内镜下经鼻切除眶尖海绵状血管瘤

Transnasal endoscopic removal of orbital apex cavernous hemangioma

目的探讨内镜下经鼻手术切除眶尖海绵状血管瘤的策略和适应证。方法回顾性分析11例术前诊断并为术后组织病理证实为海绵状血管瘤的患者，其中男4例，女7例；年龄30—62岁，中位数年龄47岁。术前接受眼科专科检查和鼻科评估。手术由同一高年医师在全麻鼻内镜下进行，开放筛窦并打开眶纸板，用棉片将疝出的脂肪及眼内肌推入眶内后，切除眶内肿瘤。术后在眼科和鼻科随访。结果CT扫描和MRI检查提示肿瘤位于肌锥外（鼻侧）4例，位于视神经和内直肌之间6例，位于视神经外侧1例。9例实现肿瘤全部切除；2例为减压手术。7例同时进行了眶壁重建。随访时间为6～47个月。术后4例手术前后视力无变化，其余7例视力明显改善。3例视野缺损术后2周内逐渐消失。无手术中及手术后并发症。结论位于眶内鼻侧肌锥外或肌锥内视神经内侧的眶尖海绵状血管瘤可采用经鼻入路内镜手术切除。用棉片将眶脂肪及肌肉推入眶内及术者鼻内镜手术成熟经验，为手术成功关键点。

Objective To explore the strategy and indications of endoscopic transnasal resection of orbital apex cavernous hemangiomas （OACH）. Methods Eleven patients aged from 30 to 62 years-old diagnosed as OACH bypostoperative histopathology were reviewed retrospectively. Four males and 7 females were included. Both ophthalmological examination and rhinologie evaluation were adopted preoperatively. The surgeries were carried out under general anesthesia endoscopically by the same senior surgeon. After ethmoidectomy, the orbital lamina papyracea was opened, and the orbital fat and muscles were pushed back into the orbit by using the brain cotton, and then the orbital tumor was removed. The patients were kept follow-up both in ophthalmologic and rhinologic departments. Results As suggested by preoperative imagings, 4 lesions located in the extraconal space （nasal side） , 6 between the optic nerve and the internal rectus muscle of the intraeonal space, and 1 outside the optic nerve in the intraconal space. Total resection was achieved in 9 cases, and orbital decompressions were done in 2 cases. Meanwhile, orbital wall reconstruction was done in 7 cases. The follow up ranged from 6 to 47 months. Seven patients achieved visual acuity improvement and no deteriorations were found in other 4 patients. Defects of vision field in 3 patients disappeared after 2 weeks. No operative or postoperative complications occurred. Conclusions The OACH located in the nasal side of extraconal space and between the optic nerve and the internal rectus muscle of the intraconal space can be accessed endoscopically by intranasal approach. Using the brain cotton to push the orbital fat and muscles back into the orbit and an experienced endoscopic surgeon are important to access a successful intranasal endoscopic removal of orbital apex tumor.