Management of Sphenoidal Sinus Lesions by Septal-assisted Approach: Surgical Skills and Advantages

Summary： The aim of this study was to develop a less invasive trans-septal approach for the endo- scopic management of sphenoid sinus lesions. We performed a septal-assisted surgical procedure for endoscopic sphenoidectomy in 38 patients with isolated or combined sphenoidal sinus lesions, including fungal balls, mucoceles, purulent cystic sphenoidal sinusitis, etc. The posterior portion of the nasal sep- turn became flexible after removal of the vomer and the sphenoidal rostrum. The superior portion of the common meatus was expanded to accommodate the endoscope after the septum was repositioned con- tra-laterally. The lesions were individually managed through the enlarged ostiums while damage to the mucosa of the front sphenoidal wall was avoided. All the procedures were completed successfully without intraoperative complications, and the bony ostiums were identified easily and enlarged accu- rately. During the follow-up period of 16 weeks to 2 years, no re-atresia or restenosis was observed. The recurrence rate was 0. No postoperative complications were recorded. All the responses from the pa- tients were satisfactory. It was concluded that endoscopic sphenoidectomy assisted by trans-septal ap- proach is a feasible, safe, effective and minimally invasive approach for selected cases with unilateral or bilateral lesions in the sphenoid sinuses.

Treatment of Organized Hematoma of the Sphenoid Sinus with Pre-Operative Embolization and Endoscopic Resection

The differential diagnosis for expansile masses of the sphenoid sinuses includes both benign and malignant lesions. We herein present a case of a 79-year-old female who presented with chronic epistaxis and an expansile soft tissue mass centered in the sphenoid sinus with erosion of the skull base. Endoscopic resection of the lesion was performed, with histopathological examination revealing organized hematoma. To our knowl- edge, this is the first reported case of sphenoid sinus organizing hematoma treated with pre-operative embolization followed by endoscopic excision.

Study of the relationship between sphenoid sinus volume and protrusions in the sphenoid sinus

The relationship between the volume of sphenoid sinus (SS) and the prevalence of internal carotid artery (ICA) and optic nerve (ON) protrusions in the SS was studied by using high-resolution CT imaging. The ICA and ON protrusions in SS were observed in randomly selected normal head CT scanning images from 350 adult subjects. Ac-cording to the incidence of ICA protrusion, three groups were divided into no ICA protrusion (70.75%), unilateral protrusion (8.68%) and bi-lateral protrusions (20.57%). The ON protrusion accounted for 16% in 350 subjects and accom-panied absolutely with ICA protrusion, but ICA protrusion appeared without accompanying with ON protrusion. The SS volume depended upon the protrusions in it and showed statistical dif-ferences, without ICA protrusion, the smallest size (11.16 ± 1.60) cm3;the unilateral protrusion, medium size (14.20 ± 1.80) cm3 and the bilateral protrusion, the largest size (25.03 ± 2.21) cm3. By observing 3D reconstructed models of ON and SS, we found ON was adjacent to SS (46%) and to posterior ethmoid sinuses (44%). The current study indicates that SS volume is varied with numbers of the protrusions and that ON location varies with the pneumatization of SS. Our results provide an anatomical basis to the surgeries for SS and its surrounding structures.

Application and Care of Two Kinds of Sphenoid Sinus Packing Materials after Pituitary Tumor Resection with the Transnasal Endoscopic Approach

