不同手术入路对颈静脉孔区的显露程度及其临床应用价值探讨

目的比较各颈静脉孔区手术入路的显露范围,为选择恰当的手术入路切除不同范围的颈静脉孔区病变提供解剖学依据。方法成人头颈标本6具随机将标本分为A、B、C三组,每组2具尸头。其中A组应用颈侧入路、B组依次采取鼓室底入路和改良鼓室底入路、C组依次选择Ⅰ型颞下窝入路及改良Ⅰ型颞下窝入路进行颈静脉孔区解剖,比较各手术入路对颈静脉孔区及其周围解剖区域的显露程度。结果颈侧入路对颈静脉孔的颅外部分及咽旁间隙显露良好;鼓室底入路在颈侧入路的基础上进一步显露乳突、乙状窦垂直段、颈静脉球、颈静脉孔神经部;Ⅰ型颞下窝入路又在鼓室底入路的基础上扩大显露外耳道深部、中耳腔及岩骨内颈内动脉垂直段;改良鼓室底入路和改良Ⅰ型颞下窝入路很好地弥补了鼓室底入路和Ⅰ型颞下窝入路对乙状窦水平段和颈静脉孔血管部显露不足的缺陷。结论不同颈静脉孔区手术入路对颈静脉孔区的显露程度各不相同。以此为依据,根据颈静脉孔区病变的范围选择手术入路对有效显露和切除病变,减少结构和功能破坏具有现实的指导意义。     

颞下-耳前颞下窝入路对颈静脉孔区显露程度的定量研究

目的 定量研究颞下-耳前颞下窝入路各手术步骤对颈静脉孔区的显露程度,为临床个体化的选择手术入路,保护重要结构功能提供可靠的解剖依据.方法 选择经10%福尔马林固定的成人头颈湿标本6具(12侧),模拟颞下-耳前颞下窝入路,并分成连续的五个步骤,用脑立体定向仪测定各步骤对颈静脉孔区的显露面积,用游标卡尺测量颈内动脉垂直段的显露长度.结果 颞下岩前入路对颈静脉孔区的显露面积为(370.86±123.46)mm2,切除颞下颌关节,移位颈内动脉后显露面积显著增加(P<0.05).向前移位颈内动脉后,对颈内动脉前壁、侧壁的显露分别增至(13.69±4.54)mm和(12.64±3.84)mm,与切除颞下颌关节间存在显著差异(P<0.05).结论 颞下-耳前颞下窝入路自侧前方显露颈静脉孔区,前移颈内动脉后可显露颈静脉孔前缘,并显著增加对岩斜坡区和颈内动脉垂直段的显露.     

不同内镜手术入路对翼腭窝及颞下窝的显露程度比较及其临床应用价值探讨

目的应用不同的内镜手术入路解剖翼腭窝及颞下窝,比较内镜下各手术入路的显露范围,为恰当选择内镜手术入路处理翼腭窝及颞下窝病变提供解剖学方面的依据。方法 4具8侧成人尸头标本,0°内镜引导下分别采取上颌窦后壁入路、扩大上颌窦后壁入路、鼻腔外侧壁入路、揭翻经上颌窦入路进行解剖学研究,观测各手术入路的有效显露范围。结果上颌窦后壁入路能显露翼腭窝上部和颞下窝内侧区深部;扩大上颌窦后壁入路在以上手术入路的基础上进一步显露翼腭窝下部;鼻腔外侧壁入路再进一步显露整个上颌窦和上颌窦底壁平面以上的颞下窝内外侧区;揭翻经上颌窦入路则能更进一步显露整个颞下窝。结论不同的内镜手术入路对翼腭窝及颞下窝的显露程度各不相同,以此为基础选择相应的手术入路处理不同范围的翼腭窝及颞下窝病变将有利于充分显露和有效切除病变,并尽可能避免不必要的手术损伤和并发症。     

