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。     

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。     

内镜经口入路颈静脉孔区神经鞘瘤切除术

目的 探讨内镜经口入路切除颈静脉孔区神经鞘瘤的可行性及效果.方法 采用单纯内镜经口入路切除9例颈静脉孔区神经鞘瘤,其中男3例,女6例;年龄15 ～61岁;临床表现:舌下神经麻痹8例次,迷走神经麻痹6例次,舌咽神经麻痹3例次,面神经麻痹1例次,听力下降1例次.结果 9例颈静脉孔区神经鞘瘤均获得完全切除,且保留了该区域的颅神经功能.除1例患者术后出现暂时性吞咽困难及患侧迷走神经麻痹的并发症外,未见其他并发症发生.9例患者术后随访4-29个月,平均14.3个月,所有患者迷走神经和舌咽神经麻痹均得到了改善和恢复,面神经麻痹和听力下降得到了恢复,舌肌运动获得了改善,但半舌萎缩无明显变化.结论 内镜经口人路可以安全、彻底、微创地切除颈静脉孔区神经鞘瘤,并且能够保留和改善后组颅神经功能.     

颈静脉孔哑铃形神经鞘瘤

报告一例49岁男性颈静脉孔神经鞘瘤患者、MKI检查人加权显示左颈静脉孔有一增强的哑铃形肿块，较小部分位于左小脑桥脑角，较大的部分位于左咽旁间隙。放射科报告可能为颈静脉孔颅神经肿瘤。手术采用经左颈、乳突根治和枕下颅骨切开术切除整个肿瘤，并切除乙状窦和颈静脉球，颈内静脉的大段和第IX一见颅神经一起被切除。舌下神经不能保留，因肿瘤和此神经严重粘连。用腹直肌鞘的前板封闭硬脑膜，用游离的腹直肌瓣填塞顿外的缺损。最后做气管切开，预防吸入性肺炎。患者虽有轻度左面瘫和IX～I颅神经麻痹，但术后经过无特殊发生。水后第22…     

颞骨和颞下窝联合入路侧颅底肿瘤切除术

目的探讨安全和彻底摘除广侵侧颅底及其相邻区的肿瘤的手术入路和方法。方法通过颞骨和颞下窝联合入路,应用显微外科技术摘除肿瘤,并尽可能维护或重建颅底和颅神经。结果６２例侧颅底良、恶性肿瘤（巨细胞瘤１２例、神经鞘瘤９例、骨瘤４例、骨化纤维瘤２例、颈静脉球瘤９例、脑膜瘤２例、粘液软骨瘤１例、先天性胆脂瘤２例、鳃源性囊肿３例、外耳道中耳癌１４例和鼻咽癌４例）,经术后随访５年或５年以上,无复发为４２例（６７．７％）,带瘤生存为１６例（２５．８％）,死亡为４例（６．５％,均为恶性肿瘤）。无颅内外感染、脑脊液漏或皮瓣坏死等并发症。结论颞骨和颞下窝联合入路适用于侵及颞骨、颅中窝、颅后窝和颞下窝等多解剖区肿瘤的手术切除。     

CT与MRI在颈静脉孔区肿瘤鉴别诊断中的价值

探讨CT与MRI在颈静脉孔区各型肿瘤的鉴别诊断价值。结合文献回顾性分析9例经手术病理证实的颈静脉孔区肿瘤的CT或MRI资料。对CT与MRI显示颈静脉球瘤（2例）、神经鞘瘤（3例）、脑膜瘤（2例）、脊索瘤（1例）及中耳癌（1例）在颈静脉孔改变,病灶的内部结构、病灶生长侵犯方向与范围进行分析。CT与MRI在颈静脉孔区各型肿瘤鉴别诊断中有重要价值。     

颈静脉孔神经鞘瘤的手术治疗

报告1986～1992年在德国汉诺威Nordstadt医院手术治疗的16例颈静脉孔神经鞘瘤。其中男11例，女5例，平均年龄43岁。初始症状有：听力下降（50％）、头痛（66％）、声嘶（38％）、咽下困难（38％），另有1例肩部无力，1例面部感觉异常。在病程进展期，有75％出现感音神经性聋，31％出现舌肌无力，25％出现面瘫，13％出现三叉神经分布区感觉异常，44％出现小脑机能障碍。根据放射学及手术所见，将肿瘤分为以下四型：A型，肿瘤起源于桥小脑角，颈静脉孔侵犯较轻；B型，肿瘤起源于颈静脉孔，向颅内或依外扩展；C型，肿瘤起源于颈外，并侵入颈…     

