经岩颅中窝进路治疗岩斜坡和脑干肿瘤

经耳蜗进路、额岩进路及领下小脑幕进路手术治疗岩斜坡病变有损伤耳蜗、颅神经和运动神经之虞。本文介绍了5例经岩颅中窝进路治疗岩斜坡和脑干肿瘤的经验。手术方法：行颅中窝开颅术,骨窗平颅中窝底,有达颧弓根前至少Zcm以上以充分暴露岩尖中前部,切开、下翻硬脑膜,向中线牵拉领叶、暴露岩尖、颅中窝底及脑干,可见三叉神经自脑干发出并进入Meckel’s腔,不处理硬脑膜中动脉,通常不需切开天幕;用金刚石电钻磨除Kawase氏三角（颈内动脉、耳蜗底及第工、见对颅神经之间区域）骨质：首先将硬脑膜自颅中窝底分离,注意勿损伤膝状神经节…     

颅底与累及颅底区肿瘤的手术治疗(附88例报告)

目的总结颅底与累及颅底区肿瘤的手术治疗效果。方法前颅底区肿瘤58例(良性8例,恶性50例)采用鼻骨移位进路前颅底大块切除和附加前额开窗,颅面联合切除;侧颅底区肿瘤27例(良性12例,恶性15例),良性肿瘤采用乳突切除进路和颈侧切开进路切除,恶性肿瘤分别采用颞骨次全切除高位颈侧切开进路、颅中窝进路和颞下窝颈侧切开下颌骨外旋联合进路三种进路切除;鼻咽部3例巨大良性肿瘤,采用鼻腔上颌窦与软腭切开进路切除。结果23例良性肿瘤经1～3年随访,除1例术后复发行再次手术切除外,其余均无复发。65例恶性肿瘤经5年以上随访。50例前颅底区恶性肿瘤3年生存率为64%,5年生存率为46.8%;15例侧颅底区恶性肿瘤3年生存率为46.7%,5年生存率为26.7%。远期疗效较低与本组多为晚期病例有关。结论本组病例根据肿瘤发生的部位、侵犯范围和病理类型所采用的手术进路,能充分暴露病变,有利于肿瘤的切除,从而取得了较好的治疗效果,未发生严重并发症。     

颅中窝-乳突联合进路面神经减压术

目的探讨颅中窝-乳突联合进路面神经减压手术适应症、手术方法效果。方法对2000年1月—2007年4月收治的5例外伤性面瘫（House-Brackmann分级Ⅳ-Ⅴ级）患者行颅中窝-乳突联合进路面神经减压术。结果5例行颞骨高分辨CT扫描均显示颞骨骨折,3例显示颅中窝底突起的骨碎片,流泪试验均为阳性。术后随访1-2年,2例面瘫Ⅳ级、2例面瘫Ⅴ级患者完全恢复,1例面瘫Ⅴ级患者恢复至Ⅲ级。结论根据颞骨高分辨CT扫描和流泪试验判断面神经损伤的部位以选择手术进路,颅中窝-乳突联合进路适于面神经全程减压术。     

颞下窝-翼腭窝-咽旁间隙肿瘤手术进路探讨

目的：探讨如何选择最佳手术进路切除颞下窝-翼腭窝-咽旁间隙肿瘤,以提高疗效,减少并发症和后遗症。方法：回顾性分析66例颞下窝、翼腭窝、咽旁间隙肿瘤患者,包括组织学诊断、影像学检查及手术人路。结果：50例良性肿瘤患者术后随访2～5年,均无复发;16例恶性肿瘤患者,术后随访2～5年,生存期不足1年4例,2～4年8例,5年及以上4例。结论：扩大上颌骨切除术适于上颌窦原发恶性肿瘤侵及翼腭窝、颞下窝和（或）咽旁间隙的患者;面正中揭翻术适于鼻腔、鼻窦、鼻咽及翼腭窝良性肿瘤及局限的恶性肿瘤患者;颈侧高位切开下颌骨外旋人路术适于咽旁间隙肿瘤累及翼腭窝和（或）颞下窝的患者;颈颌径路-下颌骨截骨术适于咽旁间隙-颞下窝良、恶件肿瘤侵犯侧颅底及翼腭窝的患者。     

