颞骨显微外科技术培训模式研究

目的分析总结颞骨显微外科技术培训课程,检验培训效果,探讨耳显微外科医生外科技术培养模式。方法采用问卷方式收集2013年6月到2014年6月期间北京协和医院耳显微外科技术研修班3期共35位学员信息,调查分析学员参加完学习班后于所在医院按照研修班技术开展手术的情况、遇到的障碍、对研修班教学特点的评价等。结果 35位学员中,副高级以上职称54.29%(19/35),主治医师及以下45.71%(16/35),其中博士、硕士、本科及大专学历分别为34.29%、17.14%、40.00%及8.57%,所在科室医生人数大于15人者为54.29%(16/35),小于等于15人者45.71%(19/35);参加学习班后开展手术的学员比例为65.71%(23/35),未开展手术学员比例34.29%(12/35);学员普遍认为课前讲解分步教学、结合实际手术讨论、操作导师实时指导、良好的器械设备是颞骨显微外科技术培训成功的重要因素。结论颞骨显微外科技术的培训应以临床应用为目的,课前讲解分步教学、结合实际手术讨论、操作导师实时指导、良好的器械设备是高效有益的颞骨显微外科技术培训成功的重要因素。     

乳突根治术后复发的原因及再手术原因分析

目的　探讨首次乳突根治术后复发的因素及再次根治术的临床要点。方法　分析23例（23耳）行乳突再根治手术患者的门诊和住院资料,再次行根治术前的乳突CT、术式、术中情况、术后内镜及听力学检查,统计分析手术前、后气导平均言语听阈等。结果　23例患者,术中无胆脂瘤者10例,有胆脂瘤者13例,选择手术方式不正确占17.39%（4/23）,病灶残留、清除不彻底者占78.26%（18/23）,术腔引流不畅者占82.61%（19/23）,咽鼓管鼓口存在病变者占34.78%（8/23）。再次根治手术行改良乳突根治术+Ⅱ型鼓室成形术+耳甲腔成形术10耳（43.48%）,改良乳突根治术+Ⅱ型鼓室成形术2耳（8.70%）,改良乳突根治术+Ⅲ型鼓室成形术+耳甲腔成形术8耳（34.78%）,改良乳突根治术+Ⅲ型鼓室成形术+外耳道后壁重建术1耳（4.35%）,乳突根治术2耳 （8.70%）。术后术腔抗生素纱条填塞14 d,持续消炎治疗1周,嘱患者滴耳、定期返院换药等综合治疗。术后5～9周干耳,平均干耳时间7周。手术后23耳均干耳,无再次复发,术腔恢复良好,术后随访1年,21耳（91.30%）行鼓室成形术,术后鼓膜未再出现穿孔、流脓液等症状,且术后3个月的气导平均言语听阈、骨气导差均低于术前水平,两者差异均具有统计学意义（P<0.05）。结论　仔细的术前CT阅片、耳内镜及听力学评估、手术者扎实的耳显微外科基本功、术式的选择、病灶残留、术腔引流不畅、咽鼓管病变等均是乳突根治术后复发因素,如行再次手术时,应当充分认识复发原因,制定正确的手术方案以达到干耳目的。     

钛网应用于开放式鼓室成形术32例

目的 探讨应用钛网重建外耳道后壁并上鼓室外侧壁开放式鼓室成形术中的手术疗效。方法 胆脂瘤型及骨疡型中耳炎患者32例（32耳）根治病灶后,均应用钛网重建外耳道后壁并上鼓室外侧壁,同期行开放式鼓室成形术。结果 术后30耳外耳道形态接近正常生理状态,29耳鼓膜移植物生长良好,干耳率90.62%,干耳时间平均（15.89±4.02）d。术后气导听力提高在15dBHL以上者27耳,区骨导差＜20dBHL者22耳。结论 应用钛网重建外耳道后壁并上鼓室外侧壁的开放式鼓室成形术,可较好地恢复外耳道和中耳的解剖结构和生理功能,患者听力提高远期效果显著。     

