cranionasal communication tumor resection

At the same time, the cranial nasal tumor (cranial nasal communication tumor) invading the cranial cavity and sinus and nasal cavity is divided into cranial source, nasal source and bone source according to its origin. Meningiomas and neurofibroma are the main types of cranial tumors. In addition to a small number of angiofibroma and sensory neuroblastoma, the nasal type is a multi-malignant tumor, and most of them are primary, rarely transferred from it. Bone source refers to tumors that actually originate from bone tissue, and are mostly benign, including osteoma, chondroma, osteoblastoma, chordoma and ossifying fibroma, and a few are malignant, such as osteosarcoma. Cranial nasal communication tumors are involved in the intracranial, sinus and nasal cavity, and sometimes extend into the iliac crest. Surgery is difficult. Previously, it was performed by neurosurgery and otolaryngology, ophthalmology, transcranial approach, staging or one-stage surgical resection. After the tumor was resected, the dura mater and/or brain tissue directly faced the sinus or nasal cavity. In the 1960s, about 70% of patients developed cerebrospinal fluid leakage, meningitis, epidural or brain abscess, mortality and mortality. The residual rate is quite high. Since then, due to improvements in dural defect repair and skull base reconstruction, the surgical effect has gradually improved. In 1973, Tessier used a skull base approach to treat craniofacial deformities. After 9 years, Derome used the approach to remove the skull base tumor, which enabled the neurosurgeon to remove the cranial nasal communication tumor and reconstruct the skull base through a single incision. reality. Treatment of diseases: neurofibromatoma meningioma Indication 1. Craniofacial combined approach is suitable for most craniocerebral communicating tumors, because it can be "monolithic" resection, especially for malignant tumors. 2. Transcranial approach is mainly suitable for benign cranial nasal communication tumors. Contraindications 1. A wide range of malignant tumors. 2. If you are old and weak, or have important organ dysfunction, surgery should be cautious. 3. There are acute inflammation in the nasal cavity and sinus. Preoperative preparation 1. Compound nitrofurazone nasal drops were used 1 week before surgery, and antibiotics were applied 2 days before surgery. 2. Shave 1 day before surgery. Patients undergoing transcranial combined approach surgery still need to cut nose hair and shave the beard. If you want to take a fascia or a skin, you should prepare a donor area. 3. Blood-rich meningioma or angiofibroma should be prepared for adequate blood supply. In order to reduce bleeding, embolization can be done before surgery. 4. In order to facilitate the exposure, the lumbar subarachnoid space is placed before the operation, and the appropriate amount of cerebrospinal fluid is released during the operation. Removed after surgery. Surgical procedure Transcranial combined approach Intracranial and facial surgery are performed at the same time, but the first thing to do depends on the nature of the tumor and the original site. Malignant tumors originating from the upper sinus (sphenoid sinus, ethmoid sinus and frontal sinus) are first exposed from the face to minimize the exposure time of the cranial content; tumors originating from the intracranial are first undergoing transcranial surgery. A wide range of cranial nasal communication tumors that are difficult to fully cut can be staged. (1) intracranial exposure resection: make the coronary flap turn forward, pay attention to retain the supraorbital nerve and artery. The cranial periosteum was cut as far as possible along the skin incision. If necessary, the scalp after the incision was separated under the aponeurotic aponeurosis, and the cranial membrane was cut 1 to 2 cm after the skin incision and freely turned up. It is better to retain more submucosal tissue on the surface of the periosteum so that the tumor is placed on the skull base after resection. Do double free bone flap, the height does not need to exceed 4cm, the leading edge is as close as possible to the upper edge of the iliac crest, and the open frontal sinus is treated well. Separate and lift the dura mater of the anterior cranial fossa, and separate the adhesion between the tumor and the tumor until the sphenoid ridge and the posterior part of the stencil, revealing the tumor. If the dura mater is violated by the tumor, the dura mater will be removed. If the tumor has invaded the dura mater, the dura mater should be cut, the front of the superior sagittal sinus is cut after the suture, and the cerebral palsy below it is cut, the frontal lobe is lifted, and the dura mater and the affected hard are removed. Meninges. Separation of the anterior cranial fossa, especially the dura mater of the olfactory fossa, or removal of the dura mater of the tumor, the dura mater may be ruptured or has defects, should be repaired: small cracks can be directly sutured; larger defects need to be used twice The defect area material (various fascia, cranial periosteum, freeze-dried dura mater, etc.) was repaired. If the defect is quite large and extends to the front of the optic chiasm, the posterior margin of the repair material is difficult to be tightly sutured, and the intracranial