The infratemporal fossa approach to skull base surgery.

The infratemporal fossa approach, in conjunction with the application of microsurgical technique and improved perioperative care, has permitted significant advances in lateral skull base surgery. The glomus jugulare tumor is the prototypical neoplasm resected by this approach, although this technique can be applied to a host of additional benign and malignant lesions of the skull base. This approach entails identification and control of the cranial nerves and great vessels in the neck, anterior transposition of the facial nerve, and infralabyrinthine petrosectomy. Intracranial tumor extension and petrous carotid artery involvement remain limiting factors. Significant morbidity, particularly neurologic deficit and hemorrhage, may occur due tot the nature and location of lateral skull base tumors. Recent advances in preoperative embolization and temporary carotid artery balloon occlusion have advanced the limits of resection via the infratemporal fossa approach.     

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。     

儿童侧颅底肿瘤的诊断和治疗

目的:探讨儿童侧颅底肿瘤的临床特点、诊断及治疗方法.方法:回顾性分析8例儿童侧颅底肿瘤的临床表现、影像学特点及治疗方法.其中颞部并中、后颅窝巨大三叉神经鞘膜瘤1例.颞部并中、后颅窝黑色素神经外胚层肿瘤1例,婴幼儿颞骨纤维瘤病1例,斜坡脊索瘤1例,鼻咽部胚胎型横纹肌肉瘤2例,神经母细胞瘤2例.1例经颞下窝Fisch C型及迷路上联合径路、1例经岩骨径路、4例经颞下窝Fisch C型径路将肿瘤全切除,1例经腭径路行肿瘤次全切,1例单纯行化疗未做手术.7例手术患儿中4例术前、术后化疗,3例术后化疗.结果:除1例脊索瘤患儿术后5个月复发死亡外,其余7例患儿均存活(6例手术、1例未手术),其中2例鼻咽部胚胎型横纹肌肉瘤术后小灶复发,1例神经母细胞瘤化疗后未行手术的患儿,6个月后复发.除术前1例外展神经、3例三叉神经受累及外,术后2例出现短暂脑脊液漏,1例同侧听力丧失.1例声嘶(同侧声带外展麻痹),2例吞咽困难,术后3～4个月渐恢复.7例手术患儿均无伤口感染裂开及皮瓣坏死,未出现面瘫、脑膜炎及偏瘫、死亡等严重并发症.结论:儿童侧颅底肿瘤生长部位深在、临床症状复杂多样、隐匿、不典型,往往确诊时已为晚期,积极行CT和MRI检查有助于提高早期诊断率.手术切除肿瘤仍为首选,手术前后配合放、化疗.手术径路的选择应依据病变的部位和范围,颞骨和颞下窝联合径路可以最大限度切除侵及该区域的肿瘤,保存脑神经功能,减少并发症.     

Anterolateral and lateral skull-base approaches for treatment of neoplastic diseases

PURPOSE: Neoplasms affecting the anterolateral and lateral skull base have different sites of origin and histology, and its resection is technically difficult. The purpose of this study was to describe the surgical outcome and overall and disease-free survival of patients who had anterolateral and lateral skull base procedures for treatment of neoplasms with and without adjuvant therapy. MATERIALS AND METHODS: A retrospective study was performed on 26 patients who underwent anterolateral or lateral skull-base procedures through subcranial approaches such as maxillectomy with ethmoidectomy, osteoplastic maxillotomy, transmandibular, infratemporal, and transtemporal/infratemporal techniques for treatment of neoplastic diseases. Twenty-one cases were malignancies, with no evidence of metastasis. These approaches were combined frequently with a transbasal, pterional, subtemporal, or temporo-occipital craniotomy. Survival and disease-free intervals were evaluated with the Kaplan-Meier product limit method. RESULTS: Nine cases were maxillary antrum malignancies with extension to the middle fossa and/or infratemporal fossa, 7 with nasopharyngeal neoplasms, 3 malignant lesions in the infratemporal fossa, and 3 with auditory canal carcinomas. The rest had miscellaneous diagnosis. Major morbidity occurred in 15% of cases. Perioperative mortality was 0. From 21 cases with malignancies, 4 had recurrences and the overall survival was 78% at 36 months of follow-up. CONCLUSION: Anterolateral and lateral skull-base surgery is done with low morbidity and no operative mortality. The oncologic results are better than those reported in the literature probably because of a stringent selection of cases, although a longer follow-up period is required.     

