枕下经颈-颈静脉突入路切除颈静脉孔肿瘤临床初探

目的探讨枕下经颈-颈静脉突(STJP)入路切除颈静脉孔肿瘤的临床价值及适用范围。方法回顾总结2000年1月以来经STJP入路手术的14例颈静脉孔肿瘤病人的临床资料及术后随访情况。结果14例颈静脉孔肿瘤中,1例局限于颈静脉孔区;5例向颅内发展;其余8例虽肿瘤主体位于颅内,但部分瘤体长至颅外,其中2例跨枕大孔进入颈椎管上部,6例呈哑铃型长出至颈静脉孔外口处,后者中有2例向前累及颈动脉鞘。手术全切除10例,近全切除1例,次全切除3例。无1例发生术后脑脊液漏。术后1例病人出现短期患侧眼外展麻痹和面神经不全损害(HBⅢ级),余13例(92.9%)无新增脑神经损害表现。除1例病人失访外,其余病人均随访3~60个月,随访时术前原脑神经损害均已逐渐恢复或代偿,无1例残留吞咽困难。结论STJP入路显露范围较广泛,操作简便,不破坏迷路,无需轮廓化面神经管,对颅底结构破坏较少,适用于切除主体向颅内发展为主的颈静脉孔肿瘤。     

颈静脉孔神经鞘瘤的外科治疗

目的 探讨颈静脉孔神经鞘瘤的手术入路及治疗效果。方法 回顾性分析采用显微外科手术治疗颈静脉孔神经鞘瘤２４例,其中颅内型（Ａ型）：肿瘤主体位于桥小脑角（１２例）;骨内型（Ｂ型）：肿瘤主体位于颈静脉孔内,向颅内生长（５例）;颅外型（Ｃ型）：肿瘤主体位于颅外,并向颈静脉孔生长（１例）;混合型（Ｄ型）：肿瘤由颈静脉孔向颅内外生长,呈哑铃型（６例）。Ａ型采用枕下乙状窦后入路,Ｂ型采用远外侧入路,Ｃ型和Ｄ型采     

头颈外科

20050006枕下经颈颈静脉突入路达颈静脉 孔区的显微解剖研究/刘庆…//中国耳鼻咽喉 颅底外科杂志.2004,10(3).132～135 目的:研究一期切除颈静脉孔区复杂性肿瘤的 微创手术入路。方法:选择经10%福尔马林固人头 颈标本10具,显微镜下模拟枕下经颈颈静脉突入 路的手术操作,逐层显露颈静脉孔区,研究该区显微 解剖特征及显露范围。结果:该入路直接沿乙状窦、 颈内静脉的移行方向显露颈静脉孔区结构,其中后 颅窝可经枕下显露,颞下窝藉寰椎与下颌升支间的 自然间隙显露。通过切除颈静脉突和迷路下骨质分 别自后、外、下和上方显露静脉孔。头侧直…     

枕下经颈-颈静脉突入路达颈静脉孔区的显微解剖研究

目的 研究一期切除颈静脉孔区复杂性肿瘤的微创手术人路。方法 选择经10％福尔马林固定成人头颈标本10具，显微镜下模拟枕下经颈一颈静脉突人路的手术操作，逐层显露颈静脉孔区，研究该区显微解剖特征及显露范围。结果 该人路直接沿乙状窦、颈内静脉的移行方向显露颈静脉孔区结构，其中后颅窝可经枕下显露，颞下窝藉寰椎与下颌升支间的自然间隙显露。通过切除颈静脉突和迷路下骨质分别自后、外、下和上方显露颈静脉孔。头侧直肌是界定颞下窝结构和枕下三角内结构的确切标志。后组颅神经，交感千和颈内动、静脉行于其前方，椎动脉寰椎上段及其周围的静脉丛行于其后方。结论 枕下经颈一颈静脉突人路可自多个方向充分显露颈静脉孔区结构，且可保护面神经、迷路、耳蜗和椎动脉等结构免受不必要的损伤。     