小脑脑桥角脑膜瘤的显微手术治疗

目的：提高小脑脑桥角（CPA）脑膜瘤的显微手术治疗效果。方法：回顾性分析27例CPA脑膜瘤，根据影像学特征及肿瘤生长方式分为3种类型：Ⅰ型肿瘤基底位于内听道附近者（包括向天幕下生长者）12例；Ⅱ型肿瘤基底在CPA和岩尖向中上斜坡及中颅窝延伸者12例；Ⅲ型肿瘤基底在颈静脉孔附近主要向枕骨大孔延伸者3例。Ⅰ型采用枕下乙状窦后入路；Ⅱ型采用颞枕开颅乙状窦前入路；Ⅲ型采用枕下开颅远外侧入路。结果：按脑膜瘤切除Kabayashi法分级：Ⅰ级4例，Ⅱ级6例，Ⅲ-ⅣA级7例。2例于术后2周内因脑干缺血、水肿或肺部感染死亡。20例随访（平均3.8年），19例恢复良好。2例肿瘤复发，行伽玛刀治疗。结论：Ⅰ型经CPA开颅乙状窦后入路手术切除容易，主要注意保护面神经和听神经；Ⅱ型采用颞枕开颅乙状窦前入路肿瘤全切除可能性大；Ⅲ型采用枕下开颅远外侧入路肿瘤暴露佳，但要注意后组脑神经的保护。     

乙状窦后入路切除颈静脉孔区哑铃形肿瘤

目的 探讨颈静脉孔区哑铃型肿瘤的手术入路及治疗效果。方法 回顾性分析采用枕下乙状窦后入路切除4例颈静脉孔区哑铃型肿瘤的临床资料。结果 肿瘤全切除3例，大部切除1例，无手术死亡及严重并发症。结论 经乙状窦后入路可以安全切除哑铃型颈静脉孔区肿瘤。术中应注意保护好后组颅神经。     

颈静脉孔应用显微解剖及其临床价值

目的 深入了解颈静脉孔的显微解剖学特点,探讨如何充分显露颈静脉孔结构。方法 本研究利用１０例（２０侧）福尔马林固定的成人头颈标本,采用颞下窝入路（Ａ型）对静脉孔区的结构进行显微解剖学观察。结果 １４侧颈静脉孔可划分为前、后两部分,Ⅸ神经位于颈静脉孔前腔隙,Ｘ、Ⅸ神经和颈静脉球位于后腔隙,Ｘ、Ⅸ神经位于颈静脉球的内侧面;４例标本中颈静脉孔划分成前、中、后三部位,Ⅸ神经位于前腔隙,Ｘ、Ⅸ神经位于中腔隙     

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。     

Conservative facial nerve management in jugular foramen schwannomas

OBJECTIVE: Although transposition of the facial nerve is crucial in infiltrative vascular lesions involving the jugular foramen, the objective was to show that a conservative approach to management of the facial nerve is sufficient with jugular foramen neuromas because of their noninfiltrative, less vascular nature and medial location in the jugular foramen. STUDY DESIGN: Retrospective case review. SETTING: Tertiary, private, multiphysician, otologic practice. PATIENTS: Sixteen patients with jugular foramen schwannoma (18 procedures) treated between January 1975 and October 1995. The 8 male and 8 female patients ranged in age from 13 to 66 years (mean age 47.7 years). INTERVENTION: One-stage, total jugular foramen neuroma removal without transposition of the facial nerve, using a variety of surgical approaches. MAIN OUTCOME MEASURES: Facial nerve transposition (yes or no), House-Brackmann facial nerve grade, lower cranial nerve status, complications. RESULTS: One-stage total tumor removal was accomplished in all the cases. In 13 (72%) of the neuromas, removal was accomplished without facial nerve transposition. Transposition was performed in 2 revision cases in which scar tissue from a previous operation prevented complete control of the carotid artery and safe removal, 2 cases with large tumor extension anteriorly to the petrous apex, and 1 case with extensive involvement of the middle ear. A House-Brackmann facial nerve Grade I or II was obtained in 16 of the 18 procedures, with 1 Grade III and 1 case that remained Grade V, as it was preoperatively. CONCLUSIONS: One-stage, total tumor removal can be achieved with excellent control of the important vascular structures and without transposition of the facial nerve in a majority of jugular foramen schwannomas.     

