颅周骨膜瓣在内镜颅底外科手术中的应用

Applications of vascularized pericranial flaps in endoscopic skull base surgeries

目的探讨颅周骨膜瓣在内镜颅底外科手术中的应用及其临床效果。方法首先通过20例成人临床影像学测量以及5例尸头解剖操作确定修补前颅底、鞍区及斜坡硬膜缺损所需颅周骨膜瓣的长度。然后纳入2016—2022年间上海交通大学医学院附属第六人民医院耳鼻咽喉头颈外科收治的25例采用颅周骨膜瓣进行颅底修复重建的患者资料,其中男19例,女6例,年龄11~59岁。包括13例脑脊液鼻漏(其中外伤性12例)和12例鼻窦颅底肿瘤患者。采用描述性统计方法总结患者的临床、手术资料及随访结果。结果20例成人影像学测量结果显示前颅底、鞍区、斜坡三个区域完全切除后的平均缺损面积分别是16.13、14.03和13.12 cm2,重建需要的颅周骨膜瓣长度分别为(118.77±3.44)mm、(133.99±5.08)mm和(181.76±6.31)mm。12例鼻窦颅底肿瘤患者病理包括嗅神经母细胞瘤(n=6)、鳞状细胞癌(n=3),余为软骨肉瘤、骨肉瘤、侵袭性神经鞘瘤各1例,其中8例行术后放疗;1例肿瘤相关性脑脊液鼻漏(听神经瘤)术前已行放疗。本组25例患者均成功实现了颅底重建,术后未发现脑脊液漏、颅内感染、额纹消失、头皮坏死等并发症。随访2~4年,所有患者的瓣膜均存活良好,未发现脑脊液漏。结论对于大的颅底缺损重建或鼻腔带蒂黏膜瓣不可用时,颅周骨膜瓣可作为一个安全有效的选择。

Objective To study the feasibility and efficacy of pericranial flaps for the repairs of large anterior skull base defects.Methods The average length of the pericranial flaps needed for skull base repair was determined with computed tomography measurements in 20 adults and anatomical dissections in 5 cadaver specimen.A series of patients who underwent endoscopic skull base surgeries and subsequent reconstructions with pericranial flaps at the Department of Otolaryngology Head and Neck Surgery,Shanghai Jiao Tong University School of Medicine Affiliated Sixth People′s Hospital from 2016 to 2022 were retrospectively reviewed.There were 19 males and 6 females,aged from 11 to 59 years,including 13 cases of cerebrospinal fluid(CSF)rhinorrhea(12 traumatic)and 12 cases of sinonasal skull base tumors.Descriptive statistical methods were used.Results The mean areas of anterior skull base,sellar,and clival defects were 16.13,14.03 and 13.12 cm 2,respectively,and the mean pericranial flap lengths were(18.77±3.44)mm,(133.99±5.08)mm,(181.76±6.31)mm,respectively.Among sinonasal skull base neoplasms,the pathologies included olfactory neuroblastoma(n=6),squamous cell carcinoma(n=3),chondrosarcoma(n=1),osteosarcoma(n=1),and invasive schwannoma(n=1),in whom 8 patients underwent adjuvant radiotherapy after surgery.One patient(7.7%)had acoustic neuroma-related CSF leak before radiotherapy.All 25 patients successfully underwent skull base reconstruction without complications such as CSF leak,intracranial infection,forehead wrinkles disappearance,or scalp necrosis.All flaps survived well with no CSF leaks within the follow-up period of 2-4 years.ConclusionPericranial flap is a safe choice for large anterior skull base defects following resection of sinonasal skull base neoplasms and complex traumatic CSF leaks when endonasal flaps are not available.