胆脂瘤中耳炎术中应用不同材料外耳道壁重建临床疗效观察

目的观察在胆脂瘤中耳炎低壁式乳突切开术中,应用不同材料行外耳道修复重建的临床疗效,达到提高听力和避免复发的目的。方法对94例（94耳）胆脂瘤中耳炎病人,分别用带蒂颞肌骨片及同种异体鼻中隔软骨,于低壁式鼓室成形术中行外耳道壁修复重建术,其中应用带蒂颞肌骨片53例（耳）,同种异体鼻中隔软骨41例（耳）。结果所有重建的外耳道壁基本接近正常生理形态,无外耳道闭锁或塌陷。术后1.5-2.5月左右移植筋膜表面基本鳞状上皮化,并保持干耳。术后听力骨片组骨气导差平均20.86dBHL,其中〈20dB25耳,20-30dB19耳,〉30dB9耳,术后骨气导差缩小在10dB以上者42例（占79.25%）;软骨组骨气导差平均21.23dBHL,其中〈20dB21耳,20-30dB14耳,〉30dB6耳,术后骨气导差缩小在10dB以上者33例（占80.49%）。组间分析χ2=0.221,P〉0.05,临床疗效差异无显著性。结论利用带蒂颞肌骨片及库存同种异体鼻中隔软骨修复重建外耳道,两者均取材方便、血运良好,不易坏死及萎缩,术后能保持良好的外耳道形态,且疗效肯定。     

路向何方——试论耳显微外科的发展

从普鲁士帝国的军医用骨凿敲开乳突骨质,挽救了急性乳突炎战士的生命时起,耳外科经历了使用自然光、头灯照明,以骨凿、刮匙、放大镜为工具的漫长岁月,使手术目的由救命、实现干耳转变为保存与重建听功能.上个世纪30年代,国际耳科学的先驱们利用手术显微镜这一视线与光轴重叠,并能释放术者头颈和双手的良好工具,开创了耳显微外科领域的新纪元,听力重建成为耳显微外科的主要目的与追求,术后听力好坏成为鉴定手术成效的主要标志.     

鼓室成形术的有关问题

近一个多世纪以来，围绕着听力重建这个主题，耳显微外科得到了长足的发展。在切除病变的基础上，保存、恢复和提高听力已成为耳科医师的共识。历史上对传导性聋手术疗法的尝试始于1640年，Marcus Bancer是首例鼓膜成形术的术者；1876年报道了耳硬化症的镫骨切除术，1901年有人偿试对听小骨缺失的患者在鼓膜和前庭窗之间重建连接。但由于技术、设备及抗生素等条件的限制，成功病例甚少。抗生素、手术显微镜以及听觉生理学理论的发展大大提高了耳显微外科手术的水平。1952年Wullstein和Zollner提出了围绕听骨链重建（ossicular chain reconstruction，OCR）为中心的鼓室成形术的分类方法，奠定了耳显微外科及传导性聋听力重建手术的基础。特别是近20年来，随着临床听力学及新材料、新技术的应用，鼓室成形术得到不断的发展和完善。     

螺旋CT多平面重建在先天性小耳畸形外耳道及中耳成形术中的应用

目的探讨螺旋CT多平面重建(multi-plane reconstruction,MPR)在对先天性小耳畸形进行外耳道及中耳成形术时的应用价值。方法回顾分析32耳先天性小耳畸形外耳道闭锁患者(均为Schuknecht分型之C型)的资料。采用螺旋CT行HRCT(High resolution CT,高分辨率CT)容积扫描,获取标准横断位及冠状位图像,并利用扫描原始数据作斜横断位、斜矢状位重建,使重建平面同时包含筛区和听小骨,通过横断位及冠状位CT图像确定面神经走行和听小骨形态,通过MPR确定外耳道成形的角度和深度。术中参照上述检查结果进行手术操作。将上述32耳与另外41耳(也为Schuknecht分型之C型)未行MPR者就以下两点进行比较:(1)寻找中耳的成功率;(2)两组病例中术式相同者(均为Ⅰ期外耳道及中耳成形加耳廓重建)的手术时间。结果 (1)行MPR检查的32耳中,29耳顺利找到中耳(90.6%),由于乳突气化不良、面神经畸形等因素,未能寻找到中耳者3耳(9.4%);而在未行MPR者41耳中,28耳顺利找到中耳(68.3%),未能找到中耳者13耳(31.7%)。经卡方检验两组差异具有显著性。(2)采用MPR者平均手术时间为(342.75±41.70)min(n=28),未采用MPR者平均手术时间为(398.48±61.02)min(n=23),经t检验二者差异具有显著性。结论应用螺旋CT多平面重建技术,可以在一次采取数据后,在任意平面重建真实影像,为外耳道和中耳成术形提供正确的角度和深度参考数据,对提高手术成功率,缩短手术时间具有重要价值。     

