上纵隔暴露术在颈部晚期癌手术中的应用

目的　研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法　 1992～ 1999年对 18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌 10例 ,晚期复发甲状腺癌 2例 ,晚期颈段气管癌 2例 ,锁骨上巨大转移癌 4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除 10例 ,切除一侧胸锁关节和锁骨内侧 1 2者 4例 ,切除胸骨柄和双侧锁骨内侧 1 3者 4例。其中 1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对 10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损 ,覆盖并保护下颈部和上纵隔大血管。结果　通过上纵隔暴露与清扫术 ,16例患者的肿瘤得以完整切除。 2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术 ,其中 1例在分离肿瘤时术中发生气胸。术后 2例发生咽瘘 ,其中 1例因伤口感染发生右侧颈总动脉假性动脉瘤 ,均经及时处理后治愈。 1例于术后 2个月发生无名动脉出血死亡。术后 1年、2年和 3年生存率分别为 72 2 % ( 13 18)、2 2 2 % ( 4 18)和 11 1% ( 2 18)。结论　上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径     

晚期甲状腺癌累及颈总动脉的挽救性手术

目的:探讨累及颈总动脉的晚期甲状腺恶性肿瘤手术治疗的可能性。方法:回顾我院耳鼻咽喉科2006-07-2009-08期间收治的4例晚期甲状腺恶性肿瘤患者,CT示颈总动脉包裹于肿瘤中。其中低分化鳞状细胞癌2例,乳头状癌2例。3例行全甲状腺全喉切除双侧颈淋巴结清扫术,1例切除肿瘤及累及气管,保留全喉及切除气管段之气管膜部及软骨,永久性气管造瘘,颈胸部皮瓣转移修补上纵隔气管壁。术中1例颈总动脉破裂行修补术。术后2例乳头状癌及1例低分化鳞状细胞癌患者未作放、化疗,1例低分化鳞状细胞癌患者补充放、化疗。随访6个月～2年。结果:术后6个月,未放化疗的1例低分化癌患者脊柱转移,1年后仍生存,1年半后失访。其余3例随访6个月～2年未见局部明显复发或全身转移。结论:晚期甲状腺恶性肿瘤累及颈总动脉时仍可以考虑手术治疗,其中喉、气管结构应在不影响治疗效果的前提下尽量保存,缺损气管段的修复在这类病例应放在次要的地位。     

上纵隔暴露术

头颈外科医生在肿瘤的治疗中难免会遇到这种情况:肿瘤向胸骨柄和锁骨扩展,累及上纵隔。不暴露上纵隔,则不能彻底切除肿瘤,使病人失去了手术救治机会。因此,有必要探讨上纵隔暴露的问题。本文综述国外有关上纵隔暴露术的文献如下。【上纵隔暴露术的指征】 1.喉癌术后气管造口周围复发(以下简称造口复发):其发生率为3～14%,后果严重,死亡率高,手术有治愈的可能。Sisson报告在行上纵隔暴露术的病人中,50%为造口复发,为主要的手术指征。氏将造口复发分为四型:Ⅰ型,肿瘤局限,位于气管造口上方,食管未受累;Ⅱ型,肿瘤亦位于气管造口上方,累及食管;Ⅲ型,肿瘤位于气管造口下方,扩展到上纵隔;Ⅳ型,肿瘤向气管造口外扩展,累及锁骨下。Ⅰ     

全喉咽食管切除及纵隔清扫术后立即重建

喉全切除后气管造口复发癌之最有效的治疗方法是通过胸骨的颈或上纵隔清扫术和将气管向上胸部移位。切除后的缺损区应用胸肌皮瓣修复。对于病变已侵及食管或原发于下咽和颈段食管的晚期癌则行全喉咽食管切除然后经后纵隔上提胃与舌根吻合。作者们应用上述方法治疗了39例患者,其中有30例(占76%)于术后21日内恢复经口进食。7例发生颈部胃皮肤瘘(约占18%),其中3例经保守治愈,另外4例需用颈或胸部皮瓣覆盖闭合,术后很快死亡2例(占5%)。39例患者中良性病变3例,术后生存率100%;复发癌15例行全咽食管切除及纵隔清扫术治疗,其中     

