The middle fossa transpetrous approach to the anterior-superior cerebellopontine angle

We present a new approach to the skull base, medial and superior to the internal auditory canal, for tumors involving the anterior-superior cerebellopontine angle, petrous apex, and clivus. This approach is accomplished through a middle fossa craniotomy and involves removal of the bone anterior and medial to the internal auditory canal and medial to the cochlea and carotid artery. It combines the advantages of complete tumor removal, low mortality rate, and hearing preservation.     

Retrolabyrinthine transtentorial approach to lesions of the anterior cerebellopontine angle.

Various surgical approaches to the cerebellopontine angle have been used for removal of acoustic neuromas. A retrolabyrinthine transtentorial approach has been developed that allows (1) access to the anterior cerebellopontine angle and all portions of the basilar artery, (2) extra dural retraction of the lateral sinus and cerebellum while avoiding the vein of Labbé, and (3) preservation of hearing. This approach allows good exposure of tumor and accurate visualization of cranial nerves. To avoid complications, control of spinal fluid is mandatory and great care must be taken to avoid injury of the cranial nerves. The retrolabyrinthine or translabyrinthine transtentorial approach enables skilled neurosurgeons and neurotologists to gain access to lesions that are located in areas difficult to approach.     

The enlarged middle cranial fossa approach for surgery of the temporal bone and of the cerebellopontine angle

Due to the fact that the temporal bone has broad segments of bone anterior to and behind the internal auditory canal which are empty of functionally important structures, a broad exposure of the cerebellopontine angle may be obtained from above. This technique is adequate for the management of acoustic neurinomas up to 3 cm in diameter. A low postoperative morbidity and a high percentage of hearing preservation with total tumor removal were obtained in a series of 190 cases. This report underlines the advantages of the procedure and points to various other indications.     

The enlarged middle cranial fossa approach for surgery of the temporal bone and of the cerebellopontine angle

Summary Due to the fact that the temporal bone has broad segments of bone anterior to and behind the internal auditory canal which are empty of functionally important structures, a broad exposure of the cerebellopontine angle may be obtained from above. This technique is adequate for the management of acoustic neurinomas up to 3 cm in diameter. A low postoperative morbidity and a high percentage of hearing preservation with total tumor removal were obtained in a series of 190 cases. This report underlines the advantages of the procedure and points to various other indications.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

Transotic approach to the cerebellopontine angle.

The transotic approach to the cerebellopontine angle for resection of tumors invading the internal auditory canal provides superior illumination and exposure for optimal preservation of facial nerve function. Separation of facial nerve from tumor is enhanced with an anterior exposure that allows visualization of the intracranial segment of the nerve before tumor removal without significantly increasing total operative time. Facial nerve grafting or hypoglossal-facial anastomosis may be incorporated into the procedure at the time of tumor resection using the transotic approach. When combined with a musculofascial patch secured to the dural defect, the initial subtotal petrosectomy with eustachian tube and middle ear cleft obliteration generally avoids the complication of an immediate or delayed postoperative cerebrospinal fluid leak. The transotic approach is indicated for tumors up to 2.5 cm in size that are not adherent to the brain stem.     

Extended retrolabyrinthine transtentorial approach to petroclival lesions

In this communication, an extension of the retro-labyrinthine approach that has permitted safe, effective access to the petrous tip and clivus is presented. The basic technique involved complete mastoidec-tomy, preservation of the middle and inner ear structures, removal of the sigmoid and middle fossa plates, middle and posterior fossa craniotomies, ligation of the superior petrosal sinus, and division of the ten-torium. Nine cases that exemplified the versatility of this approach constituted the basis of this paper: 2 cholesteatomas, 2 basilar artery aneurysms, 2 chordomas, and 3 meningiomas. The indications for, and complications of, this method have been discussed.     

Middle fossa transpetrosal approach for petroclival and brainstem tumors

Objective: The purpose of the study was to demonstrate the utility of the middle fossa transpetrosal approach with anterior petrosectomy for difficult-to-access petroclival and pontine lesions. Study Design: Retrospective case review in academic tertiary referral center. Methods: Patients for inclusion had pontine and prepontine lesions of the petroclival region. Middle fossa transpetrosal approach with anterior petrosectomy with excision or biopsy of the lesion was performed. The main outcome measure was postoperative neurologic status including motor and cranial nerve function. Results: No patient experienced neuromuscular compromise or cranial nerve deficits as a direct result of the surgical procedure. Complications consisted of a subdural temporal lobe hemorrhage and one case of cerebrospinal fluid rhinorrhea. Conclusions: The middle fossa transpetrosal approach with anterior petrosectomy was utilized for five patients with petroclival or pontine tumors. In this small series, it served well to spare cranial nerves and allowed avoidance of serious vascular injury. To our knowledge, this is the first reported use of this procedure for pontine venous angiomas.     