epidural and sinus and nasal cavity of the tumor should be left after 3 to 4 months. Use a high-speed micro drill to open the anterior cranial fossa around the tumor. The range depends on the size of the tumor: if the tumor is limited to the midline, it is only necessary to open the sieve plates on both sides in the anterior and posterior direction. However, the cranial nasal communication tumors involve the sinus sinus air chamber, so the sieving paper template (the inner wall of the iliac crest) should be included. If the tumor has invaded the sputum, the inner part of the dome should be removed together. When grinding open the anterior cranial fossa, be careful not to injure the optic nerve in the posterior. (2) Excitation of the extracranial (face): In order to avoid accidental injury to the cornea, the eyelids are temporarily sutured. On the affected side or the larger side of the tumor, starting from the medial side of the upper eyelid, passing down between the medial malleolus and the nasal root, along the nasal side (nose and buccal groove) around the nose to open the skin, subcutaneous and periosteum (Weber) -Fergusson incision), do not damage the external nasal cartilage. The soft tissue is separated under the periosteum, and the medial malleolar ligament is broken, and the medial wall of the dome, the inner wall of the ankle, the nasal bone, the maxillary frontal process, the tear bone and the bone of the pear-shaped hole are exposed, and the lacrimal sac is reserved. After electrocoagulation, the pre- and post-mesh arteries are cut. An arc-shaped incision was made between the contralateral medial malleolus and the nasal root. The same method revealed the medial side of the contralateral crest and the medial wall of the ankle, and electrocoagulation cut the anterior and posterior anterior arteries. Separate the bone and nasal mucosa around the piriform hole, and bite off the lateral margin of the maxillary frontal and piriform holes on the affected side to enlarge the exposure. The nasal bone was transected at the base of the nose, and the nasal back and nose were slanted to the opposite side. The nasal mucosa was cut open to reveal the tumor. If the tumor involves the maxilla and the maxillary resection is performed, the lower end of the skin incision should be extended downward, the upper lip is cut, and the lower eyelid incision is added (the maxillary resection method is omitted). After the facial exposure is completed, the tumor is pushed down from the skull, and the tumor and the surrounding bone are pulled down through the facial incision, and the connected soft tissue is cut, and the tumor in the intracranial epidural, sinus and nasal cavity is pulled out and removed. (3) reconstruction of the skull base: If the anterior cranial fossa defect is small, as long as the dural is repaired tightly, and a layer of periosteal flap is placed underneath it, there is no need for bone skull reconstruction. Those with larger defects should be rebuilt and the materials and methods of reconstruction should be different. The method of Draf and Samii is that the dura mater can be directly sutured without obvious defects. If there is a defect, the dura mater can be cut along the anterior and lateral anterior cranial fossa. The anterior lateral defect area is repaired with lyophilized dura mater; if the defect is too large, some sputum scales can be bitten off, and the unilateral or bilateral iliac fascia can be freely inverted and placed together with the diaphragm muscle in the anterior cranial fossa. Then, a methacrylic resin or plexiglass sheet with a small number of small holes is appropriately covered on the dura mater of the bone defect area, and a plurality of needles are fixed by suture. Finally, the periosteal flap formed at the time of craniotomy is placed on the top of the resin sheet, and the base portion is sutured with the dura mater at the leading edge of the bone window. The posterior edge of the periosteal flap is sutured with the dura mater at the sphenoid slab and the sphenoid ridge, or sutured. On a row of small bone holes drilled along the sphenoid bone. Derome's skull base reconstruction method is generally used. (4) suture and tamponade: double-frontal free flap reduction and fixation, coronary flap reduction and suture. Fix the medial malleolar ligament on the lacrimal bone, such as the tears have been disconnected, using the Jones tube reconstruction. Nasal bone reduction, filling the nasal cavity with Vaseline gauze and iodoform gauze. Layered sutured facial incision soft tissue. 