| BackgroundTranssphenoidal surgery (TSS) was developedat the turn of the century.The transsphenoidal extracranial approach to the pituitary initiated by Koenig in1898involved splitting and retracting of the superior maxilla. Shortly thereafter, Giordana suggested a more superior approach with an osteoplastic resec-tion of the nose and anterior wall of the frontal sinus,reaching the sphenoid sinus through the ethmoids.In1970,Schloffer ueed this method for the first suc-cessful removal of a pituitary tumor.Use of Giordana’s approach spread rapidl-y despite the disfigurement entailed,the operative morbidity,and the frequency of infection. Kanavel observed that the majority of pitui-tary tumors grew downward, eroding the sellarv floor, he abandoned the earlier extensive and multi-staged procedures and advocated elevation of the nose and a direct appro-ach through the sphenoid sinus.Others introduced modifications of Kanavel’s method.For example,Gadianao’s translabial-sphenoidal approach,Cushing’s tra-nsseptal trans-septal-sphenoidal approach and Chiari’s transethmoidal-sphenoidal approach et al.By1930, Cushing and most U.S. surgeons abandoned the trans-sphenoidal procedure,because of intracranial surgery and limited exposure and the risk of meningitis.By1950,with the application of antibiotics and cortisone,the transsphenoidal approach was extensive used. Neurosurgeons introduced intr-aoperative radiofluoroscopy (1957, Guiot), microsurgical transseptal hypophysec-tomy, and selective anterior hypophysectomy (1965, Hardy). Hardy indicated the safety of the transsphenoidal removal of pituitary tumors with suprasellar extension. With application of neuronavigation and endoscopic and intra-operat-ive MR,the transsphenoidal approach is more safer.According to literature,about90-95%pituritary tumours were selected removaled by transsphenoidal approach now.Computerized tomographic (CT) cuts passing through the anterior nasal spine and the most prominent part of the sellar floorwere found to be useful in minimizing the chances of anatomical disorientation during the transsphenoidal microsurgical approach as well as in preoperative planning and selection of the length and choice of the instruments to be used. The sphenoid sinus is best defined as developing after pneumatization penetrates the sphenoid bone. Pneumatization of the sphenoid sinus begins at the ostium and progresses in a posterosuperior direction. The sphenoid sinus initially develops in the lower half of the body of the sphenoid bone,whereas the upper part of the body of the sphenoid bone unites with the ethmoid labyrinth. Anatomical variation of sphenoid sinus is bigger,as well as the sella turcica and sella floor.Somatotypy of spenoid sinus morphology contains concha type and pre-sella type and sella type.The septation of sphenoid sinus is one or two or even more,and respective septation cavity is asymmetric.Protrusion and dehiscence of Internal Carotid Artery (ICA) and Optic Nerve (ON) into the sphenoid sinuses cavity can be observed. Davoodi found protrusion and dehiscence of Internal Carotid Artery (ICA), Maxillary Nerve (MN), Vidian Nerve (VN) and Optic Nerve (ON) during the sphenoid sinuses cavity were various by CT scaning paranasal sinuses.It is necessary for preoperative detailing neurovascular structures in sphenoid sinuses by use of CT scan images. Measured angle of anatomical markers and distances from columella nasi to apertura sphenoidalis/sella turcica may directed length and orientation of nasal speculum by preoperative3D-CT.The crucial procedure by transsphenoidal approach hypophysectomy is accurately located sellar floor along midline.Hardy safely removed pituitary tumors by using intra-operation X-ray locating sellar floor early days. C-arm machine has been used to locate sellar floor during intra-operative surgery in later stage.Applications of neuronavigation and endoscopic technical and Intra-operative MR imaging can locate sellar floor,and distinguish neurovascular structures adjacent sphenoid sinus,and judge remnant of tumors,and promote resectability,and reduce operative complications and recurrence. Some pituitary tumors that is not invade parasella and sella type sphenoid sinus and straightness type of sallar floor.can be observe anatomical mark and simply locate sellar floor by pre-operative3D-CT of skull.Putting operative posturey is crucial procedure that completing operation.Todays,majority of selective operative posture play that supine position and fifteen to thirty angle of head hypsokinesis.The angle of head hypsokinesis has difficultly unified and more various,but referenc line of body surface can reduce those defect.Xiao SX showed that The nose tip-ear apex line provides a precise, simple, and practical tool for orienting the sphenoid sinus, sellar floor and surgical trajectory of the endonasal transsphenoidal approach.3D-CT images more clearly and intuitively display the sella turcica anatomy. Throught