经鼻内镜颅底手术后蝶窦炎的诊断与治疗
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摘要
目的回顾分析经鼻内镜颅底手术后蝶窦炎的致病原因,总结其诊断与治疗特点并评价预后。方法纳入2005年6月至2017年12月行经鼻内镜颅底手术后继发蝶窦炎的患者共24例,采用扩大内镜经鼻入路手术开放蝶窦并清除病灶;通过鼻窦CT、MRI、鼻内镜检查,以及视觉模拟评分(VAS)和Lund-Kcnncdy评分评价患者预后。结果临床表现以头痛(21例,87.50%)、鼻塞(11例,45.83%)、流涕(9例,37.50%)为主要症状。术前鼻窦影像学检查可见广泛性蝶窦壁骨质增厚和(或)蝶鞍骨质不连续,蝶窦壁黏膜呈中等强化征象;术中鼻内镜下可见后组筛窦和蝶窦区黏膜水肿、息肉、瘢痕形成。手术前后VAS评分之头痛(F=118.961,P=0.000)、鼻塞(F=3.519,P=0.035)、流涕(F=30.563,P=0.000)和Lund-Kennedy评分(F=26.064,P=0.000)差异具有统计学意义,其中术后3和12个月V AS评分之头痛(均P=0.000)、流涕(均P=0.000)和Lund-Kennedy评分(均P=0.000)均低于术前。结论经鼻内镜颅底手术视野不充分,不恰当应用人工材料可导致蝶窦炎症反应,引起较严重的头痛、鼻塞和流涕症状;以内镜下扩大开放蝶窦,清理窦内病变组织和修复材料为首选治疗方法,从而改善症状和使黏膜上皮化。
Objective To retrospectively analyze the etiology of sphenoid sinusitis secondary to endoscopic transnasal skull base surgery, summarize the characteristics of diagnosis and treatment, and evaluate the prognosis. Methods Clinical data of 24 cases of sphenoid sinusitis secondary to endoscopic transnasal skull base surgery from June 2005 to December 2017 were collected. Endoscpic extended sphenoidectomy was performed to remove the lesion. Nasal CT, MRI,nasal endoscope, Visual Analogue Scale(VAS) and Lund-Kennedy score were used to evaluate the prognosis of patients. Results Clinical symptoms of those patients included headache(21 cases, 87.50%), nasal obstruction(11 cases, 45.83%) and runny nose(9 cases, 37.50%). Preoperative nasal sinus imaging examinations showed extensive hyperosteogenesis of sphenoid sinus walls and/or discontinuous bone substance of sella turcica, and moderate enhancement of mucosa of sphenoid sinus walls. Intraoperative endoscopic display showed edema, polyp and scar formation of mucosa in posterior ethmoidal sinus and sphenoid sinus. There were significant differences between preoperative and postoperative VAS scores, such as headache(F = 118.961,P = 0.000), nasal obstruction(F = 3.519, P = 0.035) and runny nose(F = 30.563, P = 0.000), and LundKennedy score(F = 26.064, P = 0.000). VAS scores in headache(P = 0.000, for all) and runny nose(P =0.000, for all) and Lund-Kennedy score(P = 0.000, for all) 3 months and one year after surgery decreased significantly in comparison with before surgery. Conclusions Insufficient surgical field for endoscopic transnasal skull base surgery, inappropriate and unreasonable use of artificial materials can lead to severe sphenoid sinus inflammation and more severe symptoms such as headache, nasal obstruction and runny nose. An extended sphenoidectomy should be adopted under endoscope and the lesions and artificial repair materials must be cleaned, so as to improve the symptoms and achieve mucosal epithelization.
Objective To retrospectively analyze the etiology of sphenoid sinusitis secondary to endoscopic transnasal skull base surgery, summarize the characteristics of diagnosis and treatment, and evaluate the prognosis. Methods Clinical data of 24 cases of sphenoid sinusitis secondary to endoscopic transnasal skull base surgery from June 2005 to December 2017 were collected. Endoscpic extended sphenoidectomy was performed to remove the lesion. Nasal CT, MRI,nasal endoscope, Visual Analogue Scale(VAS) and Lund-Kennedy score were used to evaluate the prognosis of patients. Results Clinical symptoms of those patients included headache(21 cases, 87.50%), nasal obstruction(11 cases, 45.83%) and runny nose(9 cases, 37.50%). Preoperative nasal sinus imaging examinations showed extensive hyperosteogenesis of sphenoid sinus walls and/or discontinuous bone substance of sella turcica, and moderate enhancement of mucosa of sphenoid sinus walls. Intraoperative endoscopic display showed edema, polyp and scar formation of mucosa in posterior ethmoidal sinus and sphenoid sinus. There were significant differences between preoperative and postoperative VAS scores, such as headache(F = 118.961,P = 0.000), nasal obstruction(F = 3.519, P = 0.035) and runny nose(F = 30.563, P = 0.000), and LundKennedy score(F = 26.064, P = 0.000). VAS scores in headache(P = 0.000, for all) and runny nose(P =0.000, for all) and Lund-Kennedy score(P = 0.000, for all) 3 months and one year after surgery decreased significantly in comparison with before surgery. Conclusions Insufficient surgical field for endoscopic transnasal skull base surgery, inappropriate and unreasonable use of artificial materials can lead to severe sphenoid sinus inflammation and more severe symptoms such as headache, nasal obstruction and runny nose. An extended sphenoidectomy should be adopted under endoscope and the lesions and artificial repair materials must be cleaned, so as to improve the symptoms and achieve mucosal epithelization.
