前颅底肿瘤的术式选择及颅底重建

目的：探讨前颅底肿瘤的手术方式及术后颅底缺损重建技术。方法：对25例前颅底肿瘤患者根据原发肿瘤的生长部位和颅内外受累的情况，分别采用冠状切口经额颅内入路手术、鼻侧切开或扩大鼻侧切开术或颅面联合手术，采用带蒂骨膜瓣或帽状腱膜骨膜瓣重建颅底缺损。结果：肿瘤全切除23例，近全切除1例，部分切除1例，术后全部病例临床症状改善，无手术死亡、脑脊液漏、颅内感染及其他严重并发症。随访1年至13年，存活1年以上者22例，3年以上者12例，5年以上者9例，10年以上者3例。5、10年生存率分别为56．25％（9／16）、37．5％（3／8）。结论：术式选择取决于原发肿瘤的生长部位和颅内外受累的情况；颅面联合手术是一种安全、有效的手术方式；带蒂帽状腱膜骨膜瓣可用于较大颅底缺损的重建，具有安全、取材方便、效果好等优点，值得推广。     

颅面联合进路在头颈部恶性肿瘤术中的应用

我院头颈外科对头颈部较晚期恶性肿瘤侵及前颅底和侧颅底２４例病人进行手术治疗。其前颅底采用经额窦后壁进路的颅面联合术，侧颅底多采用经颈——下颌进路的方法整块切除肿瘤。中耳外耳道癌则行颞骨次全切除。全组无手术死亡。筛窦癌８例，眼睑癌侵及眶内１例，软腭咽侧壁癌３例，中耳外耳道癌６例，扁桃体癌３例，鼻咽癌１例，磨牙后三角区癌２例。１年生存率７５％（１８／２４），３年生存率５７．９％（１１／１９），５年生存率４２．９％（３／７）。     

颅面联合进路在头颈部恶性肿瘤术中的应用

我院头颈外科对其颈部较晚期恶性肿瘤侵及前颅底和侧颅底２４例病人进行手术治疗。其前颅底采用经额窦后壁进路的颅面联合术，侧颅底多采用经颅－－下颌进路的方法整块切除肿瘤。中耳外耳道癌则行颞骨次全除，全组无手术死亡。筛窦癌８例，眼睑侵及眶内１例，软腭咽侧壁癌３例，中耳外耳道癌６例，扁桃体癌３例，鼻咽癌１例，磨牙后三角区癌２例，１年生存率７５％，３年生存率５７．９％，５年生存率４２．９％。     

前颅底肿瘤术后并发症的预防和处理

目的探讨前颅底肿瘤术后并发症的预防和处理措施。方法对38例前颅底肿瘤经额颅内入路手术或颅面联合入路手术，并对颅底缺损进行修复。结果肿瘤全切除35例，近全切除2例，部分切除1例。术后出现脑脊液鼻漏2例（5．26％），经加压包扎后控制，颅内出血2例（5．26％），经开颅再次手术处理后治愈。脑水肿1例，1例术后失语、1例颅腔积气。均无手术死亡、脑脊液漏和颅内感染及其他严重并发症发生。结论术前对患者全身状况的正确评估，安全、有效地分隔颅腔和鼻腔的前颅底手术重建，术中彻底止血、术后严密观察和细致护理，是预防和处理前颅底肿瘤术后并发症行之有效的方法。     

前颅底肿瘤21例临床分析

目的探讨前颅底肿瘤的手术治疗与颅底缺损修复的方法,为临床提供帮助。方法对2002年3月至2008年1月本科收治的21例前颅底肿瘤进行回顾性分析。其中鼻侧切开或＂H＂鼻侧切开4例,面中掀翻4例,上颌骨外旋2例,经口腭入路1例,经鼻内镜下手术10例;根据颅底缺损大小选用肌肉、阔筋膜、鼻中隔黏骨膜片、筛骨垂直板作为修补材料,如果缺损较大,则采用上述复合组织进行修复。结果21例中完全切除瘤体20例,大部分切除1例。无手术死亡病例。随访时间半年-5年,失访1例。良性肿瘤12例中,11例彻底切除,均无复发;1例瘤体大部分切除,带瘤生存良好,未见残瘤体明显增大。随访的恶性肿瘤8例中,1例术后2年死亡,1例术后16月复发,再次手术后随访半年无复发,其余病例生存良好。结论要提高前颅底肿瘤切除的手术疗效,必须谨慎选择手术入路,尽可能完全切除肿瘤,安全地修复和重建颅底。     

