鼻科学

内镜下纤维胶封闭技术处理内镜扩大的经蝶入路术后脑脊液鼻漏 术后脑脊液鼻漏处理是目前鼻内镜进路切除中线颅底病变的研究热点问题。尽管重建技术不断改进,但还没有技术能彻底有效的防止术后脑脊液鼻漏。作者报道9例在意大利那不勒斯大学神经外科接受经鼻内镜扩大颅底手术（3例颅咽管瘤,2例鞍结节脑膜瘤,     

经鼻内镜手术治疗颅底脊索瘤

脊索瘤是一种起源于胚胎发育时期残留脊索组织的先天性低恶性肿瘤，多发生于骶尾部及颅底中线部位，尤其是斜坡区域，其预后与肿瘤切除程度密切相关，肿瘤完全切除的患者多能长期生存。由于颅底脊索瘤多呈浸润性生长，侵袭范围广，累及颅底重要神经、血管及脑组织等，手术完全切除极其困难，因此被认为是神经外科治疗的难题之一。近年来随着神经内镜技术的发展，以及术中神经导航系统、电生理监测、经鼻超声系统和多普勒超声血管探测仪等监测技术的广泛应用，经鼻内镜入路能在直视下最大可能地安全切除颅底脊索瘤，并尽可能保留重要神经、血管功能，其手术创伤小，术后脑脊液漏等并发症发生率低，并且患者生存质量明显提高，已成为颅底脊索瘤手术治疗的首选方法。为进一步全面认识经鼻内镜治疗颅底脊索瘤的疗效及优缺点，我们查阅了近年来国内外公开发表关于经鼻内镜手术治疗颅底脊索瘤的相关文献，并从术前肿瘤评估分型、手术策略、肿瘤手术切除程度及其影响因素以及术后并发症等几方面对其进行综述。     

内镜下颅底手术体会

目的 总结内镜下颅底手术的方法和临床经验.方法 回顾性分析2003年7月～2011年8月在鼻内镜下完成的鼻颅底区域手术15例临床资料,探讨鼻颅底手术的相关技术与方法,总结临床经验.结果 15例均采用鼻内镜下进行鼻颅底手术,所有患者均取得满意疗效.其中垂体瘤7例,术后视力或内分泌症状明显改善;外伤性脑脊液鼻漏3例,修补后症状消失;外伤性视神经病5例,行视神经减压术后视力均有不同程度恢复;1例外伤性视神经病术后出现脑脊液鼻漏,经过保守治疗后痊愈.结论 经鼻内镜鼻颅底手术具有创伤小、术后恢复快、并发症少等优点.术中正确识别颅底的解剖标志、恰当的颅底修复,有助于保证手术安全,提高手术疗效.     

儿童内镜鼻颅底外科研究进展

随着鼻内镜外科技术的发展,其在儿童鼻颅底病变的治疗上也开始得到越来越多的应用,但鉴于儿童解剖特点及手术的难度,此类手术并不普及。本文对儿童鼻颅底外科的发展现状、相关解剖及鼻内镜鼻颅底手术重建的方法和特点进行阐述,并对儿童鼻颅底病变的诊疗和未来发展方向进行展望。     

虚拟现实系统在鼻内镜颅底外科中的应用前景

虚拟现实(virtual reality，VR)是目前国内外各大行业领域研究的热门，与人工智能（artificial intelligence,AI）共同引导科技前沿。目前该技术主要应用于娱乐，包括游戏、购物、家居、电影方面，在机械制造、航空航天等领域也取得广泛研究及应用。但因医学专业性较强，对于此技术的要求较其他专业更高，所以VR在医学领域的应用还有待发展。同时，随着科学技术的进步，鼻内镜颅底外科经过耳鼻咽喉科、神经外科、影像科、病理科、麻醉科等多学科的共同努力，鼻内镜手术已成为全球主流的颅内肿瘤切除术的首选术式。目前，国内外有很多学者已经开始将VR技术应用于神经外科，包括颅内、侧颅底、斜坡等区域。因此，对于正处于青少年时期的鼻内镜颅底外科来说，VR无疑是发展过程中的重要基石。     