颅中窝-侧颅底沟通性恶性肿瘤的手术治疗

目的 探讨颅中窝．侧颅底沟通性晚期恶性肿瘤的手术治疗方法。方法 16例颅中窝-侧颅底沟通性恶性肿瘤分别采用了：①耳后“C”形切口,颞骨次全切除进路与高位颈侧切开联合进路行颅中窝-侧颅底和腮腺区肿瘤切除6例;②颞侧舌形切口,颅中窝进路颅内外肿瘤切除4例;③颞-耳-下颌骨外旋进路行咽旁、颞下窝、颅中窝肿瘤切除6例。其中13例术后进行放射治疗。结果 16例中11例术后存活3年以上,5例术后3年内死亡。按寿命表法统计,3年生存率为69％。结论 本组所采用的三种手术方式,能较好地暴露颅内外病变,并进行肿瘤切除。对颅底区晚期恶性肿瘤采用手术及术后放射治疗等积极措施可取得一定的治疗效果。     

颅中窝-侧颅底沟通性恶性肿瘤的手术治疗

目的　探讨颅中窝 侧颅底沟通性晚期恶性肿瘤的手术治疗方法。方法　 16例颅中窝 侧颅底沟通性恶性肿瘤分别采用了 :①耳后“C”形切口 ,颞骨次全切除进路与高位颈侧切开联合进路行颅中窝 侧颅底和腮腺区肿瘤切除 6例 ;②颞侧舌形切口 ,颅中窝进路颅内外肿瘤切除 4例 ;③颞 耳 下颌骨外旋进路行咽旁、颞下窝、颅中窝肿瘤切除 6例。其中 13例术后进行放射治疗。结果16例中 11例术后存活 3年以上 ,5例术后 3年内死亡。按寿命表法统计 ,3年生存率为 6 9%。结论本组所采用的三种手术方式 ,能较好地暴露颅内外病变 ,并进行肿瘤切除。对颅底区晚期恶性肿瘤采用手术及术后放射治疗等积极措施可取得一定的治疗效果     

累及翼突鼻咽纤维血管瘤的手术方法—附5例报告

目的：探讨源于翼突鼻咽纤维血管瘤的手术治疗方法和意义。方法：采用硬腭－唇龈联合进路，切除上颌结节部和部分上颌窦后外侧壁，暴露翼突内外板，将翼突与肿瘤整块切除。结果；5例随访，5年1例，3年，2年各2例，均无复发。结论：切除肿瘤附着的翼突，防止肿瘤术后复发和术中出血是有效的。     

扩大的颅中窝进路作听神经瘤切除术

作者们报告了经颅中窝、迷路-小脑幕进路,作为改良的扩大颅中窝进路。论述了该进路的优点。这些结果是用三种类型颅中窝进路完成37例听神经瘤和其他小脑脑桥角肿瘤摘除术经验基础上取得的。手术进路的选择:(1)颅中窝进路,为House所介绍,适应局限于内耳道的听神经瘤。(2)扩大的颅中窝进路,为多数有经验的神经-耳科医师们所采用,同时作了不同的改进。适应于术前估计不足、从内耳门突入颅后窝1.0～1.5     