颅面联合入路手术在颅底肿瘤治疗中的应用：21例体会

背景与目的：颅底肿瘤由于位置深在，解剖复杂，手术难度较大。本文总结我们治疗21例颅底肿瘤的体会，以探讨颅底肿瘤的手术路径选择及治疗效果。方法：回顾性分析我院1991～2004年经颅面联合入路手术切除的颅底肿瘤21例，其中累及前颅底17例，中颅底2例，后颅底2例；累及颅底至硬脑膜14例，累及颅底、硬脑膜至脑组织4例。结果：21例中5例为初治患者，16例为综合治疗后局部复发者；其中18例采用颅面联合人路前颅底鼻窦沟通切除术，3例采用耳前颞下窝人路切除术。13例行手术并放疗，其中1例为术前放疗，12例为术后放疗；8例行单纯手术治疗。本组病例均作了术后随访，随访时间最长为11年，最短为5个月。3年生存率为70．0％。5年生存率为42．9％。结论：颅面联合人路手术连续整块切除颅底肿瘤是可行的；术后结合放射治疗可以提高颅底肿瘤患者的生存率。     

前颅底肿瘤的术式选择及颅底重建

目的:探讨前颅底肿瘤的手术方式及术后颅底缺损重建技术。方法:对25例前颅底肿瘤患者根据原发肿瘤的生长部位和颅内外受累的情况,分别采用冠状切口经额颅内入路手术、鼻侧切开或扩大鼻侧切开术或颅面联合手术,采用带蒂骨膜瓣或帽状腱膜骨膜瓣重建颅底缺损。结果:肿瘤全切除23例,近全切除1例,部分切除1例,术后全部病例临床症状改善,无手术死亡、脑脊液漏、颅内感染及其他严重并发症。随访1年至13年,存活1年以上者22例,3年以上者12例,5年以上者9例,10年以上者3例。5、10年生存率分别为56.25%(9/16)、37.5%(3/8)。结论:术式选择取决于原发肿瘤的生长部位和颅内外受累的情况;颅面联合手术是一种安全、有效的手术方式;带蒂帽状腱膜骨膜瓣可用于较大颅底缺损的重建,具有安全、取材方便、效果好等优点,值得推广。     

经扩大前颅底入路显微手术切除前颅底肿瘤

目的 探讨经扩大前颅底入路对20例前颅底肿瘤的显微手术。方法 回顾性分析20例前颅底肿瘤显微手术的入路和手术切除相关因素。结果 20例前颅底肿瘤经扩大前颅底入路，其中经硬膜下入路15例，经硬膜外入路5例．全切除10例，次全切除6例，大部切除4例。结论 经扩大前颅底入路容易显露前颅底结构，对脑组织牵拉轻，扩大了手术适应证，降低了肿瘤切除的风险。     

