经迷路进路听神经瘤术后脑脊液漏的预防及处理

目的 探讨经迷路进路听神经瘤切除术后脑脊液漏发生的影响因素及处理方法。方法1999年以来采用迷路进路或扩大迷路进路听神经瘤切除术85例，前41例采用传统关闭术腔技术，后44例对关闭技术进行改良，分析其脑脊液漏的发生率。发生脑脊液漏者行保守或手术治疗。结果 传统关闭技术组中脑脊液漏的发生率为19．5％(8／41)，改良关闭技术组中脑脊液漏的发生率为2．3％(1／44)，两组差异有显著性意义(P=0．013)。传统关闭技术组中脑脊液漏多数发生在大型听神经瘤中，其发生率随肿瘤增大有上升的趋势。9例脑脊液漏的患者中，3例经保守治疗；6例经手术修补成功，其中5例1次修补成功。结论 改良关闭术腔技术可显著降低经迷路进路听神经瘤切除术后脑脊液漏的发生率，手术修补为终止脑脊液漏的有效措施。     

颅后窝进路听神经瘤切除术

近年来,听神经瘤切除术均由颅后窝、迷路和颅中窝三途径进入手术。各途径均有其优缺点。经内耳道听神经瘤切除(DiTullio等),易识别面神经内耳道段。颅后窝进入,可早期定位面神经。颅后窝和经迷路联合进路(Glasscock)则能保留乙状窦,且可较好地暴露脑干,适于大听神经瘤切除。颅中窝进入用于内耳道内的小听神经瘤,术后可能保存听力。作者自1978至1980年间,取半坐位经颅后窝进路先后进行了74例听神经瘤切除术。无一例死亡,并发症亦少。其中脑脊液耳、鼻漏7例。脑膜炎3例和术后出血2例。术后无脑干梗塞形成。74例患者中,73例均一次手术切除肿瘤。1     

并发慢性中耳乳突炎的大听神经瘤经扩大迷路进路二期手术切除

目的：探讨经扩大迷路进路摘除伴发慢性中耳乳突炎的大听神经瘤的手术方法。方法：先一期手术彻底清除鼓室乳突病灶，术毕封闭中耳乳突腔；2周后行二期手术，经一期径路进行听神经瘤切除术。结果：2例并发慢性中耳炎的大听神经瘤均得到全切，术后面神经功能正常，切口一期愈合。随访半年以上无感染发生。结论：并发慢性中耳乳突炎的大听神经瘤同样可经扩大迷路进路进行手术切除。     

大型听神经瘤迷路径路手术中外耳道及鼓室的处理

目的讨论大型听神经瘤迷路径路手术中外耳道及鼓室的处理方法。方法对115例经迷路径路切除大型听神经瘤的临床病例资料进行总结,分析外耳道和鼓室的处理方法,其中96例术中保留外耳道后壁,19例术中切除外耳道并填塞中耳。结果 115例大型听神经瘤均采用迷路径路,肿瘤全切除103例(89.6%),近全切除9例(7.8%),次全切除3例(2.6%);术后脑脊液漏8例,发生率7.0%。结论通过迷路径路切除大型听神经瘤能取得良好的手术效果,术中外耳道和鼓室的正确处理能够获得良好的手术显露,并能够有效的降低脑脊液漏的发生率。     

纤维蛋白胶用于颅内手术初步效果

颅内手术有可能发生脑脊液漏,常用肌肉、脂肪块填塞,自体硬脑膜、筋膜和缝合封漏。作者介绍自体纤维蛋白胶(AFG)应用可减少漏的发生。颅内手术8例(听神经瘤4,囊性腺癌1例,听神经瘤修复术后切口脑脊液漏1,颅前窝脑膨出1,乳突术腔脑膨出1)AFG 应用,经一年多随访无漏发生。AFG 包括组     

前庭神经鞘膜瘤术后乘坐飞机诱发脑膜炎

前庭神经鞘膜瘤（听神经瘤）的手术途径有四种：l。经迷路八路；2．经枕下八路；3．经颅中窝入路；4经迷路和依中窝联合入路。术后脑脊液漏的发生率11～27％，并发脑膜炎的发生率为2～7％。前庭神经鞘膜瘤经迷路八路切除术后不久，病人出院乘飞机回家途中发生急性细菌性脑膜炎的病例尚未见报道，作者报道2例如下。例1，男，40岁，经迷路切除左侧前庭神经鞘膜瘤。术后并发CSF鼻漏，后来自愈，未发生脑膜炎。出院时从伦敦飞抵爱丁堡着陆过程中，患者诉头痛。住院后测体温38．SC，颈部强直。CSF检查：WBCZ100，葡萄糖lmmol／L，涂片未见…     