summarizing operative postures of26cases pituitary tumors,cheng G found that line of microscope-nares-zygoma tip part erecting the ground can contrbute to locate sellar floor.Above two body surface and putting operative posture,there are more various with regard to acromegaly,and this studys of patient cases was less,and not guided by base studys. Meanwhile,there were less analouous literatures at home and abroad.Therefore,according to3D-CT(MPR) of skull has making some base studys of the single-nostril transsphenoidal approach,and discovering a universal reference line of operative posture,and designing one clinical studys,and summarizing its clincal advantages.Section oneAnatomical angle measurement of adult in the single-nostril transsphenoidal approach:application of CT multi-planar reformationObjectiveThrough measuring some anatomical angles in the single-nostril transsphenoidal approach,to discuss some parameters of anatomical angle during the single-nostril transsphenoidal approach,and to discovery body surface referenced plane of operative posture by the single-nostril transsphenoidal approach.Methods294cases of adults patients from October2011to January2012in zhujiang hospital of southern medical university,were prospectively collected and scaned from the Head-neck CTA by PHILIPS Brilliance64row CT.original images scanned were imported three dimensional work place of Philips Extended Brilliance Workspace,and were doing multi planar reformation.according to scanned and located image,there were two lines from anterior nasal spine root to sella lowest point and from Maxillary central incisors bottom to auditory canal,were measured angle of sella lowest point-anterior nasal spine root-the bottom of nasal cavity(∠1)and angle of the connection of the line of Maxillary central incisors bottom to auditory canal crossing with the bottom of nasal cavity(∠2);through sagittal images from multiple planar reformation,were measured angle of tuberculum sellae-anterior nasal spine root-the bottom of nasal cavity(∠3), angle of dorsum sellae-anterior nasal spine root-the bottom of nasal cavity(∠4), angle of right sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(Z5)and left sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(∠6).The datas measured were analysed by statistics software of SPSS13.0,measurement datas played in mean±standard deviation(x±s),and analysed by one-way analysis of variance during those groups,and anslysed through q test(Newman-Keuls way)between two groups.the correlation analysis used Spearman way,difference has statistical significance until P<0.05.Results(1)angle of sella lowest point-anterior nasal spine root-the bottom of nasal cavity∠1(29.7±3.1°), angle of the connection of the line of Maxillary central incisors bottom to auditory canal crossing with the bottom of nasal cavit∠2(29.5±3.1°), angle of tuberculum sellae-anterior nasal spine root-the bottom of nasal cavity∠3(33.6±3.8°), angle of dorsum sellae-anterior nasal spine root-the bottom of nasal cavity∠4(28.8±3.6°), angle of right sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavit∠Z5(33.9±4.2°), left sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity∠6(33.6±4.5°).(2)∠1and∠2have a positive linear correlation(r=0.78,P<0.05); the among groups from∠1to∠6were significantly different(P<0.05);while this difference was not found among∠1with∠2(P=0.80)or∠2with∠4(P=0.68)or∠3with∠5(P=0.98)or∠3with∠6(P=1.00)or∠5with∠6(P=0.99), other every two groups had significant differences(P<0.05).Conclusion Angle of sella lowest point-anterior nasal spine root-the bottom of nasal cavity∠1is approximately equal to angle of the connection of the line of Maxillary central incisors bottom to auditory canal crossing with the bottom of nasal cavity∠2,and line from anterior nasal spine root to sella lowest point approximately parallels line from Maxillary central incisors bottom to auditory canal. when virtual plane of maxillary central incisors bottom to bilateral auditory canal erects the ground,the line of anterior nasal spine root to sella lowest point erects the ground,and it means line of microscope-nasal cavity-sellar floor erects the ground.Angle of right sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(Z5)is approximately equal to left sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(∠6),that means that right sphenoid sinus mouth and left sphenoid sinus mouth lie the same level. Angle of tuberculum sellae-anterior nasal spine root-the bottom of nasal cavity(∠3)is approximately equal to angle of right/left sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(∠5/∠6),that means anterior wall of sella turcica is exposed below bilateral sphenoid sinus mouth plane. Compare with angle of sella lowest point-anterior nasal spine root-the bottom of nasal cavity∠1and angle of the connection of the line of Maxillary central incisors bottom to auditory canal crossing with the bottom of nasal cavity∠2,angle of right/left