鼻颅底肿瘤手术术式的合理选择

近年来，鼻内镜技术的发展显著地促进了鼻颅底外科的发展，在很大程度上取代了传统的鼻颅底肿瘤切除的手术方式，但不是所有的鼻颅底肿瘤都适合经鼻内镜手术，应严格把握适应证，遵循颅底肿瘤手术治疗原则，选择合理的手术方式。该文总结了该科近几年来所开展的鼻颅底肿瘤手术经验，就如何根据肿瘤病理学特点、原发部位、肿瘤大小和侵犯范同选择鼻颅底肿瘤手术术式进行了探讨，并介绍了几种手术入路，包括内镜下经鼻蝶鞍区肿瘤手术，内镜下经鼻-鼻中隔-筛-蝶入路蝶鞍、斜坡巨大肿瘤手术，内镜下经鼻-上颌窦后壁入路鼻颅底、侧颅底交通性肿瘤和经鼻内镜入路与经颅联合入路鼻颅底交通性肿瘤切除术。结果表明利用鼻内镜技术切除中线鼻颅底肿瘤，具有独特的优势，但应严格把握手术适应证，选择合适的手术方式。     

内镜颅底外科带血管蒂黏膜瓣技术的研究进展

正经鼻内镜颅底外科因微创的手术入路、术中肿瘤暴露充分、全切除率高、术后恢复快、住院时间短等优势越来越受到颅底外科医师的青睐。在过去的10年中,经鼻内镜颅底入路相关解剖的深入研究以及内镜器械和影像学技术的发展极大地改善了颅底腹侧及硬膜内病变的暴露与切除[1-2]。颅底重建是此类手术最关键的步骤之一,关系手术成败。在黏膜瓣技术被引入内镜颅底修补术之前,颅底较     

内镜下扩大的经鼻入路处理前颅窝以及鞍周病变的临床应用与进展

近年来，内镜经鼻入路手术已成为处理鞍区病变的常规方法，它具有不牵拉脑组织、视野广阔的优点。随着对内镜下解剖结构的进一步了解、止血技术的成熟、内镜器械的改进、颅底重建技术和材料的进步，又出现了内镜扩大的经鼻入路（extended endoscopic endonasal approach，EEEA），并用于处理颅底中线区的多种病变。     

应用改良前岩骨入路治疗岩斜区及脑干病变

目的　探讨应用改良的前岩骨入路显微外科手术治疗岩斜区和脑干病变的方法和经验。方法　前、中颞部骨瓣开颅达中颅底水平 ,磨除颧弓上半部 ,从中颅底剥离并抬起硬脑膜显露Kawase三角。完成岩尖磨除后 ,硬脑膜内前颞下入路“T”形切开天幕 ,可充分显露并切除位于上、中斜坡、中脑和上桥脑腹侧的病变。结果　手术中病变显露满意 ,肿瘤全切除 5例( 83 3 % ) ,手术后仅 1例出现新增动眼神经麻痹 ( 16 7% )。结论　改良的前岩骨入路对岩斜区和脑干腹侧病变的显露 ,明显优于经典的Kawase入路     

经颅前颅底入路切除颅面肿瘤

本文报道２８例颅面区肿瘤经颅前窝底入路切除，术中采用颅骨膜及帽状腱膜进行颅底重建，术后无一例发生脑脊液漏和颅内感染。本入路具有术野广阔，切除颅面及眶部病变彻底，颅底修复可靠等优点，是处理毗邻颅前窝底病变的一种可行方法。     

经单鼻孔-蝶窦入路切除垂体腺瘤

目的 探讨经单鼻孔-蝶窭入路切除垂体腺瘤的手术方法、操作要点，并评价其疗效。方法 回顾性分析6例经单鼻孔-蝶窦入路切除垂体腺瘤手术经验。结果 手术时间平均65min，肿瘤全部切除4例，次全切除2例。术后全部恢复良好，全部病人视力迅速好转。结论 经单鼻孔-蝶窦入路切除垂体腺瘤术缩短了手术路径，暴露所需时间短，创伤小，是一种处理鞍内和大部位于鞍内的肿瘤的有效的微侵袭手术方法。     