经乳突颅外修补听神经瘤术后脑脊液漏

枕下进路或迷路进路听神经瘤切除术后可并发脑脊液耳漏或鼻漏,作者采用经乳突颅外修补。1980～1988年共做10例,术后两个月复查均无症状,迄今7例未复发、1例死于他病,2例失联系。术式:耳后切口延至胸锁乳突肌前缘,切口应避开前次手术切口,由正常的皮下组织“桥”将两术区隔开。如前次手术为后颅窝进路则需钻开乳突气房、暴露鼓窦和鼓窦入口,确认漏出部位在乳突气房抑或鼓窦入口,用骨蜡及骨粉混合物封住漏口。去掉砧     

巨大岩尖胆脂瘤诊治初探（附2例临床分析）

目的：探讨岩尖胆脂瘤的临床特征、手术进路和方法,以提高手术疗效,减少并发症。方法：对2例巨大颞骨岩尖胆脂瘤患者采用迷路进路切除病灶,对其中1例成功施行了耳内镜辅助下迷路进路病灶切除术。结果：2例术后均无脑脊液漏和感染,无眩晕或平衡失调。结论：颞骨CT扫描及MRI对临床诊断及手术进路的选择有重要作用。手术清除病灶为本病治疗的惟一措施,经迷路进路为彻底清除胆脂瘤、处理面神经及脑脊液漏提供了最直接的途径,而彻底清除病变和术后长期严格随访、定期清理术腔是预防复发的关键。     

经耳蜗进路修补难治性脑脊液漏

脑脊液漏是经颞骨进入颅内的耳神经外科手术和侧颅底手术的常见并发症 ,按常规方法封闭乳突和中耳术腔 ,少数难治性脑脊液漏病例不能最终控制 ,致脑膜炎反复发作。其中一部分病例可能与岩尖气房有关。该文报道 4例患者曾施行经枕下或经迷路进路切除颅内肿瘤后并发脑脊液漏 ,用脂肪组织封闭乳突、中耳、耳咽管无效 ,最后采用经耳蜗进路岩尖切除术 ,脑脊液漏完全治愈 ,最长随访时间 3年余无复发。该作者利用颞骨高分辨率 CT扫描及颞骨组织病理学观察方法对岩尖气房进行了研究。手术方法 :经原迷路进路或乳突根治术腔取出中耳、乳突内填塞的脂…     

听神经瘤手术的初步体会

目的探讨听神经瘤切除术的方法及效果。方法采用经迷路进路手术切除听神经瘤4例,经乙状窦后进路手术切除听神经瘤6例,对其临床资料进行回顾性分析。结果肿瘤全切除8例,次全切除1例,近全切除1例,面神经功能保留9例,术后短期并发症4例,无死亡病例。结论依据听力情况及肿瘤大小来决定手术进路,术中面神经监测、熟悉的解剖及良好的显微手术技巧是保证肿瘤全切、减少面神经损伤和并发症的关键。     

Reducing the risk of cerebrospinal fluid rhinorrhea following translabyrinthine surgery of the posterior fossa

ObjectiveTo describe the procedure and results of an adapted closure and reconstruction technique for translabyrinthine surgery that focuses on identifying and managing potential pathways for CSF egress to the middle ear and Eustachian tube.MethodsRetrospective review of a cohort of translabyrinthine acoustic neuroma cases that were reconstructed using this technique.ResultsIn addition to meticulous packing of potential conduits using soft tissue, hydroxyapatite cement is used to seal opened air cell tracts prior to obliteration of the mastoid defect using adipose tissue. Early results of a small patient cohort using this technique are encouraging and there were no wound infections. There was a single case of CSF rhinorrhea associated with incomplete sealing of opened petrous apex cells, with no recurrence after appropriate implementation of the described protocol during revision surgery.ConclusionProactive management of potential conduits of CSF egress including opened air cell tracts has a high likelihood of reducing rates of rhinorrhea and need for revision surgery after the translabyrinthine approach to the posterior fossa.     