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。     

颈静脉孔区脑神经鞘瘤

目的探讨颈静脉孔区脑神经鞘瘤的诊断和治疗。方法总结2001年11月至2005年6月手术治疗的11例颈静脉孔区脑神经鞘瘤，其中颅内型5例，颈静脉孔型3例，颈部型1例，混合型2例。手术方法包括迷路进路3例，乙状窦后进路2例，颞下窝进路6例。结果11例手术均全切除肿瘤。术后无一例出现死亡、偏瘫、昏迷及颅内出血等严重并发症。2例乙状窦后进路患者术后听力仍部分保留。术中均保留面神经解剖完整性。面神经功能采用House-Braekmann分级，颅内型5例，术后I级2例，Ⅱ级2例，Ⅳ级1例。颞下窝进路6例，术后Ⅰ级1例，Ⅲ级1例，Ⅳ级2例，V级2例；其中面神经功能Ⅰ级者术中未行面神经移位。术前后组颅神经障碍者9例，术后后组颅神经障碍者11例。吞咽功能出院前完全代偿者7例，基本代偿者1例，部分代偿者2例，失代偿者1例；术后6个月除1例失代偿者仍需长期软食，部分代偿外，其余10例均能正常饮食。11例患者术后均出现声嘶，术后6个月，声嘶均好转。术后有2例患者出现脑脊液漏，表现为切口处皮下积液，均经局部加压包扎后好转，其中1例于术后2个月再次出现脑脊液漏，经局部麻醉下漏口修补后治愈。11例患者均未出现颅内感染。结论颈静脉孔区脑神经鞘瘤手术效果好，依据磁共振成像检查对肿瘤分型采取不同的手术方法。对颅神经功能的保护和锻炼是治疗的重点。     

Clinical Presentation and Management of Jugular Foramen Paraganglioma

Objectives

Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.

Methods

Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications.

Results

Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications.

Conclusion

Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.     

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.     

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.     

Schwannomas of the jugular foramen

Schwannoma is an important entity in the differential diagnosis of the enlarged jugular foramen. Our recent experience with 4 consecutive large schwannomas over a 12-month period is presented. As these tumors are usually less vascular than glomus jugulare tumors, they are frequently more amenable to surgical extirpation. Radiologic clues to their identity include discrete borders and less angiographic vascularity when compared with glomus jugulare tumors. Our operative treatment of these cases has evolved to include preoperative embolization with Ivalon sponge particles, followed by a lateral temporal bone resection in exposing the jugular foramen. A posterior fossa craniotomy is done as a second stage when necessary. This staging allows for less morbidity and greater chance for total tumor removal. The surgical technique and relevant anatomy are reviewed and illustrated.     

Jugular foramen schwannoma: analysis on its origin and location.

OBJECTIVE: To examine the microsurgical anatomy of the jugular foramen and correlate anatomical findings to clinical manifestations of jugular foramen schwannomas concerning tumor origin and location. STUDY DESIGN: Anatomical analysis of jugular foramen was performed by dissection of 25 cadavers (50 sides). By retrospective review of 9 cases of jugular foramen schwannomas surgically treated, the origin and location of tumor were studied. SETTING: Tertiary referral center. MAIN OUTCOME MEASURES: The anatomical characteristics of jugular foramen, lower cranial nerves, and inferior petrosal sinus were correlated with the origin and growth pattern of jugular foramen schwannomas. RESULTS: The superior and inferior ganglions of the glossopharyngeal nerve and the superior ganglion of the vagus nerve were located within the jugular foramen. The superior ganglions of the glossopharyngeal and vagus nerves were located superiorly, whereas the inferior ganglion of the glossopharyngeal nerve was found inferiorly in relation to the inferior petrosal sinus orifice. In our series of 9 cases of jugular foramen schwannoma, the most common nerve of origin was the vagus nerve, followed by the glossopharyngeal nerve. CONCLUSION: The reason for the predilection of the jugular foramen schwannoma for the glossopharyngeal and vagus nerves may be associated with the presence of their ganglions within the jugular foramen. Also, the inferior petrosal sinus may act as a barrier to tumor growth, and the location of the ganglion of tumor origination within the jugular foramen in relation to the inferior petrosal sinus may be correlated to the predominant direction of tumor extension.