经颌下或颧弓入路的颅底肿瘤的外科治疗

【目的】探讨颅底及近颅底肿瘤的手术入路及治疗方法，并评价其手术效果。【方法】应用经颌下及颧弓入路对11例颅底及近颅底肿瘤进行了手术治疗。术后随访1～3．5年。总结分析了3种不同的手术径路与方法、适应症以及治疗效果。【结果】采用3种不同的手术入路使侵及颅底的几类肿瘤都能获得足够的暴露，术野清楚、操作方便，均能清晰完整地摘除瘤体。本组病例随访时间为1～3．5年，所有病例均健在，至今未出现颅脑症状和神经损伤以及肿瘤复发。【结论】颅底及近颅底肿瘤根据其所在部位、性质及瘤体大小采用适当的入路可获得足够的显露，并达到良好的手术效果。     

经扩大口咽入路切除斜坡肿瘤

[目的]探讨切除斜坡肿瘤的理想手术入路.[方法]采用经扩大口咽入路成功切除1例斜坡脊索瘤,评价术中暴露情况,术中出血,手术时间、围手术期并发症.[结果]通过扩大口咽入路能使肿瘤充分暴露,并安全而完整地切除肿瘤,术中出血600 mL.[结论]扩大口咽入路能对斜坡下部获得较好的暴露,是切除斜坡下部肿瘤理想的手术入路之一.     

额颞-颞下入路治疗中颅凹型三叉神经鞘瘤疗效分析

[目的]探讨经额颞-颞下入路对中颅凹型三叉神经鞘瘤的手术优点.[方法] 回顾分析5例经额颞-颞下入路手术切除中颅凹型三叉神经鞘瘤临床资料.4例全切,1例大部切,海绵窦内有残留.2例断颧弓.[结果] 术后病人临床症状不同程度改善,其中1例病人术后出现一过性动眼神经麻痹,术后1月恢复;1例出现脑脊液漏,经抗炎治疗和腰大池置管引流痊愈.本组无死亡病例.1例大部切病人术后行γ刀治疗,复查MRI,残存肿瘤无增大.[结论] 经额颞-颞下入路对切除中颅凹型三叉神经鞘瘤具有创伤小,距离近,显露好等优点.     

经单鼻孔-蝶窦入路显微手术治疗23例垂体腺瘤疗效分析

[背景]观察垂体腺瘤的手术治疗效果.[病例报告]回顾性分析经单鼻孔-蝶窦入路显微手术治疗的23例垂体腺瘤病人资料,其中肿瘤全切除者为21例,次全切除者为2例.[讨论]经单鼻孔-蝶窦入路显微手术是治疗垂体腺瘤有效且安全的手术方法.     

345例腮腺肿瘤临床分析

[目的]通过对我院近10年345例腮腺肿瘤的统计分析,探讨其发病原因、最佳治疗方案,提高腮腺肿瘤患者的治愈率及生存质量.[方法]回顾我院近10年的腮腺肿瘤病例,随访其治疗效果及生存质量,进行统计分析.[结果]345例腮腺肿瘤中,良性301例,恶性44例.良性肿瘤如多形性腺瘤、沃辛瘤的发病有增多的趋势.345例腮腺肿瘤患者中,326例行保留面神经、腮腺浅叶或全叶切除术,19例沃辛瘤患者行腮腺区域性切除术.术后效果良好,无面神经损伤及肿瘤复发病例.行腮腺区域性切除术者,无面部凹陷畸形、味觉出汗综合征,较好地保存了患侧腮腺功能.[结论]腮腺良性肿瘤有增多的趋势,warthin瘤等好发腮腺后下极的肿瘤行腮腺区域性切除术,术后效果良好,保存了腮腺的功能,提高了患者的生存质量.     