Translabyrinthine and transotic surgery for acoustic neuroma

The results and complications of translabyrinthine and transotic surgery for petrous apex lesions between 1980 and 1992 are presented. An acoustic neuroma was found in 52 patients. In 1988, the translabyrinthine approach was modified into the transotic approach and replaced the former technique. There was no mortality in this series, but two patients had mild brainstem infarcts and there was post-operative bleeding into the cerebellopontine angle in one. Cerebrospinal fluid (CSF) leakage was seen in six patients and meningitis in two. Three suffered deep vein thrombosis in their legs. There was one case each of herniation of the cerebellum and gastric bleeding. Post-operative facial nerve function was good in 88%, moderate in 10% and poor in 2%. In the case of acoustic neuromas the aim was total tumour removal, but if there was a serious risk of damaging the nerve anatomically, near total or subtotal removal was performed. During the study period, there was a gradual decrease in facial nerve morbidity and surgical complications. This was attributed to increasing experience, the modified wider approach and better post-operative care.     

扩大迷路径路切除经枕下径路手术后复发的听神经瘤

目的：探讨听神经瘤经枕下径路手术后复发、后经扩大迷路径路再次切除肿瘤的方法及效果。方法：对5例复发的听神经瘤患者，采用扩大迷路径路手术，在经典迷路径路的基础上，通过充分切除岩骨骨质扩大手术视野，将复发的肿瘤组织完全切除。结果：5例听神经瘤直径为2．5～4．0cm，均全部切除，无死亡病例，未发生颅内感染及脑脊液漏；面神经功能与术前一致；术后CT和MRI复查均显示无肿瘤残存，小脑、脑干位置恢复正常。经0．5～2年7个月的随访，至今未见复发，患者已恢复正常生活和工作。结论：枕下径路手术容易残留内听道内的肿瘤，再次手术采用扩大迷路径路可直接暴露肿瘤并到达脑干，既可避免瘢痕粘连区，方便定位面神经，又能全部切除复发的肿瘤，且具有创伤小、面神经功能保存完好等优点。     

Prevention and treatment of cerebrospinal fluid leak after translabyrinthine acoustic tumor removal.

OBJECTIVE: To determine the incidence rate of cerebrospinal fluid (CSF) leak after translabyrinthine acoustic tumor removal using titanium mesh cranioplasty and to compare with previous series and historical controls. STUDY DESIGN: Database analysis with historical controls. SETTING: Tertiary referral neurotologic private practice. PATIENTS: The series of 389 patients who underwent titanium mesh cranioplasty after translabyrinthine tumor removal between March 2003 and July 2005. The results were compared with those in a group of 1,195 translabyrinthine tumor removal patients from our previously published series and with those in a group of 324 patients from the immediately preceding two-year period. INTERVENTION: Cranioplasty using titanium mesh after acoustic tumor removal. MAIN OUTCOME MEASURES: Rates of CSF leak for this method and previous methods of closure. RESULTS: Thirteen patients (3.3%) had CSF leaks when using the new method of titanium mesh closure. This compares with rates of 10.9% and 8.7% in series in which other methods of closure were used (p < 0.001 and 0.003). The rates of CSF leak requiring reoperation were 0.5%, 2.5%, and 1.9% for the new and the two older series, respectively. CONCLUSION: In our hands, titanium mesh cranioplasty seems to reduce the rate of CSF leaks after the translabyrinthine removal of acoustic tumors.     

Cerebrospinal fluid leak following acoustic neuroma removal

Cerebrospinal fluid (CSF) leak has been a constant and unresolved complication of acoustic tumor surgery. This study retrospectively reviews 381 primary acoustic tumor surgeries performed by a single, senior, neurotologist and neurosurgeon team from 1979 through 1991. There were 68 cerebrospinal fluid leaks in 66 patients (66/381; 17%). There was no significant difference in the incidence of CSF leak between the translabyrinthine group (21%) and the retrosigmoid transmeatal group (16%). Translabyrinthine leaks were evenly divided between rhinorrhea and the postauricular wound while retrosigmoid transmeatal leaks were predominantly rhinorrhea. Eleven of 14 translabyrinthine wound leaks responded to pressure dressing and suture. The remaining 3 ceased with continuous lumbar cerebrospinal fluid drainage. Ten of 14 cases of translabyrinthine rhinorrhea responded to continuous lumbar cerebrospinal fluid drainage, and those in whom it failed were cured with revision of the mastoidectomy/labyrinthectomy cavity. Twenty-one of 28 cases of retrosigmoid transmeatal rhinorrhea responded to continuous lumbar cerebrospinal fluid drainage, and those in whom it failed were cured with extracranial, transmastoid revision. The incidence of cerebrospinal fluid leak was not influenced by age, sex, size of tumor, postoperative hydrocephalus, or the intraoperative use of autologous fibrin glue. Meningitis was an unusual complication, occurring in 3% of all patients.     

Hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma surgery-update.