Background: Neuroendoscopic transsphenoidal approach for resection of pituitary adenomas has the advantages of less damage, fewer complications, and a faster recovery than the traditional approach and has beening favored by neurosurgeons. However, there has no standard method of selecting suitable packing materials after the operation to relieve pain in patients and achieve the ideal hemostatic effect. We compared the postoperative complications and treatment effects of two different packing materials in patients with pituitary adenomas. Objective: To investigate the advantages and disadvantages of using a catheter balloon and iodoform gauze for hemostasis in patients undergoing pituitary tumor resection by neuroendoscopic transsphenoidal approach. Materials and Methods: We retrospectively analyzed these data of 48 cases treated with pituitary adenoma resection by the single nasal approach from January 2018 to October 2019 in Sun Yat-sen University Cancer Center. According to the type of sphenoid sinus packing material used, these patients were divided into balloon tamponade oppression group (24 cases) and tela iodoformum oppression group (24 cases), respectively. The balloon tamponade oppression group received catheter balloon tamponade oppression hemostasis, and the tela iodoformum oppression group underwent tela iodoformum oppression hemostasis. The outcomes and complications were compared between the two groups in which two kinds of sphenoid sinus packing materials were used for hemostasis after tumor resection by transnasal endoscopic approach. For the catheter balloon compression hemostasis method, on account of the plasticity of the balloon, the volume of water in the balloon can be adjusted according to the size of the patient’s own sphenoid cavity. The amount of bleeding and several complications in terms of discomfort during placement and removal of the packing material, rebleeding after removal of the packing, cerebrospinal fluid rhinorrhea and electrolyte disturbance are compared between the two groups. Results: 48 patients were enrolled. The two groups’ data of patients were similar in age structure, sex ratio, tumor size at baseline and so on. No complications, such as abscess formation, were found in both groups. The success rate in the compression with catheter balloon group was 100% (24 of 24 patients);and in the iodoform gauze group 83.33% (20 of 24 patients). A catheter balloon was more successful in stopping bleeding at early stage than iodoform gauze. There were no statistically significant differences in the hospitalization stay time, operating day to discharge day and tampon indwelling time (P > 0.05). There were also no significant differences in pairwise comparison between the catheter balloon group and iodoform gauze groups in the incidence of cerebrospinal fluid rhinorrhea or electrolyte disturbance between the two groups (P > 0.05). The incidence of headache in the catheter balloon group was statistically significantly lower than that in the iodoform gauze group (P < 0.05). Conclusion: In patients undergoing endoscopic pituitary tumor resection, compression and hemostasis by means of catheterization expansion lead to lower rates of injury and complications and have a good effect, so this method is worthy of being recommended for clinical practice.

Solitary Fungus Ball of the Sphenoid Sinus

A 50-year-old woman with long standing nonspecific disturbing headaches of the mid-face and rear of the head plus retro-orbital pain for about one year duration was proved to suffer from the fungus ball involvement of the left sphenoid sinus after operation. The diagnosis was established by histopathologic examination of the specimen removed at the time of operation.

VITAPEX联合AH-Plus在窦道型慢性根尖周炎治疗中的疗效观察

目的 探讨VITAPEX 糊剂联合AH-Plus 糊剂治疗窦道型慢性根尖周炎的效果.方法 64 颗窦道型慢性根尖周炎随机分两组.实验组VITAPEX 略超充封药后1~2 个月,去VITAPEX,改AH-Plus 糊剂加牙胶尖永久充填;对照组氧化锌丁香油糊剂加牙胶尖永久性充填.观察比较两组在3~6 个月后有无叩痛、窦道是否愈合,并拍X 线分析根尖周骨质改变的情况.结果 实验组叩痛和窦道均较对照组有显著改善,且根尖周骨质增加显著（P〈0.05）.结论 VITAPEX 糊剂联合AH-Plus 糊剂对窦道型慢性根尖周炎病变进行治疗,可取得较好的临床效果.

蝶窦气化停滞的影像学表现及鉴别诊断

目的分析蝶窦气化停滞的CT和MRI影像学表现,并与蝶骨区骨、软骨源性肿瘤及肿瘤样病变鉴别。方法回顾性分析13例蝶窦气化停滞和20例蝶骨区骨源性肿瘤的CT及MRI资料,包括发生部位、大小、密度、有无膨胀、钙化、骨皮质改变,MRI信号、抑脂后信号改变、强化程度、邻近结构改变等,并进行统计学比较。结果蝶窦气化停滞多见于蝶骨体(4例)、翼突(3例)和多部位受累(6例)。停滞区域以混合密度为主,最长径为0.8~4.1 cm,钙化7例,无膨胀性改变13例,骨皮质完整13例;MRI T1WI高信号11例,等信号2例,T2WI高信号10例,等信号3例,抑脂后信号减低13例,无明显强化10例,轻微强化3例。邻近结构无改变13例。结论蝶窦气化停滞是少见解剖变异,以混合密度为主,骨皮质完整,无膨胀性改变,MRI抑脂信号减低,无明显强化有助于鉴别。

