腮腺肿瘤的外科治疗

目的 通过回顾分析探讨彻底切除腮腺区肿瘤组织最佳方式。方法 自1985年5月～1996年12月间,进行腮腺手术65例;其中浅叶切除及面神经解剖术42例,腮腺浅叶及深叶切除解剖面神经4例,全腮腺及面神经和该区皮肤整块切除,胸大肌肌皮瓣修复19例。结果 42例进行腮腺浅叶切除及面神经解剖,全腮腺切除解剖面神经4例,全腮腺及面神经和该区皮肤整块切除,应用胸大肌肌皮瓣修复19例均成活取得较好外观。组织病理学检查,混合瘤34例,血管瘤1例,腺癌9例,粘液表皮癌6例,腺样囊腺癌8例,恶性淋巴瘤3例,混合瘤恶变4例。结论 腮腺良性肿瘤采用浅叶切除或者深浅叶切除解剖面神经是外科治疗最佳术式。晚期恶性肿瘤侵出皮肤及面神经扩大整块切除,应用胸大肌肌皮瓣修复该区皮肤缺损是外科治疗极好方法。     

超声刀在腮腺浅叶功能性手术中的应用

目的探索及比较超声刀在腮腺浅叶功能性手术中应用的可行性及优越性。方法自2011年1月至2014年5月手术治疗64例腮腺浅叶肿瘤患者,随机分为传统刀片组、电刀组和超声刀组。均行腮腺浅叶功能性手术,对术中出血量、手术时间、术后3天总引流量、术后面神经功能障碍、术后涎腺漏等进行统计分析。结果 3组患者在术中出血量、手术时间、术后3天总引流量、面神经损伤及术后涎腺漏发生率的差异均具有统计学意义(P<0.05),超声刀组明显优于传统刀片组和电刀组。结论在腮腺手术中应用超声刀可缩短手术时间、减少术中出血量,患者术后恢复好,并发症低,值得临床推广。     

腮腺良性肿瘤手术中耳大神经的解剖与保留

目的对腮腺良性肿瘤患者耳大神经进行解剖、保留,由此提高患者术后生活质量。方法2001年9月~2006年6月以改良术式治疗成年腮腺良性肿瘤患者20例,术中解剖、保留耳大神经;对耳大神经的位置、毗邻关系、直径、走行、分支、分布等解剖要素进行解剖观察,保留耳大神经主干及耳后、耳垂、耳前支,腮腺支部分或全部切除。术后观察、随访,了解术区及面神经恢复情况、肿瘤有无复发、耳大神经支配区感觉恢复情况。结果耳大神经的分支、分布有其规律性。耳大神经在下颌角水平之上0~2cm依次分为耳后支、耳垂支、耳前支、腮腺支,神经主干末段和分支起始段均分布于腮腺筋膜浅层表面。术后患者有暂时性的外耳廓区轻度麻木,术后1周~4月后患者的外耳廓感觉基本恢复正常,无1例发生外耳廓区皮肤长期麻木。患者在面神经功能恢复、肿瘤复发、术区外形等方面与常规术式无明显差异。结论耳大神经及各分支具有不可代替的解剖生理功能,改良术式能将其较好保留,显著降低术后并发症,提高患者生活质量。     

改良腮腺切除术与传统腮腺切除术对腮腺肿瘤的疗效对比

目的 比较改良腮腺切除术与传统腮腺切除术对腮腺肿瘤的治疗效果.方法 收取腮腺肿瘤患者80例作为研究对象,按照手术方式的不同划分为观察组与对照组.观察组43例,行改良腮腺切除术;对照组37例,行传统腮腺切除术.对两组患者围手术期情况、并发症发生情况以及术后生活质量恢复情况进行对比.结果 观察组患者住院时间明显短于对照组,差异具有统计学意义(P＜0.05),其他围手术期指标两组差异不显著.观察组术后并发症发生率(13.95％)明显低于对照组(45.95％),差异有统计学意义(P＜0.05).观察组肿瘤复发率为2.33％,对照组为5.41％,两组相较无显著差异(P＞0.05).观察组患者生活质量恢复有效率为88.37％,对照组为83.78％,两组相比差异无统计学意义.但观察组生活质量改善率为60.47％,远高于对照组(24.32％),差异有统计学意义.结论 改良腮腺切除术对于腮腺肿瘤具有良好的临床疗效,且安全性高,对于患者生活质量改善具有积极的意义,值得临床推广应用.     

