内镜下经鼻入路暴露岩尖的解剖研究

目的通过影像学、内镜手术两种方法对内镜下经鼻入路暴露岩尖这一手术入路进行研究,为临床应用提供依据。方法选取24具国人成人尸头标本,进行轴位、冠状位及矢状位高分辨率CT扫描,观察与内镜下经鼻入路暴露岩尖的相关解剖标志,并测量其距离。选择5例10%甲醛固定、动脉灌注染料的尸头标本,模拟内镜下经鼻入路暴露岩尖（10侧）。记录内镜下解剖图像,描述其相关解剖关系。结果通过影像学资料可了解蝶窦发育情况并测量一系列颅底骨性解剖标志的距离,蝶骨嵴至两侧视神经管眶口直线距离相比较无显著性差异（P〉0.05）。所有标本通过内镜经鼻入路均从颈内动脉内侧到达岩尖,翼管及翼管动脉可作为寻找颈内动脉的重要解剖标志。结论影像学资料应作为内镜下经鼻入路暴露岩尖手术的术前常规参考;蝶骨嵴位于两侧视神经管眶口的中点,为术中可靠的解剖标志。从解剖学角度内镜下经鼻入路暴露岩尖具有可行性,该入路径路短,副损伤小,可作为临床治疗岩尖病变的重要术式之一。     

Transpalatal approach to the petrous apex

A case is described in which a transpalatal, transpharyngeal approach was used for access to a cyst of the petrous apex. Although its indications are limited, in selected patients this conservative procedure has advantages over the more invasive lateral routes.     

Supracochlear approach to the petrous apex: case report and anatomic study.

OBJECTIVE: The case of an 11-month old infant with petrous apex abscess drained through the supracochlear air cells prompted an anatomic study of the dimensions of this approach. Of the various approaches to the petrous apex, the supracochlear dissection has been the least described. STUDY DESIGN: Twenty temporal bones were dissected to completely expose the epitympanum. This required mastoidectomy, exenteration of zygomatic root and epitympanic air cells, and removal of the incus. Measurements were taken from three sides of a triangle described by the tegmen tympani (TT), tympanic facial nerve (TFN), and superior semicircular canal (SSCC). Similar measurements were obtained from standard coronal computerized tomographic (CT) scans from a random series of 20 patients. RESULTS: Mean lengths of the sides of the triangle were 7.0 mm (TT), 5.3 mm (TFN), and 4.8 mm (SSCC). The superior petrous apex air cells or marrow space was accessible through the supracochlear exposure in all specimens. Mean lengths from the coronal CT images were 4.2 mm (TT), 3.2 mm (TFN), and 8.45 mm (SSCC). CONCLUSIONS: The authors conclude that the supracochlear approach may provide adequate access to the superior petrous apex for drainage and biopsy in selected cases.     

经鼻内镜蝶窦进路岩尖胆脂瘤切除

目的 探讨经鼻内镜蝶窦进路岩尖部胆脂瘤囊内切除术的可行性及疗效.方法 回顾性分析2001-2006年经鼻内镜蝶窦进路切除鞍旁、岩尖部胆脂瘤患者3例的临床资料.3例患者均在全麻下经鼻内镜全筛窦、蝶窦开放,于蝶窦外侧壁、颈内动脉前方磨开颅底骨板进入岩尖部,切开并扩大胆脂瘤囊壁后,采用吸引、刮除和冲洗的方法将胆脂瘤进行囊内清除.结果 3例岩尖胆脂瘤经囊内切除手术,均一次清除干净,手术前伴有头痛和眶尖综合征的2例患者于术后当天即有症状改善,术后1～4周症状完全恢复,全部患者未发生手术并发症.术后随访3～7年,全部患者症状未再发,影像学检查胆脂瘤无复发.结论 靠近鞍旁区域的岩尖胆脂瘤可以采用经鼻内镜蝶窦进路行囊内切除手术,远期疗效可靠.     