枕下乙状窦后-内听道上入路显微手术切除岩斜区脑膜瘤

目的总结应用枕下乙状窦后-内听道上入路显微手术切除岩斜区脑膜瘤的方法和经验。探讨岩斜区脑膜瘤的显微手术技术,提高肿瘤手术切除程度与术后疗效。方法回顾性分析采用枕下乙状窦后-内听道上入路显微手术治疗的11例岩斜区脑膜瘤的临床资料,并对手术方法进行分析。结果肿瘤全切除8例(72.7%),次全切除3例。术后新增脑神经损害2例(18.2%),无手术相关死亡病例。结论应用枕下乙状窦后-内听道上入路,采用显微神经外科技术处理岩斜区脑膜瘤,可获得满意的手术疗效。该入路明显扩大对中颅窝和上斜坡的显露,是切除主体位于后颅窝,同时累及中颅窝的岩斜区肿瘤的良好途径,掌握手术技巧和术中注意事项,有利于提高肿瘤切除率和疗效。     

骑跨中后颅窝哑铃型三叉神经鞘瘤的手术治疗

目的探讨两种入路切除向中后颅窝侵犯的哑铃型三叉神经鞘瘤的手术效果。方法对两种入路治疗的24例中后颅窝哑铃型三叉神经鞘瘤的手术效果进行分析,手术入路选择为幕上额颞开颅为基础辅以硬膜间（Dolenc）入路,幕下开颅枕下乙状窦后开颅为基础的硬膜下入路。结果经幕上组入路共16例,全切7例,次全切9例,经幕下组入路共8例,肿瘤全切6例,次全切2例。结论额颞硬膜间（Dolenc）入路残存率、死亡率较经枕下乙状窦后入路低,但肿瘤全切率及神经功能保留率较幕下入路低。     

不同手术入路对颈静脉孔区显露程度的比较研究及其临床应用价值探讨

目的比较各颈静脉孔区手术入路的显露范围,为选择恰当的手术入路切除不同范围的颈静脉孔区病变提供解剖依据。方法成人头颈标本6具随机分为A、B、C三组,每组2具尸头。其中A组应用颈侧入路、B组分别采取鼓室底入路和改良鼓室底入路、C组分别选择A型颞下窝入路及改良A型颞下窝入路进行颈静脉孔区解剖,比较各手术入路对颈静脉孔区及其周围解剖区域的显露程度。结果颈侧入路对颈静脉孔的颅外部分及咽旁间隙显露良好;鼓室底入路在颈侧入路的基础上进一步显露乳突、乙状窦垂直臂、颈静脉球、颈静脉孔神经部;A型颞下窝入路又在鼓室底入路的基础上扩大显露外耳道深部、中耳腔及岩骨段颈内动脉垂直段;改良鼓室底入路和改良A型颞下窝入路很好地弥补了鼓室底入路和A型颞下窝入路对乙状窦水平臂和颈静脉孔血管部显露不足的缺陷。结论不同颈静脉孔区手术入路对颈静脉孔区的显露程度各不相同。以此为依据,根据颈静脉孔区病变的范围选择手术入路对有效显露和切除病变,减少结构和功能破坏具有现实的指导意义。     

不同手术入路对颈静脉孔区的显露程度及其临床应用价值探讨

目的比较各颈静脉孔区手术入路的显露范围,为选择恰当的手术入路切除不同范围的颈静脉孔区病变提供解剖学依据。方法成人头颈标本6具随机将标本分为A、B、C三组,每组2具尸头。其中A组应用颈侧入路、B组依次采取鼓室底入路和改良鼓室底入路、C组依次选择Ⅰ型颞下窝入路及改良Ⅰ型颞下窝入路进行颈静脉孔区解剖,比较各手术入路对颈静脉孔区及其周围解剖区域的显露程度。结果颈侧入路对颈静脉孔的颅外部分及咽旁间隙显露良好;鼓室底入路在颈侧入路的基础上进一步显露乳突、乙状窦垂直段、颈静脉球、颈静脉孔神经部;Ⅰ型颞下窝入路又在鼓室底入路的基础上扩大显露外耳道深部、中耳腔及岩骨内颈内动脉垂直段;改良鼓室底入路和改良Ⅰ型颞下窝入路很好地弥补了鼓室底入路和Ⅰ型颞下窝入路对乙状窦水平段和颈静脉孔血管部显露不足的缺陷。结论不同颈静脉孔区手术入路对颈静脉孔区的显露程度各不相同。以此为依据,根据颈静脉孔区病变的范围选择手术入路对有效显露和切除病变,减少结构和功能破坏具有现实的指导意义。     