显微镜下经颅底入路切除中颅底肿瘤的疗效观察

目的探讨在显微镜下经颅底入路切除中颅底肿瘤的效果。方法选取该院收治的26例中颅底肿瘤患者,采用经翼点或其扩大入路在显微镜下进行手术治疗,患者出院后进行随访。观察术后及随访效果,并观察患者并发症的发生情况。结果 26例患者中肿瘤全切除的患者有19例,肿瘤大部分切除的患者有4例,肿瘤部分切除的患者有3例,无手术死亡的病例。随访的20例患者中,全切除患者中有4例复发,其中1例已经死亡。结论在显微镜下经翼点或其扩大入路进行手术是治疗中颅底肿瘤的常用方法。其不仅能够在手术中减少对脑组织的牵拉,还能够提高手术切除率,减少患者的并发症与死亡率,值得在临床上推广应用。     

髋臼骨折的手术治疗

[目的]通过总结髋臼骨折手术治疗结果的分析,进一步提高手术治疗效果.[方法]1998年1月至2002年12月共手术治疗髋臼骨折26例,男17例,女9例;平均31岁.受伤距手术5～14 d;常用手术入路为K-L入路,髂腹股沟入路.[结果]23例随访,优15例,良5例,可3例.[结论]及时手术、解剖复位、内固定、早期功能锻炼、对髋关节功能恢复有良好的疗效.     

经眉弓眶上锁孔入路切除前颅底和鞍区病变

目的:探讨经眉弓眶上锁孔入路治疗前颅底和鞍区病变的显微手术技术和效果.方法:采用经眉弓皮肤切口,做3.0 cm×2.5 cm包括眶缘及部分眶板在内的额下骨窗;应用显微手术切除前颅底和鞍区肿瘤28例.结果:28例肿瘤全切26例,2例垂体瘤行次全切除.术后无严重并发症.平均随访24个月,全切肿瘤无复发.结论:经眉弓眶上锁孔入路可明显减少手术创伤,同时能提供足够的手术空间,并能有效地处理前颅底和鞍区病变.     

伴慢性蝶窦炎的垂体瘤经蝶窦显微手术初步探讨

[目的]探讨伴有慢性蝶窦炎的垂体瘤经蝶窦显微手术方法,如何预防继发颅内感染.[方法]对15例伴有慢性蝶窦炎的垂体瘤患者施行经蝶窦手术,术中完整地剥除蝶窦粘膜,打开鞍底前及切瘤后,用双氧水、酒精及庆大霉素浸泡蝶窦腔及瘤腔各2次,每次1min,X线或导航定位下显微放大8～15倍切瘤,切瘤后用链霉素粉肌肉浆封闭鞍底,术后加强抗炎3～5d.[结果]本组肿瘤全切除12例,次全切除3例,无死亡及其他并发症.[结论]慢性蝶窦炎不应再成为经蝶入路的禁忌症.     

鼻内镜下鼻腔鼻窦内翻性乳头状瘤手术36例临床分析

[背景]探讨鼻内镜在鼻腔鼻窦内翻性乳头状瘤手术治疗中的应用价值.[病例报告]回顾性分析2008年3月—2012年11月间因鼻腔鼻窦内翻性乳头状瘤治疗住院并行鼻内镜或联合柯-陆式入路治疗的患者36例,术后7⁹d出院,进行19d出院,进行1⁴年回访,观察恢复及有无复发情况.结果见,4例(Ⅱ期2例、Ⅲ期2例)复发,其余均取得满意疗效.[讨论]鼻内镜手术是Ⅰ,Ⅱ期鼻腔鼻窦内翻性乳头状瘤的首选手术方法,Ⅲ,Ⅳ期根据病变情况选择鼻内镜手术或联合传统手术方式进行手术;长时间随访对及早发现肿瘤复发并进行手术治疗是有必要的.     