Extraorbital pseudotumor of the petrous apex: biopsy via a transnasal endoscopic approach

Extraorbital idiopathic pseudotumors of the skull base are very uncommon. We report the case of a 50-year-old woman who presented with left ophthalmoplegia and vision loss. Imaging studies revealed an enhancing lesion involving the left petrous apex and cavernous sinus. A transnasal endoscopic approach was used to obtain a biopsy of the left petrous apex. Pathology identified the lesion as an idiopathic pseudotumor. The patient was treated with high-dose steroids and steroid-sparing immunomodulators, and she experienced a significant improvement. To the best of our knowledge, this is the first reported case of a transnasal endoscopic approach to a biopsy of a pseudotumor involving the petrous apex. We discuss the features of this case, and we review the literature on this condition.     

经迷路下径路切除岩尖病变显微解剖学

目的探讨经迷路下入路切除岩尖病变之手术入路,为手术入路提供解剖学标志和依据。方法①应用30例干颞骨标本依次测量颈内动脉膝部到面神经管垂直段的距离、面神经管到岩尖的距离以及颈内动脉到岩锥后面的距离。并在干颞骨标本上磨出该手术路径;②应用10具(20侧)经10%甲醛固定成人尸头湿标本,在手术显微镜下模拟迷路下入路切除岩尖气房,分别测量后半规管最低点到颈静脉球最高点骨板之间距离,面神经管垂直段和乙状窦骨板之间距离。结果①干颞骨标本测量:面神经管垂直段到颈内动脉膝部距离为(13.26±1.66)mm,面神经管垂直段到岩尖的距离为(34.48±1.07)mm,颈内动脉膝部到岩部后面的距离为(9.68±1.53)mm;②湿标本模拟手术测量:面神经管垂直段中点到乙状窦前壁距离为(6.42±2.65)mm,后半规管骨管到颈静脉球距离为(5.76±3.38)mm。能够完成迷路下手术入路的13侧。结论经迷路下入路手术切除岩尖病变能够保护内耳道、耳蜗、迷路不受损伤,保存听力,是一个具有临床应用意义的手术途径。     

The middle cranial fossa approach to the petrous apex

Petrositis is still a very real complication of otitis media. The most striking diagnostic feature is facial and/or retrobulbar pain, and it is the most consistent symptom. External rectus paralysis was present in only one of the four cases presented in this series. Treatment is surgical. In order to spare the cochlea and give adequate exposure to the apical cells, the middle fossa approach to the petrous apex is presented, to be used alone or in conjunction with mastoidectomy.     

内镜下经外耳道耳蜗下径路切除岩尖病变的应用解剖学研究

探索内镜下经外耳道耳蜗下径路切除岩尖病变的手术入路,观察内镜下后下鼓室及圆窗周围重要的解剖标志,寻找定位耳蜗下通道的解剖标志,同时在高分辨颞骨CT三维重建下量化耳蜗下通道,为该手术入路提供国人恒定的解剖标志及影像学依据。     

Transcanal anterior approach for cystic lesions of the petrous apex.

OBJECTIVE: To investigate the utility of a newly described approach, the transcanal anterior approach that is a modification of the subcochlear approach for the drainage of cystic lesions of the petrous apex. STUDY DESIGN: Prospective temporal bone study. SETTING: Tertiary referral center. MATERIALS: A total of six cadaveric temporal bone specimens (four males) were included. Right ear in four specimens and left ear in two specimens were used. INTERVENTIONS: The approach commenced with postauricular skin incision. After the transsection of the meatal skin, antero-inferior tympanotomy was performed. Anteroinferior canaloplasty localized the carotid canal. As much as 0.5 cm of the vertical segment of the internal carotid artery was skeletonized. After the identification of the artery, petrous apex cells were reached by drilling the cortical bone between the cochlea and the internal carotid artery. An air cell tract was established. Position and length of the tract in two specimens were demonstrated on the 1 mm-cut computerized tomography scans. MAIN OUTCOME MEASURES: Utility of the approach was investigated based on the established criteria: anteroposterior diameter and height of the fenestra of the tract, length of the tract from the cochlea to the deepest point of the tract (depth of the tract), and the injury risk of the internal carotid artery and the cochlea. RESULTS: The mean anteroposterior diameter, the height, and the length were 4.7 +/- 1.05 mm, 3.2 +/- 0.68 mm, and 14.7 +/- 1.1 mm, respectively. Injury did not occur in the cochlea or internal carotid artery in any of the specimens. CONCLUSION: With the subcochlear approach, there is always potential risk of injury to the cochlea, the internal carotid artery, and the jugular bulb. Although this new approach includes a technically challenging stage (exposing the vertical portion of the internal carotid artery), partly exposing the vertical portion of the artery provides a safer approach, which decreases the injury risk for the round window and the jugular bulb. Additionally, measurements show that it is possible to reach a considerable part of the petrous apex cells.     