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。     

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。     

Infratemporal fossa approach to tumours of the temporal bone and base of the skull.

In spite of the development of a superior (middle cranial fossa) and posterior (translabyrinthine) approach to the temporal bone, tumours situated in the infralabyrinthine and apical compartments of the pyramid and surrounding base of the skull were still a challenge for neurosurgeons and otologists as well. The infratemporal fossa approach closes the existing gap in the surgical management of the most hidden lesions of the temporal bone. The approach features the permanent anterior transposition of the facial nerve, resection of the mandibular condyle and mobilization of the zygoma and lateral orbital rim. Obliteration of the pneumatic spaces of the temporal bone, with permanent occlusion of the Eustachian tube and blind sac closure of the external auditory canal, avoids the danger of post-operative infection and leads to primary wound healing in the shortest time. Three types of infratemporal fossa approach are presented and dicussed on the basis of 51 operated patients.     

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。     

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 ,均未发生脑脊液漏等任何颅内并发症 ,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     

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。     

Surgical treatment of eosinophilic granuloma of the infratemporal fossa: a successful treatment option

The patient was a 16-year-old girl complaining about progressive swelling on the right side of her face, right headache, and right orbital proptosis. A CT scan revealed a lytic mass centered in the greater wing of the right sphenoid bone with extension into the orbit, middle cranial fossa, and infratemporal fossa. The patient underwent a subtemporal-preauricular infratemporal fossa approach, which allowed complete resection of the tumor, with a low morbidity. The pathological diagnosis was eosinophilic granuloma. At 36 months after the initial treatment the patient is free of disease. We conclude that lesions of this complex anatomic area are a challenge to biopsy and treat and they could be treated only with radical surgery with low morbidity, at centers with expertise in skull base surgery.     

Combined subcranial approaches for excision of complex anterior skull base tumors

OBJECTIVE: To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach. PATIENTS: Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured. RESULTS: Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches. CONCLUSION: Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.     

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     

标准面移位进路术治疗颅中窝底前外侧良性肿瘤

目的：观察改良标准面移位进路术治疗颅中窝底前外侧良性肿瘤的可行性及效果。方法：对10例原发于翼腭窝、鼻咽部并向颅中窝海绵窦旁、颞下窝或翼颌间隙呈扩张性生长的较大良性肿瘤行单纯改良标准面移位进路和颅面联合进路2种术式切除,术中对面部切口、上颌骨拆卸、复位、固定、窦内黏膜取舍及鼻腔外侧壁保留等做了部分改进。结果：术后平均随访3年2个月,成功9例,死亡1例,无出血、感染和移位骨坏死脱出等并发症。结论：采用改良标准面移位进路术治疗颅中窝底前外侧良性肿瘤,手术安全,疗效好。     

侵及前颅底肿瘤的再手术治疗

本文收集１９７５－１９９４年间对侵及前颅底肿瘤再手术者９例，其中良性肿瘤２例，恶性７例。有８例采用扩大的鼻侧切开径路，另１例采用鼻侧额眶径路，并就该类手术方法、颅底缺损的处理及并发症等问题进行简要讨论。     

颞下窝肿瘤的外科治疗

目的 :探讨颞下窝肿瘤的手术进路及手术方法。方法 :根据肿瘤病变的性质及范围采用耳前上、耳后下、改良Ferguson Weber及下颌骨下 4种手术进路。 结果 :手术结果按Kaplan Meire生存率计算 ,其 2年生存率良性肿瘤为 10 0 % ,恶性肿瘤为 4 7.1%。结论 :应根据肿瘤部位、性质与相邻解剖关系选择合适的手术进路 ,以保证手术能安全、有效及顺利进行     

Extensive nasopharyngeal angiofibromas: the maxillary swing approach

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibromas. A retrospective analysis in a tertiary care center revealed five cases with extensive nasal angiofibromas operated using the maxillary swing approach between 2010 and 2012. All patients had tumor extension to the lateral-most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus, while another had severe temporal lobe compression through the roof of the infratemporal fossa. All patients underwent tumor excision using the maxillary swing approach. Patients were followed up for a minimum period of 1 year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumor exposure and vascular control could be achieved in all cases resulting in complete tumor excision. The mean operative time was 4.5 h. Post-operative healing was satisfactory with palatal fistula formation in two cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibromas and leads to optimal anatomical exposure with minimal morbidity.     

