文献摘要

延伸至翼顎窩的解剖以延長鼻中隔黏膜瓣蒂
Lengthening the nasoseptal flap pedicle with extended dissection into the pterygopalatine fossa

Volume 4, Issue 4

關鍵字 :
鼻中隔黏膜瓣,經鼻內視鏡手術,顱底缺損,翼顎窩, Nasoseptal flap, endoscopic endonasal approach, cranial base defect, pterygopalatine fossa

作者 :
Karthik S. Shastri, MD ; Luciano Cesar P. C. Leonel, PhD; Varun Patel, MD; Marcelo Charles-Pereira, MD; Tyler J. Kenning, MD; Maria Peris-Celda, MD, PhD; Carlos D. Pinheiro-Neto, MD, PhD

譯者 :
臺北榮民總醫院 耳鼻喉頭頸部 鼻頭頸科 藍敏瑛醫師

摘要:


Objectives/Hypothesis: Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications.


Study Design: Anatomical study and retrospective clinical cohort study.


Methods: Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies.


Results: The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 ± 0.40 cm/9.3 ± 0.39 cm following standard harvest, 2.52 ± 0.61 cm/9.75 ± 1.06 cm following SPA foramen release, 4.93 ± 0.89 cm/12.16 ± 0.54 cm following full IMAX dissection, and 6.18 ± 0.68 cm/13.41 ± 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients.


Conclusions: Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting.

專家評論:


延伸至翼顎窩的解剖以延長鼻中隔黏膜瓣蒂


臺北榮民總醫院 耳鼻喉頭頸部 鼻頭頸科 藍敏瑛醫師


顱底解剖結構複雜,不論是鼻腔或腦部組織長出的腫瘤,都可能侵犯至顱底,經鼻內視鏡手術 (endoscopic endonasal approach) 目前已是世界先進國家採用的主要趨勢。在顱底缺損 (cranial base defect) 的修補上,我們多採用多層式重建技術。鼻中隔黏膜瓣 (nasoseptal flap) Hadad Bassagasteguy 2006 年提出,是目前透過經鼻內視鏡顱底手術後,重建顱底缺損時常用的黏膜瓣。鼻中隔黏膜瓣的使用,顯著降低了顱底手術時腦脊髓液漏 (cerebrospinal fluid [CSF] leak) 的發病率,從早期的 20% - 30% 降低至 5% 以下。雖然鼻中隔黏膜瓣大多能提供足夠的表面積,以覆蓋顱底缺損,但是前顱底缺損 (anterior cranial base defect) 的最前處、以及經斜坡路徑 (transclival approaches) 的後顱窩 (posterior fossa) 缺損之全面覆蓋 (full coverage),可能會受到限制。此團隊過去的研究發現:從翼顎動脈孔 (sphenopalatine artery [SPA] foramen) 釋放鼻中隔黏膜瓣蒂,和將解剖擴展到翼顎窩 (pterygopalatine fossa, PPF),可改善黏膜瓣的覆蓋範圍 (flap reach) 和可用表面積。此篇研究將使用屍頭解剖 (cadaveric dissection),來量化解剖擴展到翼顎窩後,鼻中隔黏膜瓣的增加長度,並呈現 7 位臨床患者的應用結果。


此研究設計為進行 12 個屍頭解剖。先遵循標準方法取鼻中隔黏膜瓣,向前拉黏膜瓣以測量黏膜瓣前緣 至前鼻棘 (anterior nasal spine) 的距離。接著繼續進行解剖至翼顎動脈孔和 PPF,再測量從翼顎動脈孔釋放、釋放上頜內動脈 (internal maxillary artery)、和橫切斷 (transection) 顎降動脈 (descending palatine artery) 後的類似間隔測量。此方法也應用在 7 例因應各種不同疾病患者的顱底手術中。結果顯示:1) 以標準方法取鼻中隔黏膜瓣時 (standard harvest),自前鼻棘測量的鼻中隔黏膜瓣平均長度,和最大黏膜瓣伸展距離為 1.91 ± 0.40 cm / 9.3 ± 0.39 cm2) 當從翼顎動脈孔釋放鼻中隔黏膜瓣蒂時 (SPA foramen release),量測距離為 2.52 ± 0.61 cm / 9.75 ± 1.06 cm3) 當釋放上頜內動脈時 (full IMAX dissection),量測距離為 4.93 ± 0.89 cm / 12.16 ± 0.54 cm4) 當橫切斷顎降動脈 (DPA transection) 後,量測距離為 6.18 ± 0.68 cm / 13.41 ± 0.75 cm。所有 7 位臨床患者的鼻中隔黏膜瓣,都無黏膜瓣癒合不良 (dehiscence)、或壞死 (necrosis) 情形。因此,作者認為:廣泛解剖鼻中隔黏膜瓣蒂至翼顎動脈孔和上頜內動脈,可顯著增加黏膜瓣的長度和伸展範圍 (length and reach)。此手術技巧提供了大的前顱底缺損,以及顱頸交界處缺損 (craniocervical junction defect) 重建的可行方式。此方式應用於 7 位臨床患者的結果相當成功,但之後需要更大型的臨床研究來做印證。


然而,解剖鼻中隔黏膜瓣蒂到上頜內動脈的手術技巧,頗具挑戰性且有潛在風險,有可能傷到血管而影響黏膜瓣的存活,或暴露的上頜內動脈之後有破裂出血的可能性。使用游離黏膜瓣或脂肪組織,來覆蓋鼻中隔黏膜瓣蒂是一個可行的保護方法。無論如何,本篇作者提供醫師在臨床上施行經鼻內視鏡手術時,若有大的前顱底缺損、以及有顱頸交界處缺損需要重建時,一個有效且具實行性的方式。


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