Endonasal endoscopic approach to the pterygopalatine and infratemporal fossae

The pterygopalatine fossa and infratemporal fossa are spaces located under the skull base, housing important neurovascular structures. Surgical access to these spaces is challenging because of their deep location and complex anatomy. Their surgical access has been classically carried out through multiple craniofacial approaches until the advent of endoscopic endonasal surgery at the end of the XX^th century. Our goal is to describe the transmaxillary-transsphenoidal-transpterygoid approach to the pterygopalatine and infratemporal fossae through endonasal endoscopic surgery based on anatomo-surgical dissection and an illustrative clinical case. We conclude that after careful radiologic evaluation of the feasibility of this technique, the endonasal endoscopic access to these spaces for tumor resection is efficient with reduced surgical morbidities. The endonasal approach is versatile and can be fashioned according to the nature and extent of the lesion.     

Mucocele of the petrous apex.

The first case of a primary mucocele of the petrous apex is presented and the differential diagnosis is briefly discussed. Since this area is unavailable for direct examination, a thorough radiographic evaluation is essential. A mucocele should be suspected when a lytic lesion has a multiloculated appearance and when the contralateral petrous apex is highly pneumatized. Even then, a biopsy may still be needed to make a definitive diagnosis. The appropriate treatment for these cystic lesions is fistulization into a radical mastoid cavity or an exteriorized sphenoid sinus.     

Surgical approaches to the petrous apex

The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.     

The preauricular subtemporal approach for transcranial petrous apex tumors.

OBJECTIVE: To review our series of 51 patients with transcranial petrous apex tumors who were surgically managed through a preauricular subtemporal approach. STUDY DESIGN: A retrospective analysis of patient medical records. SETTING: Tertiary care academic medical center. PATIENTS: All patients with transcranial petrous apex tumors who were surgically treated between July 1988 and July 2005 with a preauricular subtemporal approach. INTERVENTION: The preauricular subtemporal approach with preservation of hearing was used in all 51 cases. MAIN OUTCOME MEASURES: The degree of tumor resection and long-term results. RESULTS: Total tumor resection was achieved in 45 patients, and tumor was left in the cavernous sinus in 6 cases. Magnetic resonance imaging surveillance revealed no recurrent tumor in 36 patients, stable residual disease in 5 cases, and regrowth of tumor in 10 individuals (mean follow-up, 8.8 yr). DISCUSSION: The postauricular infratemporal fossa approach allows adequate exposure to the petrous apex but with the expense of conductive hearing deficit. The preauricular subtemporal approach allows wide access for transcranial petrous apex tumors with preservation of hearing. Tumor control using this approach was achieved in 41 (80%) of 51 of the patients in this series.     

How to perform microscopic/endoscopic resection of large petrous apex lesions

The endoscope and microscope can be used conjointly in certain sites, such as middle ear cholesteatoma or for resection of cerebellopontine angle tumours. Petrous apex tumours are classically accessed via a lateral otological approach, or, for the most anterior tumours, via an endonasal endoscopic approach. Surgical access via a lateral incision is limited inferiorly by the superior bulb of the internal jugular vein, medially by the labyrinth, facial nerve and internal auditory canal, superiorly by the dura mater, and laterally by the internal carotid artery. Via an anterior endonasal approach, the corridor formed by the internal carotid artery and the paraclival dura limits access to the posterior part of the petrous apex, restricting this approach to certain cholesterol granulomas or small cholesteatomas. None of these approaches, on its own, is sufficient in the case of an extensive petrous apex lesion. The objective of this technical note is to describe the combined microscopic/endoscopic approach comprising sequential use of the microscope and the endoscope via a lateral approach for the management of large petrous apex lesions.