy of the endoscopic surgical treatment. STUDY DESIGN: Retrospective review. METHODS: Thirteen consecutive patients who presented with maxillary sinus muco(pyo) celes were studied. Subjects with history of preceding sinus/nasal surgery or facial trauma were excluded. The presenting signs and symptoms, radiological findings, and surgical management were reviewed. RESULTS: There were six women and seven men with an age range of 31 to 71 years. Two patients had environmental allergies. Nine patients complained of cheek pressure or pain, six of nasal obstruction, and eight of nasal drainage. On endoscopic nasal examination, the medial wall of maxillary sinus was bulging with prolapsed middle meatal mucosa in 10; drainage was seen in 7, but none had polyps. The sinus involvement was limited to the maxillary sinus and the ipsilateral ethmoid on computed tomographic studies in 10 cases. Patients were treated with endoscopic ethmoidectomy, middle meatal antrostomy, and marsupialization of the mucocele. Intraoperative cultures grew organisms in five patients. Postoperative follow-up ranged between 10 and 66 months. Two patients required lysis of adhesions in the middle meatus, and one, revision antrostomy. All patients had a patent middle meatal antrostomy and healthy maxillary sinus mucosa at latest follow-up. The presenting symptoms resolved or improved in 12 cases. CONCLUSIONS: The etiology of maxillary sinus mucoceles is not well understood. Mechanical obstruction or allergy or both do not seem to play an important role. An infectious origin is also not supported by the above data. Endoscopic sinus surgery is a reliable therapeutic measure with a favorable long-term outcome.