颈静脉孔区肿瘤的分型和手术治疗

颈静脉孔（JugularForamen，JF）位于斜坡中线的两侧，内听道的下方，枕骨大孔的外上方，是后颅窝内重要的颅底通道。其位置深在，形状和大小变异较大，内有重要的神经血管穿行，包括颈内静脉、岩下窦、枕动脉脑膜支、咽升动脉脑膜支、舌咽神经、迷走神经、副神经等，毗邻重要复杂，故被认为是颅底诸骨孔中结构最复杂，手术难度最大的区域。另有学者认为，由于颈静脉孔实际上为一自颅内开口通向前、外、下方的骨性管道，称其为颈静脉管（JugularCanal）更为合适。     

颈静脉孔神经鞘瘤的外科治疗

目的 探讨颈静脉孔神经鞘瘤的手术入路及治疗效果。方法 回顾性分析采用显微外科手术治疗颈静脉孔神经鞘瘤２４例,其中颅内型（Ａ型）：肿瘤主体位于桥小脑角（１２例）;骨内型（Ｂ型）：肿瘤主体位于颈静脉孔内,向颅内生长（５例）;颅外型（Ｃ型）：肿瘤主体位于颅外,并向颈静脉孔生长（１例）;混合型（Ｄ型）：肿瘤由颈静脉孔向颅内外生长,呈哑铃型（６例）。Ａ型采用枕下乙状窦后入路,Ｂ型采用远外侧入路,Ｃ型和Ｄ型采     

颞盂入路及其在颈静脉球体瘤切除术中的应用

目的介绍颞盂入路切除向颅内外扩展的颈静脉球体瘤。方法采用颞盂入路联合乳突或乳突枕下入路,监控颈内动脉(ICA)和面神经远心端,从颈静脉孔外、后、下3个侧面,于直视下分离切除肿瘤。结果5例颈静脉球体瘤成功切除,术后恢复良好(无下颌运动障碍)。结论颞盂入路联合乳突或乳突枕下入路,可监控ICA远心端和面神经,充分暴露并安全切除颈静脉球体瘤。     

颈静脉球体瘤的诊断与治疗

目的 提高对颈静脉球体瘤的认识,以利于其诊断和治疗.方法 回顾性分析颈静脉球体瘤12例,总结其临床表现、影像学特征、治疗方法 及效果.结果 颈静脉球体瘤早期常见的临床症状为搏动性耳鸣和听力下降,中晚期常出现耳部症状及面神经麻痹等神经症状;MRI检查可见特征性表现:"椒一盐"征;根据肿瘤大小及部位、扩展方向采用不同的手术入路取得了较好疗效.结论 颈静脉球体瘤临床表现复杂,容易误诊,CT、MRI的应用提高了对颈静脉球体瘤的诊断水平,手术的方式决定于肿瘤的大小、侵犯范围、有无联合病变以及颅神经状况,应根据个体情况而定.     

颈静脉球体瘤的诊治

目的：探讨颈静脉球体瘤手术进路及临床治疗方法。方法：18例患者术前均行神经耳科、影像学检查,根据肿瘤的大小及肿瘤的部位、扩展方向选择不同的手术入路,即耳内入路6例;耳后入路4例;侧颅底入路、颞下窝入路5例;经颞枕颈联合入路3例。肿瘤全切除14例,次全切除或大部分切除4例。结果：18例中,14例肿瘤全切除均满意,其中2例术后3年复发;4例部分切除术后残留瘤体放疗后1年复查无变化。随访2～6年,复查纯音测听：6例听力恢复平均24dB,12例听力与术前检查结果无明显差异。CT、MRI复查结果：12例患者的术腔为软组织填塞,未见肿瘤复发;2例术后3年出现患耳耳鸣,经CT和MRI检查见乳突腔有瘤组织复发,再次手术治疗后2年随访未见复发;4例次全切除和部分切除的患者,经术后放疗后2年复查CT、MRI,结果与放疗前瘤体的大小无明显差异。结论：手术治疗是颈静脉球体治疗的有效手段,根据肿瘤大小选择手术入路可以确保肿瘤的完整切除,术前肿瘤局部选择性血管栓塞可有效地减少术中出血和手术时间,对于残留组织可用放疗控制其发展。     