侵犯气管的分化型甲状腺癌气管袖状切除术

目的 寻找侵入气管及喉的分化型甲状腺癌手术治疗的方法，探讨包括气管及喉部分切除在内的根治性手术可行性和有效性。方法 3例均为女性，2例为甲状腺乳头状癌，1例滤泡状癌，均侵入气管。一例采取右侧甲状腺腺叶切除术、气管袖状切除术及声门下喉部分切除术，术后因喉切缘肿瘤残留补充放疗总量55Gy；另一例采取左侧甲状腺腺叶切除术、气管袖状切除术及左改良根治性颈淋巴结清扫术；第三例采取全甲状腺切除、气管袖状和喉部分切除术、双侧改良根治性颈淋巴结清扫术和上纵隔淋巴结清扫术。结果 术后均无声音嘶哑，呼吸平稳，无需气管切开，均无吻合口漏。随访近2年均未见吻合口狭窄和肿瘤复发。结论 对侵入气管及喉的分化型甲状腺癌患者进行包括气管袖状切除术在内的根治性手术治疗是可行和有效的。     

纵隔气管切开术

颈部晚期癌症侵犯上纵隔在治疗上是一大难题，根治性手术需切除喉、部分气管和食管，并行胸腔内气管切开造口术，即纵隔气管切开术。作者行颈部晚期癌侵犯纵隔后手术切除及纵隔气管切开术12例，总结手术方法及经验。术前尽可能确定病变范围、肿瘤能否完整切除及有无远处转...     

前上纵隔切开术的应用体会

目的探讨侵入前上纵隔头颈肿瘤的手术方法。方法6例患者,其中颈段气管癌1例、甲状腺癌3例、鳃裂癌转移和气管瘘口复发癌各1例。采用切除胸骨柄和患侧1/3锁骨的方法,切开前上纵隔,切除肿瘤以及上纵隔淋巴结清扫术,2例颈动脉肿瘤受侵处同期植入125Ⅰ粒子组织间放疗。3例气管缺损分别应用前臂皮瓣、胸锁乳突肌骨膜瓣和气管端-端吻合修复,并应用胸大肌瓣充填前上纵隔。结果6例未发生术中严重并发症;随访3年以上。4例死亡,其中1例术后第4周因心脏病突发而死亡,3例分别在术后6个月、8个月和1年因感染引起颈动脉大出血或舌根部、气管局部复发而死亡。结论常规CT或MRI检查明确肿瘤范围制定手术方案,依据术中肿瘤切除后气管缺损范围采用不同方法整复,应用胸大肌肌瓣充填前上纵隔,保护大血管。同时2例颈动脉肿瘤受侵处术中植入125Ⅰ粒子组织间放疗,扩大手术适应证,提高了疗效。此手术方法术野暴露好,耳鼻咽喉头颈外科医生可独立完成,不失为减轻患者痛苦或延长生命的有效方法。     

老年胸骨后甲状腺肿瘤外科治疗

目的探讨老年胸骨后甲状腺肿瘤的手术入路方法。方法采用颈部低领式切口入路,按甲状腺常规切除方法进行。对于坠入上纵隔较深的肿瘤采用“共力牵引”法,而对于甲状腺癌需进行上纵隔暴露及淋巴结清扫的病例,采用咬除锁骨内1/3及部分胸骨的方法,充分暴露上纵隔。结果22例老年胸骨后甲状腺肿瘤采用低领式切口入路均获成功。无手术并发症。随访率100%,随访29个月,无复发病例。结论采用颈部低领式切口入路完成老年胸骨后甲状腺肿瘤切除具有创伤小,时间短,并发症少的优点。“共力牵引”法方便了术中暴露。甲状腺恶性肿瘤采用咬除锁骨内1/3及部分胸骨的方法,可充分暴露上纵隔。     

甲状腺癌侵犯上纵隔的外科治疗

目的探讨甲状腺癌侵犯上纵隔的外科治疗方法。方法回顾性分析了河北医科大学第四医院耳鼻咽喉一头颈外科1988～1999年经治的516例甲状腺癌中10例侵犯上纵隔患者的术前诊断、手术进路、手术方法及术后并发症。结果甲状腺癌侵及上纵隔的发病率占全部甲状腺癌的1．9％(10／516)。侵犯方式主要3种：①气管、食管沟及上纵隔淋巴结转移；②肿瘤的直接侵犯；③原发胸骨后恶性甲状腺肿瘤。手术方式有3种：①不切开胸骨的肿块切除；②加胸骨纵行切开的肿块切除；③胸骨部分或扩大切除术(包括锁骨)。完整切除肿瘤9例，姑息切除1例。术后乳糜漏2例，声带麻痹2例，甲状颈干动脉出血1例，膈神经麻痹1例，气胸1例。全部病例随访3年以上，1、3、5、10年生存率分别为10／10、8／10、6／9、4／7。结论甲状腺癌侵犯上纵隔，采用手术治疗可获得良好的远期效果。     

