影像导航引导鼻内镜下前颅底骨化纤维瘤切除术

Resection of the ossifying fibroma of anterior skull base with nasal endoscope under the guidance of image navigation

目的探讨影像导航系统在经鼻内镜切除前颅底骨化纤维瘤手术中的作用。方法选择影像导航引导下经鼻内镜手术切除累积眶纸板、颅底骨质的筛窦骨化纤维瘤12例男性患者,初次手术9例,复发病例3例。术前行鼻窦CT连续扫描,骨算法,层厚1mm。结果CT显示所有病例筛骨水平板、眶纸板受累。4例前界至额隐窝前缘(鼻骨后);6例累及眶尖与蝶窦外侧壁交界处;1例广泛累及上颌骨、蝶骨大翼、蝶鞍和斜坡。11例彻底切除病灶,1例(病变广泛者)切除大部分肿瘤。平均手术时间3.2小时,影像导航配准过程平均25分钟。1例术中并发脑脊液漏,术中鼻内镜下修补成功;3例术中损伤眶纸板,无手术及术后并发症。术后随访5个月～4年,姑息手术病例肿瘤生长缓慢,其余病例无复发,症状明显改善。结论借助影像导航引导,经鼻内镜手术切除累及眶纸板、前颅底骨质的骨化纤维瘤,具有一定优势,但病灶不应广泛侵及额隐窝、蝶骨及斜坡。

OBJECTIVE To discuss the role of image navigation in resection of the ossifying fibroma involving anterior skull base with nasal endoscope and related techniques. METHODS Twelve male cases with ethmoidal ossifying fibroma involving orbital wall and anterior skull base were underwent intranasal endoscopic sinus surgery under the guidance of image navigation. There were 9 primary cases and 3 recurrent cases. All the patients took the sequential nasal sinuses CT examination with 1 mm thick preoperatively. RESULTS CT scans demonstrated that the orbital wall and anterior skull base were involved in every case. The anterior boundary of the lesion was against the back of the nasal bone in 4 cases. The lesions were adjacent to the orbital apex and lateral wall of the sphenoid sinus in 6 cases. The maxillary bone, sella turcica and clivus were widely invaded in 1 case. The tumors were totally removed in 11 cases, partially removed in 1 case. The average operative time was 3.2 h and the average registration time was 25 minutes. CSF leakage occurred in 1 case and was repaired during surgery. There were 3 cases with lamella papyracea injury. No complications occurred. No recurrence had happened and the symptoms were obviously improved after follow-up for 5 months to 4 years in 11 cases with totally removed tumor. CONCLUSION Ethmoidal ossifying fibroma involving orbital wall and anterior skull base can be totally removed with nasel endoscope under the guidance of image navigation.