采用不同程度扩大中颅窝入路对小脑脑桥角区的显露及损伤程度的解剖学评价

目的对经中颅窝入路小脑脑桥角区的显露程度及其损伤程度进行定量综合评价。方法通过对成年国人带颈头颅标本6具(12侧),模拟常规经中颅窝入路的手术操作,在中颅窝入路的基础上,分别磨除内听道上壁和弓状隆突。按Ammirat标准进行评价不同手术入路及其扩大后对小脑脑桥角区的显露程度,用Horgan法计算出显露面积,并根据损伤程度评分,评价经中颅窝及其扩大后的损伤程度。结果经中颅窝入路及其磨除内听道上壁和弓状隆突的显露程度进行评分,分别为0分、2分和3分;显露面积分别为0(、523.00±101.98)mm2和(706.30±119.39)mm2,每一步扩大后显露面积均较前明显增加(P<0.001)。对经中颅窝入路及其磨除内听道上壁和弓状隆突的损伤程度进行评分,分别为1分、5分和10分。结论①单纯中颅窝入路对小脑脑桥角区显露有限。②在单纯中颅窝入路的基础上进行2次扩大后,小脑脑桥角区的显露程度和显露面积明显扩大,但相应的损伤程度扩大,尤以磨除弓状隆突后损伤程度最大。     

迷路后入路在桥小脑角区手术中的应用

目的　探讨迷路后入路在桥小脑角区手术中的应用方法和临床价值。方法　回顾分析上海交通大学医学院耳科学研究所2011-01-01～2016-01-01收治的42例桥小脑角区疾病患者,均采用迷路后入路暴露手术区域,术中应用显微镜-内镜双镜联合技术。结果　所有病例均成功手术。听神经瘤及胆脂瘤病例均完全切除,术后可测听力保留率（AAO-HNS听力评级A、B、C级）为66.7%（6/9）,术后面神经功能良好（HB分级I-II级）,无1例患者出现脑脊液漏等颅脑并发症,随访中未见复发。颅神经疾病术后症状均消失,术后均保留可测听力,面神经功能良好,术后无后组颅神经等非责任神经并发症。结论　迷路后入路创伤较小,听觉及面神经功能保留率高,在内镜辅助下特别适合功能性颅神经手术及位于内耳道口且直径＜15 mm的桥小脑角听神经瘤及胆脂瘤的治疗。     

翼点入路切除前、中颅底沟通瘤

目的　对 7例前、中颅底沟通瘤的手术入路及治疗经验进行总结。方法　颅眶沟通瘤 3例 ,中颅底沟通瘤 4例 ,均采取翼点及其改良入路 ,其中 5例采取硬膜外入路 ,2例结合硬膜内外入路切除肿瘤。结果　 6例患者实现肿瘤全切 ,1例次全切除 ,无手术死亡。结论　翼点入路是切除前、中颅底沟通瘤的理想入路 ,具有显露充分、易于掌握和改良等优点 ;采取带蒂颞肌瓣充填肿瘤切除后的残腔 ,反折骨膜修补硬膜的颅底重建方法可以有效地防止各种并发症的发生。     

颞下经岩尖-小脑幕入路手术的显微解剖研究

目的 为颞下经岩骨入路手术处理斜坡及脑干腹侧病灶提供解剖学资料。方法 模拟颞下经岩尖—小脑幕入路的手术操作,在手术显微镜下对20侧(10具)福尔马林固定的国人成年带颈头颅标本进行解剖,并观测各主要解剖结构的相互关系。结果 颞下硬脑膜外经前内侧的三叉神经压迹、外侧的岩浅大神经沟及岩上窦所形成的三角区磨削岩骨尖。其周围结构的测量结果为:上半规管垂直于岩骨嵴,位于弓状隆起下方,耳蜗位于内听道前方、岩骨颈内动脉膝后方,内听道位于上半规管与岩浅大神经夹角中央。20侧中有2侧面神经膝裸露,耳蜗至膝状神经节的距离约为3.30 mm±0.79 mm,耳蜗距颈内动脉膝约2.48 mm±1.14 mm,内听道距岩斜缝约16.03 mm±1.94 mm,颈内动脉水平段距岩上窦约10.73 mm±2.00 mm。结论 颞下经岩尖—小脑幕入路能增加岩斜坡及脑干腹侧的显露,但显露范围有限,且需一定程度的颞叶牵拉。同时可能因为不熟悉解剖而误伤耳蜗、颈内动脉及第Ⅶ脑神经、第Ⅷ脑神经,选择应用时应审慎考虑。     

The middle cranial fossa approach to the petrous apex

Petrositis is still a very real complication of otitis media. The most striking diagnostic feature is facial and/or retrobulbar pain, and it is the most consistent symptom. External rectus paralysis was present in only one of the four cases presented in this series. Treatment is surgical. In order to spare the cochlea and give adequate exposure to the apical cells, the middle fossa approach to the petrous apex is presented, to be used alone or in conjunction with mastoidectomy.     

乙状窦后经路小脑脑桥角手术并发症

目的：探讨经乙状窦后径路小脑脑桥角手术并发症的类型及处理方法。方法：对近10年来施行乙状窦后径路小脑脑桥角手术36例的临床资料进行回顾性分析。结果：36例患者除2例神经性聋未愈外，其余并发症均治愈。结论：了解手术并发症的类型及发病机理对预防和处理并发症是重要的。