经鼻内镜手术治疗以眼部症状为首发的真菌性蝶窦炎

目的探讨以眼部症状为首发的真菌性蝶窦炎的早期诊断及导航辅助下真菌病变清除术。方法对2007年1月-2022年12月广州市中山大学附属第一医院耳鼻咽喉科收治的17例以眼部症状为首发的真菌性蝶窦炎患者的临床表现、影像学检查、手术方法及术后转归等方面进行回顾性分析,总结临床经验。结果17例患者影像学均符合真菌性鼻窦炎,且术后病理确诊为真菌感染。11例患者术后眼部症状得到不同程度改善,包括视力下降、眼球运动障碍、眼睑下垂等,6例患者术后症状无明显改善。结论临床上病因不明的渐进性视力下降及迁延不愈的头痛,应考虑真菌性蝶窦炎可能,及时完善头颅CT、MRI等检查,一经确诊首选鼻内镜下手术治疗。术中导航技术可辅助准确定位病变并判断病变范围,保障手术安全并提高手术效率。侵袭性真菌性鼻窦炎需要联合系统性抗真菌治疗。

蝶窦解剖对无功能垂体大腺瘤垂直方向生长的影响

目的探讨蝶窦相关解剖对无功能垂体大腺瘤沿垂直方向扩展的影响。方法回顾性分析65例无功能垂体大腺瘤患者影像资料,根据肿瘤鞍上扩展值(suprasellar expansion value,SEV),分为鞍上组(SEV>0)和鞍下组(SEV≤0)。比较蝶窦气化类型、蝶窦主隔偏向、蝶窦体积、蝶窦主隔最大宽度,并进行多因素Logstic回归分析,筛选出有价值的影响因素。结果与鞍下组比较,鞍上组蝶窦气化更好(P=0.016),蝶窦主隔最大宽度更宽(P=0.003),蝶窦主隔更居中(P=0.048),蝶窦体积更小(P=0.040),差异具有统计学意义。多因素Logstic回归分析显示:蝶窦主隔最大宽度(OR=6.23,P=0.013)和蝶窦体积(OR=0.72,P=0.024)是影响无功能垂体大腺瘤沿垂直方向扩展的独立预测因素。结论蝶窦体积越小、蝶窦主隔越宽,无功能垂体大腺瘤越倾向于向鞍上生长。

神经内镜辅助下经鼻蝶窦手术治疗垂体瘤的效果及对嗅觉功能、神经内分泌激素水平的影响

目的:探讨神经内镜辅助下经鼻蝶窦手术治疗垂体瘤的效果及对嗅觉功能、神经内分泌激素水平的影响。方法:回顾性将我院2018年03月至2022年02月收治的垂体瘤患者58例作为此次的研究对象,其中采用显微镜辅助下进行经鼻蝶窦手术的28例作为对照组,神经内镜辅助下进行经鼻蝶窦手术的30例作为观察组,均观察至患者出院,并进行随访1年。比较两组围术期指标,术后1个月视力下降、头痛及性功能障碍缓解率,术前、术后1个月激素水平、T细胞亚群、生活质量评分、嗅觉功能,研究期间并发症发生情况,随访1年后复发情况。结果:与对照组比较,观察组的出血量相对更少,术后住院时间较短,肿瘤全切率相对更高;术后1个月,与对照组进行比较,观察组视力下降、头痛及性功能障碍缓解率均相对更高;相比术前,两组术后1个月血清泌乳素(PRL)、促甲状腺素(TSH)、生长激素(HGH)、促肾上腺皮质激素(ACTh)水平均降低,观察组低于对照组,外周血CD3^(+)、CD4^(+)水平、CD4^(+)/CD8^(+)值、社会功能、躯体功能、心理功能、物质生活状态各项生活质量评分术后1个月则均升高,观察组高于对照组;与术前比较,两组术后1个月嗅觉功能均升高,但观察组低于对照组;研究期间,观察组并发症总发生率3.33%低于对照组的25.00%;随访1年后,观察组的复发率0.00%同样低于对照组的14.29%(P<0.05)。结论:神经内镜辅助下经鼻蝶窦手术可有效提高垂体瘤患者的生活质量以及视力下降、头痛等临床症状缓解率,缩短住院时间,同时还能够改善患者的免疫功能以及嗅觉功能,稳定患者神经内分泌激素水平,降低并发症发生以及复发率。