全喉切除术后造瘘口复发癌的外科处理

报告7例喉全切除术后侵及下颈部与上纵隔的瘘孔复发癌。其主要临床特点为术后数月至1年出现下颈部肿胀,进行性呼吸困难;食管受累时可出现吞咽困难。CT扫描、X线、B超和纤维气管镜检查对明确肿瘤范围和确定手术切除具有重要意义。施行上纵隔暴露术彻底切除肿瘤是对其有效的治疗。     

Mediastinal dissection — 1976: Indications and newer techniques

Head and neck neoplasms may invade the mediastinum by direct extension or metastases to the tracheoesophageal or jugulo-subclavian lymph nodes. The clavicles and manubrium are a barrier to adequate resection in this type of disease. In 1962, the senior author reported six mediastinal dissections for stomal recurrences after laryngectomy. Later techniques for staging the removal of manubrium and clavicles and preparing the regional flaps were devised to avoid major complications arising from operating in thin area which usually had prior treatment with radiation and/or surgery. Over 60 transsternal radical neck dissections have been performed in the past 20 years. We have in the past evaluated the morbidity and survivals in stomal cases and present here our revised indications and techniques.     

How we do it: the anterior thoraco‐cervical approach to tumours of the thoracic inlet

? Tumours that arise in the thoracic inlet and superior mediastinum may be benign or malignant and present the surgeon with a difficult problem of access. ? The standard approach to the thoracic inlet from below offers limited exposure to the vascular and neural structures superior to the tumours. ? The anterior thoraco‐cervical approach to the root of the neck and superior mediastinum combines the anterior cervical approach with a limited upper median sternotomy. If further access is required to achieve surgical clearance a full sternotomy split can be performed. ? The approach offers excellent exposure and helps to facilitate complete resection of benign and malignant tumours, which would otherwise be deemed inoperable or difficult to resect completely through other standard approaches. ? In contrast to previously described anterior transcervical thoracic approaches which required resection of part of the clavicle or manubrium as well as thoracotomy with increased morbidity, the anterior thoraco‐cervical approach is associated with little morbidity and the postoperative stay is short.     

腮腺淋巴上皮瘤样癌的诊断与治疗

目的:探讨腮腺淋巴上皮瘤样癌(LELC)的诊断与治疗,进一步提高诊治率.方法:收集我科18例经病理证实的腮腺LELC,回顾性总结和分析本病的临床表现、诊断、治疗及预后.结果:18例腮腺LELC患者中,均为单侧腺体发病;除2例未做EB病毒血清学检查外,其余患者血清学检查结果显示EBV-VCA-IGA阳性率为93%(15/16);EBV-EA-IGA阳性率为75%(12/16);EBV-DNA酶阳性率为63%(10/16).18例均接受原发灶切除及同侧颈淋巴清扫术.其中腮腺全叶加面神经切除2例,其余均为保留面神经的腮腺浅叶切除术6例;腮腺大部分切除术5例;腮腺全切除术5例;颈上、中部淋巴颈清扫术14例;根治性淋巴清扫术4例,颈淋巴结转移率67%(12/18).所有患者接受术后放疗50～70 Gy.全组病例1年以上随访,术后2～4年4例局部复发而行再次手术,1、3、5年生存率分别约为94%(17/18)、72%(13/18)、50%(9/18);死亡原因主要为远处转移和肿瘤复发.结论:腮腺LELC的发生与EB病毒感染可能有密切关系,组织病理学表现酷似未分化型鼻咽癌,确诊前需常规行鼻咽活检以排除转移病灶,腮腺LELC颈淋巴结转移率较高,局部侵袭强,治疗上除行局部广泛切除外还应作颈淋巴结清扫,术后辅助放射治疗.     

Median sagittal mandibulotomy in head-neck tumors

BACKGROUND: Histologically proven radical resections are the goal in patients with head and neck cancer because of improved survival rates. The frequency of histologically radical resections using the median mandibulotomy and the morbidity of this approach for tumors of the oropharynx and the parapharyngeal space are described in a patients series. METHODS: The follow-up includes 16 consecutive patients who were operated on by a median mandibulotomy approach between 1995 and 1998. The oncological benefit (tumor free margins), complications and the functional results (ability of opening the mouth mastication, swallowing, speech, cosmesis and pain) were reviewed. RESULTS: In 15/16 cases a histological radical resection was achieved. 14 patients were irradiated postoperatively. In this group 3 patients had an osteoradionecrosis, one an osteomyelitis of the mandible. The functional results were worse in more advanced tumors. CONCLUSION: The indications for a median mandibulotomy are primarily T3 and T4 tumors of the oral cavity and oropharynx, rarely expansive benign parapharyngeal tumors. In most cases a histological radical resection is achieved even in advanced tumors, probably due to the wide exposure of the involved area. In contrast this approach is associated with a high morbidity.     