内镜下经鼻入路显露视神经和眼眶的解剖研究

目的研究内镜下经鼻入路至视神经和眼眶的相关解剖,为临床提供参考。方法选用30具骨性颅底标本,测量相关的解剖数据。选5具成人灌注尸头,采用两种内镜经鼻入路显露视神经和眼眶。结果采用经鼻中隔旁入路,可显露双侧视神经;采用经中鼻道入路,可显露同侧视神经和部分眶内结构。结论经鼻入路的内镜手术是治疗视神经和眶内病变的新选择。     

经上颌骨翻转入路切除颅底侵入瘤的护理

目的：探讨经上颌骨翻转入路切除颅底侵入瘤手术病人 的护理。方法：总结自2000年3月－2002年3月采用经上颌骨翻转入路手术切除的12例颅底侵入瘤病人的护理措施，主要包括心理护理、术前准备、术后生命体征监测、手术切口的护理、呼吸道护理、并发症观察与护理及出院指导。结果：该 组病例肿瘤全部切除，无死亡，未发生重要血管损伤， 未导致新的颅神经损伤。结论：经上颌骨翻转入路切除颅底侵入瘤手术复杂、创伤大、细致、全面的观察和护理对患者顺利康复至关重要。     

经眶-颧弓入路切除颅底肿瘤手术配合

颅底病变位置深 ,周围有许多重要神经血管 ,手术显露困难 ,常需牵拉脑组织增加显露。过度牵拉脑组织容易造成脑牵拉伤 ,严重影响了颅底手术的效果。因此 ,要提高颅底肿瘤全切除率 ,降低手术死亡率 ,就必须减少脑牵拉伤。近年来采用大范围切除颅底骨性结构 ,增加手术显露 ,即是减少颅底手术脑牵拉伤的一种行之有效的方法 ,经眶 -颧弓入路开颅手术就是其中一种。我院自 1998年 2月～ 1999年 3月共实施了 2 0例 ,术后 1周复查ＣＴ ,无 1例出现手术部位脑挫伤、脑内血肿。原有肿瘤周围水肿均有不同程度好转。手术死亡 1例 ,系蝶骨嵴内 1/ 3脑膜…     

侧颅底手术过程中脑及颅神经功能保护

手术是绝大部分侧颅底病变的首选治疗方式。因侧颅底解剖结构复杂, 毗邻脑及重要血管神经, 手术容易致死或致残, 限制了该部位手术的实施。脑、后组颅神经、面神经、听力功能是该部位手术保护的重点, 恰当处理功能保留和切除病变的关系、良好的外科操作技能以及合理使用介入、导航等新的辅助技术是侧颅底手术中实现器官功能保护的关键。     

Interdisciplinary surgical treatment of anterior skull base tumors]

OBJECTIVES: We present our clinical experiences regarding interdisciplinary surgical treatment of anterior skull base tumours and evaluate postoperative results. METHODS: Fifty-seven patients (25 male, 32 female) with benign and malignant neoplasms involving the anterior skull base were retrospectively reviewed. In all cases tumour resection was carried out by an interdisciplinary rhino-neuro-surgical skull base operating team. Forty-three of 57 patients (75.4%) underwent common transbasal tumour resection and 11 (19.3%) were operated on from an extended transbasal approach. An extensive transbasal approach for tumour resection was used in 3 patients (5.3%). Postoperative mortality and morbidity were evaluated over a period of 6 months. RESULTS: In all 57 patients a good access to the frontal fossa and the sinuses was achieved. By means of the transbasal approaches, one-step tumour removal was possible in all cases. Tumor diameter ranged fom 12 mm to 114 mm. Even tumours extending as far as the hard palate required no additional transfacial procedures. Surgical mortality was 3.5%. Permanent postoperative complications were noted in 4 cases (7.02%) and transient postoperative complications in 7 (12.28%). CONCLUSION: In dealing with anterior skull base tumours, interdisciplinary surgical procedures using transbasal approaches provide a satisfactory outcome at a low rate of postoperative complications. When transbasal approaches are applied, no additional transfacial skull base exposure using midfacial incisions is required.     