60例前颅底区沟通性肿瘤的外科治疗

目的：探讨前颅底区沟通性肿瘤的外科治疗方法和效果方法：回顾性分析1997午1月至2006年12月60例前颅底区沟通性肿瘤患者的资料，均行外科治疗，经病理证实良性肿瘤21例，恶性肿瘤39例手挂入路的选择为颅面联合入路44例，眶内容物剜除术5例，鼻侧切开术3例，前额硬膜外入路5例，眶外侧入路3例。结果：肿瘤全切51例，次全切除4例，部分切除5例。肿瘤切除后前颅底区组织缺损的修复采用带蒂额肌帽状腱膜颅骨裂层瓣修复27例。术后45例临床症状有所改善，无手术死亡病例并发症主要为颅神经损伤5例，伤口感染4例，其中局部加强换药愈合2例，清创缝合愈合2例，暂时性的脑脊液漏2例。术后放射治疗23例，剂量为45Gy～65Gy，术前或术后化疗15例，主要方案为DDP（顺铂）、5-FU（5-氟脲嘧啶）、平阳霉素。经信访或门诊随访1年～9年，死亡11例，失访2例。结论：前颅底区沟通性肿瘤以外科治疗为主，手术治疗是有效的，颅面联合入路是主要的手术方式，肿瘤切除后前颅底区组织缺损的修复采用带蒂额肌帽状腱膜颅骨裂层瓣修复是可靠和安全的。此区肿瘤的手术治疗难以达到肿瘤切除的“安全界”，局部复发和远处转移是主要的死亡原因，需有计划地进行综合治疗，提高患者的生存率和生存质量。     

前颅底沟通瘤的外科治疗

目的探讨前颅底沟通瘤的诊断、手术方式和疗效。方法对21例前颅底沟通瘤患者进行了手术治疗，并对其疗效进行了随访。结果肿瘤全切17例，大部或部分切除4例。3例出现并发症，其中脑脊液漏1例（5天后自愈），单眼运动障碍加重1例，糖尿病昏迷1例。除糖尿病昏迷患者术后6天死亡外，余20例均痊愈。术后随访3个月～4年，10例资料完整者恢复良好，无肿瘤复发。结论术前依据病人的临床表现、CT或MRI所见评价肿瘤来源，以最短路径、最小脑组织牵拉显露肿瘤主体的思路选择手术入路。术中肿瘤切除后，严密缝合硬脑膜，根据颅底骨缺损范围选择不同方法重建颅底。术后对恶性肿瘤或未能全切肿瘤者辅以放疗，常能获得良好的疗效。     

头颈部癌肉瘤12例临床分析

[目的]探讨头颈部癌肉瘤的诊断与治疗。[方法]回顾性分析1964～2001年收治的12例头颈部癌肉瘤病人的临床资料,其中甲状腺4例,上颌窦3例,喉、口底、口颊、颌下腺、耳廓各1例。12例患者均行根治性手术,3例行术后放疗,2例行术后化疗。[结果]1年、3年、5年累积生存率分别为66.67%、16.67%、8.33%。[结论]头颈部癌肉瘤恶性度高,治疗后容易复发,宜采用以手术为主的综合治疗。     

Paragangliomas of the Head & Neck: the KMC experience

To determine the clinical features, investigations, intra-operative findings, surgical approaches used and the results of the treatment for paragangliomas of the head and neck. Retrospective study of 14 cases of paragangliomas in head and neck seen over a period of 10 years including five carotid body tumors, seven glomus jugulares and two glomus tympanicums. HRCT scans and bilateral carotid angiography were done in all cases of glomus jugulare. Pre-operative embolization was done in most cases. The trans-cervical approach was used for all cases of carotid body. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare tumors. Postaural tympanotomy approach was used for both patients with glomus tympanicum. In one case of extratympanic glomus jugulare tumor with hypoglossal palsy, a neck exploration was done to isolate and excise the tumor. Five patients with carotid body tumors presented as unilateral, painless, pulsatile swelling in the upper neck. Intra-operatively, three of the tumors were classified into Shamlin’s Grade II and one each into Grade III and Grade I. A carotid blow-out occurred in one of the patients with Grade II disease, which was managed. ECA resection had to be done in one case. Seven patients were diagnosed to have glomus jugulare and two with glomus tympanicum. Six glomus jugulare tumors presented with hearing loss, ear discharge and obvious swelling. Glomus tympanicums presented with hearing loss but no bleeding from the ear. On examination, tumors presented with an aural polyp with no VII nerve deficits. Both tympanicums were classified as Fisch Type A, three of the jugulares classified as Type B, two as Type D2 and one as Type D1. Tumors were found to be supplied predominantly by the ascending pharyngeal artery. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare. The transcanal approach was used for both patients with glomus tympanicum. Paragangliomas are uncommon tumors that need accurate diagnosis and skilled operative techniques. Though the surgical approaches may appear complicated, the removal provides good cure rates with minimal morbidity and recurrence. Lateral skull base approaches should be the armamentarium of every head and neck surgeon.     

