松脇由典, 大村和弘, 森良介ほか 鼻性髄液漏の診断と治療 耳鼻咽喉科展望53(5):300-310, 2010.
Davide Locatelli, Federico Rampa, Ilaria Acchiardi, Maurizio Bignami, Francesca De Bernardi, Paolo Castelnuovo
Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience.
Neurosurgery. 2006 Apr;58(4 Suppl 2):ONS-246-56; discussiom ONS-256-7. doi: 10.1227/01.NEU.0000193924.65297.3F.
Abstract/Text
OBJECTIVE: To describe surgical endoscopic experience in the repair of cerebrospinal fluid leaks treated by transnasal approaches.
METHODS: Different surgical approaches and techniques in the repair of cranial base defects are reviewed in a series of 135 patients.
RESULTS: Success rate at first attempt was 93.3%. Only 9 patients (6.7%) needed a second surgical repair, and in one patient, a coronal approach with frontal craniotomy was necessary. In the other eight cases, an endoscopic procedure was chosen. Two patients needed a third endonasal endoscopic surgical repair, with successful outcome.
CONCLUSION: The target of endoscopic endonasal technique in the repair of cerebrospinal fluid leaks is to ensure a stable duraplasty with the least invasive approach avoiding craniotomy. A correct diagnosis surely allows the choice of the best treatment, surgical approach, graft, and technique. Our multidisciplinary approach to this pathology during these years has been essential to gain our challenging results.
Timothy J Martin, Todd A Loehrl
Endoscopic CSF leak repair.
Curr Opin Otolaryngol Head Neck Surg. 2007 Feb;15(1):35-9. doi: 10.1097/MOO.0b013e3280123fce.
Abstract/Text
PURPOSE OF REVIEW: The purpose of this review is to discuss endoscopic management of cerebrospinal fluid leaks and to highlight recent advances in both outcomes and technique.
RECENT FINDINGS: Endoscopic techniques targeting the repair of skull-base defects have evolved as instrumentation for intranasal use has developed. The principles of endoscopic repair mirror those of open repair, with emphasis placed on site identification, site preparation, accurate graft placement and postoperative management. Several patient factors will affect the surgical and medical care of patients with cerebrospinal fluid rhinorrhea, including location, cause and overall medical condition. Numerous techniques have been described and large series attest to high success rates. The use of radiographic image-guidance systems promises to advance localization of the leak site. Endoscopic repair of cerebrospinal fluid leaks remains an accurate and complete method for the repair of cerebrospinal fluid leaks with decreased operative morbidity.
SUMMARY: Endoscopic repair of anterior skull-base defects has a high success rate and markedly decreased morbidity as compared with traditional intracranial approaches. The endoscopic approach should be considered the technique of choice for repair of most cerebrospinal fluid fistulae and skull-base defects.
H M Hegazy, R L Carrau, C H Snyderman, A Kassam, J Zweig
Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.
Laryngoscope. 2000 Jul;110(7):1166-72. doi: 10.1097/00005537-200007000-00019.
Abstract/Text
OBJECTIVES/HYPOTHESIS: Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair.
METHODS: We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients.
RESULTS: Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication.
CONCLUSION: The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.
Yoshinori Matsuwaki, Hiroshi Moriyama
[Progress in endoscopic sinus surgery].
Nihon Rinsho. 2010 Jul;68(7):1360-5.
Abstract/Text
Once in the early part of the 20th century, endonasal ethmoidectomy was called as 'easiest way to kill a patient'. Many instruments' advances such as, endoscope, high-vision CCD camera and TV monitor, and power instruments have significantly advanced the ability of surgeons to execute endoscopic sinus surgery (ESS). Recently, image guided operating room equipped with image guided systems and CT scanning, which can reflect anatomic changes during surgery, carrying the promise of increased safety. To successfully perform ESS, the surgeon must have a complete understanding of the complex anatomy of the skull base, nose, and paranasal sinuses. Fresh cadaver dissection in skills laboratory supports both surgeons' anatomical knowledge and technical procedures using actual instruments. Nowadays, ESS has revolutionized the approach for surgery of the paranasal sinuses and has expanded to include endoscopic approaches to the skull base and orbit.