Invasive sphenoid sinus aspergillosis mimicking sellar tumor: a report of 4 cases and systematic literature review

Background:Invasive sphenoid sinus aspergillosis is a rare but life-threatening condition usually found in immunocompromised patients.When involving cavernous sinus and surrounding structures,patients are frequently misdiagnosed with a neoplasm or sellar abscess.Timely diagnosis and intervention are crucial to patients’outcomes.The objective of this study is to review cases of invasive sphenoid sinus aspergillosis to describe disease manifestations,imaging features,treatment,and outcome.Case presentation:We describe four patients with invasive sphenoid sinus aspergillosis misdiagnosed as sellar tumors preoperatively.The mass was completely removed in three patients and partially removed in one patient microscopically.Pathological examinations confirmed Aspergillus in all cases.All four patients received anti-fungal agents postoperatively.There was no recurrence at the time of each patient’s follow-up date.One patient with complete resection was lost to follow-up while the other three patients’neurologic function improved.Additionally,we performed a systematic review regarding invasive sphenoid sinus aspergillosis of existing English literature.Conclusion:With regard to clinical symptoms,headache,vision impairment,and ophthalmoplegia were observed in over half of the patients in the literature.A sellar mass with bone destruction on CT and involvement of cavernous sinus is highly suggestive of invasive fungal sphenoid sinusitis.Immediate surgical removal of the lesion is recommended for invasive sphenoid sinus aspergillosis to preserve nerve function and increase the likelihood of survival.

神经内镜下经鼻蝶窦扩大鞍底入路颅咽管瘤切除术在复杂性颅咽管瘤患者中的应用

目的分析神经内镜下经鼻蝶窦扩大鞍底入路颅咽管瘤切除术在复杂性颅咽管瘤患者中的应用效果。方法选择行神经内镜下经鼻蝶窦扩大鞍底入路颅咽管瘤切除术治疗的复杂性颅咽管瘤患者48例作为研究组,另择同期接受开颅入路颅咽管瘤切除术治疗的复杂性颅咽管瘤患者48例作为对照组。比较两组手术情况、临床缓解率与肿瘤全切率,垂体功能、炎症反应、应激指标,并发症等情况。结果研究组手术时间、肿瘤切除时间、住院时间更短(P<0.05);研究组全切除率、临床缓解率更高(P<0.05)。术后1个月两组血清促甲状腺激素(TSH)、生长激素(GH)、促肾上腺皮质激素(ACTH)、总甲状腺素(TT4)水平降低,但研究组高于对照组(均P<0.05)。术后1 d,两组全血中性粒细胞计数与淋巴细胞比值(NLR)、血清降钙素原(PCT)、C反应蛋白(CRP)、白介素-6(IL-6)、血管紧张素Ⅱ(AngⅡ)、肾上腺素(E)、去甲肾上腺素(NE)水平提高,但研究组低于对照组(均P<0.05)。至术后1个月,研究组并发症发生率更低(16.67%vs 45.83%,P<0.05)。对照组复发7例,经手术治疗后,全切4例,次全切2例,部分切除1例;术后并发症发生情况,3例发生尿崩症,1例发生颅内感染。研究组复发8例,经手术治疗后,全切6例,次全切2例;术后并发症发生情况,2例发生尿崩症。结论神经内镜下经鼻蝶窦扩大鞍底入路颅咽管瘤切除术可提高复杂性颅咽管瘤患者临床缓解率与肿瘤全切率,降低炎症反应、应激指标,改善垂体功能,安全性较高,对复发性颅咽管瘤的治疗效果也良好。