OBJECTIVE: To update the outcome of hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma (TLAN) surgery. PATIENTS: One hundred eight previously reported patients undergoing abdominal fat graft reconstruction versus hydroxyapatite cement cranioplasty with additional 4-year follow up. Ninety additional patients undergoing a uniform technique of hydroxyapatite cement cranioplasty after TLAN. INTERVENTION(S): After TLAN, strips of abdominal fat are placed through the dural opening and medial to the level of the mastoid antrum, filling the lateral mastoid cavity. MAIN OUTCOME MEASURE(S): Cerebrospinal fluid (CSF) leaks and wound complications. RESULTS: No additional CSF leaks or wound complications were identified in the patients included in the previous report. In the new series of 90 consecutive patients, there was one CSF leak. CONCLUSION: Hydroxyapatite cranioplasty is a reliable method to avoid CSF leaks after TLAN surgery.     

Adjunctive use of endoscopy during acoustic neuroma surgery.

OBJECTIVE/HYPOTHESIS: In specific clinical situations, endoscopes offer better visualization than the microscope during acoustic neuroma (vestibular schwannoma) surgery and can therefore decrease the incidence of the postoperative complications of cerebrospinal fluid (CSF) leakage and recurrence of tumor. This study was undertaken to determine if the use of adjunctive endoscopy provides complementary information to the operating surgeon during surgery for acoustic neuromas. METHOD: Seventy-eight patients with acoustic neuromas underwent tumor excision by two neurotologists (PAW., D.S.P.), together with their respective neurosurgical partners, via a retrosigmoid (suboccipital) approach (n = 68), translabyrinthine approach (n = 7), or middle cranial fossa approach (n = 3). Endoscopy with a rigid glass lens endoscope was used during tumor removal to examine posterior fossa neurovascular structures, and after tumor excision to inspect the internal auditory canal (IAC), inner ear, and middle ear, depending on the approach used. One of the authors (D.S.P.) has not used adjunctive endoscopy during resections via the translabyrinthine and middle cranial fossa approaches, and therefore, these cases were excluded from the data collection and analysis. RESULTS: Complete tumor excision was achieved in 73 patients. Endoscopy allowed improved identification of tumor and adjacent neurovascular relationships in all cases. In addition, residual tumor at the fundus of the IAC (n = 11) and exposed air cells (n = 24) not seen with the microscope during retrosigmoid approaches were identified endoscopically. In one of the translabyrinthine cases, the endoscope allowed identification of open air cells not visualized with the microscope. None of the 78 patients developed CSF rhinorrhea. Incorporating the endoscope did not significantly increase operative time. CONCLUSIONS: Endoscopy can be performed safely during surgery to remove acoustic neuromas. The adjunctive use of endoscopy may offer some advantages including improved visualization, more complete tumor removal, and a lowered risk of CSF leakage.     

Cerebrospinal fluid leak prevention after translabyrinthine removal of vestibular schwannoma

OBJECTIVES/HYPOTHESIS: The purpose of the report was to present an update on the authors' results for prevention and management of cerebrospinal fluid (CSF) leak after translabyrinthine approach for vestibular schwannoma. STUDY DESIGN:: Retrospective case review. METHODS: The study was conducted at Gruppo Otologico (Piacenza, Italy), a tertiary referral center for neurotology and skull base surgery. In all, 710 patients underwent translabyrinthine approach for the removal of vestibular schwannoma at that institution between April 1987 and December 2002. The medical records were retrospectively reviewed to identify tumor size, the incidence of postoperative CSF leak, and its treatment. RESULTS: The overall rate of CSF leak was 1.4%. CONCLUSION: The use of proper surgical technique minimizes the risk of CSF leak. Study results show that the continued application of the authors' proposed preventive measures resulted in the maintenance of a low rate of CSF leak. Immediate management of CSF fistulae helps prevent meningitis.     

Factors affecting the development of cerebrospinal fluid leak and meningitis after translabyrinthine acoustic tumor surgery

Meningitis and cerebrospinal fluid (CSF) leak are serious complications of acoustic tumor surgery. Previous reports have varied in the incidence of and the predisposing factors to these complications. This study reviews a series of 723 acoustic tumors removed via the translabyrinthine approach at the House Ear Clinic in Los Angeles. The incidences of CSF leak and meningitis were 6.8% and 2.9%, respectively. The patients who developed these problems were compared to the remainder of the study population for differences in age at surgery, tumor size, operative time, and length of hospital stay. Meningitis occurred more frequently in larger tumors, and patients with either complication had a longer hospital stay. The presence of CSF leak did not predispose to meningitis. It is concluded that technical factors account for postoperative CSF leak and meningitis after translabyrinthine acoustic tumor removal.