Martin Scholsem, Felix Scholtes, Frèderick Collignon, Pierre Robe, Annie Dubuisson, Bruno Kaschten, Jacques Lenelle, Didier Martin
Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience.
Neurosurgery. 2008 Feb;62(2):463-9; discussion 469-71. doi: 10.1227/01.neu.0000316014.97926.82.
Abstract/Text
OBJECTIVE: The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience.
METHODS: We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear.
RESULTS: Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure.
CONCLUSION: The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.
日本神経感染症学会治療指針作成委員会編：細菌性髄膜炎の診療ガイドライン、神経治療24(1):3-64、2007.
Yasushi Shigeta, Tetsushi Okushi, Mamoru Yoshikawa, Makoto Iida, Tsuguhisa Nakayama, Daiya Asaka, Takanori Hama, Eri Mori, Junya Kojima, Takuto Yoshida, Jiro Iimura, Kota Wada, Yoshinori Matsuwaki, Kiyoshi Yanagi, Hiroshi Moriyama, Nobuyoshi Otori
[Endoscopic sinus surgery complications a prospective multicenter study].
Nihon Jibiinkoka Gakkai Kaiho. 2012 Jan;115(1):22-8.
Abstract/Text
OBJECTIVE: Our objective was to determine the rate of complications in endoscopic sinus surgery (ESS) and associated risk factors.
METHODS: We prospectively studied 1,382 subjects undergoing ESS for rhinosinusitis and cystic sinus disease at 16 hospitals during 2007 and 2008. Surgeons provided information on peri-and postoperative complication occurrence.
RESULT: Results of complications were seen in 80 subjects (5.8%), the most frequent was perioperative lamina papyracea injury. Analysis showed the complication rate to be linked to gender, and anesthesia type, but not the grade of surgeon.
CONCLUSIONS: While care should be taken to avoid them, complications should be identified and treated in a timely and accurate manner.
Noam A Cohen, David W Kennedy
Revision endoscopic sinus surgery.
Otolaryngol Clin North Am. 2006 Jun;39(3):417-35, vii. doi: 10.1016/j.otc.2006.01.003.
Abstract/Text
Patients with recurrent chronic sinusitis after prior surgical intervention pose a particular challenge to the otorhinolaryngologist. Establishing a correct diagnosis is the first step and requires review of the original presurgical symptoms and imaging; review of the more recent symptoms and images;and reevaluation of environmental, general, and local host factors that may contribute to persistent disease. Although primary chronic rhinosinusitis is typically a medical disease, postsurgical persistent disease may result directly from iatrogenic causes, requiring early surgical revision. Even in this setting, however, proper preoperative medical therapy is essential. Diagnostic evaluation should include meticulous endoscopic evaluation and appropriate radiologic studies. CT typically is required in the coronal and axial planes and ideally is performed using a computer-assisted surgical navigation protocol and with reconstructions in the sagittal plane, allowing for "scrolling" through the altered anatomy and conceptualizing the surgical issues at hand. When the decision to undergo revision surgery is made, the patient and the physician need to comprehend the rigorous and prolonged schedule of postoperative care and débridements that may be required for long-term success. Appropriate surgical technique emphasizing mucosal preservation and complete dissection must be adhered to. The surgeon must be aware that bony thickening is likely to be present and to make the dissection significantly more difficult than in the primary case. Medical management and endoscopic surveillance postoperatively is continued until a stable cavity is achieved.
森山 寬： 内視鏡下鼻内副鼻腔手術. CLIENT 21 －21世紀耳鼻咽喉科領域の臨床：中山書店, 2000；396-410.
松脇由典：【耳鼻咽喉科の外傷に強くなる】 外傷性鼻性髄液漏. JOHNS 25:1337-1342, 2009.
G Har-El, R M Swanson
The superior turbinectomy approach to isolated sphenoid sinus disease and to the sella turcica.
Am J Rhinol. 2001 Mar-Apr;15(2):149-56.
