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颅底肿瘤不易早期诊断,延迟诊断（delay in diagnosis）几乎是100％。由于颅底位置深在,其中又含有诸多重要血管神经。导致该处肿瘤大多数不能常规切取活检。常规穿刺活检由于没有影像指导,可能穿刺不到目标,还可能损伤重要神经血管,风险较高。超声或CT引导下穿刺活检均存在各自的缺点,不易在临床推广。我院自2011年逐步开展导航技术在颅底及面侧深区肿瘤诊治中的应用,取得了一些经验。本文简单介绍了导航的基本原理及该技术在颅底肿瘤穿刺活检中的临床应用体会。     

Navigation-guided resection with immediate functional reconstruction for high-grade malignant parotid tumour at skull base

The authors report a case of navigation-guided tumour ablation of a high-grade epithelial-myoepithelial carcinoma of the right parotid gland extending to the skull base. Immediate functional reconstruction of the mandible with a prosthetic temporomandibular joint and facial nerve was performed. Postoperative follow-up showed no evidence of local tumour recurrence or distant metastasis with satisfactory temporomandibular and facial nerve function.     

穿刺小标本改良石蜡块制作方法及评价

目的: 改良现有琼脂预包埋石蜡包埋法,评价该包埋法对空芯针穿刺活检小标本组织完整性、组织学形态、蛋白质和DNA检测的影响。方法: 取10例口腔黏膜鳞癌空芯针穿刺活检标本,分别进行成型包埋模具的改良琼脂预包埋石蜡包埋法及常规石蜡包埋法,前者缩短脱水时间至3.5 h,后者为12 h。样本处理后,分别行H-E染色、组织学形态、免疫组织化学（IHC）和DNA荧光原位杂交（FISH）等检测,并对检测结果进行对比分析。采用GraphPad Prism 9软件包对数据进行组间t检验。结果: 改良琼脂预包埋法较琼脂预包埋法降低了操作难度,易于推广。与常规石蜡包埋法相比,组织脱水时间显著缩短（P<0.001）,对镜下组织学形态及后续IHC和FISH检测无影响。结论: 改良琼脂预包埋石蜡包埋法满足临床病理诊断对组织处理的要求,是值得推广的空芯针穿刺活检标本组织包埋法。     

Utility of navigation system-guided submandibular gland core needle biopsy in the diagnosis of immunoglobulin G4-related sialadenitis

Pathological diagnosis is important for the definite diagnosis of immunoglobulin G4-related sialadenitis (IgG4-RS). Core needle biopsy (CNB) is a scarless technique; however the pathological heterogeneity of IgG4-RS (a particular feature of this disease) could be the potential cause of the inferior diagnostic capability of submandibular gland CNB (SMG-CNB) for IgG4-RS. The aim of this study was to explore technical improvements in SMG-CNB and improve its diagnostic power in IgG4-RS diagnosis. Eighteen patients clinically suspected for IgG4-RS were enrolled and underwent both SMG-CNB and SMG surgical biopsy. A navigation system (Brainlab) was employed during SMG-CNB to obtain representative samples and avoid blood vessel injury. Histopathological and immunopathological findings for the SMG-CNB samples were in good concordance with SMG surgical biopsy. There was no statistically significant difference between SMG-CNB and SMG surgical biopsy in IgG-positive cell count (132.4 ± 59.3 vs 132.2 ± 47.5, P = 0.99), IgG4-positive cell count (102.2 ± 39.7 vs 97.2 ± 27.6, P = 0.67), or IgG4-positive/IgG-positive cell count ratio (78.6% ± 0.1% vs 75.2% ± 0.1%, P = 0.29). A moderate or strong significant correlation was found between SMG-CNB and SMG surgical biopsy for these cell counts and ratio (all P < 0.01). The diagnostic consistency of SMG-CNB and SMG surgical biopsy was 100%. The Brainlab navigation system may assist in collecting representative SMG-CNB samples from typical pathological lesions. Tissues obtained from SMG-CNB are sufficient for the pathological diagnosis of IgG4-RS. Standardized SMG-CNB is expected to replace SMG surgical biopsy for IgG4-RS diagnosis.     

Endoscopic endonasal skull base surgery in pediatric patients. A single center experience

Object

At present, a minimally invasive endoscopic endonasal approach is considered an efficient option for lesions affecting the anterior and middle skull base with sellar and parasellar region involvement. In this study we will retrospectively analyze the pediatric patients that we have been treating in the same medical center for the past four years, using an endoscopic approach in the skull base.