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。     

枕下经颈-颈静脉突入路达颈静脉孔区的显微解剖研究

目的 研究一期切除颈静脉孔区复杂性肿瘤的微创手术人路。方法 选择经10％福尔马林固定成人头颈标本10具，显微镜下模拟枕下经颈一颈静脉突人路的手术操作，逐层显露颈静脉孔区，研究该区显微解剖特征及显露范围。结果 该人路直接沿乙状窦、颈内静脉的移行方向显露颈静脉孔区结构，其中后颅窝可经枕下显露，颞下窝藉寰椎与下颌升支间的自然间隙显露。通过切除颈静脉突和迷路下骨质分别自后、外、下和上方显露颈静脉孔。头侧直肌是界定颞下窝结构和枕下三角内结构的确切标志。后组颅神经，交感千和颈内动、静脉行于其前方，椎动脉寰椎上段及其周围的静脉丛行于其后方。结论 枕下经颈一颈静脉突人路可自多个方向充分显露颈静脉孔区结构，且可保护面神经、迷路、耳蜗和椎动脉等结构免受不必要的损伤。     

颈静脉孔区肿瘤临床表现及影像学分析

目的探讨颈静脉孔区肿瘤的临床特点、影像学特征。方法回顾性分析2006年5月-2009年12月32例颈静脉孔区肿瘤的临床及影像学资料,术前32例患者均行颞骨薄层CT和头颅MRI平扫加增强扫描,22例怀疑颈静脉球瘤患者于术前24dx时内行血管造影和肿瘤供血血管栓塞。32例颈静脉孔区肿瘤有31例行肿瘤全切手术,1例怀疑颈静脉球瘤患者因乙状窦血栓性静脉炎导致患者反复发热未行手术治疗。术后病理诊断颈静脉球瘤21例,神经鞘瘤10例。结果32例颈静脉孔区肿瘤主要临床表现为耳鸣、听力下降和周围性面神经麻痹。颈静脉球瘤的特征性表现为侵蚀性骨质破坏及“盐和胡椒”征：神经鞘瘤表现为压迫性骨质改变、多发囊变并中度强化。结论CT与MRI的合理结合应用,有助于病变的临床诊断和鉴别,有利于下一步手术方案的选择。     

颈静脉孔的显微外科解剖研究

目的研究颈静脉孔的硬脑膜结构和孔内神经、血管结构的行程及形态特征。方法显微镜下模拟枕下极外侧入路、颈-乳突入路和Fisch颞下窝入路的手术操作，研究10例福尔马林及乳胶灌注头颈标本颈静脉孔的显微解剖特征。结果在颈静脉孔的颅内开口，舌咽神经与迷走、副神经间被纤维或骨性结构隔开。在颈静脉孔内，脑神经行于颈静脉球上方的内侧，舌咽神经位于最前方，所有神经束均可用显微外科技术分开，副神经的脑根同脊髓根一起进入颈静脉孔后又加入迷走神经。颈静脉球及临近颈内静脉接受来自乙状窦、岩下窦、椎静脉丛、舌下神经管静脉丛、髁导静脉及岩斜下静脉的静脉回流。结论颈静脉孔的颅内开口可分为岩部、颈内部(或神经部)和乙状窦部．颈静脉孔内脑神经的不同神经纤维束在整个行程中彼此独立，副神经仅由脊髓根构成。     

内镜辅助下枕下远外侧髁后入路颈静脉孔区的应用解剖

目的:将神经内镜应用于远外侧入路,为内镜辅助下枕下远外侧手术治疗颈静脉孔区病变提供形态学基础。方法:模拟枕下远外侧入路,应用神经内镜及手术显微镜对10例4%多聚甲醛固定的成人头颈部标本和10例成人颅骨标本的颈静脉孔区进行显微解剖和观测。结果:骨性颈静脉孔形态、大小多变。在保留枕髁和颈静脉结节的前提下,可以充分显露颈静脉孔内外口。颈静脉孔区的血管与神经关系复杂。结论:熟悉颈静脉孔区的显微解剖有利于术中保护重要的神经和血管。应用神经内镜技术,可在不磨除枕髁和颈静脉结节的情况下对颈静脉孔区结构进行良好地显露。     

Reversible cochleo-vestibular deficits in two cases of jugular foramen tumor after surgery

Primary jugular foramen (JF) tumor, such as glomus jugular tumor or JF schwannoma, may manifest as a lower cranial nerve deficit; in addition, it can be accompanied by deafness or vertigo if it affects the cranial nerve (CN) VIII. Recently, we encountered JF schwannoma 1 and glomus jugulare tumor 1. Both cases invaded the adjacent cerebellopontine angle, leading to cochleo-vestibular deficits prior to the operation. After surgery, recovery of the audiovestibular function, including hearing, auditory brainstem response and caloric response, was anticipated in both patients. Therefore, cochleo-vestibular deficits in JF tumors can be attributed to compression neuropathy, rather than tumor infiltration.     