Abstract/Text
Sphenoidotomy or sphenoidectomy are most commonly performed as part of a more extensive pansinus procedure. However, rhinologists may find themselves occasionally in a need to surgically treat an isolated sphenoid sinus disease. With the introduction of endoscopic sinus techniques and instrumentation, intranasal sphenoidotomy has become increasingly popular. The most common approach used is the intranasal, transethmoid sphenoidectomy. Alternatively, many surgeons perform middle turbinectomy to approach the sphenoid sinus transnasally. We describe our direct transnasal, nontransethmoid, nontransseptal approach to the sphenoid sinus. Superior tubinectomy is performed to enhance the exposure of the anterior sphenoid wall. Seventy patients underwent sphenoid sinus exploration for isolation sphenoid sinus disease or for pituitary lesions. Surgical goals were achieved in all patients and there were no complications related to the technique. The superior turbinectomy approach to isolated sphenoid sinus disease provides excellent exposure and avoids the sequelae of total ethmoidectomy or middle turbinectomy.
S J Zinreich, S A Tebo, D M Long, H Brem, D E Mattox, M E Loury, C A vander Kolk, W M Koch, D W Kennedy, R N Bryan
Frameless stereotaxic integration of CT imaging data: accuracy and initial applications.
Radiology. 1993 Sep;188(3):735-42. doi: 10.1148/radiology.188.3.8351341.
Abstract/Text
To evaluate the spatial accuracy of a rapid interactive method of transferring computed tomographic (CT) information between its display on a computer screen to its source (test object, operating field), a multidimensional computer combined with a six-jointed position-sensing mechanical arm was tested with a Plexiglas model consisting of 50 rods of varied height and known location, a plastic replica of the skull, and, subsequently, three patients. The median error value between image and real location was 1-2 mm (P > .95), regardless of the registration target sites. The accuracy, however, increased with the selection of widespread registration points, and 95% of all errors were below 3.70 mm (P > .95). The results compare favorably with the four most commonly used stereotaxic framed units. A misregistration error of 0.3-2.2 mm was found during intraoperative correlation between anatomy on the CT display and actual anatomic location in the operative field.
松脇由典, 常喜達裕, 大橋洋輝ほか：頭蓋底疾患に対するナビゲーション手術 頭蓋底疾患に対する経鼻的ナビゲーション手術. 耳鼻咽喉科展望 52:379-381, 2009.
鴻信義, 松脇由典： 頭蓋底疾患に対する最新のナビゲーション手術 術中画像更新システムの活用. 耳鼻咽喉科展望; 53:35-41, 2010.
[www.entnet.org/Practice/policyIntraOperativeSurgery.cfm AAO-HNS official website, policy statements, 2002.]（米国耳鼻咽喉科頭頚部外科学会のガイドライン）.
P J Wormald, Mike McDonogh
The bath-plug closure of anterior skull base cerebrospinal fluid leaks.
Am J Rhinol. 2003 Sep-Oct;17(5):299-305.
Abstract/Text
BACKGROUND: This study presents the technique and results of cerebrospinal fluid (CSF) leak closure by placement of a fat plug on the intracranial surface of the dura. A prospective cohort study of all consecutive patients undergoing endoscopic closure of an anterior skull base CSF leak using the bath-plug technique was performed at a tertiary care center.
METHODS: Thirty-three patients presented with CSF leaks: 6 were traumatic, 7 were spontaneous, 9 were iatrogenic, and 10 were associated with a meningoencephalocele. The average age of the patients was 40 years and the male-to-female ratio was 1.2:1. All patients underwent the bath-plug technique for closure of CSF leaks. The surgical technique was presented.
RESULTS: Thirty-one of the 33 patients had a successful primary closure of their CSF leak with 2 patients requiring a repeat procedure. After an average of 28 months follow-up, there were no recurrent leaks in any of the patients. This gives a primary closure success rate of 94% and a secondary closure rate of 100%.
CONCLUSION: The bath-plug technique for closure of anterior skull base CSF leaks was a reliable technique for a large variety of causes.
A C Stamm, S S Pignatari
Nasal septal cross-over flap technique: a choanal atresia micro-endoscopic surgical repair.