侧颅底肿瘤的手术入路和修复重建

目的侧颅底肿瘤的外科治疗极具挑战,本研究探讨侧颅底肿瘤开放手术入路及修复重建选择。方法 2009年8月至2018年1月,北京口腔医院头颈肿瘤团队完成的侧颅底肿瘤患者196例,纳入本研究。结果 42 例为腮腺深叶或咽旁肿瘤,30例为颞下窝恶性肿瘤或交界性肿瘤,无颅内外沟通,124例为颅内外沟通肿瘤。16例应用腮腺浅叶切除后下颌支后缘入路,43例应用颌下切口-下颌骨暂时性离断入路,13例应用冠-面联合切口,面神经暂时性离断或下颌骨升支及乳突切除入路,124例颅内外沟通肿瘤采用多学科联合手术,冠-面联合切口或颞枕开颅-颅颈联合入路。155例接受了组织瓣移植修复,其中颞肌筋膜瓣59例,游离背阔肌皮瓣74例,颌下腺瓣22例。皮瓣移植成功率为100.0%。27例患者发生术后深部创口感染,术后缺损一期行组织瓣移植或颌下腺瓣填塞明显降低术后感染率。1例患者术后出现颅内感染,升级抗生素后痊愈。所有颅内外沟通患者均出现不同程度脑脊液瘘,其中58例严重患者给予腰大池引流3~7天症状消失。2例患者发生围术期死亡。结论 肿瘤病理类型、发病部位、是否颅内外沟通、颌面组织缺损程度、既往治疗史等均是侧颅底肿瘤手术入路和修复重建选择需要重视的局部因素。     

Computed tomography-guided transfacial buccal space core biopsy of deep head and neck space lesions: our experience

Deep head and neck space lesions can present a number of diagnostic challenges due to their deep anatomical position and difficult access for diagnostic tissue sampling. We describe a series of percutaneous ‘transfacial’ buccal space computed tomography (CT)-guided core biopsies of these lesions and subsequent histological findings. Six patients underwent CT-guided core biopsy of deep parotid, parapharyngeal, or masticator space lesions over a 30-month period. We describe our biopsy technique and correlate our histological findings with subsequent surgical resection where performed. Five of six of CT-guided biopsies obtained sufficient tissue for histological interpretation with varying findings, including salivary gland tumours and squamous cell carcinoma confirmed on subsequent resection. One patient was treated palliatively following core biopsy. No biopsy-related complications were observed. In our small series, percutaneous CT-guided transfacial biopsy via the buccal space has proved an excellent option for the minimally invasive tissue acquisition of deep head and neck space lesions.     

Recurrent ameloblastoma in the anterior skull base： Report of 3 cases

Ameloblastoma is a benign but locally invasiveepithelial odontogenic tumor. Recurrence ofameloblastoma is most common after inadequate treat-ment, with an incidence up to 90% in the mandibleand 100% in the maxilla[1]. Despite radical resectionsincluding adjacent soft tissues, a recurrence rate of5% to 15% has been reported[2]. However, only a fewcases of recurrence reported in the literature involvedthe temporal fossa [3～5]. We presented 3 patients withrecurrent ameloblastoma in the anterior …     

Intracranial application of free fasciocutaneous flaps in a novel sandwich technique for skull base reconstruction

Free tissue transfer has been the gold standard of extensive skull base reconstruction, but the onlay of free flaps onto skull base defects carries the risk of cerebrospinal fluid (CSF) leakage. The purpose of this study was the evaluation of a novel technique of a combined sub- and onlay concept with a partially intracranially positioned folded free fasciocutaneous flap in terms of flap applicability, versatility and complication rate. Within 5 years, 7 patients with anterior (n = 4), middle (n = 2) or posterior (n = 1) skull base defects were reconstructed with free extended lateral arm (n = 3) or anterolateral thigh (n = 4) flaps. The flaps were partially intracranially positioned and fixed with osteo-dermal sutures. Both flaps proved to be applicable in terms of sealing efficiency, minimizing intracranial flap volume and folding. No flap loss was observed. Specific complications consisted of one pneumocranium via an accessory frontal sinus and one cerebellar herniation due to lumbar CSF loss. No flap failure or haematoma of the intracranial flap part occurred. This new concept of intracranial positioning of fasciocutaneous flaps in a sandwich technique using osteo-dermal sutures should be considered as a primary treatment for skull base reconstruction rather than merely as a salvage manoeuvre.     

Chordoma of the anterior skull base presenting as a swelling of the medial canthus of the eye

Intracranial chordomas are locally infiltrative tumours that usually present with deficits of the cranial nerves. Because of their location in the skull base they are difficult to cure and pose complex problems in management. We report an unusual case of a chordoma that presented as a swelling of the medial canthus. Diagnosis of chordoma might not be considered in this site, which is unfortunate because its superficial location offers the possibility of complete excision and cure.     

