颌后入路治疗髁突颈部骨折

目的:探讨颌后入路治疗下颌骨髁突颈骨折的治疗方法及效果。方法:对23例单侧成人下颌骨中低位髁突颈骨折患者,经颌后入路,术中保护腮腺及面神经,行切开解剖复位坚强内固定术。结果:23例患者均取得良好解剖复位,无1例出现涎瘘,无1例出现面神经麻痹,咬合关系恢复良好,通过早期锻炼张口,均能恢复术前张口度,无关节强直出现。结论:颌后入路治疗下颌骨中低位髁突颈骨折,有术野暴露充分、操作方便、有效保护面神经及腮腺等优点。     

下颌骨升支"箱盖式"入路手术切除咽旁间隙巨大肿瘤

目的:探讨一种改良的下颌骨升支切开入路切除咽旁间隙巨大肿瘤的方法。方法:按腮腺切口切开暴露。于下颌角切断咬肌附丽至骨膜下,沿骨膜下剥离至乙状切迹,于下颌孔外垂直截骨至乙状切迹下近1.0cm,垂直转向下颌骨升支后缘,肿瘤切除后,下颌骨升支后份游离骨板复位,钛板固定。结果:采用该手术入路切除咽旁间隙肿瘤3例,均完整切除,无手术并发症。结论:该术式术野暴露好,外形影响小,减少了并发症发生,适用于咽旁间隙巨大肿瘤切除。     

下颌骨外旋入路切除咽旁肿瘤的临床分析

咽旁间隙（parapharyngeal space，PPS）肿瘤发病率较低,暴露咽及咽旁间隙（PPS）肿瘤的最大障碍是下颌骨。不少学者先后应用下颌骨外旋入路切除咽旁间隙肿瘤及颅底肿瘤，均获满意效果。2002-2008年期间，采用下颌骨切开外旋入路切除咽旁间隙肿瘤11例，现将报道如下：     

下颌骨外旋入路切除颞下窝肿瘤手术分析

目的：：分析颞下窝肿瘤下颌骨外旋手术入路的效果。方法：回顾11例下颌骨外旋入路切除颞下窝肿瘤的临床资料,5例在下颌骨颏孔前方截骨,4例在下颌角前截骨,2例在颏正中截骨。结果：下颌骨外旋入路根据肿瘤的性质、部位、大小及与周围神经血管的关系,灵活的选择下颌骨截骨部位,均可充分显露颞下窝肿瘤达到较好的切除效果。结论：下颌骨外旋入路是切除颞下窝肿瘤安全有效术式。     

下颌骨旁正中劈开入路在治疗腮腺深叶巨大肿瘤中的应用

采用下颌骨旁正中劈开入路切除腮腺深叶巨大肿瘤在临床上应用不多。本文报告采用下颌骨旁正中劈开入路切除腮腺深叶巨大肿瘤1例,并对腮腺深叶巨大肿物切除的手术入路进行文献复习及讨论。患者术后随访,无复发,效果满意。     

两种颌后入路治疗下颌骨髁突骨折方法的研究

目的:探讨两种颌后入路治疗下颌骨髁突颈骨折的治疗方法及效果。方法:64例成人下颌骨中低位髁突颈骨折患者,随机分为A、B两组,经颌后入路,分别采用腮腺前缘入路及横断腮腺入路,解剖复位髁突骨折行坚强内固定术。结果:64例患者均取得良好解剖复位,咬合关系恢复良好,无关节强直出现。A组2例出现面神经麻痹。B组2例出现涎瘘,4例出现面神经麻痹症状。结论:颌后入路可有效治疗髁突骨折,且腮腺前缘入路较横断腮腺入路减少了手术并发症的发生。     

RI扫描对腮腺肿瘤诊断意义的研究

腮腺肿瘤对放射线不敏感,对抗肿瘤药物效果不明显,唯一治疗方法是根治性手术。而腮腺肿瘤有多种组织类型,术前诊断困难,即使同一组织型亦有不同的恶性度,所以全部腮腺肿瘤都应作广泛切除;但是,由于面神经分支走行于腮腺实质内,牺牲面神经术后可出现面瘫。所以,一般良性肿瘤可做保留面神经的浅叶或深叶切除,恶性度高的肿瘤应做包括面神经的广泛切除,根据不同情况可切除部份嚼肌和下颌骨。腺样囊性癌有侵犯面神经周围淋巴的危险,为了安全可切除面神经走行部分的颞骨。低度恶性肿瘤一般是根据肿瘤距离面神经的远近来决定是否切除面神经。因此,腮腺肿瘤术前诊断时对恶性度的判断是很重要的。     