Am J Rhinol. 2001 Mar-Apr;15(2):143-8.
Abstract/Text
Choanal atresia is a congenital malformation of the posterior portion of the nasal cavity, which is usually unilateral. The incidence is estimated to be 1 in 5,000 to 8,000 live births. Several surgical approaches have been described to correct choanal atresia since Emmert's initial trocar perforation in 1853, including transnasal, transpalatal, transseptal, sublabial transseptal, transantral, and external rhinoplasty. Although the micro-endoscopic transnasal access is a more conservative technique, it allows greater surgical precision, and is currently recommended by many authors; choanal atresia repair is still considered a challenge, with risks of intraoperative and postoperative complications and re-stenosis. This paper reports the results of a series of 33 patients operated via the transnasal micro-endoscopic surgical approach, and describes a new endoscopic technique that the authors call "nasal septal crossover flap technique."
Aldo Cassol Stamm, Shirley S N Pignatari, Eduardo Vellutini
Transnasal endoscopic surgical approaches to the clivus.
Otolaryngol Clin North Am. 2006 Jun;39(3):639-56, xi. doi: 10.1016/j.otc.2006.01.010.
Abstract/Text
Transnasal endoscopic-assisted techniques to the clivus region can be safe and effective. Endoscopic-assisted approaches provide improved visualization and are a superior alternative to open surgical approaches in most cases. Nevertheless, problems such as infection, CSF leakage, and difficulty controlling intradural bleeding still remain. Surgeons must always remember that, although high technology such as endoscopes, image-guided surgery systems, imaging studies, and advanced anesthetic drugs were essential for the development and improvement of the skull base surgery, the success of this type of surgery depends on perfect knowledge of the anatomy, intense endoscopic surgery training, and a multidisciplinary partnership.
Richard J Harvey, João F Nogueira, Rodney J Schlosser, Sunil J Patel, Eduardo Vellutini, Aldo C Stamm
Closure of large skull base defects after endoscopic transnasal craniotomy. Clinical article.
J Neurosurg. 2009 Aug;111(2):371-9. doi: 10.3171/2008.8.JNS08236.
Abstract/Text
OBJECT: The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies.
METHODS: The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications.
RESULTS: Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 +/- 20.2 years and a mean follow-up period of 182.4 +/- 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 +/- 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epistaxis that required further care, but there were no complications related to intracranial infections or bleeding. Some minor sinonasal complications occurred.
CONCLUSIONS: Skull base endoscopic reconstructive techniques have significantly advanced in the past decade. The use of pedicled mucosal flaps in the reconstruction of large dural defects resulting from an endoscopic transnasal craniotomy permits a robust repair. The CSF leak rate in this study is comparable to that achieved in open approaches. The ability to manage the skull base defects successfully with this approach greatly increases the utility of transnasal endoscopic surgery.
Yoonho Lee, Woo Jung Kim
How to make the blockage between the nasal cavity and intracranial space using a four-layer sealing technique.
Plast Reconstr Surg. 2006 Jan;117(1):233-8.
Abstract/Text
BACKGROUND: Craniofacial surgery for facial advancement or correction of severe craniofacial malformations such as orbital hypertelorism, Crouzon's disease, and Apert's syndrome may carry great risk. Postoperative infection after craniofacial surgery is a life-threatening complication. Ascending infection via nasofrontal communication in frontofacial monobloc advancement, intracranial Le Fort III osteotomy, correction of hypertelorism (intracranial approach), and acute trauma of cribriform plate can lead to life-threatening meningitis and meningoencephalitis.
METHODS: A four-layer sealing technique for the closure of nasofrontal communication using Gelfoam, galeopericranial flap, rib bone graft, and Tissel is a very effective method. Until the rib bone graft is taken up, Gelfoam is used to temporarily block bony defects and prevents displacement of the rib bone graft. The authors used galeoperiosteal flap for the sufficient blood supply to the rib bone graft. Tissel is used as a biologic adhesive and for blockage of the surrounding gaps.