Microsurgical treatment of cerebrospinal fluid rhinorrhea in sphenoidal sinus

Objective：To explore the clinical manifestation,diagnosis and surgical treatment of cerebrospinal fluid rhinorrhea in sphenoidal sinus.Methods： Nine cases of cerebrospinal fluid rhinorrhea in spenoidal sinus from 2007 to 2009 were retrospectivelyanalyzed consisting of their possible etiological factors,clinical manifestations, localization of the leakage site and treatment methods. Among them, there were 3 cases of traumatic rhinorrhea, 4 postoperative rhinorrhea and 2 spontaneous rhinorrhea. All 9 patients underwent 3-dimensional CT scan in sellar region including all para-nasal sinus. Leakage site was identified and repairing procedure was performed through trans-sphenoidal approach.Results：All cases were cured with the trans-sphenoidal microsurgical procedure. They were followed up for 9 months to 2 years. No recurrence, no infection and epilepsy complications were observed.Conclusion：For the cerebrospinal fluid rhinorrhea at sphenoidal sinus, it is critical to identify the leakage site accurately and the trans-sphenoidal approach is a microinvasive and effective way to repair the leakage, which is worthy to be advocated.

鼻内镜下经蝶窦蝶鞍区手术中蝶窦前壁的应用解剖

目的：为鼻内镜下经蝶窦蝶鞍区手术准确寻找蝶窦口，避免损伤蝶腭动脉提供解剖学资料。方法：在15例国人头颅标本上，用游标卡尺和角规对30侧蝶窦前壁进行解剖学（走行、位置、外径以及与相关结构的距离）观察和测量。结果：鼻小柱根部至蝶窦口下极及蝶腭孔的距离分别为（60．40±3．21，58．10～72．76）mm和（62．14±1．93，59．50～73．40）mm；蝶腭孔至蝶窦口下极的距离为（12．20±1．10，8．10～16．35）mm，在蝶腭孔处蝶腭动脉的外径为（1．99±0．13，1．50～2．80）mm；蝶窦口下极至鼻中隔后上动脉及鼻中隔后下动脉的距离分别为（3．49±0．24，2．78～5．20）mm和（6．42±1．08，4．30～8．50）mm。结论：蝶窦口是经蝶窦蝶鞍区手术的重要标志；开放蝶窦时宜从蝶窦口内下方开放，以免损伤蝶腭动脉。

内窥镜蝶窦及蝶鞍区手术应用解剖学研究

１１０个头部标本的蝶窦解剖观察测量表明，蝶窦双侧气化相同者占４１．８％，不同者占５８．２％。前鼻棘至蝶窦口和鞍底的距离分别为５４．６ｍｍ和７１．３ｍｍ，蝶窦口和鞍底与鼻底的用度分别为３２．６°和３３．１°。视神经管和颈内动脉在蝶卖内形成隆起的比率分别是５２．７％和５０．９％。文中讨论了蝶窦气化类型、蝶窦膜性开口和中隔，以及蝶窦与视神经管和颈内动脉的毗邻关系在内窥镜蝶窦及蝶鞍区手术时的意义。

内窥镜视神经管减压术应用解剖

观察了１０７具成人尸头标本视神经管及其与蝶窦和筛窦的毗邻关系。所有标本中，视神经管在蝶筛窦外侧壁形成隆起者为７２．４％，视神经管与毗邻结构的关系复杂，但其内壁与后筛窦或／和蝶窦相毗邻最为多见，内壁长１０．２ｍｍ，厚０．４ｍｍ，是内窥镜下行视神经管减压术的关键部位。文中讨论了内窥镜下行视神经管减压术时值得注意的一些问题。

