Surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base
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摘要: 目的 探讨经鼻内镜切除旁中线颅底良性病变的手术入路。方法 回顾性分析2018年8月—2021年2月采用经鼻内镜手术治疗的40例旁中线颅底良性病变患者的临床资料，其中胆脂瘤9例，血管瘤6例，血管外皮细胞瘤1例，神经鞘膜瘤6例，蝶窦外侧隐窝脑膜脑膨出伴脑脊液鼻漏15例，鼻咽癌放疗后骨炎3例。所有患者行经鼻内镜手术切除，根据病变位置选择不同的手术入路。结果 40例患者病变全切，全切率为100%。1例术后出现脑脊液鼻漏，经修补后治愈。随访3~30个月，39例患者术后有不同程度的上颌部或下颌部麻木感，2周~6个月麻木感消失；1例神经鞘膜瘤患者术后1年仍遗留一侧上唇麻木。结论 经鼻内镜切除旁中线颅底良性病变手术安全性及治愈率较高。手术入路的选择主要以翼突为中心点向周围扩展，根据病变位置选择径路最短、损伤最小的入路，同时也要根据术者擅长术式选择内镜手术入路。Abstract: Objective To investigate the surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base.Methods Retrospectively analyze 40 cases of the clinical data of patients with benign lesions of the skull base from August 2018 to February 2021 with transnasal endoscopic surgery, including 9 cases of cholesteatoma, 6 cases of hemangioma, 1 case of hemangiopericytoma, 6 cases of schwannoma, 15 cases of sphenoid sinus lateral crypt meningocele and cerebrospinal fluid leak, 3 cases of nasopharyngeal carcinoma bone inflammation after radiotherapy. All patients underwent transnasal endoscopic surgery, and different surgical approaches were selected according to the lesion location.Results The total resection rate was 100% in 40 patients. One patient had cerebrospinal fluid rhinorrhea, which was cured after repair. During the follow-up period of 3-30 months, 39 patients had different degrees of numbness in the maxillary or mandibular region, and the numbness disappeared from 2 weeks to 6 months; one patient with schwannoma still had numbness on one side of the upper lip one year after surgery.Conclusion Transnasal endoscopic resection of benign lesions in the paramedian skull base has a high surgical safety and cure rate. The surgical approach selection mainly focuses on the pterygoid process and extends to the periphery. The shortest and least damaging approach should be selected according to the lesion location, and the endoscopic approach should also be selected according to the surgeon's expertise.
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Key words:
- endoscopic surgery /
- pterygoid approach /
- paramedian lateral skull base
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图 3 翼腭窝颞下窝神经鞘瘤的影像 3a~3c：强化CT提示右侧翼腭窝、颞下窝肿物，边界清，无明显强化；3d~3g：头核磁平扫及强化提示右侧翼腭窝、颞下窝肿物，长T1长T2信号，边界清，轻度不均匀强化；3h：经鼻内镜上颌窦后壁-翼突入路切除，术中肿瘤全切；3i、3j：术后1周及3个月复查强化核磁，肿瘤全切；图 4 自发性脑脊液鼻漏(右侧蝶窦外侧隐窝)的影像 4a：核磁水成像提示右侧蝶窦长T2信号；4b：腰穿脑室造影提示右侧蝶窦造影剂外漏，局部骨质缺损；4c：术中见右侧蝶窦外侧隐窝骨质缺损，予修补；4d：术后1年复查鼻内镜见术腔上皮化良好；图 5 右侧鞍旁表皮样囊肿的影像 5a、5b：头核磁强化示右侧鞍旁类圆形异常信号，环形强化；5c：术中可见囊内豆渣样物；5d：术中分离囊壁过程中鞍旁硬脑膜表面出现少许清亮液体，人工硬脑膜修补；5e：术后1 d复查头核磁见肿瘤全切；5f：术后4个月复查头核磁未见复发。
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