引文
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[11] Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R.Expanded endonasal approach:fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa[J].Neurosurg Focus, 2005, 19:E6.
[12] Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group of Rhinology; Chinese Medical Association, Society of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group of Rhinology. Guidelines for the diagnosis and treatment of chronic rhinosinusitis(2012,Kunming)[J]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi,2013, 48:92-94.[中华耳鼻咽喉头颈外科杂志编辑委员会鼻科组,中华医学会耳鼻咽喉头颈外科学分会鼻科学组.慢性鼻-鼻窦炎诊断和治疗指南(2012年,昆明)[J].中华耳鼻咽喉头颈外科杂志,2013, 48:92-94.]
[13] Lund VJ, Kennedy DW. Staging for rhinosinusitis[J].Otolaryngol Head Neck Surg, 1997, 117(3 Pt 2):S35-40.
[14] Kutlay M, Durmaz A, Ozer I, Kural C, Temiz C, Kaya S, Solmaz I, Daneyemez M, Izci Y. Extended endoscopic endonasalapproach to the ventral skull base lesions[J]. Clin Neurol Neurosurg, 2018, 167:129-140.
[15] Chakravarthi S, Gonen L, Monroy-Sosa A, Khalili S, Kassam A.Endoscopic endonasal reconstructive methods to the anterior skull base[J]. Semin Plast Surg, 2017, 31:203-213.
[16] Feng S. Development of artificial dural mater[J]. Zhongguo Yi Liao Qi Xie Xin Xi,2017, 13:31-32.[冯珊.人工硬脑膜材料发展概述[J].中国医疗器械信息,2017, 13:31-32.]
[17] Wei HQ, Wang HM, Zang J, Zhang JR, Wang YB, Wang Y,Jiang XJ. Application of vascularized nasoseptal flap to endoscopic anterior skull base reconstruction[J]. Zhongguo Er Bi Yan Hou Lu Di Wai Ke Za Zhi,2014, 20:490-494.[魏宏权,王洪明,臧健,张静茹,王义宝,王勇,姜学钧.带血管蒂鼻中隔黏膜瓣在鼻内镜下前颅底缺损修复重建中的应用[J].中国耳鼻咽喉颅底外科杂志,2014, 20:490-494.]
[18] Pinheiro-Neto CD, Ramos HF, Peris-Celda M, FernandezMiranda JC, Gardner PA, Snyderman CH, Sennes LU. Study of the nasoseptal flap for endoscopic anterior cranial base reconstruction[J]. Laryngoscope, 2011, 121:2514-2520.
[19] Ivan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT,Pletcher SD, Jahangiri A, Wagner J, Aghi MK. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J]. J Clin Neurosci,2015, 22:48-54.
[20] Momata Y, Miyamota Y, Ishikawa K, Takechi M, Yuasa T,Tatehara S, Nagayama M, Suzuki K. Evaluation of feasibility of hydroxyapatite putty as a local hemostatic agent for bone[J]. J Biomed Mater Res, 2002, 63:542-547.
[21] Patel RB, Kwatler JA, Hodosh RM. Bone wax as a cause of body granuloma in the cerebellopontine angle:case illustration[J]. J Neurosurg, 2000, 92:362.
[22] Tao XH. Application of artificial dural repair materials in neurosurgery[J]. Zhongguo Zu Zhi Gong Cheng Yan Jiu, 2012,16:2217-2220.[陶小虎.人工硬脑膜修补材料在神经外科的应用[J].中国组织工程研究,2012, 16:2217-2220.]
[2] Amin SM, Fathy H, Hussein A, Kamel M, Hegazy A, Fathy M.Endoscopic endonasal approach to the lateral wall of the cavernous sinus:a cadaveric feasibility study[J]. Ann Otol Rhinol Laryngol, 2018, 127:903-911.
[3] Shkarubo AN, Koval KV, Chernov IV, Andreev DN, Panteleyev AA. Endoscopic endonasal transclival approach to tumors of the clivus and anterior region of the posterior cranial fossa(results of surgical treatment of 136 patients)[J]. World Neurosurg,2019, 121:E246-261.
[4] Bernat AL, Priola SM, Elsawy A, Farrash F, Pasarikovski CR,Almeida JP, Lenck S, De Almeida J, Vescan A, Monteiro E,Zadeh GM, Gentili F. Recurrence of anterior skull base meningiomas after endoscopic endonasal resection:10 years'experience in a series of 52 endoscopic and transcranial cases[J]. World Neurosurg, 2018, 120:E107-113.