Extirpation of a jugular foramen schwannoma via the transcervical-transmandibular approach

Schwannomas of the jugular foramen are rare lesions. We present a case of a schwannoma of the spinal accessory nerve that occurred in the jugular foramen and skull base of a 52-year-old woman. The tumor was completely extirpated via a transcervical-transmandibular approach with an excellent functional result. The approach used afforded excellent exposure of the lateral or midline skull base, as well as maximum control of the major neurovascular structures in the upper neck and skull base.     

Chondrosarcomas of the jugular foramen

Objectives/Hypothesis: Chondrosarcomas of the jugular foramen are extremely rare tumors. Our review of the literature revealed eleven previously reported cases. The aim of this study is to describe the presenting symptoms, radiographic findings, operative procedures, and postoperative outcome of five histologically confirmed cases of chondrosarcomas arising from the jugular foramen. A review of the literature is also presented. Study Design: Retrospective study of an quaternary referral otology and skull base private center. Methods: Five cases of surgically treated and pathologically confirmed jugular foramen chondrosarcomas were identified. The follow‐up of the series ranged from 23 to 42 months (mean, 32.8 ± 7.7 months). Results: A single stage procedure was adopted in all the cases. Two patients underwent type A infratemporal approaches, one patient underwent a transotic approach extending to the neck with ligature of the internal jugular vein, one patient underwent a petro‐occipital transigmoid approach, and one patient underwent a combined petro‐occipital transigmoid–transotic approach. Gross total tumor removal was achieved in all patients. The most common complications were lower cranial nerve deficits. To date, no recurrence or residual tumors have been observed at radiological controls. Conclusions: We believe that the primary treatment for chondrosarcomas of the jugular foramen is gross total surgical resection of the tumor. It is our philosophy to reserve postoperative radiotherapy for patients with histologically aggressive tumors, as well as in cases with subtotal resection and recurrent tumors.     

Meningioma of the jugular foramen: glomus jugulare mimic and surgical challenge

OBJECTIVES: Meningiomas involving the jugular foramen are rare lesions, with approximately 34 cases reported in the English literature. Clinically, these tumors mimic the more common glomus jugulare tumor. After surgical resection, meningiomas have worse cranial nerve outcomes and higher recurrence rates than glomus tumors. There is controversy regarding the selection of surgical approach, particularly with regard to management of the facial nerve. A reliable means of accurate preoperative diagnosis would help surgical planning and patient counseling. STUDY DESIGN: We present a series of six consecutive large jugular foramen meningiomas resected by a single surgeon from 1996 to 2002. METHODS: Retrospective case series (chart review). RESULTS: The preoperative diagnosis was correct in nearly all (6/7) cases on the basis of the characteristic imaging findings seen with a combination of temporal bone dedicated computed tomography and high-resolution enhanced magnetic resonance imaging. Five of six patients had lateral facial nerve rerouting (infratemporal fossa Fisch type A), and three patients also had posterior rerouting (transcochlear approach with division of greater superficial petrosal nerve). Total tumor removal was accomplished in 83%. One patient suffered recurrence over a mean follow-up period of 2.5 years. New postoperative vocal cord palsies occurred in 50% of patients, and all required vocal cord medialization. At 1 year, 50% of patients had normal or near normal (House-Brackmann I or II) facial function. Postoperative cerebrospinal fluid leaks occurred in two patients, and both eventually required ventriculoperitoneal shunts. CONCLUSIONS: Meningiomas involving the jugular foramen are surgically challenging tumors that pose unique diagnostic issues. The majority of these lesions can be completely resected. A relatively high postoperative complication rate, which can be controlled with appropriate intervention, is seen with these surgeries.