经迷路下-颈静脉突入路切除颈静脉孔区神经鞘瘤

目的回顾经迷路下-颈静脉突入路手术切除颈静脉孔区神经鞘瘤的病例，探讨该入路的临床价值。方法回顾总结2例经迷路下-颈静脉突入路手术切除的颈静脉孔区神经鞘瘤的临床资料，并复习相关文献。结果2例肿瘤均得到完全切除。术后1例患者出现短暂轻度的后组脑神经损害及面神经不全损害表现（House Brackmann Ⅱ级）；1例患者原先后组脑神经损害表现改善，无面神经损害表现，听力保留；术后均无脑脊液漏发生。术后随访6个月，2例患者面神经或后组脑神经损害均逐渐恢复或代偿，无肿瘤复发。结论经迷路下-颈静脉突入路操作简便，能在保护迷路的基础上充分暴露颈静脉孔区，适用于主体位于颈静脉孔内并向颅内脑池明显扩展的神经鞘瘤的手术切除。     

听神经瘤枕下乙状窦后锁孔入路的临床探讨

目的 探讨改良听神经瘤枕下乙状窦后入路的手术方法，预防并发症，减少手术损伤。方法 对12例听神经瘤采用单侧枕下乳突后小“J”形皮肤切口，枕下乙状窦后“锁孔”入路显微手术切除肿瘤，后颅窝开颅术改咬骨窗为开骨瓣术。结果 10例肿瘤全切除，1例全切除；面神经解剖保留9例，术后2－9个月复查面神经House-Brackmann（H－B）Ⅰ-Ⅱ级、Ⅲ－Ⅳ级，Ⅴ级1例。术后见明显并发症。结论 改良枕下乙状窦后“锁孔”入路是一种有效、安全、便捷的微创手术入路。它的优点是解剖复位、创伤小、并发症少，并有利于美容。     

A Hearing Preservation Technique for the Resection of Extensive Jugular Foramen Tumors

Objective To describe a modified surgical approach for patients who maintain hearing function with jugular foramen tumors that extend to the posterior cranial fossa and the neck. Study Design A retrospective review of 6 patients with jugular foramen tumors that were resected by a combined suboccipital and infralabyrinthine–transcervicomastoid approach. Methods A combined suboccipital and infralabyrinthine–transcervicomastoid approach is characterized as follows: 1) There is no ablation of ear structures except the infralabyrinthine mastoid bone; the auricle is retracted anteriorly while preserving the bony wall and skin of the ear canal. 2) After superficial parotidectomy, a limited length of nerve VII from the intratemporal vertical segment is rerouted to divisions of the parotid portion. 3) The tumor is removed along with the internal jugular vein and sigmoid sinus, then the extended intracranial mass is resected through an additional suboccipital approach. Results Five of the 6 patients had complete removal of all gross tumors. There were no major complications or mortalities. The preoperative levels of hearing were preserved in 5 of the 6 patients. Favorable facial function in the immediate postoperative period was noted in 4 of the 6 patients. Incomplete paralysis of 2 patients recovered eventually. Conclusion We propose that a combined suboccipital and infralabyrinthine–transcervicomastoid approach to the jugular foramen can provide sufficient exposure to resect most dumbbell‐shaped tumors, and it could be the initial treatment of choice for patients with remnant hearing.     

内耳的显微解剖及临床应用

目的了解内耳及相邻结构的显微解剖,为术中切除岩骨骨质提供解剖学参数.方法在显微镜下对15例成人尸头标本的内耳及相邻结构进行解剖学测量.结果乙状窦沟、内听道孔、颈静脉孔、耳蜗、岩嵴和后半规管最后点等可作为手术标志.后半规管最后点和内听道孔后缘到乙状窦沟距离为9.8mm及22.0mm,岩骨后面到面神经管垂直部距离9.1mm,岩嵴到颈静脉球窝顶距离15.1mm,岩嵴最后点到耳蜗距离为28.6mm.结论熟练掌握内耳及相邻结构的解剖,严格限制骨质切除范围,就能既得到满意的手术暴露,又不引起更多并发症.     