腮腺肿瘤再手术时面神经的处理

目的探讨腮腺肿瘤再次手术时面神经的处理。方法对近6年来我院收治的36例腮腺肿瘤术后复发，再次手术时面神经的处理方式，进行回顾性分析总结。其中7例有2次以上腮腺肿瘤手术史，有病理记载恶性者9例，有面瘫者5例。结果再手术行腮腺浅叶加肿瘤切除22例，均保留神经。行全腮腺切除14例，其中5例切除面神经。术后病理报告恶性者11例。结论对良性病例术中应保留面神经。对恶性病例，再次手术时对面神经是否保留，不能以肿瘤大小而定，而应根据病理分类、肿瘤与面神经粘连程度而定。恶性病例术后行综合治疗。     

腮腺肿瘤手术20例临床分析

目的探讨腮腺肿瘤的手术方式、手术范围及预后。方法对1998--2004年间行解剖面神经的腮腺肿瘤切除术20例临床随访资料进行分析。结果腮腺浅叶切除术13例中,并发腮瘘1例;全腺叶切除术7例中,并发暂时性面瘫1例,无Frey综合征。随访10个月至6年无复发。结论腮腺良性肿瘤需行解剖面神经的浅叶及肿瘤切除术或全腮腺切除术;恶性肿瘤在面神经未受累时行保留面神经的腮腺全切术,术后辅以放疗,可以减少肿瘤复发和面瘫等并发症。     

功能性手术在腮腺浅叶良性肿瘤治疗中应用的体会

目的探讨功能性手术在腮腺浅叶良性肿瘤治疗中的应用。方法回顾性分析2008年7月至2010年12月收治的18例腮腺浅叶肿瘤患者临床资料,通过保留耳大神经、顺向面神经区域解剖及腮腺浅叶部分切除等方法对腮腺浅叶肿瘤的术式进行改良,分析术后患者的并发症情况。结果手术过程均顺利,术后双侧颌面部基本对称,手术瘢痕不明显,患者对外观满意。术后2例发生暂时性面瘫,1例发生腮腺漏,未发生Frey综合征、血肿及腮腺囊肿。术后随访6～24个月,均未见肿瘤复发。结论在掌握好适应汪的前提下,腮腺功能性手术对腮腺浅叶良性肿瘤的治疗效果等同于腮腺浅叶全切除术,且术后并发症明显减少,患者生活质量明显提高。     

腮腺区面神经鞘瘤临床分析

[目的]探讨腮腺区面神经鞘瘤的临床特点和治疗方法。[方法]对7例腮腺区面神经鞘瘤行手术切除。[结果]1例术中误诊为恶性肿瘤而切除面神经致术后永久面瘫(面神经功能Ⅳ级),2例未损伤神经无面瘫,4例肿瘤切除后损伤面神经术后面瘫(面神经功能Ⅱ～Ⅲ级)。[结论]腮腺区面神经鞘瘤临床少见,术前易误诊,治疗以手术为主,肿瘤应完整切除,术中避免过度牵拉神经以免损伤。     

腮腺区域性切除术的临床应用

腮腺区局限性肿块的治疗方法常规以手术治疗为首选 ,但其术式的选择一直未得到完全统一。我科自 1987年—1999年对腮腺区局限性肿块选用解剖与肿块相近的面神经分枝后 ,肿块加其周边部分腮腺组织切除——即腮腺区域性切除的方法对 136例病例进行了治疗 ,取得了满意的临床效果 ,     

腮腺恶性肿瘤外科治疗130例分析

[目的]探讨腮腺恶性肿瘤的手术方法、面神经处理及预后.[方法]回顾分析130例住院手术病例,其中初治85例、复治45例、术前面瘫18例.行腮腺及肿块切除保留面神经87例,腮腺、肿块及面神经切除33例,扩大切除10例.[结果] 5年生存率为76.2%.其中术前有无面瘫分别33.3%、81.3%(P＜0.01),有无颈淋巴结转移为54.2%、80.4%(P＜0.01).[结论]腮腺恶性肿瘤的预后因素主要是术前有无颈淋巴结转移、面瘫、肿瘤的临床分期及恶性程度,首次术式选择合理是减少局部复发的关键.     

Conservative parotidectomy for the treatment of parotid cancers

A conservative parotidectomy is defined as any procedure that is less than a classic superficial parotidectomy, and where less than a full facial nerve is dissected. The aim of this study was to evaluate the oncologic effects of a conservative parotidectomy in a series of patients with malignant tumors of the parotid gland.

