頭蓋底骨髄炎は, 外耳道や中耳, 副鼻腔などに生じた炎症の直接的な波及, または遠隔臓器からの血行性の波及による, 頭蓋底および側頭骨の骨髄炎を特徴とする病態である。 今回われわれは, 上咽頭癌との鑑別に苦慮した頭蓋底骨髄炎の症例を1例経験したため, 若干の文献的考察を加えて報告する。
症例は66歳, 男性。 左耳痛を主訴に前医を受診した。 左急性中耳炎と診断され, 内服加療を開始したが, 耳痛が増悪するため, CT, MRI を含め精査が施行された。 画像所見で上咽頭腫瘍が疑われたため, さらなる精査, 加療を目的に当院当科紹介となった。 当科受診後, 局所麻酔下に複数回生検を行うも, 悪性所見は得られなかった。 しかし, 耳痛に加え頭痛も出現したため, 全身麻酔下に生検を施行した。 生検時, 上咽頭組織をかなり深部まで採取したところ, 内部から大量の排膿を認めた。 病理検査では悪性所見は認められず, 同時に施行した培養検査, グラム染色では明らかな起因菌は同定できなかった。 術後, 耳痛および頭痛は著明に改善した。 臨床経過, 検査所見から総合的に頭蓋底骨髄炎と診断し, 治療を開始した。 6週間の抗菌薬投与を行い, 現在症状の再燃なく, 外来経過観察となっている。
頭蓋底骨髄炎は予後不良な疾患であり, 早期診断, 早期治療が求められる。 本症例のように腫瘍との鑑別が困難であるケースや, 培養陰性のケースなど診断に難渋する場合があり, 十分に注意を要する疾患であると考える。 診断にあたっては, 全身麻酔下で十分な組織を採取するために, 積極的に手術も検討すべきと考える。
The “SONAVIA” and “SONAVIA Lock-on System” as assistive devices for fine needle aspiration biopsy cytology for thyroid nodular lesions and cervical lymph nodes Ultrasound-guided fine needle aspiration cytology (FNAC) for lesions such as thyroid nodules and enlarged cervical lymph nodes is presently an essential medical procedure that is frequently performed in clinical practice. Accidental puncturing of important organs may lead to serious consequences such as hemorrhaging. We report an FNAC assistive device that we developed to safely collect samples without the need to completely rely upon the surgeon's skill and expertise.
The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward and may overcome weak points of previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. However, the spread in the robot-assisted thoracic surgery does not progress as expected at present. Because target area is wide in the thoracic cavity, it is necessary for safe and effective utilization of da Vinci by devising it. There are many problems including education, training, cost, advanced medical care, the insurance publication for the future development.
Endoscopic sinus surgery (ESS) has become widespread as a standard surgical method for chronic rhinosinisitis (CRS). By the development of various surgical devices such as microdebridder and navigation system, ESS became safer and more adequate compared with conventional sinus operations such as Caldwell-Luc procedure. Especially, microdebridder enables rapid resection and smooth mucosal healing.
Radical and thorough as well as appropriate removal of the sinus pathology leads the patient recovery from the diseases. On the other hand, inappropriate and rough manipulation during the surgery may cause major complications such as orbital injury and CSF leakage. Above all, prevalence of orbital injury with the use of microdebridder, which resulted in permanent orbital dysfunction, has been increasing.
Key points for safer and effective usage of microdebrider are as follows,
1. Understand anatomy, especially anatomical relations of basal lamellas and ethmoidal air
2. Examine pre-op CT.
3. Keep a clear and proper field of endoscopic view.
4. Always, watch blade endoscopically.
5. Crush ethmoidal cells with conventional forceps, then debride them with microdebridder.
6. Use debridder not only as blade but also as suction tube.
7. Never press orbital wall and skull base directly with blade.
8. Know about the complications which actually occurred, and then learn how to prevent it.
9. Try to do “mucosal preservation” with microdebridder.
Microdebridder is very useful tools for smooth mucosal healing. OR time becomes shorter, and the stress for the patients are less. However, this "powered instrument" always have some risk of orbital and cranial complications, which tend to progress rapid. surgeon should first understand such features of this device, then carefully and effectively use it for the better outcomes.
Three-dimensional imaging (3D-CT) and virtual reality temporal bone simulator would provide accurate anatomical information to perform skull base surgery and useful for preoperative surgical planning and simulation operation.
We presented a case of trigeminal neurinoma of the parapharyngeal space that involved the middle of the skull base.
The tumor was resected by the Combination of Orbito-zygomatic approach with transcervical approach, which preserves the facial nerves. This is a useful procedure for accessing to infratemporal fossa or parapharygeal space.
There have been many techniques described for inferior turbinate reduction, including submucosal turbinoplasty, turbinectomy, and diathermy. Submucosal tissue resection preserving mucosal surface has been recommended against the risk losing the physiologic function of the nose. Here, we described a new technique, submucosal inferior turbinoplasty and neurectomy with the coblater 2 wand ICW. The current surgical technique would be an easy and effective method for the inferior turbinate tissue reduction for the treatment of allergic rhinitis and inferior turbinate hypertrophy.