改良外鼻锥体侧翻术在颅底肿瘤手术中的应用

目的:介绍改良外鼻锥体侧翻术在颅底肿瘤手术的临床应用。方法:回顾性研究改良外鼻锥体侧翻术治疗的20例颅底肿瘤的诊断及外科手术治疗结果。结果:20例颅底肿瘤均累及鼻腔、双侧筛窦、蝶窦及眶内侧壁。侵犯翼腭窝、颞下窝2例,侵犯颅内者2例;均行改良外鼻锥体侧翻术治疗,其中2例鼻咽纤维血管瘤患者同时行额颞颧开颅及大部分上颌骨移位手术;2例行颅面联合入路手术。术后10例患者行放疗。患者术后无手术并发症,随访8～60个月,有6例肿瘤复发。结论:改良外鼻锥体侧翻术是治疗鼻腔、筛窦、蝶窦肿瘤累及颅底的一种安全、有效的外科治疗方法;在肿瘤向翼腭窝、颞下窝及颅内侵犯时应辅以其他手术入路。     

改良的面中部揭翻术

标准的面中部揭翻术于 1974年由 Casson等介绍 ,该术式包括一长的唇下切口 ,切开软骨、梨状孔和鼻底 ,广泛的面中部骨膜下剥离暴露术区。随后此术为Conley和 Price(1979)推广。此标准术式可较好的窥视鼻腔、鼻咽部 ,但由于上外侧软骨和鼻骨仍与面中部相连使暴露受限。因而不少学者对此术作改良 ,代表性的有 Pahvolaine和 Malmberg(1986 )等采用鼻中隔贯穿性切开和双侧鼻外侧软骨切断的方式 ,使上部外侧软骨和鼻骨及下部外侧软骨从面中部分离 ,更好地暴露鼻后部、鼻咽 ,尤其是鼻额管、筛板区等。作者认为此改良术式不仅术野暴露好 ,且并发…     

Distance from acoustic neuroma to fundus and a postoperative facial palsy.

OBJECTIVE/HYPOTHESIS: Generally, patients with small acoustic neuroma have less facial palsy after its removal. The middle cranial fossa approach is mainly applied to the small acoustic neuroma and tumor size does not influence the prognosis of facial palsy. The internal auditory canal cannot be fully opened in the middle cranial fossa approach, and the facial nerve is tightly attached in the fundus. According to these anatomical factors, we hypothesized that acoustic neuromas located away from the fundus might be removed with less facial nerve damage. We investigated the distance between the acoustic neuroma and fundus and its clinical relationship. STUDY DESIGN: Retrospective study of 45 patients with acoustic neuroma who underwent a middle cranial fossa approach. METHODS: The distance between the acoustic neuroma and fundus and the tumor diameter were measured on T2-weighted and contrast-enhanced magnetic resonance images, respectively. These data were compared with the postoperative facial nerve function. RESULTS: The mean distance was 3.0 +/- 1.8 mm (range, 0-10 mm), and the mean diameter was 11.3 +/- 3.7 mm (means +/- standard deviation; range, 4-20 mm). Neither the distance nor the diameter had any correlation to the degrees of postoperative facial palsy either immediately or at 3 months after surgery. CONCLUSIONS: As far as the nerve was anatomically preserved, postoperative facial nerve function seemed to be influenced by factors other than surgical manipulation among small acoustic neuromas. Although the tumor fills in the fundus, it may not influence postoperative facial nerve function and also may not interfere with indication of the middle cranial fossa approach for removal of the acoustic neuroma.     

累及颅底肿瘤的手术切除与入路选择

目的　探讨颅底肿瘤切除的最佳手术入路。方法　回顾分析 1993～ 2 0 0 0年中国医学科学院中国协和医科大学肿瘤医院外科处理侵及颅底肿瘤 84例的经验 ,讨论侵及颅底不同部位病变手术入路特点 ,以求选择最好的手术入路彻底切除肿瘤 ,同时尽量保护颅底、颅内重要结构 ,减少并发症。结果　患者年龄 6～ 78岁 ,平均 4 3 8岁。良性肿瘤 14例 ,恶性肿瘤 70例。采用各种手术入路切除累及咽旁颅底肿瘤 38例 ;同时有前、中颅底破坏 7例 ;肿瘤同时累及中、后颅底 13例 ;侧颅底颞下窝肿瘤 2 6例。用各种组织瓣修复颅底缺损或填充 6 0例。 6例并发脑脊液漏 ,2例迟发脑脓肿 ,修复组织瓣部分坏死 3例 ,无手术死亡及严重颅脑并发症。恶性肿瘤 3年生存率 6 7 5 % (2 7/ 4 0 )。结论　最佳手术入路的选择应相对于颅底不同部位的肿瘤 ,针对特殊的解剖结构而选择 ,可以根据以下几个因素综合考虑 :①肿瘤部位及累及的范围 ;②安全、充分地切除肿瘤 ;③正常功能结构及外观影响小 ;④便于可靠有效地修复     