Neuronavigational guidance in craniofacial approaches for large (para)nasal tumors involving the anterior skull base and upper clival lesions

Objective

Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension is often challenging. In this relation computer assisted surgical (CAS) guidance might be a useful tool. Here, we explored the use of CAS in an interdisciplinary setting.

Methods

The surgical series consists of 13 patients who underwent a lateral rhinotomy combined with a subfrontal craniotomy in case of significant intracranial tumor extension. The procedures were planned and assisted by advanced CAS techniques with image fusion of CT and MRI. Tumors included carcinomas (one case associated with an olfactory groove meningioma), esthesioneuroblastoma, chordoma, chondrosarcoma and ganglioglioma.

Results

The application of CAS in the combined approaches was both safe and reliable for delineation of tumors and identification of vital structures hidden or encased by the tumors. There was no perioperative 30-day mortality; however two patients died 5 weeks and 5 months after craniofacial tumor resection due to worsening medical conditions. The most common perioperative morbidity was postoperative wound complication in two cases. Tumors were either removed completely, or subtotal resection was achieved allowing targeted postoperative radiotherapy.

Conclusion

Craniofacial approaches with intraoperative neuronavigational guidance in a multidisciplinary setting allow safe resection of large tumors of the upper clivus and the paranasal sinuses involving the anterior skull base. Complex skull base surgery with the involvement of bony structures appears to be an ideal field for advanced navigation techniques given the lack of intraoperative shift of relevant structures.     

True Parapharyngeal Space Tumors: Case Series from a Teaching Oncology Center

The Parapharyngeal Space (PPS) tumors are rare tumors accounting for 0.5% of the tumors in head and neck region. A retrospective study conducted at Department of Surgical oncology, Vydehi institute of Medical Sciences & Research center, Bengaluru, between 2010 and 2015 identified nine cases treated for PPS tumors. Patients are diagnosed on the basis of clinical examination fine needle aspiration cytology and imaging and considered for excision by one of the varied surgical approaches {transoral(1), transcervical(4), transparotid(0), transcervical-transparotid(1), transmandibular(3) or intratemporal(0) approach}. The choice of approach is defined by the size of the tumor, suspicion of malignancy and the position of the tumor with regard to the superior extent and proximity to the skull base as well as its relation with neurovascular bundle.     

Malignant Fibrous Histiocytoma/Undifferentiated High-Grade Pleomorphic Sarcoma of the Maxillary Sinus

Malignant fibrous histiocytoma (MFH) also known as undifferentiated high-grade pleomorphic sarcoma (UHPS) is a soft tissue sarcoma, composed of undifferentiated mesenchymal tumors possessed fibrohistiocytic morphology without definite true histiocytic differentiation. Head and neck localization is very rare, showing an incidence ranging from 4 % to 10 % in different series of investigations. The most frequent involved sites in UHPS are the neck and parotid, followed by the scalp, face, anterior skull base and orbit. Upper aerodigestive tract, lateral skull base and ear are rare locations. The incidence of the lymphatic metastases is also rare. The aim of this article is to report a case of UHPS in the maxillary sinus with palatal, orbital and ethmoidal involvement, with lymphatic metastasis and its surgical treatment. In addition, we review the literature of similar cases of the past 12 years.     

