| Objective: Skull base surgery as neurosurgery, otorhinolaryngology and the maxillofacial surgery, interdisciplinary very rapidly developed in recent years. However, due to anatomy of the anterior skull base adjacent to the structure of complex relationships in this anatomical location, for the lesions deeply located surgery is not easy to fully expose and completely remove the lesion, likely to cause postoperative deformity, dysfunction or other complications may occur. The nasal endoscopy is comparatively old technology with the development in optical, mechanical and electronic technology that acquired a new life over the last decade. Endoscopic can replace conventional microscopy, the nasal cavity through the natural gap, directly into the sella turcica and the parts anterior, middle and posterior to the base of the skull, under direct vision to deal with these parts of the lesion or injury, having quick recovery without cosmetic problem. The combination of transnasal endoscopic and the skull base surgery techniques greatly promoted the development of skull base surgery, not only enriched the treatment of skull base surgery but to broaden the scope of diagnosis and treatment of skull base surgery. The midline skull base surgery can handle not only the regional lesions, but also the development of lateral skull base region. However, due to complex anatomy of the skull base region, the anatomy of the lateral skull base is not sufficiently familiar to neurosurgeons. The nasal cavity space is small, available for a limited range of operation. Moreover endoscopy for the neurosurgeons is a different field of vision, the microscope and the operations are not fixed as the instruments out of the nasal passages are subject to change and is difficult to adapt for beginners. Being unfamiliar with endoscopy and lacking the knowledge of anatomical structures must not use endoscopic technique, these two major deficiencies prevents involvement of neurosurgeon. Endoscopic development is very uneven in domestic and overseas. On the other hand, in the developed countries and in our developed areas this technique is of rapid development. In the western region of Xinjiang it is still in initial stages. The purpose of this study is: 1) Observation and measurement through the internal anatomy of anterior skull base with endoscopic application. To enrich and master the required endoscopy of anterior skull base operations and anatomical knowledge. 2) To know and master out carrying of the necessary endoscopy of anterior skull base surgery, anatomical knowledge and developing the habit of endoscopic operation through the simulated training in the head of specimen bodies. 3) the Neuro endoscopy used in clinical treatment of common diseases of anterior skull base, such as cerebrospinal fluid rhinorrhea, optic nerve decompression, a variety of anterior cranial fossa tumors, etc. to improve surgical safety and efficacy in order to improve the Endoscopic diagnosis and treatment of skull base surgery. As the transsphenoidal pituitary tumor surgery has become more mature, therefore not in scope of this research. Method: The study is divided into three stages: 1) First 20 sides of 10 specimens of the cranial skull base and lateral of the sagittal section, the nasal bone anatomical landmarks associated between the distance and angle of observation and measurements. Then the 12 side of 6 specimens, after infusion for endoscopic observation and description; 2) To Endoscope the skull on 4 sides in two dried specimens, and 8sides of 4 bodies completed several simulations skull surgery: Endoscope transsphenoidal incision;Endoscope ethmoidsinus operation;Endoscope optic nerve decompression technique and endoscope orbital decompression, etc; 3) In the anatomical study and endoscopic simulated operations done under the premise of this technology used clinically for treatment of common diseases of the anterior skull base such as traumatic optic nerve injury, for various reasons cerebrospinal fluid rhinorrhea, treatment of benign tumor of anterior skull base. Result: 1) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. Nasal spine point toward anterior clinoid process and the average distance is 72.9±3.9mm. When surgical instruments 6～7cm deep passes into nasal cavity we should beware of the possibility of entering the middle cranial fossa; 2) the average distance from nasal spine to the midpoint of intraorbital opening of the optic canal is 63.4±5.3mm. The average distance from nasal spine point to the midpoint of intracranial opening of the optic canal is 69.3±4.9mm. The average distance from Nasal columella