RESULTS: There were no cases of cerebrospinal fluid rhinorrhea, epidural abscesses due to nasofrontal ascending infection, or meningitis, and no cases underwent débridement due to necrosis of the frontal bone flap. This indicated that the blockage of nasofrontal communication was successful in this series. Moreover, postoperative cosmetic outcomes were satisfactory.
CONCLUSION: This study indicated that the blockage using the Gelfoam, galeopericranial flap, rib bone graft, and Tissel application was effective for the thorough management of nasofrontal fistula and the prevention of recurrent episodes.
Ahmed Soliman Ismail, Peter D Costantino, Chandranath Sen
Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis.
Skull Base. 2007 Mar;17(2):125-32. doi: 10.1055/s-2007-970556.
Abstract/Text
UNLABELLED: Cerebrospinal fluid (CSF) leaks result from a communication between the subarachnoid space and the upper aerodigestive tract. Because of the risk of complications such as meningitis, brain abscess, and pneumocephalus, all persistent CSF leaks should be repaired. Surgical repair may be achieved transcranially or extracranially using a wide variety of autogenous, allogenic, and synthetic patching materials. We report our results with a transnasal transsphenoidal endoscopic approach for the repair of CSF leaks coupled with a multilayer closure using acellular dermis (Allodermtrade mark). We conducted a retrospective review of all patients presenting to our institution over the past 5 years with isolated sphenoid sinus CSF fistulas.
RESULTS: Twenty-one patients were included in the study. Nineteen patients (90.5%) had their sphenoid sinus CSF fistula repaired during the first attempt; 2 patients (9.5%) needed a second attempt. The multilayer repair of the CSF leak using acellular dermis via a transsphenoidal endoscopic approach is an effective and successful method of surgical repair of the fistula site. Neither the number, size, nor cause of the CSF fistula affected surgical outcomes. However, the presence of hydrocephalus was a significant negative variable, altering the surgical outcomes of our patients. The acellular dermis offers the advantage of not requiring autogenous tissue for the effective repair of CSF leaks in the sphenoid sinus.
P Castelnuovo, S Mauri, D Locatelli, E Emanuelli, G Delù, G D Giulio
Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our failures.
Am J Rhinol. 2001 Sep-Oct;15(5):333-42.
Abstract/Text
Endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea is becoming a common procedure. The purpose of this study was to perform a literature analysis centering cases of treatment failure and to review our 31 cases with a 1-year minimum follow-up. An extensive search of the literature was conducted, which focused on success rate, follow-up, diagnostic techniques, graft material used, failure rate, and comments on failures. A retrospective analysis of our 31 patients was carried out, and all cases were treated with the endoscopic approach with a 1-year minimum follow-up. From the literature analysis, the median success rate at the first endoscopic attempt is 90%. Our success rate was 87.1%. Failures were analyzed. A unique protocol for CSF leak diagnosis does not exist; we suggest our diagnostic algorithm. Graft material used depends on the authors' experience, and based on this review of cases to date, did not significantly influence the success rate. The analysis of cases of failure shows that the majority of authors omit details. More research is needed to improve prevention of failures.
松脇由典, 森山寛： 髄液漏患者への脂肪組織充填 日本医事新報4511:81-82, 2010.
L Rimondini, S Mele
Stem cell technologies for tissue regeneration in dentistry.
Minerva Stomatol. 2009 Oct;58(10):483-500.
Abstract/Text
Embryonal and adult stem cells represent a very interesting research field. Mesenchymal stem cells in particular, derived from different sources, in the last ten years have gained more interest because of their high differentiation potential and their availability. They represent a potential key component in autologos graft for tissue regeneration. Cell-therapy based tissue engineering, even in dentistry field, is based on two approaches: the first is the direct implant of cells in tissues and the second involve the use of a scaffold acting both as a template of tissue and as a carrier of cells. Interest in this technologies continues to increase in dental application as a substitute for traditional treatments and artificial components. Nevertheless, few clinical reports of this topic are available. This review will discuss the current challenges in stem cells field, in particular their differentiation toward oral tissues. Bone marrow, adipose tissues, periodontal ligament and pulp will be described as potential sources of stem cells for oral tissue regeneration.