[5] Almeida JP, Suppiah S, Karekezi C, Marigil-Sanchez M, Wong JS, Vescan A, Gentili F, Zadeh G. Extended endoscopic approach for resection of craniopharyngiomas[J]. J Neurol Surg B Skull Base, 2018, 79:S201-202.
[6] Davanzo JR, Goyal N, Zacharia BE. Expanded endoscopicendonasal resection of retrochiasmatic craniopharyngioma[J]. J Neurol Surg B Skull Base, 2018, 79:S194-195.
[7] Rahme RJ, Arnaout OM, Sanusi OR, Kesavabhotla K, Chandler JP. Endoscopic approach to clival chordomas:the Northwestern experience[J]. World Neurosurg, 2018, 110:E231-238.
[8] Prevedello DM, Doglietto F, Jane JA Jr, Jagannathan J, Han J,Laws ER Jr. History of endoscopic skull base surgery:its evolution and current reality[J]. J Neurosurg, 2007, 107:206-213.
[9] Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL.Expanded endonasal approach:the rostrocaudal axis. Part I:crista galli to the sella turcica[J]. Neurosurg Focus, 2005, 19:E3.
[10] Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL.Expanded endonasal approach:the rostrocaudal axis. Part II:posterior clinoids to the foramen magnum[J]. Neurosurg Focus,2005, 19:E4.
[11] Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R.Expanded endonasal approach:fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa[J].Neurosurg Focus, 2005, 19:E6.
[12] Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group of Rhinology; Chinese Medical Association, Society of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group of Rhinology. Guidelines for the diagnosis and treatment of chronic rhinosinusitis(2012,Kunming)[J]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi,2013, 48:92-94.[中华耳鼻咽喉头颈外科杂志编辑委员会鼻科组,中华医学会耳鼻咽喉头颈外科学分会鼻科学组.慢性鼻-鼻窦炎诊断和治疗指南(2012年,昆明)[J].中华耳鼻咽喉头颈外科杂志,2013, 48:92-94.]
[13] Lund VJ, Kennedy DW. Staging for rhinosinusitis[J].Otolaryngol Head Neck Surg, 1997, 117(3 Pt 2):S35-40.
[14] Kutlay M, Durmaz A, Ozer I, Kural C, Temiz C, Kaya S, Solmaz I, Daneyemez M, Izci Y. Extended endoscopic endonasalapproach to the ventral skull base lesions[J]. Clin Neurol Neurosurg, 2018, 167:129-140.
[15] Chakravarthi S, Gonen L, Monroy-Sosa A, Khalili S, Kassam A.Endoscopic endonasal reconstructive methods to the anterior skull base[J]. Semin Plast Surg, 2017, 31:203-213.
[16] Feng S. Development of artificial dural mater[J]. Zhongguo Yi Liao Qi Xie Xin Xi,2017, 13:31-32.[冯珊.人工硬脑膜材料发展概述[J].中国医疗器械信息,2017, 13:31-32.]
[17] Wei HQ, Wang HM, Zang J, Zhang JR, Wang YB, Wang Y,Jiang XJ. Application of vascularized nasoseptal flap to endoscopic anterior skull base reconstruction[J]. Zhongguo Er Bi Yan Hou Lu Di Wai Ke Za Zhi,2014, 20:490-494.[魏宏权,王洪明,臧健,张静茹,王义宝,王勇,姜学钧.带血管蒂鼻中隔黏膜瓣在鼻内镜下前颅底缺损修复重建中的应用[J].中国耳鼻咽喉颅底外科杂志,2014, 20:490-494.]
[18] Pinheiro-Neto CD, Ramos HF, Peris-Celda M, FernandezMiranda JC, Gardner PA, Snyderman CH, Sennes LU. Study of the nasoseptal flap for endoscopic anterior cranial base reconstruction[J]. Laryngoscope, 2011, 121:2514-2520.
[19] Ivan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT,Pletcher SD, Jahangiri A, Wagner J, Aghi MK. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J]. J Clin Neurosci,2015, 22:48-54.
[20] Momata Y, Miyamota Y, Ishikawa K, Takechi M, Yuasa T,Tatehara S, Nagayama M, Suzuki K. Evaluation of feasibility of hydroxyapatite putty as a local hemostatic agent for bone[J]. J Biomed Mater Res, 2002, 63:542-547.
[21] Patel RB, Kwatler JA, Hodosh RM. Bone wax as a cause of body granuloma in the cerebellopontine angle:case illustration[J]. J Neurosurg, 2000, 92:362.
[22] Tao XH. Application of artificial dural repair materials in neurosurgery[J]. Zhongguo Zu Zhi Gong Cheng Yan Jiu, 2012,16:2217-2220.[陶小虎.人工硬脑膜修补材料在神经外科的应用[J].中国组织工程研究,2012, 16:2217-2220.]