Revision lateral skull base surgery.

OBJECTIVE: To describe functional and reconstructive results after revision lateral skull base surgery with comparison of benign and malignant lesions. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: All patients undergoing revision surgery for benign and malignant lateral skull base tumors. INTERVENTIONS: Surgical resection of recurrent lateral skull base tumors and reconstruction of resulting defects. MAIN OUTCOME MEASURES: Cranial nerve function postoperative complications. RESULTS: Forty operations for recurrent lateral skull base tumors occurred between January 1, 1987, and December 31, 2003, with follow-up of at least 1 year. Thirty-three operations were for benign lesions, 27 of which were glomus tumors. Seven operations were for malignant tumors. Fifty-eight percent of patients had preoperative cranial nerve deficits (66% of benign tumors and 14% of malignancies). The most common preoperative deficit occurred in the Xth cranial nerve. Postoperative cranial nerve deficits were seen in 95% of patients and multiple nerve deficits were seen in 75%. The most common postoperative deficits were observed in the IXth and Xth cranial nerves. Thirty-one patients had one previous procedure, six had two previous procedures, and three had three previous procedures. Abdominal fat and temporoparietal fascia were the most common reconstruction materials. There was one case of meningitis, two cerebrospinal fluid leaks, and one pseudomeningocele. There was one recurrent adenoid cystic tumor resulting in death and two partially resected glomus tumors. Subsequent procedures are discussed. CONCLUSION: Postoperative cranial deficits are more common after revision skull base surgery than after primary surgery. Complete resection without recurrence can be expected for revision skull base surgery. Modern reconstruction techniques reduce major postoperative complications and morbidity from cranial nerve deficits.     

Surgery of anterior skull base fractures

BACKGROUND AND METHODS: The medical records of 144 patients that underwent surgery due to fractures of the anterior skull base between 1990 and 1999 were assessed retrospectively. Fracture causes, symptoms, fracture lines, surgical approaches and materials for dura repair were analyzed. RESULTS: The most frequent fracture causes were automobile (46.1%), recreational (24.8%) and occupational accidents (16.3%). While a decrease in automobile accidents was observed from 1996 (71.4%) to 1999 (33.3%), an increase in sports accidents was documented from 1990 (5.3%) to 1999 (16.7%). The most common accompanying injuries were CSF leakage (38.9%), loss of vision (28.5%) and intracranial bleeding (21.5%). The roof of the ethmoid sinus (79.7%) and the frontal sinus (anterior and posterior wall) (73.6%) were fractured most commonly. The lamina cribrosa was involved in 32.6%, the sphenoid sinus in 29.2% of the fractures. Most commonly the bitemporal Unterberger approach (75.7%) was used. To a lesser degree the uni- (13.9%) or bilateral (4.8%) Kilian approach, the reopening of the old wound (4.2%) and the endonasal approach (1.4%) were utilized. Conserved dura was applied for the closure of CSF leaks in 80.7%, periostal flaps in 20.7%, fascia lata in 14.8% and TachoComb in 8.2%. CONCLUSIONS: The results of this study indicate that posttraumatic fractures of the anterior skull base are declining in frequency. The most common causes for these injuries were automobile accidents but increasingly sports accidents. Typical fracture lines or combinations were not observed. In the period observed the bitemporal Unterberger approach and resorbable implant materials such as the coated collagen fleece TachoComb were increasingly used for surgery.     

Chondroid chordoma of the lateral skull base

A rare case of chondroid chordoma of the lateral skull base with laterocervical extension is reported. Clinical, radiological and pathological features of the tumor are described. This unusual location of chondroid chordoma enabled total resection of the neoplastic tissue through a combined laterocervical and far lateral transjugular approach.     