人工钛质听骨重建听骨链的疗效观察

目的观察用人工钛质听骨重建听骨链的疗效.方法用钛质听骨重建听骨链60例、65耳,并随访10～24月.结果听力提高＞10dB HL者58耳(89.2%),气骨导闭合＜20dB HL者37耳(56.9%),听力达应用水平45耳(69.2%).结论听骨链重建应用人工钛质听骨,生物相容性和组织亲合性好,无毒性,耐腐蚀,重量轻,与镫骨连接牢固,不易脱位,术后听力提高幅度大,疗效显著.     

高分辨率CT容积重建对内耳畸形的诊断价值

目的：通过高分辨率CT（HRCT）容积重建（VR）对正常内耳形态的观察，探讨其对先天性内耳畸形的诊断价值。方法：对10例（20耳）无耳部疾患者（对照组）和7例（11耳）先天性内耳畸形患者（病变组）行HRCT扫描，利用容积漫游技术对内耳骨迷路重建。对照组观察内耳骨迷路的正常结构，病变组观察内耳畸形情况。结果：正常耳VR图像不但显示了内耳骨迷路的细微结构，而且还反映了各结构之间的关系；病变耳立体显示了畸形部位及程度。11耳患耳中Mondini型7耳次；前庭及半规管畸形3耳次；前庭导水管扩大7耳次，其中6耳次伴随其他畸形；内耳道畸形2耳次且均伴随其他畸形。11耳畸形中9耳HRCT横断面图像和平面重建（MPR）冠状位图像、VR图像均可以清晰地显示畸形的部位和程度，其中VR图像可以直观、立体地显示畸形的空间形态结构；2耳水平半规管短小畸形患者VR图像较断面图像更好地显示了畸形的部位和程度。结论：VR三维重建可以立体显示正常内耳骨迷路的形态，直观显示内耳畸形的程度及病变位置，对内耳畸形的诊断具有重要的辅助价值。     

比较不同材料人工听骨听力重建术

目的探讨中耳炎手术I期听骨链重建的合适材料和术式。方法 2005年10月～2008年10月在北京同仁医院耳鼻咽喉头颈外科住院手术治疗慢性化脓性中耳炎480耳作为研究对象,回顾性分析480例（耳）慢性化脓性中耳炎患者的听骨链重建手术所见及术后效果。对听骨链重建术效果的影响因素进行分析讨论。对慢性化脓性中耳炎患者的患病时间以及纯音听力测试手术前、后骨气导差进行比较。480例患者的手术方式有3种：开放式听骨链重建术、联合进路听骨链重建术和鼓室探查听骨链重建术。结果 3种手术方式术后听力效果无显著差异。按不同重建方式及不同听骨材料进行分类,镫骨完整病例的术后骨气导差≤20dB者中,钛金属听小骨占33%,自体听骨占30%,陶瓷骨占20%;术后骨气导差21～30dB者中,钛金属听小骨占59%,自体听骨占59%,陶瓷骨占37%。镫骨上部不完整的病例中,术后骨气导差≤20dB者中,钛金属听小骨占25%,自体听骨占13%,陶瓷骨占11%。术后骨气导差在21～30dB者中,钛金属听小骨占48%,自体听骨占47%,陶瓷骨占43%。结论手术方式对术后效果无影响,不同听骨材料及不同植入方式对听力效果有影响。     

Stereoscopic display of a three-dimensional image of the larynx using high-speed helical scanning

