内镜下经鼻入路鼻眶颅沟通性肿瘤相关解剖与手术

Anatomical and surgical research of nasal orbital skull communicating tumor with endoscopic transnasal approach

摘要:

目的：探索内镜经鼻入路鼻眶颅沟通性肿瘤切除术的相关解剖和手术要点。方法：对2例新鲜灌注尸头标本进行内镜下经鼻鼻眶颅区域解剖，探索此区域重要解剖结构。回顾2例鼻眶颅沟通性肿瘤病例，详细介绍经鼻入路鼻眶颅沟通性肿瘤切除术的手术方法和要点。结果：上颌骨额突、额鼻嵴、纸样板、筛前动脉、额骨眶突、额窦后壁、视神经管是内镜下经鼻入路鼻眶颅区域重要解剖结构，其中额窦后壁、筛前动脉与额骨眶突构成了显露眶上区域的解剖三角，磨除上颌骨额突、额鼻嵴，去除纸样板、额骨眶突，阻断筛前动脉，向外侧牵拉眶内容物，使用角度镜可以充分暴露眶上区及额窦外侧隐窝。回顾病例1例为筛窦中分化鳞状细胞癌手术放疗后复发，另1例为鼻窦内翻性乳头状瘤伴轻中度不典型增生，术中以多个解剖结构互为参考，采用角度镜辅助操作可完整切除眶额区域病变。前颅底的脑膜缺损使用股外侧阔肌筋膜组织及鼻腔黏膜瓣修补，术后磁共振显示肿瘤切除彻底，患者无脑脊液鼻漏、颅内感染、视力下降等颅眶并发症。结论：选择合适的病例，掌握重要解剖结构及手术要点，内镜下经鼻入路可以有效切除鼻眶颅沟通性肿瘤并获得良好的疗效，避免了颅面部切口。

Abstract:

Objective: To explore the related anatomy and technical note of endoscopic transnasal approach for nasal orbital skull communicating tumor resection. Methods: Two fresh cadaveric heads were dissected under endoscope to explore the important anatomical structures in this area. Two cases of nasal-orbital-cranial communicating tumor were reviewed, and the surgical methods and technical note of nasal-orbital-cranial communicating tumor resection were introduced in detail. Results: The maxillary frontal process, frontal nasal ridge, orbital medial wall, anterior ethmoid artery, frontal orbital process, posterior wall of frontal sinus and optic canal are important anatomical structures in the nasal orbital skull area through endoscopic transnasal approach. The posterior wall of the frontal sinus, the anterior ethmoidal artery and the frontal orbital process constitute the anatomical triangle which was a landmark for the supraorbital region. Grinding the maxillary frontal process, frontal nasal ridge, removing the orbital medial wall, frontal orbital process, and coagulating the anterior ethmoid artery, pulling the orbital content laterally, the supraorbital region and the lateral recess of the frontal sinus can be fully exposed with the angled endoscope. One case was recurrence of moderately differentiated squamous cell carcinoma of ethmoid sinus after surgery and radiotherapy, and the other case was Inverted papilloma of nasal sinus with mild to moderate atypical hyperplasia. With multiple anatomical structures as the anatomical location, the lesions in the orbital frontal region can be completely removed under the angled endoscope. The meningeal defect of the anterior skull base can be repaired with thigh fascia latae and nasal mucosal flap. Postoperative magnetic resonance imaging showed that the tumor was completely resected, and the patient had no cranial orbital complications such as cerebrospinal fluid rhinorrhea, intracranial infection, and decreased vision. Conclusion: Nasal orbital skull communicating tumors can be effectively removed with good results by endoscopic transnasal approach with appropriate cases, mastering important anatomical structures and technical note, avoiding craniofacial incision.