显微外科治疗枕骨大孔区肿瘤

目的：探讨枕骨大孔区肿瘤的合理手术入路,进一步提高其手术治疗效果。方法：全组手术均在显微外科条件下完成,其中14例取枕下正中入路切除,8例取枕下远外侧入路切除。结果：本组全切除肿瘤18例,次全切除4例。无手术死亡。讨论：由于位置深在,解剖结构重要,复杂,枕骨大孔区肿瘤的手术切除有一定的难度和危险。应根据肿瘤的部位,大小和性质选用枕下正中入路可枕下远外侧入路,枕下远外侧入路更适合于枕骨大孔区前方和前外侧方肿瘤的显微手术。     

A different technique used for the closure of sigmoid sinus during infratemporal approach

Objective: Glomus jugulare tumors and neuromas frequently affect the jugular foramen area and necessitate special surgical approaches. It is often essential to stop blood flow by occluding internal jugular vein from below and the sigmoid sinus from above. Obviously, injury to the venous structures without proximal and distal control results serious haemorrhage. We describe here, a different technique for the closure of sigmoid sinus during infratemporal approach and compare it with the other techniques. Methods: During the infratemporal approach, for closing the sigmoid sinus, we removed the bone over the sinus and from the posterior fossa dura located anteriorly and posteriorly to the sigmoid sinus. Then a 2/0 atraumatic silk suture was passed horizontally through dura which is behind and in front of the sinus. A muscle graft was then placed between the suture and sigmoid sinus. Results: We used that technique in 7 patients who had a glomus jugulare tumor. In that technique, the blood flow was completely stopped without penetrating the sinus. Conclusion: Sigmoid sinus can be closed without incision of the sinus or the dura. This decreases the chances of injury to the sinus and dura resulting in less bleeding and less chances of CSF leak.     

Surgical management of jugular foramen meningiomas: a series of 13 cases and review of the literature

OBJECTIVE: Primary meningiomas occurring within the jugular foramen are exceedingly rare lesions presumed to originate from arachnoid-lining cells situated within the jugular foramen. The objective of this study is to analyze the management and outcome in a series of 13 primary jugular foramen meningiomas collected at a single center. STUDY DESIGN: Retrospective study. SETTING: Quaternary referral otology and skull base private center. METHODS: Charts belonging to 13 consecutive patients with pathologically confirmed jugular foramen meningioma surgically treated between September 1991 and May 2005 were examined retrospectively. The follow-up of the series ranged from 12 to 120 (mean, 42.8 +/- 27.5) months. RESULTS: Four (28.5%) patients underwent single-stage tumor removal through the petro-occipital transigmoid (POTS) approach. In two patients with preoperative unserviceable hearing, a combined POTS-translabyrinthine approach was adopted. Two patients underwent a combined POTS-transotic approach because of massive erosion of the carotid canal. A modified transcochlear approach type D with posterior rerouting of the facial nerve and transection of the sigmoid sinus and jugular bulb was performed in two patients with a huge cerebellopontine angle tumor component with extension to the prepontine cistern together with massive involvement of the petrous bone and middle ear and encasement of the vertical and horizontal segments of the intrapetrous carotid artery. In one patient with evidence of a dominant sinus on the site of the tumor, a subtotal tumor removal via an enlarged translabyrinthine approach (ETLA) was planned to resect the intradural component of the tumor. Two patients in our series underwent a planned staged procedure on account of a huge tumor component in the neck. One of these patients underwent a first-stage infratemporal fossa approach type A to remove the tumor component in the neck; the second-stage intradural removal of the tumor was accomplished via an ETLA. The last patient underwent a first-stage modified transcochlear type D approach to remove the intradural tumor component followed by a second-stage transcervical procedure for removal of the extracranial component. Gross total tumor removal (Simpson grade I-II) was achieved in 11 (84.6%) cases. Subtotal removal of the tumor was accomplished in two patients. Good facial nerve function (grades I and II) was achieved in 46.1% of cases, whereas acceptable function (grade III) was achieved in the remaining cases 1 year after tumor removal. Hearing was preserved at the preoperative level in all four patients who underwent surgery via the POTS approach. After surgery, no patient recovered function of the preoperatively paralyzed lower cranial nerves. A new deficit of one or more of the lower cranial nerves was recorded in 61.5% of cases. CONCLUSIONS: Surgical resection is the treatment of choice for jugular foramen meningiomas. Among the various surgical techniques proposed for dealing with these lesions, we prefer the POTS approach alone or combined with the translabyrinthine or transotic approaches. Despite the advances in skull base surgery, new postoperative lower cranial nerve deficits still represent a challenge.     

