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摘要: 目的 总结造成医源性脑脊液耳鼻漏常见的手术方式及治疗手段，分析迟发性医源性脑脊液耳鼻漏相关的危险因素。方法 回顾性分析2010年1月—2020年1月上海交通大学附属第六人民医院耳鼻咽喉头颈外科收治的35例医源性脑脊液耳鼻漏患者的临床资料。根据患者术后出现脑脊液漏的时间间隔将患者分为迟发组与非迟发组，分析两组患者基线资料、并发症及手术成功率的差异，进一步分析迟发性医源性脑脊液耳鼻漏的独立危险因素。结果 造成医源性脑脊液耳鼻漏的手术方式包括经鼻内镜鼻窦手术(n=11)、经蝶垂体瘤手术(n=8，包括单纯经蝶7例、经蝶联合伽玛刀外科治疗1例)、开放性颅脑手术(n=12)和放疗(n=4)。所有患者均接受手术探查+颅底修补重建。用于颅底修补重建的材料包括带蒂血管瓣、腹部脂肪、颞肌/筋膜等。迟发组患者脑膜炎发生率显著高于非迟发组，且差异有统计学意义(20% vs 60%，P=0.041)。两组患者性别、放疗史、高血压史、糖尿病史、手术成功率差异均无统计学意义。二元Logistic回归分析显示性别、年龄、放疗史、高血压史、糖尿病史、手术方式均与迟发性医源性脑脊液耳鼻漏无显著相关性。结论 迟发性医源性脑脊液耳鼻漏患者合并中枢神经系统感染的风险升高。及时发现并干预，结合患者既往手术史、颅底缺损部位，选取合适的手术入路及颅底重建方式，对于促进患者术后恢复、减少神经系统后遗症具有重要意义。Abstract: Objective To explore the common causes of iatrogenic cerebrospinal fluid(CSF) otorrhinorrhea, and further analyze the risk factors for delayed iatrogenic CSF otorrhinorrhea.Methods The clinical data of 35 iatrogenic CSF otorrhinorrhea patients in department of Otorhinolaryngology Head and Neck Surgery from January 2010 to January 2020 were retrospectively analyzed. Patients were divided into delayed and non-delayed iatrogenic CSF leak groups, according to the time intervals from medical intervention to CSF leak occurrence. The differences of baseline data, complications and success rate between the two groups were analyzed, and the risk factors of delayed iatrogenic cerebrospinal fluid otorrhinorrhea were further analyzed.Results Endoscopic sinus surgery (n=11), transsphenoidal pituitary surgery(n=8), craniotomy(n=12), and radiotherapy(n=4) all contribute to iatrogenic CSF otorrhinorrhea. Compared with the non-delayed group, the incidence of meningitis in the delayed group was significantly higher(20% vs 60%, P=0.041). There were no significant differences in gender, radiation, hypertension, diabetes, and success rate between the two groups. Additionally, binary logistic regression analysis showed that sex, age, history of radiation, hypertension and diabetes, as well as causes of CSF otorrhinorrhea had no association with delayed iatrogenic CSF leakage.Conclusion Patients with delayed iatrogenic CSF otorrhinorrhea have an increased risk of meningitis. Timely diagnose and intervention with appropriate surgical approach and reconstruction method ensures good clinical outcomes.
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表 1 迟发性医源性脑脊液耳鼻漏临床资料比较
例，x±s 指标 非迟发组(n=25) 迟发组(n=10) P 年龄/岁 56.4±2.4 45.5±2.7 0.015 性别 0.216 男 16 4 女 9 6 放疗史 4 2 0.721 高血压史 6 1 0.086 糖尿病史 4 0 0.303 手术方式 0.052 ESS 11 0 经蝶垂体瘤手术 4 4 开放性颅脑手术 8 4 脑膜炎史 5 6 0.041 手术成功率/% 96.0 100.0 1.000 
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表 2 迟发性医源性脑脊液耳鼻漏危险因素分析
指标 B Wald OR 95%CI P 年龄 -0.044 0.986 0.957 0.877~1.044 0.321 性别 0.820 0.551 2.270 0.261~19.767 0.458 放疗史 -0.566 0.141 0.568 0.029~10.949 0.708 高血压史 -0.996 0.506 0.370 0.024~5.737 0.477 糖尿病史 -19.507 0.000 0.000 0.000 0.999 手术方式 0.805 1.646 2.237 0.654~7.655 0.199
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