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。     

颅底脊索瘤的显微手术治疗探讨

探讨颅底脊索瘤的临床特点及手术治疗方案。方法回顾性分析湘雅医院神经外科2011年1月—2019年12月经显微手术治疗的33例颅底脊索瘤患者的病例资料,统计手术入路、病变切除程度及术后并发症等情况,分析患者临床疗效。结果33例患者中,全切除19例,次全切除12例,大部分切除2例,全切除率57.6%。术后有2例患者新发眼球外展受限、复视,术后1个月逐渐恢复正常;术后脑脊液鼻漏2例,均为经鼻蝶术后患者,其中1例予腰大池引流1周后拔管无脑脊液漏,1例行脑脊液漏修补术;有2例术后出现垂体功能减退,予激素替代治疗2~3个月后逐渐恢复。无围手术期死亡病例。术后随访时间6个月~108个月,19例全切除患者中有5例复发,复发率26.3%;12例次全切除患者中有4例明显进展;2例大部分切除患者中1例术后进展迅速,半年后死亡。33例患者中位无进展生存期（PFS）73个月,5年PFS 63.2%,5年生存率96.7%。结论颅底脊索瘤首选治疗方式是外科手术,术前应对其进行详细的影像学评估,选择合适的颅底手术入路尽可能提高肿瘤全切除率,术后辅助放疗可延缓肿瘤复发。     

内镜经鼻浴缸塞技术在儿童脑脊液鼻漏修补术中的应用

目的探讨内镜经鼻浴缸塞技术在儿童脑脊液鼻漏修补术中的安全性和有效性。方法回顾性分析2016年9月—2019年9月北京儿童医院耳鼻咽喉头颈外科收治的16例脑脊液鼻漏患儿的临床资料。其中男10例,女6例,年龄5~123月龄,中位年龄57.5月龄。患儿常规进行鼻窦薄层CT及MRI检查,并进行了全身麻醉下经鼻内镜浴缸塞技术脑脊液鼻漏修补术。术后定期随访,对手术效果及并发症进行评估。对所有患儿的人口学特点、症状、体征、颅底漏口位置及面积、治疗及预后情况等进行归纳总结。结果16例患儿中,外伤性脑脊液鼻漏7例,先天性脑脊液鼻漏9例。单纯性脑脊液鼻漏2例,合并基底型脑膜脑膨出14例。颅底漏口分别为左侧筛板6例,右侧筛板4例,左侧筛顶2例,右侧筛顶1例,左侧额窦后壁2例,右侧蝶窦顶壁1例。漏口最大直径1~4 mm 4例,5~10 mm 7例,11~20 mm 5例。其中15例手术获得一次性成功,仅1例额窦后壁外伤性脑脊液漏内镜手术修补失败,改由神经外科行开颅修补术。术后随访24~60个月,中位随访时间32.5个月,均未复发或出现并发症。结论内镜经鼻浴缸塞技术法儿童脑脊液鼻漏修补术是一种安全、有效的手术方式,具有操作简便、创伤小、并发症少等优点。     

儿童颅底肿瘤经鼻内镜外科手术治疗分析

摘要：目的探讨分析鼻内镜手术在治疗儿童颅底肿瘤中的应用。 方法回顾性分析中南大学湘雅医院鼻颅底外科 2010年6月—2019年11月收治确诊为颅底肿瘤并行鼻内镜治疗的患儿共44例,其中鼻咽纤维血管瘤17例,朗格汉斯组织细胞增生症7例,骨化纤维瘤5例,原始神经外胚层肿瘤2例,横纹肌肉瘤2例,脑膜瘤2例,间叶性软骨错构瘤1例,颅咽管瘤1例,表皮样囊肿1例,血管纤维脂肪瘤1例,生殖细胞瘤1例,骨母细胞瘤1例,脊索瘤1例,侵袭性垂体腺瘤1例,纤维瘤病1例。 结果44例患儿中43例在鼻内镜下完全切除,仅1例鼻咽纤维血管瘤分期切除。术后44例均进行定期随访,随访时间3个月至9年。5例失访,其中骨母细胞瘤1例,脑膜瘤1例,横纹肌肉瘤1例,鼻咽纤维血管瘤2例;12例术后接受放化疗,其中朗格汉斯组织细胞增生症7例,原始神经外胚层肿瘤 2例,横纹肌肉瘤1例,脊索瘤1例,生殖细胞瘤1例,随访至今患儿状况良好,均无复发及转移;1例鼻咽纤维血管瘤复发;再次手术后治愈;其余26例患儿术后未见复发。结论鼻内镜颅底手术治疗儿童颅底肿瘤是可行、有效及安全的。     

鼻内镜微创手术治疗鼻颅底肿瘤36例临床分析

目的 探讨鼻内镜微创外科技术应用于鼻颅底肿瘤的适应证、疗效及安全性.方法 回顾性分析2000年1月至2004年6月鼻内镜下行鼻颅底肿瘤切除术36例,其中鼻咽血管纤维瘤16例、鼻窦骨化纤维瘤8例、垂体瘤8例、嗅神经母细胞瘤4例.患者术后均行病理检查证实.鼻咽血管纤维瘤患者术前行供血动脉介入栓塞术;嗅神经母细胞瘤患者术后给予放疗;2例较大的垂体瘤患者手术未能完全切除,术后给予放疗.结果 36例患者均行肿瘤全部或者大部分切除.3例患者出现脑脊液鼻漏并发症,其中2例分别采用中鼻甲黏膜和肌肉组织修补成功,另1例仪给予降颅压、抗炎处理后自愈.术后随访4～8年均无复发.结论 在正确选择适应证的前提下,鼻内镜微创手术能够安全有效地处理鼻颅底肿瘤.     