Carcinoma of the external auditory canal and middle ear: therapeutic strategy and follow up

BACKGROUND: Carcinomas of the external auditory canal (EAC) and the middle ear are rare and considered to have a poor prognosis. The recommended therapeutic strategy consists of surgical excision and postoperative radiotherapy. However, there are different opinions about the extend of the primary operation. PATIENTS AND METHODS: A series of 21 patients with carcinoma of the EAC and middle ear were treated at the ENT-Department of the Hospital Fulda from 1985 to 2003. Their records and radiologic findings were reviewed retrospectively with particular reference to tumor type and size, its relation to surrounding tissues, surgical procedures and radiation techniques. The tumors were staged according to the modified Pittburgh staging system for temporal bone carcinomas. The average follow-up time was 6.2 years (range 0.2 - 18.75). RESULTS: 17 patients suffered from carcinoma of the EAC, 4 carcinomas were primarily located in the middle ear. There were 15 squamous cell carcinomas, 3 adenoidcystic carcinomas, 2 adenocarcinomas and one mucoepidermoid carcinoma. 12 patients came primarily to our institution and were staged as follows: pT1 (n = 2), pT3 (n = 2), pT4 (n = 8). 8 patients showed up with recurrent or residual tumors (all of T3 or T4 stage). One patient could not be classified. In 5 cases the tumor was inoperable. These patients underwent combined chemoradiation therapy. All other 16 patients were operated and most of them received adjuvant radiation therapy. In the group of patients who were primarily operated overall 5-year survival rate was 100 %. In contrast, patients who's recurrent or residual tumors were resected had a 5-year survival rate of only 33 %. Patients who received combined chemoradiation therapy showed a 2-year survival rate of 75 %. CONCLUSION: Carcinoma of the EAC and middle ear should be treated primarily by a lateral or subtotal temporal bone resection stage dependent combined with a parotidectomy as well as a neck dissection. Local resection of the EAC is not sufficient, not even in T1 tumors. As from stage T2, in cases of recurrent tumor removal and questionable free margins as well as in cases with lymph node metastases an adjuvant radiation therapy should be added. The most important survival factor is removal of the primary tumor with histologically clear margins.     

颌面部肿瘤外科治疗

颌面部肿瘤治疗的特点是既要根治性切除,又要考虑病人术后的面容外观、咀嚼和言语功能。颌骨多囊性病变一般采取刮治术,但呈蜂窝样表现者则应考虑做颌骨切除并一次植骨。微血管吻合技术的发展,促使各种游离皮瓣为口腔癌切除后组织缺损的整复提供了优越条件。对cNO病人则主张做肩胛舌骨上颈淋巴结清除。高度恶性的涎腺癌在做根治性切除术后,必须辅助术后放射治疗。     

舌骨咽切开术治疗舌根癌

目的 探讨舌根癌外科治疗的最佳进路和方法。方法通过舌骨咽切开术治疗11例舌根癌,同期行会厌切除者4例,喉水平部分切除者1例。选择性颈清扫术1例,单侧功能性颈清扫术2例,双侧功能性颈清扫术1例,单侧根治性颈清扫术6例,一侧根治性和另一侧功能性颈清扫术1例。结果鳞状细胞癌10例,胚胎性横纹肌肉瘤1例;术后出现咽漏1例,进食流质轻度呛咳1例,上切缘阳性者1例,淋巴结转移者7例;术后拔管率100％;2、3、5年生存率分别为81.8％,77.8％,33.3％。结论 舌骨咽切开进路可清晰暴露舌根、会厌、下咽及喉部,适用于这些部位的肿瘤切除,并发症少。     

Carotid resection and reconstruction for locally advanced head and neck tumors

Head and neck surgeons hesitate to resect the carotid artery because of the postoperative risk of neurologic sequelae. However, there is no curative therapeutic option for head and neck neoplasms involving the carotid artery, with the exception of complete tumor removal. To evaluate the benefits and risks of carotid revascularization techniques in locally advanced head and neck tumors we performed a retrospective analysis in an institutional, tertiary care medical center. Seven patients (5 males, 2 females) with a median age of 58 years underwent en bloc removal of locally advanced head and neck tumors, including carotid resection and revascularization, in the University of Vienna General Hospital, over a 15-year period. In six patients carotid reconstruction was accomplished by bypass grafting (five autologous grafts, one synthetic graft) and in one patient angiopatchplasty was used. There were no perioperative neurologic complications or deaths. Survival was > 12 months in 5/7 patients; the other 2 patients died within 6 months due to untractable progression of cancer. We conclude that carotid revascularization techniques offer the possibility of better local control for advanced head and neck tumors without additional risks of neuromorbidity or mortality.