手术治疗鼻窦-颅底区域良性纤维骨性病变

Surgical management of sinonasal and adjacent skull base benign fibro-osseous lesions

目的:探讨采用经鼻内镜和开放式手术入路治疗鼻窦-颅底区域纤维骨性病变的方法、注意事项及临床疗效。方法:15例鼻窦-颅底区域纤维骨性病变,其中骨瘤6例,骨化纤维瘤2例,骨纤维异常增殖7例。回顾3种病变的病理及CT影像特点,根据病变的位置及范围选择内镜或开放手术入路治疗。采用鼻内镜手术11例,其中单鼻入路7例,双鼻扩大入路4例;开放式手术4例,其中单纯眉弓入路1例,双冠状入路3例。结果:术后随访2个月～4年,病变完全切除10例,无复发;部分切除5例,都是骨纤维异常增殖症。全部患者临床症状及面部畸形消失或较术前明显改善。内镜手术中发生脑脊液鼻漏1例,Ⅰ期修复成功。术前复视3例,2例半年后消失,1例减轻。全部患者无眶内及颅内并发症。结论:手术是治疗临床症状明显的良性鼻窦-颅底区域纤维骨性病变的有效手段。病变位置和范围是决定采用开放式手术还是经鼻内镜入路的决定因素。内镜手术可切除由额窦后壁到斜坡的中线颅底广泛区域内的病变,而开放式手术入路可以处理眶内壁以外前颅底的病变。无论采用何种入路,骨瘤、骨化纤维瘤可作到完全切除。骨纤维异常增殖由于病变广泛且有自限性,故手术以减轻临床症状和改善面部畸形为目的,多行部分切除。即使骨纤维异常增殖致视神经管明显狭窄但视力依然正常者,预防性视神经减压不必要。

Objective：To explore the use of transnasal endoscopy and open surgical approaches for management of sinonasal and adjacent skull base benign fibro-osseous lesions,the surgical methods,precautions,clinical efficacies were also discribed.Method：Fifteen patients were reviewed,including osteoma in 6 cases,Ossifying fibroma in 2 cases and fibrous dysplasia in 7 cases.Analyzed the pathological features and CT images,and to select surgical approach according to the location and extent of lesions.Eleven patients were operated through transnasal endoscopic procedure,including 7 cases with ipsilateral nasal approach and 4 cases with extended binasal approach;4 cases with open surgical approach,including trans-eyebrow approach in 1 case and bicoronal approach in 3 cases.Result：All patients were followed up for 2 months to 4 years,gross resection of lesions in 10 cases but partial resection in 5 cases with fibrous dysplasia.The clinical symptoms and facial deformity in all cases were eliminated or significantly relieved postoperatively.Cerebrospinal fluid leakage occurred in 1 case,was successfully repaired during the endoscopic operation.Preoperative diplopia in 3 cases,2 cases disappeared after six months,one case was improved significantly.There were no postoperative orbital or intracranial complications.Conclusion：Surgery is an effective means to resect lesions which had obviously clinical symptoms.The location and extent of lesions were the decisive factor to choose an open or endoscopic approach.Endoscopic sinus surgery can manage the midline skull base lesions which extend from the posterior wall of the frontal sinus to the clivus,well the open surgical approach is suitable for lesions locating the area beyond the medial orbital wall.No matter choosing which approach,osteoma,ossifying fibroma can be completely removed.For the fibrous dysplasia,as an extensive but self-limiting lesion,the surgery is performed only for relieving symptoms and facial deformity.So the partial resection is preferred and reasonable other than radical total resection.Even the severe fibrous dysplasia lesions caused the optic canal stenosis but present normal vision,it is unnecessary to perform prophylactic decompression of the optic nerve.