A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap

BACKGROUND: In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients. METHODS: We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap. RESULTS: Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved. CONCLUSION: The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.     

腰大池引流联合鞘内注射对内镜经鼻颅底手术术后颅内感染的疗效分析

目的研究腰大池引流联合鞘内注射治疗内镜经鼻颅底手术术后颅内感染的疗效,为内镜颅底手术术后颅内感染的治疗提供依据。方法对2002年6月~2017年6月内镜经鼻颅底手术术后颅内感染病例30例进行回顾性研究,其中腰大池引流+鞘内注射美罗培南,并行全身应用美罗培南组（简称引流组）12例,其余单纯全身应用美罗培南组（简称对照组）18例,比较两组治疗过程中脑脊液白细胞计数与生化变化及治愈率。结果治疗后3 d及1周,两组患者脑脊液中白细胞计数,蛋白质定量均降低,脑脊液葡萄糖均升高,引流组改善程度优于对照组,差异均具有统计学意义（P<0.05）。引流组治愈率91.7%,对照组为77.8%。差异具有统计学意义（P<0.01）。引流组死亡率8.3%,对照组死亡率22.2%。结论腰大池引流联合鞘内注射美罗培南,并行全身应用美罗培南治疗内镜经鼻颅底手术术后颅内感染,能够明显提高疗效,降低死亡率。     

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.     

Acquisition of surgical skills for endonasal skull base surgery: a training program

Introduction : Endonasal surgery represents a radical change in the practice of cranial base surgery and requires the acquisition of new knowledge and surgical skills. The optimal training program for surgeons has not been established. Methods : We reviewed our experience with endonasal cranial base surgery from 1998 to 2006 to develop a training plan for the acquisition of surgical skills. It consists of a modular and incremental approach to endonasal skull base surgery that is designed to train surgeons to function as a team, learn endoscopic skull base anatomy, and develop fundamental endoscopic skills. Results : Stages of training are established for the otolaryngologist–head and neck surgeon and the neurosurgeon that are based on level of technical difficulty, potential risk of vascular and neural injury, and unfamiliar endoscopic anatomy. Mastery of each level is recommended before attempting procedures at a higher level. Conclusions : Standardization of training and the adoption of a modular, incremental training program are expected to facilitate the training of endonasal surgeons in both surgical specialties. Adherence to such a program during the growth phase of endoscopic skull base surgery may decrease the risk of complications as the surgeon's knowledge and surgical expertise develop.     

鼻内镜下可用的带血管蒂组织瓣文献综述

鼻内镜颅底外科术后隔绝颅腔与鼻腔的交通是该学科发展面对的挑战之一,近年利用带血管蒂组织瓣,经内镜手术入路修复颅底缺损获得满意疗效。颅底局部性和区域性带血管蒂组织瓣,修复范围广泛、取材方便、抗感染性强、易于成活,是修复颅底缺损的最佳选择。本文对内镜下修复颅底常用带血管蒂组织瓣进行综述。     

Sigmoid incision rescue nasoseptal flap technique for endoscopic endonasal skull base surgery

Conclusion The sigmoid-incision (S-I) rescue flap technique has the advantage of both reduced-invasiveness and providing a sufficient surgical corridor for endoscopic endonasal skull base surgery (EESBS). Objective Skull base reconstruction with nasoseptal flap (NSF) is critically important in managing post-operative cerebrospinal fluid (CSF) leakage after tumor removal by EESBS. The NSF needs to be elevated before sphenoidotomy and posterior septectomy to preserve the pedicle. However, most extradural surgery without CSF leakage does not require NSF and, therefore, NSF preparation is often futile. As a result, a rescue flap technique to overcome this problem has been developed, whereby a new S-I rescue flap method is used that enables wide exposure of the sphenoidal rostrum and smooth manipulation of surgical instruments to preserve the NSF pedicle. Materials and methods Starting in April 2014, 19 cases underwent EESBS with S-I rescue flap. Results All patients underwent tumor resection under an adequate operative field with smooth manipulation of surgical instruments. Two complications were experienced. One patient had CSF leak after removal of the nasal packing, but the leakage was successfully closed by conventional NSF. Another patient had epistaxis from the septal wall, but this was controlled by electrocautery.     