To evaluate the usefulness of stereoscopic images of larynges using helical CT in stereo mode, a retrospective review of the characteristics of stereoscopic viewing of larynges was made. The subjects were 3 patients with laryngeal cancer, 1 patient with laryngeal leiomyosarcoma and 1 patient with an advanced tongue carcinoma whose formalin-fixed larynx was extirpated. The larynges were scanned by high-speed helical CT using 1- to 2-mm slices. The reproduction of stereographic images was performed by the manipulation and rotation of three-dimensional structures around the y-axis on the computer display. The three-dimensional images of the complex structures, such as the arytenoid cartilage, aryepiglottic fold and pyriform sinus, were better observed by binocular images (stereograms) than by monocular images. Stereoscopic views of the larynx are useful in producing three-dimensional images of the unseen inner surface of the human body.     

Evaluation of inter‐observer variability in the grading of oral dysplasia using two different grading systems

Objectives. To compare the inter‐observer variability in grading of oral dysplasia between two consultant pathologists specialising in head and neck cancer, and one non‐specialist, using both the WHO classification 2005 and the Binary Grading system (proposed by Kujan et al. 2005). Methods. Eighty archived oral biopsy slides consisting of cases with different grades of dysplasia treated and followed up in a tertiary regional centre, were reviewed by three pathologists, blinded to the initial diagnosis and the clinical outcome. The H&E slides were graded according to the criteria of both systems. Inter‐observer reliability and variation were computed with kappa coefficient analysis. Results. The overall inter‐observer kappa agreement for the WHO grading system was κ = 0.21(95% CI: 0.10–0.34) and for the binary system was κ = 0.55(95% CI: 0.42–0.71). There was closer correlation in grading of the lesions between the two experts (WHO κ = 0.40, 95% CI: 0.28–0.53 and Binary κ = 0.59, 95% CI: 0.34–0.80), when compared to that between an expert and the non‐expert (WHO κ = 0.18 95% CI: 0.05–0.30 and Binary κ = 0.32 95% CI: 0.15–0.50) Kappa agreements between the three observers on individual architectural and cytological features of the binary system showed great variability, the highest agreement being in increased mitotic figures (κ = 0.49,95% CI: 0.25–0.72) and the lowest on atypical mitotic figures (κ = 0.15,95% CI: 0.01–0.32). Conclusions. There was closer agreement between all three pathologists when using the binary system in comparison to the WHO system, but both systems showed at best only moderate agreement. Improved agreement of scoring of individual features of the binary system should improve overall agreement of this system.     

Tricholemmal cysts of the head and neck.

PURPOSE: Tricholemmal cysts, sometimes termed pilomatrixomas, are benign skin neoplasms. This study was undertaken to evaluate the clinical experience with management of pilomatrixomas at a large, referral-based university hospital. PATIENTS AND METHODS: The records of patients treated at the UCLA Medical Center were reviewed retrospectively. Patients treated during the years 1966 to 1991 inclusive were reviewed for details of the clinical course. All pathology slides were confirmed histologically. RESULTS: Pilomatrixoma was confirmed in 53 patients. Of these, 29 patients (55%) had pilomatrixoma isolated to the head and neck region. All were treated with surgical excision. One patient (3%) experienced recurrence due to inadequate initial excision. Subsequent re-excision resulted in a cure. CONCLUSION: Tricholemmal cysts present as solitary, painless, slow-growing cutaneous nodules often resulting in discoloration of the overlying skin. Simple excision cures this benign neoplasm, and recurrences are rare. Fine-needle aspiration biopsy may aid in the diagnostic workup.     