侧颅底应用解剖学研究

目的 通过对侧颅底解剖学结构的观察与测量,为临床侧颅底手术的定位、导航提供解剖学依据。方法 10%甲醛浸泡的成人尸头10个(20侧),观测颈静脉球区域神经血管、颈内动脉毗邻的解剖关系。结果 颈静脉球,其形态可分为隆起型和低平型,舌咽神经多位于颈静脉球前内侧者,迷走神经和副神经多位于颈静脉球内侧者,颈内动脉岩骨段距离鼓膜张肌的长度平均为2.2mm,距离下颌神经和脑膜中动脉的平均长度分别为6.9mm和6.8mm。结论 侧颅底血管和神经分布密集,术者了解侧颅底血管和神经的解剖关系,有利于手术中安全扩大手术视野,避免术中损伤血管、神经。     

Giant cell tumor at the lateral skull base

Giant cell tumor is a bony tumor which primarily occurs in third to fourth decade after skeletal maturation. Usually, this tumor arises in the distal end of long bone and is quite rare in the head and neck region. We had a elderly female patient with giant cell tumor at lateral skull base of the left temporal bone without classic symptoms. Team approach with neurosurgeon was used to eradicate the tumor. The detail of this case in conjunction with treatment of giant cell tumor was reported while reviewing pertinent papers.     

Closure of complex lateral skull base defects.

OBJECTIVE: To discuss surgical reconstructive options and complications in patients with extensive lateral skull base defects. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Eligibility criteria included patients seen between July 1999 and July 2003 with malignant neoplasms of the lateral skull base requiring surgical therapy, with resultant surgical defect not amenable to primary closure. INTERVENTION: Surgical extirpation of malignant skull base neoplasm requiring free tissue transfer or rotational flap closure. MAIN OUTCOME MEASURE: Closure and healing of surgical defect, intraoperative and postoperative complications, patient survival. RESULTS: There were 11 patients, 8 males and 3 females, with an average age of 65 years. Eight patients required trapezius flap reconstruction, whereas one patient required temporalis rotational flap closure, and two patients required rectus abdominus free tissue transfers. There was one perioperative death secondary to cardiac disease. There were no immediate wound complications. One patient developed a delayed partial trapezius flap failure successfully treated with a rectus abdominus flap. CONCLUSIONS: The trapezius rotational flap is a reliable means of closing complex lateral skull base defects with minimal morbidity.     

Intracranial pressure concerns in lateral skull base surgery

This article serves as a concise review of cerebrospinal fluid metabolism and intracranial pressure regulation for otolaryngologists and lateral skull base surgeons. It examines the methodologies for maintaining cerebrospinal fluid homeostasis by preventing and treating acute elevations of intracranial pressure encountered during lateral skull base surgery.     

Management and outcome of pediatric skull base fractures

Objective

The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures.

Methods

Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed.

Results

A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome.

Conclusions

We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.     

Association of skull base and facial fractures.

A retrospective analysis of 268 trauma patients with facial fractures who received computed tomography of the head was undertaken to assess an association with skull base fractures. The incidence of skull base fracture was compared to facial fractures of various anatomic locations. Skull base fractures were significantly increased in orbital wall/rim fractures (36.0%, P = .0823). In contrast, skull base fractures related to orbital floor (27.3%, P = .6191) and maxillary/zygomatic (29.4%, P = .1148) fractures were not significantly greater and were infrequently seen with mandible (4.0%, P = .0454) and nasal (7.7%, P = .0345) fractures. The incidence of skull base fracture was directly associated with the number of facial fractures per patient; one facial fracture (21.0%), two facial fractures (30.4%), and three or more facial fractures (33.3%) (P < .05). The incidence of skull base fractures was related to the location of facial fractures and the number of facial fractures per patient. The results provide additional clinical information to facilitate the prompt detection and diagnoses of skull base fracture.     

成人侧颅底临床解剖学研究

目的:通过对侧颅底重要解剖标志的观察与测量.为临床侧颅底手术的定位、导航提供解剖学依据.方法:20具40侧10%甲醛浸泡的成人尸头(黄种人)和20例临床手术患者进行侧颅底指引标志的观察与测量.尸头标本按1～40的顺序进行编号;20侧临床手术患者按1～20的顺序进行编号.结果:通过测量得出侧项底相关定位标志的解剖数据:颈静脉孔静脉部、神经部与颅底重要指引标志的距离;迷路三角、迷路后三角及乳突表面三角的面积;侧颅底手术中面神经主动移位的最大距离.结论:耳科与颅底外科的手术几乎均在深埋于颅(颞)骨的狭窄空间内操作,周围布满了重要的血管和神经,术者了解侧颅底重要标志的定位测量数据有利于手术中安全扩大手术视野,有效避免术中损伤重要血管、神经,最大限度地保留面神经功能,最终提高患者的生存质量.     