basis point to the midpoint of intracranial opening of the optic canal is 78.3±4.5mm. During optic nerve decompression or orbital apex surgery, one should be very careful when surgical instruments inserted in depth of more than 50mm from the nasal spine points, too deep operations may even damage the carotid artery into the middle cranial fossa; 3) The average distance from opening of sphenoid sinus to the intracranial opening of the optic canal and the shortest distance between them is 15.3±3.8mm. The average angle between the sphenoid sinus opening-optic canal line and median sagittal plane is 63±7.9°. So when sphenoid sinus opened, searching at the region of 1.5cm above and lateral to the opening of sphenoid sinus will help to find the optic canal; 4) adjacent to the inner wall of the optic canal, located lateral 3 sides of the sphenoid sinus (25%), located lateral 3 sides of the ethmoid sinus (25%), located between the sphenoid and the ethmoid sinus most commonly accounting for 6 (50%). So another way to look for the optic canal is searching at the junction of sphenoid and the ethmoid sinus because for most of the optic canal is located in or near this area; 5) The average distance from nasal spine to tuberculum sellae is 69.2±4.8mm. anterior border of the pituitary can be targeted accordingly. Operations at here in-depth more than 60mm, should beware of carotid artery injury; 6) two-dimensional endoscopy image, tubular vision with fish-eye lens effects anatomical deformation is more serious distortion, the greater the angle of the lens the change more obvious, the difference between observed and real anatomy is greater. Therefore proficiency in endoscopy anatomy, repeated practice, accustomed to this vision will help to overcome the endoscopy image distortion caused by blindness and lost feeling; 7) Endoscopic treatment 13 cases of no light perception with optic nerve damaged in patients followed up for 3 to 12 months, in 7 patients visual acuity recovery observed;6 cases it is ineffective. Visual acuity of more than 1～2 weeks post-operative emergence and about 2 months after the cessation. A level of visual acuity improved in 3 cases, two level in 1 case, 3 levels in 1 case, 4 levels in 2 cases. Total efficiency of 53.8% (7/13). Vision loss by injury between operative time is divided into groups of 3～7days, 8～14days, 15～21days and 21 or more days groups, in each group there was no significant difference between the effect (P>0.05); 8) treatment of 17 cases of traumatic optic nerve damage in patients with a total of 18, 10 patients with visual acuity recovery; 8 is invalid. A level of visual acuity improved in 5 patients, 2 levels in 2 cases, 3 levels in 1 case, 4 levels of in 2 cases, the total effective rate 55.6% (10/18); 9) Endoscopic treatment of 7 cases of iatrogenic cerebrospinal fluid leak, once repaired, drain port are in the original surgical site; 10) Treated 24 cases of cerebrospinal fluid rhinorrhea in patients. Endoscopic group of 13 of 15 cases. 13 successful operations, surgical success rate was 86.6%; 11 cases of 12 patients craniotomy with successful operations, the success of surgical success rate was 83.3%; the two groups and the a success rate of secondary surgical was of no significant difference; 11) Endoscopic treatment of the ethmoid sinus ossifying fibroma butterfly in 1 case, subtotal resection, pathology as follows: juvenile ossifying fibroma, visual acuity was restored after the affected side. Conclusion: 1) Transnasal endoscopic treatment of anterior skull base lesions can maximize exposure of the regional lesions without increasing traction injury to the brain nerves and blood vessels to retain the normal structure thus reducing the postoperative complications and morbidity. With a minimally invasive, non-craniofacial incision, the patient feels less pain, quicker recovery, etc. In a series the clinical surgery illustrates conventional craniotomy and the nasal route with irreplaceable advantages; 2) Proficiency in the knowledge of the skull base relevant anatomy and after rigorous training in endoscopic procedures there is high safety; 3) For no light perception before surgery in patients with optic nerve injury, optic nerve decompression should be done in order to save their eyesight; 4)Recovery of vision after optic nerve injury depends on the mechanism and extent of optic nerve injury and not on duration from the time of injury to the time of surgery. Therefore as long as patient tends to be treated no matter how long after injury, surgery should be performed to save vision. |
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