采用翻揭或拆装扩大术野行颅底深部肿瘤切除术

目的：探讨切除颅底深部肿瘤的手术途径。方法：根据肿瘤位置的不同,分别采用（1）上颌窦前壁拆装;（2）颧弓拆装;（3）鼻锥翻揭;（4）上颌骨翻揭;（5）下颌骨翻揭;（6）唇下面中部翻揭。结果：62例患者术视野充分,肿瘤能完整大块切除,术后头面部畸形不明显,器官功能维护良好。3年生存率为86．1％,5年生存率为66．7％。结论：对颅底深部肿瘤依据不同位置有用翻揭或拆装手术途径,既能使手术野最大暴露,又可将损伤降到最低程度,符合现代颅底外科手术原则。     

鼻颅底肿瘤的内镜手术治疗

目的:分析鼻相关颅底肿瘤内镜手术的意义,探讨其适应证、入路及相关并发症的预防。方法:鼻相关颅底肿瘤48例,均在内镜下进行手术,根据肿瘤的发生部位、累及范围及性质分别采取经筛,鼻中隔经蝶,经扩大上颌窦后壁,鼻腔外侧壁,鼻外上颌骨,经口咽后壁等手术入路切除肿瘤。结果:肿瘤全切率81.3%(39/48),次全切除14.6%(7/48),大部分切除4.1%(2/48),并发症发生率18.7%(9/48),无致残及致死病例。随诊3个月至6年,中位随诊时间3年,良性肿瘤复发率8.3%(4/30),无死亡病例。恶性肿瘤Kaplan-Meier法计算3年生存率75%,5年生存率57.6%。结论:术前评估,掌握内镜手术的适应证及相关技术,采用合理的手术入路,采取恰当的方式切除肿瘤,与相关学科密切合作,保证手术的安全性,可预防并减少并发症。     

上颌外旋及下颌外旋切除前中颅底、咽、咽旁间隙肿瘤的手术研究

目的 :探讨彻底切除前中颅底、咽、咽旁间隙肿瘤的理想手术入路。方法 :采用不同部位的上颌外旋入路切除 16例前、中颅底肿瘤 ,此 16例肿瘤均累及多区 ,范围广泛 ;采用下颌外旋入路治疗 2 6例鼻咽、口咽、咽旁及颅底肿瘤。结果 :16例上颌外旋术后随访 2～ 5年 ,生存 4年以上 3例 ,3年以上 6例 ,2年以上 6例 ,术后 1.5月死亡 1例。 2 6例下颌外旋术后随访 18个月～ 6年 ,4例良性肿瘤情况良好 ,无复发 ,2 2例恶性肿瘤中 ,2例 0 .5年内死亡 ,2例 1年余复发 ,1例术后 2年死于肺部转移 ,4例存活 5年以上 ,6例存活 4年以上 ,3例存活 3年以上 ,3例存活 2年以上 ,1例存活 1年以上。大部分病例仍在继续随访中。结论 :上颌外旋及下颌外旋入路是彻底切除前中颅底、咽、咽旁间隙肿瘤理想、可靠的手术入路     

颅底脊索瘤经手术与伽玛刀治疗的预后比较

目的:通过总结颅底脊索瘤经手术治疗与伽玛刀治疗后的并发症、生存率、生活质量等特点,探讨颅底脊索瘤经手术与伽玛刀的疗效与预后.方法:对2002年1月至2010年1月期间接受手术治疗38例及伽玛刀治疗19例颅底脊索瘤患者进行随访,应用远期生活质量评分(Karnofsky performance scale,KPS)对全部患...     

颧弓颞颌径路侧颅底肿瘤切除术

目的 :评价经颧弓和颞颌径路切除侧颅底肿瘤的可行性和疗效。方法 :经颧弓和颞颌径路在手术显微镜下为侧颅底肿瘤 4例行切除术。结果 :术后随访 5年 ,良性肿瘤 3例无复发 ,非霍杰金淋巴瘤 1例存活。结论 :经颧弓和颞颌径路适用于切除侵及颞下窝、翼腭窝的侧颅底肿瘤     