Internal carotid artery aneurysm repair requiring skull base resection: a case study.

A 51-year-old man with a history of hypertension and smoking with an internal carotid artery (ICA) aneurysm was a referral from an outside hospital. He had a history remarkable for headaches for 6 months refractory to conventional therapy, but no stroke, transient ischemic attack, seizure activity, or neck pain. Arteriogram revealed a right ICA aneurysm at the level of the skull base with no accessible cervical ICA distal to the aneurysm. The petrous and intracranial ICA were normal. A team approach to repair was undertaken with a skull base resection and ICA exposure by head and neck surgeons and vascular reconstruction with vein graft from common carotid to petrous portion of ICA by vascular surgeons. A small right parietal infarction was noted in the postoperative period and became a focus of seizure activity. Anti-seizure medication was successful and transient upper-extremity weakness cleared. Transient dysfunction of cranial nerves VII and IX developed. The complex nature of the operation required expertise from different surgical specialties, and the postoperative complication mandated medical specialty and extensive inpatient and outpatient physical, occupational, and speech therapies ICA aneurysms of the skull base are uncommon. Historic treatment involved either ligation with a high risk of stroke or bypass to intracranial artery because direct repair was difficult. With a skilled team approach, direct repair as described is effective. This article focuses on the complexity of the surgical procedure, perioperative care, outcome of surgical intervention, and a multidisciplinary approach to the care of the patient undergoing ICA aneurysm repair requiring skull base resection.     

眶外侧入路手术治疗颅底脑挫伤及血肿的研究报告

目的：改良治疗颅底面脑挫伤及血肿的传统手术入路。方法：68例脑外伤患者，经眶外侧入路进行手术治疗，44例术前已出现瞳孔改变。结果：58例术后存活，死亡率14％，骨瓣回植率83％。结论：该入路暴露彻底，减压充分，便于手术操作和减轻术后脑水肿。     

侧颅底肿瘤外科与听觉功能保护

侧颅底区域上承颅脑, 下接颈部, 其间穿行重要的血管、神经、位听器官, 解剖结构复杂。切除病变同时保留重要组织器官功能是侧颅底外科的基本原则, 在神经医学、介入医学、面神经外科发展的基础上, 颅底重要神经、血管的保护已经取得显著进步, 致命并发症及其他神经功能缺失发生率已显著降低, 而听觉功能保护目前尚不理想, 如何进一步保护听觉功能逐渐成为研究热点。选择正确治疗方式、恰当的手术入路、内镜技术的应用、术中听觉电生理监测以及术中听觉功能重建等对于听觉功能保护非常重要。     

CT血管成像在颅底脑膜瘤手术中的应用

目的 探讨多排螺旋CT血管造影(MSCTA)对降低颅底脑膜瘤手术创伤的应用价值. 方法 对32例颅底脑膜瘤患者术前行MSCTA检查,观察瘤体的形态及其与邻近大血管、颅底骨质的三维关系;利用三维重建图像模拟手术操作,以术中所见为标准对照.同时随机抽取未接受MSCTA检查的22例颅底脑膜瘤患者作为对照组,比较两组的术中输血量和并发症的发生率. 结果 32例患者MSCTA皆清晰显示瘤体的形态及其与邻近大血管、颅底骨质的三维关系,与术中观察一致,通过模拟操作皆合理地设计了骨瓣的大小及形状,有效避免了瘤周重要血管的损伤,准确地评估了包裹动脉剥离的危险度,其中9例改变了常规手术入路和手术方式,4例术前早期制定了次全切手术方案及放疗计划.与对照组比较,患者术中输血量明显减少(P<0.05),术后并发症发生率也降低. 结论 MSCTA可以从多角度模拟手术操作,为术前制定手术方案提供重要信息,从而减少手术创伤和术后并发症.     