数字化导航引导下125I精确植入治疗9例颅底腺源性恶性肿瘤的效果评价

目的 探讨数字化导航引导下¹²⁵I粒子精确植入治疗颅底腺源性恶性肿瘤的可行性及疗效。方法 选取2017年9月—2019年9月应用数字化导航引导,行¹²⁵I粒子近距离植入治疗颅底恶性肿瘤的患者9例。植入术前应用三维治疗计划系统制定粒子植入计划。将三维CT数据导入导航软件AccuNavi-A 2.0 中,进行三维重建,确定粒子植入方向、角度及深度。术中按术前计划植入穿刺针,在导航引导下,调整定位针位置及方向,穿刺进入颅底靶区及周围组织,植入¹²⁵I粒子。实时验证¹²⁵I粒子植入位置。术后定期随访,比较术前、术后CT中肿瘤及靶区2个垂直的最大直径的乘积,统计局部复发率、局部控制率等指标。结果 9例颅底恶性肿瘤患者,腺样囊性癌5例,黏液表皮样癌2例,肌上皮癌1例,腺泡细胞癌1例。随访时间3~36个月,中位随访时间17个月,无失访病例。局部复发率11.1%,局部控制率77.78%。导航精确度达0.2~1.5 mm,未出现3级及以上放射性损伤。其中手术切缘阳性,未完整切除的5例患者中, CR 3例,PR 2例。2例切缘阴性患者,复查至今未发现明显新生物。外院手术后复发的2例患者,于数字化导航引导下行¹²⁵I粒子植入治疗,术后CR 1例,PR 1例。结论 颅底恶性肿瘤位置隐蔽,毗邻重要解剖结构,空间狭小,手术视野受限,单纯手术难以根治。导航引导下¹²⁵I粒子植入治疗颅底恶性肿瘤具有靶区定位精准、局部控制率高、正常组织损伤小、作用持续、安全、微创的特点,为辅助治疗颅底恶性肿瘤提供了可靠保障,值得临床推广。     

TMJ arthroscopy: rare neurological complications associated with breach of the skull base

We report an interesting case of vertigo and palsies of the right oculomotor and trochlear nerves associated with fluid collection in the region of the ipsilateral temporal lobe and cavernous sinus after bilateral arthroscopy of the temporomandibular joint (TMJ).     

Navigation-guided resection for a tenosynovial giant cell tumor involving the temporomandibular joint and skull base

Tenosynovial giant cell tumor is a very rare, benign lesion from the synovium. It seldom happens in the temporomandibular joint area and skull base that is difficult to resect and reconstruct. We present a case treated with computer-assisted navigation to help mark the tumor boundaries, protect vital structures, and facilitate the reconstruction process. Follow-up at 6 months after surgery showed no tumor recurrent and good temporomandibular joint function.     

Diagnostic value of navigation-guided core needle biopsy in deep regions of the head and neck with focal FDG uptake on 18F-FDG PET/CT

PurposeThe aim of this study was to evaluate the feasibility and diagnostic accuracy of core needle biopsy (CNB) in patients with focal fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) in deep regions of the head and neck, with the guidance of infrared navigation integrated with PET.Materials and methodsPatients with suspected primary or recurrent malignancies of the head and neck on PET/CT, from June 2016 to December 2018, were included. Before CNB, the region of interest was delineated and the ideal needle entry points, target sites, and a number of trajectories were designed on iPlan CMF 3.0. CNB was performed with the guidance of infrared navigation integrated with PET, according to the pre-plan. Sensitivity and diagnostic accuracy were analyzed by comparing the biopsy results with the final diagnosis.ResultsThirty-one consecutive patients were included. Among the 31 lesions, 18 were skull base, six were infratemporal fossa, and seven were maxillary region. The median values for SUVmax, SUVmean, and MTV were 6.09 (range: 1.43–24.67), 3.41 (range: 0.38–20.96), and 25.83 (range: 3.54–361.94) for the 31 lesions, respectively. Combined needle approaches were employed, including temporal (nine), subzygomatic (19), paramaxillary (11), and retromandibular (16) approaches. The depths of the 31 deep-region lesions, measured from the needle entry site on the skin to the target point, ranged from 1.33 cm to 7.82 cm (median 4.25 cm). There were three non-diagnostic lesions resulting from CNB, and these were all skull base. The diagnostic accuracy was 90.3%, while the sensitivity was 88%. According to the binary logistic regression for the final diagnosis, the only significant parameter was SUVmax.ConclusionWith the guidance of navigation integrated with PET, CNB is a feasible and accurate diagnostic modality, which is also an alternative to open biopsy in patients with suspected primary or recurrent malignancies in deep regions of the head and neck on PET/CT.     