颅底颈椎脊索瘤12例临床及预后分析

１９８４年－１９９１年该科共收治颅底颈椎脊索瘤１２例，其中颅底１０例，颈椎２例，男性８例，全组平均年龄３８．７岁，所有病例均行术后＾６０Ｃｏ放射治疗，颅底，颈椎平均剂量分别是５２．２Ｇｙ／５．５周和４０Ｇｙ／４～５周，４例行肉眼肿瘤全部切除术，６例肿瘤不全切除人２例行活检疫坟术，５１０例生存率分别是４１．６％和２８．５％，９例治疗后复发（７５％）３例伴远处转移，复发是治疗失入的关键，远处转移少见，     

SKULL BASE SURGERY - A NEW CONCEPT IN REGIONAL SURGERY

Surgery of the skull base has evolved over the past 100 years. This anatomical area has been approached by neurosurgeons, otologists, maxillofacial surgeons and plastic surgeons from different angles. Presently, the combined skills of these surgeons are utilized in treating lesions of this area once considered a ‘bony no man''s land’. Modern microsurgical techniques are based on the principle that removal of adequate bone from the cranial base could provide sufficient access without the necessity to retract dura. Accurate preoperative assessment by imaging, the use of microsurgical techniques, preservation of vital structures such as nerves by intraoperative monitoring, and modern anaesthetic and postoperative management have all contributed to the reduction in mortality and morbidity to acceptable levels. In the future, with refinements in imaging, stereotactic radiosurgery and chemotherapy, the above management protocol would be tailored to suit each individual patient and decided by a team of experts.KEY WORDS: Cranial fossa posterior, Craniotomy, Neuroma acoustic, Neurosurgery, Skull base, SurgerySurgery of the skull base was always considered to be difficult due to the complex anatomy of this region. The involvement of many vital structures in diseases affecting this area as well as the possibility of damage to these structures prevented surgeons from operating and it was labelled as a surgical ‘no man''s land’. Surgery of the skull base is an area where the combined skills of the neurosurgeon, otorhinolaryngologist and the reconstructive surgeon may be necessary to treat a patient adequately and safely [1]. Skull base surgery has undergone extraordinary development thanks to the pioneering effort of eminent specialists who had the foresight, single-mindedness and dedication to tackle the almost unsurmountable problems confronting them at the time. It is worth remembering pioneers such as Sir Charles Ballance who, in 1894, was the first to perform excision of an acoustic neuroma, and Cushing and Dandy who introduced silver haemostatic clips and electrocautery which helped in reducing the operative mortality to around 20 per cent [2, 3]. Despite this, leading neurosurgeons like Pennybacker and Cairnes felt that it may be unwise to operate on patients with skull base lesions because the patient may end up with more disability after surgery than before [4].The contemporary era of skull base surgery began in the early 1960''s when William House, considered the father of neuro-otology, decided to challenge the status quo. Thanks to refinements in audiological tests and radiological investigations he was able to diagnose these lesions early. He felt that a transtemporal approach to the posterior cranial fossa would be considerably safer and introduced 2 approaches – middle fossa and translabyrinthine approaches – to the cerebellopontine angle. He also introduced the microscope in neurosurgery which resulted in safe operations in areas previously considered to be hazardous. Thus, House succeeded in reducing the operative mortality for acoustic tumour surgery to less than 1 per cent [5].The various approaches to the skull base can be considered under approaches to the anterior, middle and posterior cranial skull base.Obwegeser and Tessier were responsible for expanding the extent of anterior extracranial access. Modern cranio-maxillofacial surgical techniques were initially applied for the correction of major congenital skeletal deformities in 1957 by Dr Paul Tessier [6]. Later, he applied these techniques to correct late traumatic deformities. He demonstrated that performing selective osteotomies at specific points in the skull and repositioning the cranial bones was possible with excellent cosmetic and functional results. It was a decade later that these principles were applied in the resection of tumours of the orbit and paranasal sinuses extending into the anterior skull base. Transsphenoidal approach to the pituitary fossa for removal of pituitary tumours has evolved rapidly and is now the procedure of choice in microadenomas, its greatest advantage being the reduced morbidity when compared to the transfrontal approach [6, 7, 8, 9]. Large tumours of the pituitary are resected using a combined transfrontal and transsphenoidal approach. At present anterior skull base approaches are used to treat fractures of the anterior cranial base, CSF rhinorrhoea, exophthalmos, inflammatory diseases of the frontal, ethmoidal and sphenoidal sinuses extending intracranially, and tumours of paranasal sinuses as in craniofacial resection.The