2.Derome's front skull base approach The advantage of transcranial approach is that there is no need to make another incision on the face; and the scope of exposure is large, and the tumor invading the ethmoid, sphenoid bone and slope can be removed; the optic canal, supracondylar fissure and even round hole can be opened as needed. And the foramen ovale, free to loosen the anterior group of cranial nerves. In fact, the tumor in the anterior portion of the ethmoid-sphenoidal bone can also be removed in a single piece through the base of the skull. It is removed from the upper part (rather than through the facial incision) and goes beyond the sacral-sphenoidal tumor. It is also difficult to make a real "monolithic" resection on the face, so some malignant tumors can also be considered for transcranial approach. (1) Free protection of the nasopharynx mucosa: The nasal septum and the mucosa under the sphenoid body are separated as far as possible through the nasal septum. The method is to remove the pituitary adenoma by transnasal-sphenoidal approach. The gauze is filled under the mucosa to protect the mucosa and serve as an indication during surgery. (2) The scalp incision, the formation of the bone flap, the separation of the dura mater in the anterior cranial fossa, the resection of the dural tumor, and the method of repairing the skull base dural are the same as those of the transcranial combined approach. The ideal dural repair material should be tough and thick enough to prevent cerebrospinal fluid leakage and infection. It is softer, does not affect the brain tissue bulge, and can quickly grow into the blood vessels, as soon as possible to adhere to the underlying transplanted tissue and supply blood. In view of this, Derome advocates the application of the cranial periosteum (free to the posterior periosteum through the same scalp incision) or the dermis (0.5 to 0.6 mm thick) from the abdominal wall. When the former is used to repair the dura mater, the bone surface (deep side) is toward the base of the skull, and when the latter is repaired, the epithelial surface (shallow surface) is toward the base of the skull. (3) Skull base tumor resection: the difficulty of surgery depends on the location, extent and texture of the tumor. 1 Tumors involving the ethmoid: It is easy to use a micro drill to open the tumor and remove it with a tumor clamp without worrying about injury to important structures. After the tumor is removed into the nasal cavity, if the turbinate, nasal septum and mucosa are not invaded by the tumor, they should be preserved. 2 Tumors involving the sphenoid bone: remove part of the dome until the palate is fissure, and be careful not to damage the nerves and blood vessels in the supracondylar fissure. The optic canal was opened and the extradural portion of the optic nerve was confirmed. The tumor was removed between the optic nerves on both sides. The intratumoral resection is performed first, and the residual tumor is removed together with the surrounding bone tissue including the inner wall of the ankle and the sphenoid body until the gauze is placed through the nasal septum. If the tumor invades the sphenoid wing, the resection of the dome should reach the temporal lobe of the temporal lobe, ie the upper edge of the sphenoid winglet and the supracondylar sac should be included. Excision of the anterior bed between the supracondylar and optic nerve holes, taking care not to damage the adjacent internal carotid artery. The sphenoidal wing was excised between the periosteum and the dura mater and the lower margin of the supracondylar sulcus was opened until the cranial fossa, round hole and foramen ovale, and all the anterior cranial nerves were freed. 3 Tumors involving the slope: the saddle nodule and the anterior wall of the saddle are removed to reach the slope. After excising the slope tumor, if necessary, dissect the dura along the slope to the leading edge of the foramen magnum. After separating the pharyngeal mucosa, it can also reach the front of the cervical spine. After the removal of the skull base tumor, the large piece of bone tissue has been removed, and the content of the sputum is only connected with the optic nerve and the supracondylar fissure tissue between the frontal and the dura mater, and a large cavity is left around. (4) reconstruction of the skull base: the necessity of reconstruction of the skull base is to avoid the formation of dead space and meningeal bulging in the midline; reconstruction of the skull base in the lateral side can prevent eyeball invagination or pulsating eyeball protrusion; The upper edge of the iliac crest has been removed and the reconstruction is also beautiful. Derome points out that in an open, contaminated area of the sinus, the best reconstruction material is the autologous tibia, which provides enough cancellous and cortical bone. The inner plate of the frontal bone flap can also be used. If the child is not enough material, take 1 to 3 ribs and cut it in a longitudinal direction. The cancellous bone should face the sinus and nasopharynx mucosa when implanting bone. If the inner wall and the dome have been removed, appropriate graft bone repair may be performed. If the upper edge of the iliac crest is absent, the cortical bone can be fixed on the humeral condyle. All dead spaces are filled with cancellous bone. Finally, between the nasal root and the slope, a cortical bone is placed under the saddle to close the sieve-petal area. If the slope is also removed, a vertical bone graft is placed between the saddle bottom and the anterior edge of the occipital foramen (or the anterior arch of the atlas), and then the cortical bone is placed. When reconstructing the skull base, make sure that the bone graft does not squeeze the optic nerve. The sphenoidal wing and the anterior cranial fossa defect do not need to be reconstructed. In order to further strengthen the skull base and facilitate the survival of the transplanted bone, the frontal periosteal flap formed during the craniotomy is placed on the graft bone, the posterior margin is sutured with the sphenoid tarsal suture, or the suture is fixed along the sphenoid ridge (if still There is a row of small holes drilled. (5) suture and tamponade: double frontal bone flap reduction and fixation. If the bone flap has a tumor invasion, the affected part will be removed and repaired with autologous bone. The flap was sutured and sutured. Fill the nasal cavity. If there is a sudden eye before surgery, temporarily suture the eyelids and properly compress the bandage. 