颞骨和颞下窝联合入路侧颅底肿瘤切除术

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。     

A case report of facial nerve hemangioma

Facial nerve hemangioma is a rare benign tumor that originates from the venous plexus surrounding the facial nerve. A case of facial nerve hemangioma in the geniculate ganglion was reported.

A 47-year-old man was referred with a left progressive facial palsy over 1 year. There were no complaints of associated hearing loss, tinnitus, headache, dizziness or otalgia. He had a left-side grade VI (House and Brackmann) facial palsy. Audiometry revealed normal hearing thresholds in conversation area bilaterally. CT imaging demonstrated a tumor at the left first genu of the facial nerve with expansion to the cochlea wall and middle skull base. MRI imaging demonstrated a centrally enhancing lesion measuring 5 mm × 10 mm in the geniculate ganglion. The tumor was totally removed by the middle cranial fossa approach. At the time of surgery the facial nerve was destroyed by the tumor in the geniculate ganglion. Histopathological examination diagnosed a hemangioma.     

累及颅底肿瘤的手术切除与入路选择

目的 探讨颅底肿瘤切除的最佳手术入路。方法 回顾分析1993－2000年中国医学科学院中国协和医科大学肿瘤医院外科处理侵及颅底肿瘤84例的经验，讨论及颅底不同部位病变手术入路特点，以求选择最好的手术入路彻底切除肿瘤，同时昼保护颅底、颅内重要结构，减少并发症。结果 患者年龄6－78岁，平均43．8岁。良性肿瘤14例，恶性肿瘤70例。采用各种手术入路切除累及咽旁颅底肿瘤38例；同时有前、中颅底破坏7例；肿瘤同时累及中、后颅底13例；侧颅底颞下窝肿瘤26例。用各种组织瓣修复颅底缺损或填充60例。6例并发脑脊液漏，2例迟发脑脓肿，修复组织瓣部分坏死3例，无手术死亡及严重颅脑并发症。恶性肿瘤在3年生存率67．5％（27／40）。结论 最佳手术入路的选择应相对于颅底不同部位的肿瘤，针对特殊的解剖结构而选择，可以根据以下几个因素综合考虑：①肿瘤部位及累及的范围；②安全、充分地切除肿瘤；③正常功能结构及外观影响小；④便于可靠有效地修复。     

额—耳前—颈联合入路切除巨大侧颅底沟通性肿瘤

目的 探讨适宜切除巨大侧颅底肿瘤的手术途径。方法 应用额-耳前-颈联合入路，制作眶颧骨瓣及颅骨骨瓣，结合下颌骨脱位下移，获得了充分暴露肿瘤的术野，治疗2例占据咽旁间隙、颞下窝穿颅底达颅中窝的巨大侧颅底沟通性肿瘤。结果 2例肿瘤均获得全切，术后患者恢复良好，均未发生脑脊液泼等任何颅内并发症，面部无明显畸形，咬合正常。结论 额-耳前-颈联合入路是用于切除巨大咽旁间隙、颞下窝、侵入颅中窝的侧颅底良、恶性肿瘤较理想的手术途径。     

Facial nerve hemangioma of the geniculate ganglion: An endoscopic surgical approach