侧颅底恶性肿瘤的手术治疗

目的探讨侧颅底恶性肿瘤的理想手术人路和手术治疗价值。方法2000年1月至2002年1月,对27例侧颅底恶性肿瘤进行手术治疗。采用颞下窝人路7例、颈-下颌进路15例、上颌骨外翻入路2例、鼻侧切开加额眶颧颞联合人路3例。结果全组27例肿瘤均完整切除,无手术死亡病例,术后暂时性偏瘫1例,术后脑脊液漏1例。随访到2003年5月,其1、2、3年生存率分别为100％(27／27)、86．4％(19／22)和70．0％(7／10),3年,无瘤生存率为60．0％。结论侧颅底恶性肿瘤的手术人路应视肿瘤部位而定,手术治疗有望改善患者的生存质量并延长患者的生命。     

侧颅底肿瘤切除术后缺损的修复重建

目的：探讨侧颅底肿瘤切除术后缺损的修复。方法：回顾性总结182例侧颅底肿瘤切除术后缺损的修复及愈后情况。病种包括听神经瘤（92例），颈静脉孔肿瘤（21例），颞下窝肿瘤（6例），鼻咽癌放疗后复发癌（4例），中耳癌（3例），桥小脑角的脑膜瘤（2例），蛛网膜囊肿（2例），颞骨鳞状细胞癌2例。修复部位包括硬脑膜、颅底骨、颧弓、颅底颞下窝的缺损。采用的材料有腹壁脂肪（113例）、颞肌及颞肌筋膜瓣（2g例）、胸锁乳突肌肌瓣（19例）、胸大肌皮瓣（2例）、人工脑膜（1例）、钛板（1例）。结果：采用的带血管颞肌及颞肌筋膜瓣、胸大肌皮瓣、胸锁乳突肌肌瓣全部存活，用脂肪修复成功率为98．2％（111／113），脑脊液漏2例，无颅内感染发生。结论：根据侧颅底脑肿瘤的部位和不同类型的缺损，采用不同的修复材料和方法，肿瘤切除后颅底缺损的修复重建对术后功能的保留和恢复，避免脑脊液漏、颅内感染的发生，有着至关重要的作用，是侧颅底肿瘤手术成功的关键之一。     

前、中、侧颅底恶性肿瘤手术径路的探讨

目的：评价前、中、侧颅底手术径路的实用性,可靠性及有效性。方法：自1984年6月至1998年12月,对30例颅底恶性肿瘤患者进行治疗。病变位于前颅底者13例,中颅底2例和侧颅底15例（包括4例中、外耳道癌患者）。累及前颅底者采用发际内大冠状切口并切除部分额骨入颅。或经额窦后壁入颅,然后实行颅面联合切除肿瘤,涉及中、侧颅底肿瘤则采用经颈－下颌入路方法整块切除肿瘤。中、外耳癌则实行颞骨次全切除术。结果：全组30例无手术死亡。无严重并发症,合并脑脊液漏等轻度并发症者6例（20％）,均经保守治愈。全组2年生存率为68％,5年生存率55．56％。结论：上述资料显示所提出的颅底恶性肿瘤手术径路方法安全可靠,适合于大多数前、中、侧颅底恶性肿瘤的治疗,值得推广应用。     

Pectoralis major flap in composite lateral skull base defect reconstruction

OBJECTIVE: To report our experience with the pectoralis major myocutaneous flap (PMF) for the reconstruction of composite lateral temporal bone defects extending beyond the temporal line. DESIGN: Retrospective review and illustration of specific technical modifications. SETTING: Academic tertiary care center. PATIENTS: Eight patients with composite lateral skull base defects that were reconstructed with the PMF between February 2001 and February 2006. INTERVENTION: Reconstruction with the modified pedicled PMF. MAIN OUTCOME MEASURES: Reconstruction outcomes and complications. RESULTS: Eight patients (median age, 80 years) underwent total or near-total auriculectomy, wide skin excision, and lateral temporal bone resection as part of the surgical ablation, thus requiring obliteration of the middle ear cavity as well as extensive replacement of skin cover. All patients received radiation therapy. The median postsurgical follow-up was 9 months. Complete healing of the reconstructed surgical defect with no flap loss was achieved in all cases. CONCLUSION: With specific technical modifications, the PMF can be reliably used for the reconstruction of composite lateral skull base defects extending up to and beyond the temporal line, making this flap an important alternative to free flap reconstruction in selected cases.