Latent Membrane Protein-1 Oncogene Deletions in Nasopharyngeal Carcinoma in Caucasian Patients

Objective --The latent membrane protein-1 (LMP-1) is an Epstein-Barr virus (EBV)-transforming protein expressed in nasopharyngeal carcinoma (NPC). A 30-bp deletion in the LMP-1 oncogene has been described in NPC patients from Asia. The purpose of this study was to evaluate the association between NPC and such an EBV deletion in Caucasian patients. Material and Methods --Twenty-seven patients with a diagnosis of NPC were selected. Most of the NPCs were classified as Stages III and IV using the International Union Against Cancer system. Formalin-fixed, paraffin-embedded NPC specimens were found for these cases. Hematoxylin-eosin slides were reviewed and survival analysis was done using the log-rank method. In situ hybridization for EBV-encoded non-polyadenylated RNAs and expression of LMP-1 by means of immunohistochemistry was also performed. Polymerase chain reaction for LMP-1 oncogene analysis was performed to detect the presence of a 30-bp deletion in NPC specimens and EBV-related controls. Results --The 30-bp deletion was identified in 67% of NPC cases and in 30% of controls, a statistically significant difference (p = 0.01, χ² test). LMP-1 deletion was not statistically associated with a worse prognosis in NPC patients (5-year survival: 33% in wild-LMP-1 strains vs 24% in deleted-LMP-1 strains; p = 0.053, log-rank test). Conclusion --A 30-bp deletion in the LMP-1 oncogene is present in more than half of Caucasian NPC cases EBV carrying partial deletions in the LMP-1 oncogene may play a role in the pathogenesis of NPC in Caucasian patients.     

Free flap head and neck microsurgery with VITOMⓇ 3D: Surgical outcomes and surgeon's perspective

ObjectiveTo report on the application of the 3D exoscopic system to microsurgery in a cohort of head and neck cancer patients; to analyse the performance of microvascular anastomoses, flap harvesting and insetting under exoscopic view and to evaluate the surgeon's feedback after procedures.MethodsAn observational study was performed on 10 consecutive patients undergoing exoscopic microsurgical free flap reconstruction. The VITOM^? 3D system was applied to all procedures for microsurgical anastomoses, flap harvesting and insetting. Data about the type of resection and reconstruction, intraoperative and post-operative complications were recorded. Surgeon's feedback on exoscopic experience was collected through a questionnaire.ResultsReconstruction after oncologic demolition was performed by radial forearm flap in 3 cases (30%), antero-lateral thigh flap in 4 cases (40%), composite fibula flap in 2 cases (20%) and chimeric scapula flap in 1 case (10%). The mean surgical time for the microsurgical anastomoses (1 vein and 1 artery) was 34 min (range: 32–38). No intraoperative complications occurred and only two patients experienced pharyngo-cutaneous fistula in the post-operative time. There were neither cases of loss of flap, nor need of surgical revision. None of the cases had to be converted to OM technique. The surgeon never experienced back/neck pain, headache and nausea/vertigo. Occasionally, he felt tired and stressed and he reported eyestrain after one procedure only.ConclusionsVITOM^? 3D is easy to apply in the field of head and neck microsurgery and provides optimal stereoscopic view and anatomical details. Further studies are needed to validate indications and advantages of 3D exoscope as compared to OM.     

鼠尾胶原为底物的人鼻腔纤毛上皮细胞培养模式的建立

目的 建立以鼠尾胶原为贴附底物的人鼻腔纤毛上皮细胞的体外培养模式,为人鼻腔黏液纤毛运输系统的研究提供科学有效的方法.方法 制备鼠尾胶原并铺片,以鼠尾胶原为贴附底物组织块培养法培养人鼻腔纤毛上皮细胞,培养7天时进行HE染色及扫描电镜和透射电镜观察细胞形态和结构,应用高速摄像技术测量纤毛摆动频率.结果 鼠尾胶原要平坦均匀,平均厚度约为1 mm;HE染色可见上皮细胞呈单层向周围爬开;扫描电镜下见纤毛上皮细胞呈不规则多角形,纤毛周围可见微绒毛;透射电镜下可见纤毛上皮细胞间为紧密连接;同一细胞任意两点纤毛摆动频率是相同的;同一来源体外培养的钩突和下鼻甲的纤毛摆动频率是相同的.结论 以鼠尾胶原为贴附底物人鼻腔纤毛上皮细胞的体外培养模式的成功建立,为今后研究鼻内用药对纤毛清除功能的影响提供了良好的方法和途径.     