3. Sekhar's expansion of the budget The route, Sekhar (1992), is actually based on the lower cranial craniotomy of the skull base approach in front of Derome, plus a frontal incision (for resection of the anterior skull base tumor) or a plaque. The ethmoid incision (used to remove the mid- and posterior skull base midline tumors) to further improve the exposure and reduce the traction of the frontal lobe. specific method: (1) Flap and double frontal bone flap: the anterior skin was cut from one side of the zygomatic arch to the other side, and the periosteal incision was moved 1 to 2 cm behind the scalp incision. The flap is separated downward to the superior temporal and frontal nasal seams. The periosteal flap was dissected downward to the upper edge of the iliac crest and then folded into the iliac crest. The periosteum of the vault was separated by about 2.5 cm, and the medial anterior venous artery was divided To this end, the supraorbital nerve and blood vessels need to be separated from the upper incision or the upper perforation. First do a low frontal bone flap, medial to superior sagittal sinus. After the sagittal sinus is separated, the contralateral frontal bone flap is performed. (2) frontal incision or sacral sacral incision: For the anterior skull base lesion, after releasing a proper amount of cerebrospinal fluid from the lumbar puncture tube, the dura and sphenoidal plate dura mater are separated and lifted. The dura mater in the olfactory sulcus area, if the tumor is benign, can be separated and lifted together, and the damaged area is directly sutured; if the tumor is malignant, it is left overlaid on the surface of the tumor, and the dural defect is repaired with fascia or freeze-dried dura mater. . Grind the front 2/3 dome and then grind the roots of the nose from the front to the back (slightly upward to ensure access to the anterior cranial fossa in front of the cockscomb), which will include the upper iliac crest and the dome The anterior bone is removed and the ethmoid remains. For the middle and posterior skull base lesions, the dome should be ground and moved to the posterior part of the ethmoid bone, and then the nasal bone and the ethmoid bone should be grounded from the front to the back in the plane of the sieve until the anterior ethmoid artery. The sieve bones are removed. Electrocoagulation before and after the artery. Sometimes in order to remove the tumor at the slope, it is necessary to further remove the iliac wall and the middle and posterior sinus air chambers near the apex. (3) Tumor resection: the malignant tumor of the anterior skull base is to be resected, and the benign tumor can be resected. Middle and posterior skull base tumors can usually only be treated by block resection. According to the tumor range, unilateral or bilateral optic nerve decompression is performed. The upper and outer walls of the sphenoid body are gradually removed from the front to the back (the saddle back cannot be removed). The inner wall of the cavernous sinus is a periosteum that may be damaged when the outer wall of the sphenoid bone is removed. Surgerel is used to control bleeding. The anterior wall of the sphenoid body can also be removed, but be careful not to pierce the nasopharynx wall in front. The slope tumor and the affected bone are gradually removed from the top to the bottom. Young and middle-aged patients have thicker dura mater and thinner older ones. Do not damage the basilar artery and its branches and brainstem when separating and removing tumors. Bleeding from the basal venous plexus can be controlled by bipolar coagulation or Surgilel tamponade. (4) Reconstruction: The dura mater of the anterior skull base can be directly sutured or repaired with fascia and freeze-dried dura mater. The middle and posterior skull base dural defects can be bonded with bio-adhesive when repaired with appropriate materials. The frontal sinus and sphenoid sinus mucosa were removed, and the aortic tube and the open ethmoid sinus were filled with fat blocks. The periosteal flap formed by the upper iliac vessels and the blood vessels on the trochlear formed at the time of craniotomy is placed on the skull base. The cavity left after the tumor is resected is filled with fat. The frontal bone is fixed and fixed. To avoid squeezing the periosteal flap placed on the skull base, the lower edge of the bone can be bitten off. The frontal bone flap was fixed and sutured, and the scalp was sutured. complication 1. Infection and cerebrospinal fluid leakage are common complications after surgery for cranial nasal tumors. 2. Frontal contusion caused by excessive elevation of the frontal lobe during surgery. 3. Skin flap necrosis is caused by ligation of the external carotid artery. Switching to the blood supply artery embolization before surgery can be avoided. 4. Meningeal brain swelling of the dura mater is not good, the skull base may not be reconstructed may occur.