Robotic skull base surgery: preclinical investigations to human clinical application

OBJECTIVE: To develop a minimally invasive surgical technique for the treatment of parapharyngeal space and infratemporal fossa skull base neoplasms using the technical and optical advantages of robotic surgical instrumentation. DESIGN: A robotics skull base surgery program at the University of Pennsylvania, Philadelphia, was initiated in the fall of 2005. Six experimental procedures focusing on developing approaches to the parapharyngeal space and infratemporal fossa were performed on a total of 2 cadavers and 1 mongrel dog. Based on the preclinical work, transoral robotic surgery (TORS) was then performed in February 2007 on 1 human patient with a parapharyngeal to infratemporal fossa cystic neoplasm as part of a large prospective human trial. SETTING: In each cadaver and in the dog, a TORS approach to parapharyngeal space and infratemporal fossa was performed bilaterally and in an approved training facility using the da Vinci Surgical System. For the human surgical case, a TORS approach was evaluated on one side for a benign neoplasm. The human patient underwent TORS of the parapharyngeal space and infratemporal fossa under an institutional review board-approved prospective clinical trial. PATIENTS: For the human clinical trial, a TORS approach was evaluated for a patient with a benign neoplasm of the parapharyngeal space and infratemporal fossa. MAIN OUTCOME MEASURES: The ability to access and dissect tissues within the various areas of the parapharynx and infratemporal fossa was evaluated, and techniques to enhance visualization and instrumentation were developed. RESULTS: Using TORS approaches permitted excellent access, visualization, and tissue dissection within the parapharyngeal space and infratemporal fossa in both the cadaver and canine experiments. In the first known human surgical case, TORS was used to remove a parapharyngeal space and infratemporal fossa cystic neoplasm. Wide visualization, followed by complete resection using the identical techniques developed in the preclinical models, was achieved. The robotic procedure allowed adequate and safe identification of the internal carotid artery and cranial nerves, and excellent hemostasis was achieved with no complications during or after surgery. CONCLUSIONS: The TORS approaches provided excellent 3-dimensional visualization and instrument access that allowed successful parapharyngeal space and infratemporal fossa surgical resections from cadaver models to the first known human patient application. Robotic surgery for the skull base holds potential as a minimally invasive approach to skull base neoplasms; however, continued development and investigation is warranted in a prospective human clinical trial before final conclusions can be drawn as to the full advantages and limitations of this approach.     

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。     

Skull base surgery for removal of temporal bone tumors

CONCLUSION: When selecting the appropriate surgical approach the pathological type of tumor, the physiological status as well as the functional aspects should be considered. Understanding the strengths and weaknesses of each surgical technique and knowledge of the particular tumor biology facilitates selection of the most appropriate surgical approach and a successful outcome. OBJECTIVES: The purpose of this study was to review cases that underwent skull base surgery for a variety of tumors that involved the temporal bone. We reviewed a single center's 25-year experience for epidemiologic characteristics, symptoms, treatment type and outcomes. PATIENTS AND METHODS: The medical records and radiological images of 91 patients, who underwent skull base surgery, were retrospectively reviewed. RESULTS: Among the 91 patients, 61 cases had benign disease and 30 had malignancies. A facial nerve schwannoma was the most common benign intratemporal tumor and a squamous cell carcinoma was the most common malignant tumor. With the facial nerve schwannoma, facial nerve paralysis and hearing loss were the most common presenting complaints; otalgia was the most common presenting symptom for temporal bone cancer. For patients with a glomus tumor, there was a characteristic pulsating tinnitus. A majority of the facial nerve schwannomas were resectable through the transmastoid approach. The infratemporal fossa approach type A was usually required for lower cranial nerve schwannomas and glomus jugulare tumors. However, the fallopian bridge technique with hypotympanectomy was another surgical option. Partial temporal bone resection and subtotal temporal bone resections were performed in cases with temporal bone cancer. The disease free 5-year survival of the temporal bone cancers was 42% and for the squamous cell carcinomas, it was 44%.