神经内镜下扩大经鼻蝶窦入路治疗颅咽管瘤

目的神经内镜下经鼻蝶窦入路术中能够直视肿瘤、无脑组织牵拉,已广泛应用于垂体腺瘤的手术治疗,而扩大经鼻蝶窦入路突破了传统的限制,提高了鞍上肿瘤及海绵窦区域肿瘤的切除率。神经内镜下扩大经鼻蝶窦入路治疗颅咽管瘤的安全性及有效性是目前关注的重点。方法回顾性分析20例颅咽管瘤患者的临床资料,均在神经内镜下行扩大经鼻蝶窦入路鞍区病变切除,结合国内外该入路治疗颅咽管瘤的文献进行讨论。结果20例均实现肿瘤全切除,无死亡病例。15例无任何并发症,4例出现1项并发症,1例出现2项并发症。仅1例术后新发视力、视野损伤;2例新发一过性尿崩;2例出现新发垂体功能减退;2例术中保留垂体柄,垂体功能并未见明显变化;2例术后感染,予抗生素治疗控制良好。术后随访：2例在术后8、18个月垂体核磁示可疑复发,其余最长随诊时间12个月复查时没有任何复发迹象。保留垂体柄的患者术后7个月的随访过程中未出现复发。结论神经内镜下扩大经鼻蝶窦入路切除颅咽管瘤的安全性、有效性均比较乐观。颅底重建技术的发展极大降低术后脑脊液漏发生率,为手术提供了支持与保障。     

Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies

Technical and technological innovations have spearheaded the expansion of the indications for the use of endoscopic endonasal approaches to extirpate malignancies of the sinonasal tract and adjacent skull base.ObjectiveCritical review of the available literature regarding the use of endoscopic endonasal approaches including indications, limitations, surgical techniques, oncologic outcome, and quality of life.MethodVarious endoscopic endonasal techniques are reviewed according to the origin and local extension of sinonasal and skull base malignancies including anterior cranial base, nasopharynx, clivus, and infratemporal fossa. In addition, the available literature is reviewed to assess outcomes.ConclusionEndoscopic endonasal approaches are an integral part of the armamentarium for the treatment of the sinonasal tract malignancies and skull base. In properly selected cases, it affords similar oncologic outcomes with lower morbidity than traditional open approaches. Nonetheless, these minimal access approaches should be considered a complement to well-established open approaches, which are still necessary in most advanced tumors.     

鼻内镜下颅底占位性病变的微创手术

目的探讨经鼻内镜在颅底占位性病变手术中的应用。方法回顾性分析2000年6月至2006年9月42例颅底占位性病变患者的临床资料。其中前、中颅底恶性肿瘤13例，脊索瘤8例，侵袭性垂体瘤向蝶窦、蝶鞍颅底破坏者5例，蝶骨骨纤维异样增殖症4例，翼腭窝、颞下窝神经纤维瘤3例，纤维血管瘤3例，前、中颅底骨化纤维瘤3例，其他病变3例。结果42例患者中，肿瘤完全切除36例，病变次全切除6例，2例因出血过多分两次完成手术，其余病变均1次完全切除。术后1例患者右眼失明，1例患者出现脑脊液耳漏，保守治疗1周后痊愈。42例均进行随访，随访6—81个月，其中5例失访，8例复发，6例死亡，其余患者未见复发。结论内镜下颅底占位性病变外科手术治疗安全、有效、微创，但需根据一定的技术、设备条件，严格掌握手术适应证。     

Cerebrospinal fluid rhinorrhoea as a complication of endoscopic endonasal reduction of blowout fractures

Background: Unless the orbital contents are supported, the insertion of nasal packing material during endoscopic endonasal surgery may cause serious intracranial complications such as cerebrospinal fluid leakage. Methods: Case report and literature review. Results: We report a patient with iatrogenic cerebrospinal fluid rhinorrhoea caused by intracranial entry of a Silastic sheet inserted into the nasal cavity. This skull defect and the surrounding skull base were successfully reconstructed in a multilayer fashion via an endoscopic endonasal approach. Conclusion: This case highlights the need for caution when inserting nasal packing material. During endoscopic endonasal reduction of blowout fractures, great care must be taken to support the orbital contents, in order to avoid serious intracranial complications such as cerebrospinal fluid leakage.