Latent membrane protein-1 oncogene deletions in nasopharyngeal carcinoma in Caucasian patients

OBJECTIVE: The latent membrane protein-1 (LMP-1) is an Epstein-Barr virus (EBV)-transforming protein expressed in nasopharyngeal carcinoma (NPC). A 30-bp deletion in the LMP-1 oncogene has been described in NPC patients from Asia. The purpose of this study was to evaluate the association between NPC and such an EBV deletion in Caucasian patients. MATERIAL AND METHODS: Twenty-seven patients with a diagnosis of NPC were selected. Most of the NPCs were classified as Stages III and IV using the International Union Against Cancer system. Formalin-fixed, paraffin-embedded NPC specimens were found for these cases. Hematoxylin-eosin slides were reviewed and survival analysis was done using the log-rank method. In situ hybridization for EBV-encoded non-polyadenylated RNAs and expression of LMP-1 by means of immunohistochemistry was also performed. Polymerase chain reaction for LMP-1 oncogene analysis was performed to detect the presence of a 30-bp deletion in NPC specimens and EBV-related controls RESULTS: The 30-bp deletion was identified in 67% of NPC cases and in 30% of controls, a statistically significant difference (p = 0.01, chi2 test). LMP-1 deletion was not statistically associated with a worse prognosis in NPC patients (5-year survival: 33% in wild-LMP-1 strains vs 24% in deleted-LMP-1 strains; p = 0.053, log-rank test). CONCLUSION: A 30-bp deletion in the LMP-1 oncogene is present in more than half of Caucasian NPC cases EBV carrying partial deletions in the LMP-1 oncogene may play a role in the pathogenesis of NPC in Caucasian patients.     

Combined use of histopathology with touch smear cytology in biopsies of the larynx

The aim of this prospective study is to evaluate the effectiveness of combined use of histopathology with cytology in biopsies of the larynx. Biopsies taken for this purpose are studied by using two different methods and the results are evaluated. One hundred and thirty-five patients with suspected malignant laryngeal lesions were examined by direct microlaryngoscopy for primary diagnosis. Each lesion was biopsied first. Subsequently touch smear cytology was obtained from the biopsies. In all cases, cytologic slides (one or two per biopsy) were screened and compared to corresponding biopsies. Lesions were categorized as benign, laryngeal intraepithelial neoplasia and malignant. Results obtained were compared with surgical samples obtained from patients who have undergone surgery. In other cases, where surgery was not applied, results of the follow-up were evaluated. In larynx biopsies the results for histopathology were as follows: sensitivity 93.9%, specificity 100% and accuracy 96.3%. The results for cytology were as follows: sensitivity 82.5%, specificity 94.5% and accuracy 87.4%. A comparison of cytologic evaluation versus histopathologic evaluation in laryngeal biopsies reveals that histopathology is superior. According to the study results, in 88.9% (120/135) of the cases the agreement between cytological and histopathological results was found. In two other cases (1.5%) cytologic evaluation contributed to the histopathologic diagnosis.     

Three-dimensional reconstruction of the temporal bone from histologic sections

To increase understanding of the stereoscopic anatomy of the temporal bone, we have developed a computer system for three-dimensional reconstruction of the temporal bone from human histologic sections. The results were satisfactory for reconstructing details of complicated temporal bone structures. This system is equipped with such functions that it is possible to observe the reconstructed structures from an arbitrary direction, and to investigate their internal aspects by cutting and drilling. Three-dimensional reconstruction by this method is useful not only in understanding the fundamental anatomy and stereoscopic relationship of various parts of the temporal bone, but also in simulating temporal bone surgery on reconstructed three-dimensional images.     

弱视遮盖治疗对屈光度和立体视的影响

目的研究主眼遮盖对弱视儿童屈光度和立体视的影响。方法动态分析经主眼遮盖法基本治愈的弱视62例治疗前后双眼屈光度和立体视的变化。结果62例患儿平均遮盖主眼2.5±1.7年后,视力＞0.8,基本治愈;治疗后双眼球镜度均较治疗前下降,未遮盖眼下降更明显;双眼柱镜度无显著变化,立体视功能改善与治疗前差异有显著性。结论对弱视儿童主眼进行遮盖,未加速被遮盖眼的近视化,适当的遮盖治疗不会对立体视发育造成显著影响。