Schwannomas of the parapharyngeal space and jugular foramen

Schwannomas or neurilemmomas are among the most common neoplasms occupying the parapharyngeal space, yet only 107 cases have been previously reported. Neurilemmomas involving the jugular foramen are extremely rare. Only 55 cases have been reported in the world literature. The neoplasm occurred in the parapharyngeal space in three of our patients and in the jugular foramen in another patient. Of the tumors located in the parapharyngeal space, the nerve of origin in one of them was the glossopharyngeal, which is extremely rare. Adequate exposure for complete excision of parapharyngeal space tumors is best obtained through an external incision and should not be attempted transorally. In the jugular foramen case, the neoplasm arose from the vagus nerve high in the neck and extended intracranially in a “dumbbell” shape into the posterior cranial fossa. Total removal was successfully accomplished in one stage, by using a subtotal temporal bone resection — upper neck — posterior cranial fossa approach. Surgical removal is the treatment of choice. Schwannomas rarely recur following complete excision.     

枕骨大孔区脑膜瘤的外科治疗

目的：提高对枕骨大孔区脑膜瘤的认识。方法：回顾性分析我院1993年1月－1999年12月收治的9例枕骨大孔区脑膜瘤,采用枕下正中入路,枕下远外侧入路。结果：肿瘤全切除8例,次全切除1例,无手术死亡,结论：合理选择手术入路能提高肿瘤全切除率和脑神经保护率,枕下远外侧入路是切除枕骨大孔区脑膜瘤的有效手术入路之一。     

Transjugular craniotomy for the management of jugular foramen tumors with intracranial extension.

OBJECTIVES: To elucidate indications and outcomes with the transjugular craniotomy for resection of jugular foramen tumors with intracranial extension. The transjugular approach is a lateral craniotomy conducted through a partial petrosectomy traversing the jugular fossa combined with resection of the sigmoid sinus and jugular bulb, which often have been occluded by disease. STUDY DESIGN: Retrospective review. SETTING: University medical center. PATIENTS: Twenty-eight patients with intracranial jugular foramen tumors who underwent a total of 30 surgical procedures. MAIN OUTCOME MEASURES: Pathologic findings, surgical approach, extent of tumor resection, rate of facial nerve mobilization and ear canal closure, facial and lower cranial nerve outcomes, and hearing preservation. RESULTS: Tumors included schwannoma (37%), meningioma (33%), glomus jugulare (23%), and chordoma (7%). The surgical approaches were tailored to maximize functional preservation, and included the transjugular (53%), translabyrinthine (17%), retrosigmoid (10%), and far lateral (7%) craniotomies. Translabyrinthine (3%) or transcondylarfar lateral (3%) approaches were occasionally used in combination with the trans-jugular approach. Most procedures were managed in a single stage (90%), but three patients with massive tumor in the neck required two stages. Microsurgical gross total and near-total tumor removal (37% each) were commonly achieved, although subtotal resections (27%) were occasionally performed. In only a minority of cases was facial nerve mobilization (7%) or ear canal closure (21%) required. If present preoperatively, Grade I facial nerve function was usually maintained (22 of 24 [92%]) and Hearing Class A or B could always be maintained (9 of 9 [100%]). As expected, new lower cranial nerve dysfunction was common (8 of 30 [27%]), although over half of the patients had complete lower nerve palsy preoperatively (16 of 30 [53%]). CONCLUSION: Most patients with jugular foramen tumors with intracranial extension can be managed with a single-stage transjugular craniotomy. Facial nerve mobilization or ear canal closure is usually not required, permitting conservation of facial function and hearing, when present preoperatively.     

Anomalies of transverse and sigmoid sinuses associated with contracted jugular foramina

Variations of the durai venous sinuses may present puzzling diagnostic and operative problems in the presence of thrombophlebitis. Such variations in sinuses of the posterior cranial fossa are usually associated with contracted jugular foramina and a small internal jugular vein. In the present study 214 sides of the bases of the macerated skulls were examined for the contracted jugular foramen and associated anomalies of the durai venous sinuses. In ten sides (4.67%) out of these an anomaly of the durai sinus of the posterior cranial fossa was found (two of right side and eight of left side). Out of these one case of right side was associated with the absence of groove for both transverse and sigmoid sinuses. All other cases were associated with the absence of groove for transverse sinus alone on the abnormal side. In seven cases out of these the jugular foramen was contracted on the abnormal side. The embryological basis and clinical significance of the anomalies of transverse and sigmoid sinuses is discussed here.