经鼻内镜脑脊液鼻漏修补术23例临床分析

Endoscopic repair of cerebrospinal fluid in 23 cases

目的总结鼻内镜下23例脑脊液鼻漏修补术的方法和疗效。方法回顾性分析2003年1月至2010年12月收治的脑脊液鼻漏23例的临床资料,分析其病史、手术方法及疗效。术前行高分辨率CT(HRCT)扫描及鼻内镜检查,根据漏口处黏膜的特点确定漏口的位置。术中根据漏口位置选用相应的手术方式。采用大腿阔肌筋膜作为修补材料,采用多层内置或外置法放置修补物。术后给予抗炎、止血及降颅压等对症治疗。结果23例中,有明确外伤史15例,自发性不明原因3例,手术所致2例,伴脑膜脑膨出3例。外伤及手术损伤者17例中15例CT检查发现有明显的颅底骨质缺损(蝶窦区骨质缺损5例,额窦与筛板交界处骨质缺损3例,筛板骨质缺损7例)。其余病例CT检查仅见颅底局部骨质变薄、部分骨质吸收或未见异常。随访4～72个月,22例一次修补成功,无再发脑脊液鼻漏。1例伴脑膜脑膨出者行第3次修复,术后无再发脑脊液鼻漏。术后出现并发症2例,1例为颅内感染,1例为脑积水,均治愈出院。结论鼻内镜下脑脊液鼻漏修补术是一种安全、有效和微创的手术方式。术前鼻内镜及HRCT等相关检查可帮助明确漏口位置,根据漏口位置选择相应的手术方式,指导术中修补漏口,是提高手术治疗成功率的关键。

Objective To investigate and summarize the surgical procedure and efficacy of transnasal endoscopic re- pair of cerebrospinal fluid （CSF） rhinorrhea. Methods 23 patients with CSF rhinorrhea who underwent transnasal endoscopic repair between January 2003 and December 2010 were retrospectively analyzed. The lesions were located by both HRCT scan and intranasal endoscopy and were repaired with grafts from autologous thigh muscle fascia. The grafts were placed and fixed above （inlay） or beneath （onlay） the lesions or defects. Results CSF rhinorrhea in this study dued to trauma, surgical injury, meningoencephalocele or idiopathic etiology. By HRCT examination, 15 of 17 patients with histories of trauma or surgical injury were found to have defects in the skull base, and 5 patients had intact skull base, minor local osteoporosis, or bone resorption. 22 patients had no reoccurrence during a follow- up period of 4 months to 72 months. Only one patient suffered 3 surgeries and had no reoccurrence after the third surgery. Conclusion Transnasal endoscopic approach is a safe and effective procedure with minimal invasion for CSF rhinorrhea. The key of success is proper operation mode and corresponding repair procedure.