middle cranial fossa approach described by William House is used for removal of small intra-canalicular acoustic neuromas less than 1 cm in size [5]. It is also used in performing vestibular neurectomy for Meniere''s disease. The infratemporal fossa was explored by Ugo Fisch, another famous neuro-otologist. Using microsurgical techniques, he was guided by the principle that removal of adequate amounts of bone from the skull base could provide sufficient access without the necessity of retracting the dura. The facial nerve, which traversed the operative field, could be repositioned and adequate exposure of the infratemporal course of the carotid artery could be obtained. The infratemporal fossa approach of Fisch is of three types – Type A, B and C. These give access to the entire lateral skull base from the nasopharyngeal roof, clivus, the jugular bulb, internal carotid artery and the last 5 cranial nerves. Type A provides access along the infratemporal course of the internal carotid artery and to the jugular foramen. Type B and C approaches provide anterior exposure of the lateral skull base especially to the clivus and nasopharyngeal roof. Type A and B approaches are useful in subtotal petrosectomy for extensive cholesteatoma of the petrous temporal bone, removal of glomus jugulare tumours, aneurysms of the carotid artery, high parapharyngeal tumours and malignant tumours of the middle ear cleft involving the petrous temporal bone. The type C approach provides access to the roof of the nasopharynx and the clivus for removal of tumours such as chordomas and recurrent nasopharyngeal carcinomas. These approaches, though time consuming, are safe as all the vital structures are identified and preserved while the morbidity is reduced due to minimal retraction of the brain [10, 11, 12, 13].The posterior cranial fossa was traditionally explored by the suboccipital route. This approach, though fast and relatively easy, was associated with increased morbidity due to cerebellar retraction and damage to the facial and other lower cranial nerves. To overcome this problem House had introduced the translabyrinthine approach where the morbidity was much less [5]. Modifications of this basic approach continue to evolve. Fisch described the transotic approach which gives a wider exposure when combined with the translabyrinthine approach [14]. Retrosigmoid and retromastoid approaches give wider exposure. As a result bigger tumours, up to 4 cm in size, can be resected in toto while preserving vital structures such as the facial nerve. Efforts to preserve cranial nerves was initiated by Krause in 1898 who was the first to identify the facial nerve by Faradic stimulation. Routine intraoperative nerve monitoring is now the standard practice during skull base procedures [15, 16, 17]. The contemporary monitoring systems are generally based on evoked electromyographic methods. This has resulted in better localization and preservation of function of the cranial nerves [18, 19, 20].Advances in allied specialities have also contributed to the evolution of skull base surgery and resulted in improved treatment outcome besides reducing mortality and morbidity. Improvements in diagnostic imaging especially the invention of the computerized tomographic scan, high resolution computerized tomographic scan and magnetic resonance imaging have enabled clinicians to diagnose skull base lesions early and devise simpler and less destructive operations to excise them [21, 22]. The development of interventional radiology, especially digital subtraction angiography with superselective embolization of the tumour vasculature is invaluable while operating on highly vascular tumours such as juvenile nasopharyngeal angiofibromas. Anaesthetic techniques have also improved, notably the technique of hypotensive anaesthesia and monitoring of vital parameters during these long procedures. This has resulted in minimal intraoperative mortality and reduction in postoperative morbidity.The development of stereotactic radiosurgery for the treatment of tumours of the skull base was viewed as a threat to skull base surgery. However the former is still in its infancy and the initial results, though encouraging, have not stood the test of time. The delayed complications are also many. Instead of replacing skull base surgery it may prove to be an alternative in poor-risk patients unable to withstand surgery and in patients with bilateral skull base lesions [23, 24]. In future the management of skull base lesions will be tailored to suit the individual patient and the decision will be taken by a multidisciplinary team of skull base surgeons and their associates such as radiotherapists and chemotherapists. With this approach it would be possible to deliver the best treatment to the patient with minimal morbidity. Truly an exciting field for those who are dedicated!     