The medical records of 43 patients treated at Severance Hospital from 1992 to 2002 who had been diagnosed with parotid cancers confined to the superficial lobe, and had also undergone conservative parotidectomies were reviewed. There were 16 males and 27 females, ranging in age from 8 to 84 years. Sixteen tumors (37%) were high-grade and 27 tumors (63%) were low-grade cancers. Twenty-four patients underwent neck dissection simultaneously with the primary lesion. Surgical treatment was followed by radiotherapy in 10 patients. The follow-up period ranged from 8 to 130 months, with a mean duration of time at 57.7 months.

The overall survival rate and the disease-free rate at five years were 88% and 79%, respectively. Univariate analyses showed histologic tumor grade (p = 0.003) and pathologic neck node metastasis (p < 0.001) to be significant variables. Based on multivariate analysis, only the presence of pathologically positive lymph nodes proved to be significant (p = 0.001). Occult metastases rates was 25% (3 of 12 cases) for high-grade tumors and none of the low-grade tumors had microscopic metastases. Recurrences developed in eight cases (19%). Four cases (9%) had a local or locoregional failure. Of these cases, two cases were high-grade tumors (13%, 2 of 16) and the other two cases were low-grade tumors (7%, 2 of 27). The six cases (14%) of which four cases were high-grade (25%) and two cases were low-grade (7%) had positive surgical margin but showed no evidence of local recurrence after additional postoperative radiotherapy. The incidence of postoperative facial nerve paralysis (HB > 1) was 12% (5 outof 43) for a temporary deficit, but there was no permanent paralysis.

Conservative parotidectomy with appropriate postoperative radiotherapy may be an acceptable procedure without potential morbidity, such as postoperative facial palsy, in the treatment of low-grade parotid cancers confined to the superficial lobe if the facial nerve is sufficiently distant from the tumor.     

传统及改良切口对腮腺肿瘤的疗效及面神经功能对比分析

目的比较传统及改良切口对腮腺肿瘤的疗效及面神经功能的影响。方法选择腮腺肿瘤患者82例作为研究对象,按照入院顺序,根据随机数字表法分为观察组与对照组各41例,对照组采用传统"S"形切口以及皮肤瓣修复,观察组给予改良"S"形切口及腮腺筋膜缝合,记录两组疗效与面神经功能。结果所有患者都顺利完成手术,术中无严重并发症,两组手术时间对比差异无统计学意义(P>0.05),观察组术中出血量与术后引流量明显少于对照组(P<0.05)。术后3个月观察组与对照组面神经损伤发生率分别为2.4%和14.6%,观察组明显低于对照组(P<0.05),配合面部肌肉功能训练后明显好转。观察组术后3个月的血肿、感染、皮肤麻木、涎漏等并发症发生率为7.3%,对照组为26.8%,观察组明显低于对照组(P<0.05)。结论相对于传统切口,改良切口在手术治疗腮腺肿瘤中的应用能减少术中出血量与术后引流量,促进面神经功能的恢复,减少术后并发症的发生。     

Identification of Facial Nerve During Parotidectomy: A Combined Anatomical & Surgical Study

To find out the most easily identifiable and anatomically consistent landmark for identification of facial nerve during parotid surgery. Ten cadaveric dissections and ten live parotid surgeries for different types of parotid tumours were done. Cadaveric dissection was performed in the Department of Anatomy and the surgeries were done in the Department of ENT and Head and Neck surgery of R. G. Kar Medical College of Kolkata. The distance of the facial nerve trunk from three most commonly used landmarks (viz., tympanomastoid suture, tragal pointer and posterior belly of digastric muscle) was measured in both cadaver and live patients. The ease of identification of the nerve trunk using each of the landmarks, particularly during live surgery was also assessed. The mean distance of the tympanomastoid suture from the facial nerve trunk was 3.5 mm (cadaver) and 3.87 mm (live surgery), the tragal pointer was found to be at a mean distance of 16.61 mm (cadaver) and 16.36 mm (live surgery) and in case of the posterior belly of digastric muscle it was 7.41 mm (cadaver) and 8.03 mm (live surgery). During live surgery the posterior belly of digastric was found to be the most easily identifiable landmark with a consistent anatomical relationship with the nerve trunk. The posterior belly of digastric muscle is the most easily identifiable and a very consistent landmark for facial nerve dissection during parotidectomy. When supplemented with the tragal pointer, accuracy in identifying the facial nerve trunk is very high, thereby avoiding inadvertent injury to the nerve trunk.     

Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts

BackgroundThe extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach.MethodsSixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I–V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3–4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS).ResultsClinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92).ConclusionThis study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.     