侧斜方肌肌皮瓣修复头颈肿瘤术后缺损的初步探索

目的探索侧斜方肌肌皮瓣在头颈肿瘤术后缺损中的作用及其优缺点。方法自2005年6月至2006年6月共采用带蒂侧斜方肌肌皮瓣移植修复头颈肿瘤术后缺损6例,其中舌根癌3例,鼻咽癌放疗后颈淋巴结复发累及皮肤3例,观察肌皮瓣的存活情况、组织移植后功能状态和肿瘤控制的近期疗效。结果全部肌皮瓣存活,无手术并发症,舌根缺损修复后进食、咀嚼、发音均满意,颈部缺损修复后外形满意,无垂肩畸形;全部病例随访6～18个月,1例舌根癌术后6个月死于肿瘤复发,1例鼻咽癌放疗后复发者术后6个月复发,挽救治疗中,其余4例均无瘤生存至今。结论侧斜方肌肌皮瓣可以安全地应用于舌根、颈部缺损修复;手术方便,对供区影响小是该皮瓣的优点;颈横静脉缺如偶有存在,确保充足的静脉回流是手术成功的关键。     

Place de la protonthérapie en cancérologie ORL

The absence of exit dose and the sharp lateral penumbra are key assets for proton therapy, which are responsible for its dosimetric superiority over advanced photon radiotherapy. Dosimetric comparisons have consistently shown a reduction of the integral dose and the dose to organs at risk favouring intensity-modulated proton therapy (IMPT) over intensity-modulated radiotherapy (IMRT). The structures that benefit the most of these dosimetric improvements in head and neck cancers are the anterior oral cavity, the posterior fossa, the visual apparatus and swallowing structures. A number of publications have concluded that these dosimetric differences actually translate into reduced toxicities with IMPT, for example with regards to reduced weight loss or need for feeding tube. Patient survival is usually similar to IMRT series, except in base of skull or sinonasal malignancies, where a survival advantage of IMPT could exist. The goals of the present review is to describe the major characteristics of proton therapy, to analyse the clinical data with regards to head and neck cancer patients, and to highlight the issue of patient selection and physical and biological uncertainties.     

Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.     

Current concepts in management of oral cancer--surgery

Oral cancer is the sixth most common cancer worldwide, with a high prevalence in South Asia. Tobacco and alcohol consumption remain the most dominant etiologic factors, however HPV has been recently implicated in oral cancer. Surgery is the most well established mode of initial definitive treatment for a majority of oral cancers. The factors that affect choice of treatment are related to the tumor and the patient. Primary site, location, size, proximity to bone, and depth of infiltration are factors which influence a particular surgical approach. Tumors that approach or involve the mandible require specific understanding of the mechanism of bone involvement. This facilitates the employment of mandible sparing approaches such as marginal mandibulectomy and mandibulotomy. Reconstruction of major surgical defects in the oral cavity requires use of a free flap. The radial forearm free flap provides excellent soft tissue and lining for soft tissue defects in the oral cavity. The fibula free flap remains the choice for mandibular reconstruction. Over the course of the past thirty years there has been improvement in the overall survival of patients with oral carcinoma largely due to the improved understanding of the biology of local progression, early identification and treatment of metastatic lymph nodes in the neck, and employment of adjuvant post-operative radiotherapy or chemoradiotherapy. The role of surgery in primary squamous cell carcinomas in other sites in the head and neck has evolved with integration of multidisciplinary treatment approaches employing chemotherapy and radiotherapy either sequentially or concurrently. Thus, larynx preservation with concurrent chemoradiotherapy has become the standard of care for locally advanced carcinomas of the larynx or pharynx requiring total laryngectomy. On the other hand, for early staged tumors of the larynx and pharynx, transoral laser microsurgery has become an effective means of local control of these lesions. Advances in skull base surgery have significantly improved the survivorship of patients with malignant tumors of the paranasal sinuses approaching or involving the skull base. Surgery thus remains the mainstay of management of a majority of neoplasms arising in the head and neck area. Similarly, the role of the surgeon is essential throughout the life history of a patient with a malignant neoplasm in the head and neck area, from initial diagnosis through definitive treatment, post-treatment surveillance, management of complications, rehabilitation of the sequelae of treatment, and finally for palliation of symptoms.