sphenoid sinus mouth-maxillary ridge-the bottom of nasal cavity(∠5/∠6)are approximate much four degree,that means sellar floor is completely exposed in bone window of anterior wall of sella turcica that its superior border is the line of bilateral sphenoid sinus mouth.therfore,pre-operative coronal CT multi planar reformation is useful for safely opening bone window of anterior wall of sella turcica and sellar floor.the virtual plane of Maxillary central incisors bottom to bilateral auditory canal can been conducted body surface referenced plane of operative posture by the single-nostril transsphenoidal approach. Section twoApplication of virtual plane that maxillary central incisors bottom to bilateral auditory canal in the single-nostril transsphenoidal approachObjectiveThrough retrospective collected110cases pituitary adenoma from March2006to March2012in zhujiang hospital of southern medical university, to design clinical research,and to evaluate clinical applied value of virtual plane of maxillary central incisors bottom to bilateral auditory canal in single-nostril transsphenoidal approach by microscope.Methods110patients of pituitary adenoma operated in single-nostril transsphenoidal approach by microscope were retrospective collected, and were divided into experimental group and control group whether the virtual plane of maxillary central incisors bottom to bilateral auditory canal erects the ground, and calculated operating time and hospital stays; counted the incidence of postoperative sellar bleeding and diabetes insipidus and CSF leak and intracranial infection and other complication and mortality, and essessed the ratio of resection and residual or recurrence by observing the coronal MR from postoperative1month to24months.According to evaluating the relation between pituitary adenoma and the line cavernous sinus part(C4) to supraclinoid(C2) of internal carotid artery in coronal MR,there are five grades of pituitary adenoma Knosp grade.for example: Zero grade:the cavernous sinus shape is normal,and venous plexus of cavernous sinus is enhanced,and pituitary adenoma not exceeds the inner tangent line of C2-C4blood vessel diameter.One grade:pituitary adenoma exceeds the inner tangent line of C2-C4blood vessel diameter,but it not exceeds the centre line of C2-C4blood vessel diameter,and inboard venous plexus of cavernous sinus disappears.Two grade:pituitary adenoma exceeds the centre line of C2-C4blood vessel diameter,but it not exceeds the outer tangent line of C2-C4blood vessel diameter,and superior or lower venous plexus of cavernous sinus disappears.Three grade:pituitary adenoma exceeds the outer tangent line of C2-C4blood vessel diameter, and inboard or superior or lower or outboard venous plexus of cavernous sinus disappears.Four grade:the cavernous sinus part of internal carotid artery is completely packed,and its blood vessel diameter is narrow,and venous plexus of cavernous sinus disappears,and superior wall and outboard wall of cavernous sinus outwards expands.The datas measured were analysed by statistics software of SPSS13.0,measurement datas played in mean±standard deviation(x±s),and analysed by T test during two groups,and enumeration datas played in rate(P), and analysed by χ2test during two groups,difference has statistical significance until P<0.05.ResultsThe operating time of experimental group were less than the control group(P=0.00),there was no significant difference of length of stay between two groups(P=0.245).Meanwhile, there was no significant difference of incidence of postoperative sellar hemorrhage,diabetes insipidus, intracranial infection, other complications, resection and residual or recurrence between two groups(P=0.462、 P=0.849、P=0.802、P=0.192、P=0.634、P=0.127).There was no CSF leak and death in both two groups.ConclusionsStay in hospitals time of experimental group is approximate equal to the control group,there is not obvious otherness.operative time of experimental group is approximate less one house than the control group. There was no significant difference of incidence of postoperative sellar hemorrhage,diabetes insipidus, intracranial infection, other complications, resection and residual or recurrence between two groups,that means the incidence rate of postoperative sellar hemorrhage or diabetes insipidus or intracranial infection or other complications or resection and residual or recurrence are not obvious relative with this operative posture.therefore,the operative posture that virtual plane of maxillary central incisors bottom to bilateral auditory canal erects the ground has its clinical applied value,and can be used for reference operative posture in single-nostril transsphenoidal approach by microscope. The virtual plane of Maxillary central incisors bottom to bilateral auditory canal can been conducted body surface referenced plane by the single-nostril transsphenoidal approach. |
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