Surgical treatment of synovial chondromatosis of the temporomandibular joint with erosion of the skull base: a case report and review of the literature

Synovial chondromatosis (SC) is a rare metaplastic disease of the larger joints. It is rarely observed in smaller joints, especially in the temporomandibular joint (TMJ). This disease is considered to be metaplastic and shows no malignant tendencies, but can become locally aggressive, erode the cranial base, and even spread intracranially. To date, nine cases of spread into the intracranial space have been reported in the literature; however, the disease remained extradural in all cases. The authors present a review of the literature and report the case of a 70-year-old man with SC of the right TMJ that had eroded the cranial base, reaching the dura mater; a large intracranial mass was not present. The disease was considered to be stage 3 according to Milgram's classification. The patient was treated surgically, the tumour mass was removed, reconstruction of the cranial base was performed using titanium mesh, and the joint was reconstructed with a temporal muscle interposition flap. Diagnostic images and intraoperative photographs are also presented.     

The role of operator experience in fine needle aspiration cytology of head and neck masses

Fine needle aspiration cytology (FNAC) was performed on 95 patients presenting with a mass in the head and neck region, where a subsequent surgical pathological diagnosis and adequate documentation were available. In this group, 70% of the samples were found to be of diagnostic yield. Of these, the number of true-positives was 27, and true-negatives 35. This gives a sensitivity and specificity of 90% and 97%, respectively. The accuracy was 100% when performed by a consultant and 91% when performed by junior staff. These sensitivity and specificity levels compare favourably with those reported in other studies using FNAC in head and neck lesions. Greater experience of the operator appears to improve the accuracy rate. FNAC is a useful diagnostic tool for head and neck tumours, as shown by the high specificity and sensitivity rates in this study.     

手术导航系统辅助下放射粒子植入治疗眶尖周、颅底肿瘤的探索

目的:将手术导航系统与放射性粒子内照射治疗相结合,探索更高精度植入125I放射粒子的方法,从而更加安全有效地控制已累及颅底及眶尖周的口腔颌面部恶性肿瘤。方法:肿瘤侵及颅底、眶尖周的腺样囊性癌患者11例,术前进行MRI扫描。术中运用BrainLAB手术导航系统定位并引导手术进行。结果:术中避免了颅脑及眶内组织损伤。完成了放射粒子组织内均匀分布,定位准确,无一例出现颅脑损伤及视力影响,治疗有效率(response rate,RR)达100%,疗效确切。结论:手术导航系统辅助下进行颅底眶尖周放射粒子植入是精确、安全的,有条件的情况下可考虑采用。     

Use of the Venner™ A.P. Advance™ video laryngoscope for biopsy examination of the base of the tongue

Biopsy specimens taken from the base of the tongue can be non-diagnostic, because of errors in sampling and tissue samples that are too small or superficial. The Venner™ A.P. Advance™ video laryngoscope (Intavent Direct, Maidenhead, UK) is an anaesthetic laryngoscope designed for use in patients with a difficult airway. We present a pilot study that compares video laryngoscope-assisted biopsy examination of the base of the tongue with the standard technique using a surgical laryngoscope. The video laryngoscope gives a wide view of the base of the tongue and the ability to use sinus biopsy forceps, which can take larger and deeper specimens.     

The diagnostic performance of ultrasound-guided core biopsy in the diagnosis of head and neck lymphoma: results in 226 patients

Many clinical guidelines for investigating lymphomas advise that surgical excision biopsy (SEB) should be performed for a confident diagnosis. It is increasingly recognized in clinical practice that ultrasound-guided core needle biopsy (USCNB) is a reliable diagnostic technique. We aimed to investigate the diagnostic efficacy of USCNB in head and neck lymphoma.A retrospective analysis of all diagnosed head and neck lymphomas between 2013 and 2018 was performed. Patient records, radiology and histopathology reports along with the biopsy technique: fine needle aspiration cytology (FNAC), USCNB, and SEB used were reviewed. The technique providing diagnosis and leading to initiation of treatment was identified.Two-hundred and thirty patients and 267 biopsy samples were included. A total of 226 patients underwent USCN. In 215 of 226 (95.1%) USCNB patients were fully diagnostic allowing for initiation of oncological treatment; 11 patients required a subsequent SEB to provide diagnosis. In four patients, SEB was the only investigation performed. Of the USCNB total number of procedures (number of patients n = 230 is the same coincidentally as the number of USCNB procedures), 215 of 230 (93.5%) were fully diagnostic samples.In the majority of cases, USCNB provided a definitive diagnosis allowing initiation of oncological treatment, avoiding the need for SEB. USCNB should be considered the first-line diagnostic modality in appropriate cases, as it reduces time to initiate treatment, costs and avoids patients having to undergo unnecessary surgery and possible complications.