经蝶窦入路显微外科治疗垂体大腺瘤

目的 :探索经蝶窦入路手术治疗垂体大腺瘤的效果。 方法 :1 993年 3月至 1 999年 6月经蝶窦入路手术治疗垂体大腺瘤患者 54例。结果 :全切除 3 6例 ( 66.7% ) ,大部分切除 1 2例 ( 2 2 .2 % ) ,部分切除 6例 ( 1 1 .1 % )。随访 3 5例 ,随访时间 7～3 4个月 ,其中 3 1例视力视野恢复正常 ,MRI扫描鞍上结构恢复 2 9例。主要并发症为尿崩症 9例 ( 1 6.7% )和脑脊液漏 7例( 1 2 .9% )。所有病例术后接受放射治疗。结论 :经蝶窦入路手术切除垂体大腺瘤是安全有效的 ,因为能迅速解除肿瘤对视神经和下丘脑的压迫。术后放疗效果有待长期随访证实。

蝶筛窦外侧壁应用解剖

观察57具成人尸头标本蝶、筛窦外侧壁,以及同视神经管和颈内动脉的毗邻关系.眶板前下宽,后上窄,平均厚度为0.2mm.93.86%的视神经管内壁与蝶、筛窦外侧壁毗邻,且视神经管向蝶、筛窦内突出形成隆起的比率和程度同蝶、筛窦气化程度呈正相关.2.6%的标本颈内动脉在蝶窦内形成管型隆起.掌握蝶、筛窦外侧壁解剖,以及同视神经管和颈内动脉的毗邻关系和变异特征,对防止蝶窦、筛窦手术时视神经和颈内动脉的损伤,以及成功地进行内窥镜下眶减压术和视神经管减压术具有非常重要的意义.

内窥镜下经鼻蝶切除垂体瘤手术中蝶鞍的解剖定位

目的 :为临床开展神经内窥镜下经鼻蝶切除垂体腺瘤提供解剖基础。方法 :对 2 5例成人头部固定标本进行鼻道及蝶窦底的解剖测量 ,并对 9具新鲜尸头进行内窥镜下经鼻蝶至蝶鞍的解剖观察。结果 :鼻柱根部到蝶窦口 (65 .3± 3 .1)mm ,鼻根到蝶窦口 (4 5 .4± 2 .4)mm ,蝶窦口到蝶筛隐窝顶 (7.1± 3 .4)mm ,鞍底到鼻柱根部与中鼻甲下缘连线的垂直距离 (12 .1± 2 .0 )mm ,蝶窦口长径 (3 .3± 1.5 )mm ,蝶窦口宽 (1.3± 0 .5 )mm ,蝶窦口上端距中线 (3 .0± 1.0 )mm ,蝶窦口下端距中线 (3 .9± 1.2 )mm。结论 :借助观察到的蝶窦口等解剖标记 ,内窥镜能够较好的定位蝶鞍。

鼻内镜下经蝶窦翼管神经切断术的手术探讨

目的探讨鼻内镜下经蝶窦翼管神经切断的手术方法。方法对65例难治性高反应性鼻病患者行鼻内镜下经蝶窦单侧翼管神经切断术。依据术前翼管神经重建CT用刮匙和kerrison咬骨钳自蝶窦开口处伸入蝶窦腔,去除蝶窦前壁骨质达蝶窦底壁,切割钻头沿蝶窦底壁向外下方磨除蝶窦前壁骨质或部分蝶骨体骨质直至暴露翼管神经位于蝶窦前壁的开口,电凝翼管开口处的翼管神经及其伴行血管。结果 65例患者均准确的定位翼管神经,完成了鼻内镜下经蝶窦单侧翼管神经切断术。治疗后主观总体评价显著改善率为86.1%(56例)。结论鼻内镜下经蝶窦翼管神经切断术以蝶窦为参考标志,在蝶窦前壁、底壁和外侧壁之间定位并切断翼管神经,安全可靠,值得临床推广。