Facial nerve hemangiomas are rare benign tumors arising from the venous plexus surrounding the facial nerve. Surgical management of these tumors is controversial. The goal of surgery is complete tumor removal with restoration of facial nerve function and preservation of hearing, wherever possible. The approaches most used are the translabyrinthine and middle cranial fossa approaches. In this report, we describe the first facial hemangioma treated with an endoscopic transcanal approach, combined with a retroauricular transmastoid minicraniotomy for closure of the dural defect. A great auricular nerve graft was used to reconnect interrupted nerve segments. Histopathological examination confirmed the diagnosis of a hemangioma of the first genu of the facial nerve. With magnification of the structures, the transcanal endoscopic approach allowed a radical excision of the neoplasm permitting hearing function preservation, with the possibility to work with a minimally invasive approach with respect to the labyrinthine block and cochlea. Compared to a middle cranial fossa approach, the transcanal endoscopic approach avoided labyrinthine block removal and brain retraction.     

上颌骨翻转入路在头颈肿瘤手术中的应用

目的 评价上颌骨翻转入路在鼻咽咽旁颅底及颞下窝肿瘤手术中的应用。方法 回顾1995年1月—2005年1月中国医科院肿瘤医院头颈外科应用上颌骨翻转入路手术切除60例鼻咽、咽旁颅底及颞下窝肿瘤。51例原发于鼻咽或中颅底，9例原发颞下窝。13例良性肿瘤，47例为恶性肿瘤，其中28例术前接受过放射治疗。结果 全部病例无手术相关的较重的功能障碍及外观畸形。常见并发症是腭鼻漏12例及部分骨坏死2例，均见于鼻咽癌放疗后患者。用kaplan-Meier法计算恶性肿瘤累积5年生存率与无瘤生存率分别为76．4％和36．3％，良性肿瘤分别为100％和90％。结论 上颌骨翻转入路在处理头颈鼻咽、咽旁颅底及颞下窝肿瘤时被证明是良好的选择之一，该手术路径为这些区域提供良好的手术显露和肿瘤的安全切除，以最低限度的外貌和功能影响及较少的并发症而可获得好的治疗效果。     

Microsurgical anatomy of the perigeniculate ganglion area as seen from the middle cranial fossa approach

The middle cranial fossa approach is useful for decompressing the perigeniculate ganglion area of the facial nerve in patients with serviceable hearing. The present study was designed to investigate the microsurgical anatomy of the perigeniculate ganglion area of the facial nerve from the point of view of the middle cranial fossa. We dissected 20 human temporal bones under a microscope using a middle fossa approach, and measured the angle between the lines drawn from the malleus head to the vertical crest and from the malleus head to the geniculate ganglion, and the distance from the malleus head to the geniculate ganglion. These were found to be 22.7 degrees +/- 2.2 degrees and 6.5 +/- 0.3 mm, respectively. Detailed knowledge about the microsurgical anatomy of the perigeniculate ganglion area of the facial nerve from the point of view of the middle cranial fossa is imperative for facial nerve decompression by a middle cranial fossa approach.     

Skull base dumbbell tumor: surgical experience with two adolescents.

Pediatric skull base tumors are rare and until recently were considered unresectable. We present two patients with tumors of similar anatomic position with an extracranial component in the infratemporal fossa and parapharyngeal space, an isthmus at the foramen ovale, and a superior component in the middle cranial fossa in the region of the cavernous sinus. A 15-year-old girl experienced contiguous spread of a spindle cell sarcoma; an 18-year-old boy developed a chondrosarcoma. A middle fossa approach provided the advantage of surgical avoidance of structures such as the middle ear and mastoid, facial nerve, and mandible. Postoperative recovery was rapid. Our impression is that preoperative carotid artery occlusion and a middle fossa approach for tumor resection can be performed in a young patient with acceptable morbidity and at least short-term benefit. Surgery can, therefore, provide an additional therapeutic approach to complement irradiation and chemotherapy.