24例外伤性脑脊液鼻漏的经颅手术治疗疗效分析

目的 探讨外伤性脑脊液鼻漏的经颅手术治疗效果。方法 回顾性分析24例外伤性脑脊液鼻漏患者临床资料。术前均行三维CT及MRI检查,已确定漏口所在位置,并行手术治疗。明确漏口且外置靠前的20例患者应用硬膜外入路手术;4例术前漏口未能明确或靠后者,采用硬膜下入路手术。对术前未能确定漏口及确定漏口靠后者,采用硬膜下入路将硬膜打开,探查颅底骨折及漏口所在。探及漏口后仔细分离、冲洗,对有脑组织或硬脑膜、蛛网膜疝入者,予以回纳,不能回纳者切除。结果 24例患者经一次手术全部治愈,随访患者21例,平均随访2年,无一例复发,无手术后并发症。结论 在闭合性颅脑损伤患者中,脑脊液漏的发生率为2.0%～20.8%;而在开放性颅脑损伤的患者中,脑脊液漏的发生率为7%～10%,其中80%左右为脑脊液鼻漏。脑脊液鼻漏典型的临床表现为清水样鼻漏,鼻漏的量随漏口的大小及形态不等,也可随体位改变。脑脊液鼻漏诊断的难点并不在于定性,而在于定位寻找脑脊液从何处流出,如何准确地定位漏口的位置是手术成功的关键,因此确定漏口是术前准备中的一项最重要工作,是手术成功关键因素,也消除了阴性探查的机会。外伤性脑脊液鼻漏患者经颅手术修补漏口,手术安全,并发症少,疗效满意。     

颅底及近颅底肿瘤手术入路(附126例报告)

目的探讨颅底及近颅底肿瘤切除的最佳手术入路.方法颅底及近颅底肿瘤患者126例,手术采用上、下颌外旋入路分别为13、17例耳后C型切口、经颈、颅面联合入路分别为16、48、6例;上颌骨截除术5例;鼻侧切开术5例;经腮、口、颈额、额眶入路分别为5、6、4、1例.结果89例良性肿瘤,2例复发经再次手术治愈;37例恶性肿瘤中,术后存活不足1年者4例,1年、2年、3年、5年以上者分别为6、12、10、5例.结论上颌外旋适用于切除前、中颅底肿瘤;下颌外旋适用于切除咽旁间隙良性肿瘤;耳后C型切口入路适用于颞骨肿瘤;额眶入路适用于切除眶顶、蝶骨肿瘤.     

颅底肿瘤手术的入路与疗效观察

目的:探讨颅底肿瘤手术入路与治疗效果之间的关系。方法:回顾性分析18例颅底肿瘤患者采用不同入路的临床资料。其中良性肿瘤10例,恶性肿瘤8例。前中颅底肿瘤13例,侧颅底肿瘤5例。结果:18例患者经1～5年随访,良性肿瘤10例中9例无复发,1例带瘤生存。恶性肿瘤8例中,2例鼻咽癌分别随访1年1个月和2年,生存良好。余6例分别随访3年和5年,3、5年生存率分别为50％(3/6),33.3％(1/3)。死亡原因是局部复发、肺部转移,颅内侵犯。结论:根据颅底肿瘤的大小、位置及性质选择最佳的手术入路,既能充分暴露和切除肿瘤,又能保护重要的解剖结构,减少或防止术后并发症。