Anatomical and Surgical Study to Evaluate the Accuracy of “C-M-S” Technique in Facial Nerve Identification During Parotid Surgery

Facial nerve identification is considered to be a crucial step in parotid surgery as inadvertent injury to the nerve will lead to facial paralysis. Multiple landmarks are described in literature to identify the facial nerve during parotid surgery but controversies remain as the consistency and accuracy of these landmarks vary. Numerous studies exist in literature but they fail to address a single landmark that is most reliable to identify the facial nerve during parotid surgery. The purpose of this study is to find reliable landmarks for identification of the main trunk of facial nerve during parotid surgery by evidence gathered by cadaveric dissection and intraoperative study during parotid surgery and develop a systematic approach to identify the facial nerve trunk. This prospective study included 41 cadavers (82 parotid regions) and 20 patients with parotid pathology who underwent parotidectomy. We evaluated the feasibility of our C-M-S technique to identify the main trunk of facial nerve in both anatomical and surgical study. The relationship of landmarks (tragal pointer, tympanomastoid suture, superior border of posterior belly of digastric muscle) to the facial nerve trunk was assessed and the shortest distance between them from the facial trunk was measured using a slide caliper. The measurements were compared between the anatomical and surgical study. The main trunk of facial nerve was successfully identified in all cases using C-M-S technique in both anatomical and surgical study. Distance of facial nerve trunk to tragal pointer was more in the cadaveric sample (13.04 ± 5.238 mm) compared to live patients (9.95 ± 3.967 mm) with statistically significant difference (p = 0.036). The mean distance of tympanomastoid suture and posterior belly of digastric muscle to the facial nerve trunk was similar in anatomical and surgical study with p value of 0.877 and 0.083 respectively. The tympanomastoid suture, posterior belly of digastric muscle and tragal pointer are the most useful landmarks for facial nerve identification during parotid surgery. In our study we found that the tympanomastoid suture line is the most consistent landmark present in all our cases and being closest to the facial nerve trunk in both anatomical and surgical study. Further we recommend using the “C-M-S technique” in order to locate the main trunk of the facial nerve.     

涎腺癌196例临床分析

自1975年至1985年间,我院收治涎腺癌共196例,占同期头颈部恶性肿瘤的4.2％。男115例,女81例,年龄6.5-78岁。腮腺93例,颌下腺24例,舌下腺1例,小涎腺78例。本组随访满3、5、10年以上各占153例、121例和39例。3、5、10年生存率分别为75.8％、66.1％、59％。病变位于大涎腺与小涎腺生存率相近。Ⅰ-Ⅳ期5年生存率分别为88.5％、70.7％、52.6％和45.0％。术后放射治疗能改善晚期癌(Ⅲ、Ⅳ期)的生存率。本组术后局部复发率为35.5％,远处转移率为7.1％。     

游离保留SMAS术与非游离保留SMAS术对腮腺肿瘤患者术后Frey综合征及术后复发的影响

目的对比游离保留表浅肌肉健膜系统(SMAS)术与非游离保留SMAS术对腮腺肿瘤患者术后Frey综合征及术后复发的影响。方法选择腮腺肿瘤患者99例,根据随机数字表法分为研究组50例与对照组49例,对照组给予非游离保留SMAS术,研究组给予游离保留SMAS术,记录与随访术后Frey综合征及术后复发情况。结果两组的切口长度、手术时间对比差异无统计学意义(P>0.05),研究组的术中出血量与术后住院时间显著少于(短于)对照组(P<0.05)。术后7 d研究组的面神经分级显著好于对照组(P<0.05)。研究组术后6个月的主观与客观判定Frey综合征的比例为2.0%和6.0%,显著低于对照组的14.3%和22.4%(P<0.05)。研究组术后1年的复发率为2.0%,显著低于对照组的12.2%(P<0.05)。结论相对于非游离保留SMAS术,游离保留SMAS术在腮腺肿瘤患者中的应用能减少创伤,改善面神经功能,减少术后Frey综合征及术后复发的发生。     

The effect of ionizing irradiation on the intraductal pressure of the human parotid gland

The intraductal pressure of the human parotid glands in patients who had received fractionated ionizing irradiation prior to operation for pleomorphic adenoma was studied after stimulation of the glands with a 3 % solution of acetic acid. The following observations of interest were made: 1) the stimulation raised the intraductal pressure within 1–2 seconds; 2) the mean intraductal pressure in 24 normal glands after the first stimulation reached 752 mm H2O; 3) irradiation with one single dose (5 Gy) reduced the intraductal pressure of diseased glands by about 80 % within 24 hours; and 4) after three doses of 5 Gy/day no intraductal pressure could be measured on the irradiated side.