Clinical evaluation of postoperative sinonasal surgical patients

Rhinosinusitis is a very common upper respiratory illness. Functional endoscopic sinus surgery has been successfully utilized in the surgical treatment of medically refractory rhinosinusitis. The endoscopic approach has also been extended to various skull base lesion and sinonasal neoplasms. This paper provides a brief overview of the clinical aspect of evaluating sinonasal surgical patients. Judicious use of nasal endoscopy and importance of CT imaging of the sinuses are discussed. Emphasis is placed on establishing communication between the sinus surgeon and radiologist to facilitate evaluation of the sinonasal surgical patients. Timing and specific types of imaging studies before any revision sinus surgery are discussed. Major complications associated with endoscopic sinus surgery are reviewed.     

侧颅底外科的原则、技术与进展

侧颅底外科的主要目的是在保证患者生命安全的基础上,彻底切除肿瘤,降低患者的死亡率,提高患者的生活质量。遵循基本的外科治疗原则、掌握必要的手术技术是保证手术安全和治疗效果的重要前提。随着医疗水平的整体进步,侧颅底外科进入了快速发展的新阶段,同时也面临着新的机遇与挑战。本文主要介绍了侧颅底外科的基本原则和技术进展,并对未来发展作出简要展望。     

多学科联合治疗颅鼻沟通性肿瘤

目的:探讨颅鼻沟通性肿瘤的诊断与显微外科治疗。方法:回顾性分析四川大学华西医院神经外科2004年6月~2006年1月手术治疗的17例颅鼻沟通性肿瘤。结果:本组17例病变均经鼻腔内镜辅助下行额下入路,一期手术切除并行颅底重建。手术全切14例,大部切除3例,均恢复良好,2例术后发生脑脊液漏,发生率11.8%。无死亡病例。病理结果:脑膜瘤8例(其中不典型脑膜瘤2例),嗅神经母细胞瘤5例,嗅神经鞘瘤1例,鳞状细胞癌2例,血管外皮细胞瘤1例。结论:鼻腔内镜辅助下经额下入路开颅行颅鼻沟通性肿瘤一期手术切除,并进行颅底重建疗效肯定,手术全切率高,并发症发生率低。     

6排螺旋CT三维重建及血管成像对颅颈交界畸形诊断的研究

目的:研究6排螺旋CT三维重建及血管成像对诊断颅颈交界畸形的价值。材料与方法:18例经手术治疗的颅颈交界畸形患者,术前均做6排螺旋CT检查.并行三维重建,分析椎体骨质的异常情况及椎动脉相互关系。结果:寰枢椎脱位11例(前脱位),寰枕融合12例,齿状突型颅底陷入4例,颈椎融合6例,扁平颅底2例,寰椎前后弓未闭合3例.外伤后齿状突骨折合并寰枢椎脱位2例,外伤后枢椎假关节形成,齿状凸与寰椎前弓相融合2例,齿状突发育不全l例,椎基底动脉供血不足3例,Arnold-chiari畸形9例。结论:6排螺旋CT血管造影结合多种三维重建方法可同时观察骨结构与血管走行及周围软组织关系,能够正确诊断并能发现少见的畸形.对于颅颈交界区畸形患者手术方案及手术入路的选择是非常重要的临床应用价值。     

A case report: maxillotomy for removal of a clival chordoma.

Although clival chordomas account for only a small percentage (0.2%) of all intracranial tumors, they represent a considerable challenge for the neurosurgical team. The problems of surgical accessibility to the clivus, management of postoperative complications and tendency of the chordoma to recur are well recognized. This infiltrative tumor located at the skull base has the potential to metastasize and recur, thus meeting the characteristics of a malignant tumor. The maxillotomy, as well as a number of other surgical approaches to the clivus, has been developed and refined for removal of this formidable tumor. It is important to have an understanding of the anatomy of the clivus, the pathology of a chordoma and the surgical technique of a maxillotomy. A case report demonstrates these concepts and nursing considerations for the patient undergoing a maxillotomy for resection of a clival chordoma.