内镜下65例鼻颅底肿瘤切除后颅底重建临床分析

Endoscopic skull base reconstruction after resection of skull base tumors in 65 cases

摘要:

目的 探讨鼻内镜下鼻颅底肿瘤切除后采用游离中鼻甲黏膜（FMT）、阔筋膜、鼻中隔带蒂黏膜瓣（HBF）行颅底缺损重建治疗脑脊液鼻漏的临床效果。方法 回顾性分析65例在鼻内镜下行鼻颅底肿瘤切除且行颅底重建治疗脑脊液鼻漏患者的病例资料。根据颅底缺损大小及部位选择修补材料，缺损<1.5 cm，均采用FMT（24例）；缺损≥ 1.5 cm，优先选择HBF（16例），但当HBF无法获取或不适用（缺损位于额窦后壁），选择阔筋膜（25例）。分析患者的修补效果并比较阔筋膜与HBF的修补结果。结果 采用FMT行颅底缺损重建治疗的患者有2例出现术后脑脊液漏，一次性修补成功率为91.7%；采用阔筋膜治疗的患者有1例出现术后脑脊液漏，一次性修补成功率为96%；采用HBF治疗的患者有1例出现术后脑脊液漏，一次性修补成功率为93.8%；总体成功率93.8%。采用阔筋膜行颅底修补的患者术后出现颅内感染2例、肺部感染0例、术后鼻出血2例，采用HBF行颅底修补的患者术后出现颅内感染1例、肺部感染2例、术后鼻出血2例，两种颅底修补方法术后并发症均无明显差异。结论 鼻内镜下采用HBF、阔筋膜或FMT行颅底重建治疗脑脊液鼻漏均可获得较为满意的结果。FMT对于较小（<1.5 cm）的缺损是可靠的修补材料；对于较大的缺损（≥ 1.5 cm），HBF或阔筋膜均可以采用且获得相似的结果，当HBF无法获取或不适用（缺损位于额窦后壁），选择阔筋膜是可行的。

Abstract:

Objective To explore the clinical effect of free middle turbinate mucosa (FMT), fascia lata, and pedicled nasal septum flap (hadad-bassagasteguy flap, HBF) for the management of cerebrospinal fluid (CSF) rhinorrhea after endoscopic resection of nasal-skull base tumors.Methods Clinical data of 65 patients who underwent reconstruction of skull base defect to manage CSF rhinorrhea after endoscopic resection of nasal-skull base tumors were analyzed retrospectively. The repair material was determined by the size and location of the defect. FMT was selected for the defect less than 1.5cm (n=24), HBF was preferred for the defect greater than or equal to 1.5cm (n=16), but when HBF was not available or not applicable (the defect was located on the posterior wall of the frontal sinus), the fascia lata was chosen (n=25). The repair effect of all the 65 patients was summarized and that between the fascia lata and HBF was compared.Results The overall one-time repair success rate was 93.8%, and those of FMT, fascia lata and HBF were 91.7%, 96.0% and 93.8%, respectively. During the follow-up period, the case numbers with postoperative CSF leakage were 2 in 24 repaired with FMT, 1 in 25 repaired with fascia lata, and 1 in 16 repaired with HBF. The postoperative complications in the fascia lata group and HBF group included intracranial infection (2 vs 1), lung infection (0 vs 2), and epistaxis (2 vs 2), and their differences were statistically insignificant.Conclusions With satisfactory repair effect, HBF, fascia lata and FMT are suitable for transnasal endoscopic reconstruction of skull base defect to manage CSF rhinorrhea. FMT is a reliable repair material for small (<1.5 cm) defects. For large defects (≥ 1.5 cm), either HBF or fascia lata can be used with similar repair effect. It is feasible to choose fascia lata when HBF is not available or not applicable.