经下颌下下颌骨角部前方截骨入路颞下窝颅底肿瘤的外科治疗

目的:探讨颞下窝颅底肿瘤的手术入路和手术方法。方法:对9例位于颞下窝颅底的肿瘤采用下颌下切口、下颌骨角部前方截骨入路进行手术治疗,观察手术效果,评价手术方法。结果:9例手术术野暴露充分,手术操作顺利,术后愈合良好,无严重并发症,其中良性肿瘤6例,恶性肿瘤3例,随访12～36个月肿瘤无复发。结论:下颌下、下颌骨角部前方截骨入路进行颞下窝颅底部肿瘤切除治疗效果满意。     

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。     

改良式腮腺肿瘤切除术

目的:介绍一种改良式手术切除腮腺肿瘤的方法。方法:采用耳屏前隐蔽的面部除皱术切口及耳后延长入发际的内切口,在嚼肌筋膜下翻瓣;首先解剖暴露面神经总干后,根据肿瘤的位置,选择性解剖面神经颈面干而行腮腺部分切除术,保护腮腺的部分功能;并采用蒂在上方的胸锁乳突肌局部填塞以减少术后畸形。结果:应用改良术式的16例患者中,无1例出现涎瘘及面神经损伤,随访3～6个月无1例出现Frey’s综合征,并且局部凹陷轻微,面容美观。结论:改良式手术方法切口隐蔽,容易操作,不易损伤面神经周围支,术后并发症少,是一种值得推荐的腮腺肿瘤切除术。     

Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach

The objective of this study was to evaluate any damage to the facial nerve after a retromandibular transparotid approach for open reduction and internal fixation (ORIF) of a subcondylar fracture. We studied 38 patients with 44 subcondylar fractures (3 bilateral and 38 unilateral) treated by ORIF through a retromandibular transparotid approach. All patients were followed up for 6 months. Postoperative function of the facial nerve was evaluated within 24 h of operation, and at 1, 3, and 12 weeks, and 6 months. Variables including type of fracture, degree of mouth opening, postoperative occlusion, lateral excursion of the mandible, and aesthetic outcome were also monitored. Nine of the 44 fractures resulted in transient facial nerve palsy (20%). Branches of the facial nerve that were involved were the buccal (n = 7), marginal mandibular (n = 2), and zygomatic (n = 1). In the group with lateral displacement, 2/15 showed signs of weakness, whereas when the fracture was medially displaced or dislocated 7/23 showed signs of weakness. Of the 9 sites affected, 7 had resolved within 3 months, and the remaining 2 resolved within 6 months. The mean (range) time to recovery of function was 12 weeks (3–6 months). There was no case of permanent nerve palsy. The retromandibular transparotid approach to ORIF does not permanently damage the branches of the facial nerve. Temporary palsy, though common, resolves in 3–6 months. Postoperative occlusion, mouth opening, and lateral excursion of the mandible were within the reference ranges. We had no infections, or fractured plates, or hypertrophic or keloid scars.     

Retromandibular transparotid approach compared with transmasseteric anterior parotid approach for the management of fractures of the mandibular condylar process: a prospective randomised study

Fractures of the mandibular condyle lead to displacement of the condyle and loss of the height of the ramus. A retromandibular approach is the most commonly used for open reduction and internal fixation (ORIF) of such fractures. We aimed to compare the complications associated with a retromandibular transparotid approach with a retromandibular transmasseteric anterior parotid (TMAP) approach for their management. Thirty patients were randomly selected into two groups (15 in each): Group A comprised the retromandibular transparotid approach and Group B the retromandibular TMAP. The variables evaluated were: operating time, facial nerve injury, occurrence of Frey syndrome, and sialocoele at one week, four weeks, three months, and six months. The mean (SD) age in group A and B was 33.93 (17.97) years and 33.53 (16.15) years, respectively, and there were 28 men and two women. Mean (SD) exposure time in the transparotid approach was 26.93 (5.19) minutes and 25.4 (8.35) minutes in the TMAP approach. The incidence of facial nerve injury was 2/15 patients in the transparotid group and 3/15 in the TMAP group, all of which resolved within six months. The incidence of sialocoele was 2/15 in the transparotid group. The results did not show any significant difference in complications between the two approaches, but the retromandibular transparotid approach provided straight-line access in fractures of the condylar neck, with fewer incidences of nerve injury. The anterior parotid approach, on the other hand, provided easier access for fractures that were medially dislocated or of the condylar base but had an increased incidence of facial nerve injuries.     

腮腺良性肿瘤两种切除术式的疗效比较

目的 :探讨改良腮腺部分切除术在腮腺良性肿瘤治疗中的临床应用价值。方法 :回顾性分析漯河市中心医院收治的62例腮腺良性肿瘤病例,按照手术切除方法的不同分为改良组和传统组,传统组采用传统腮腺浅叶切除术治疗,另一组采用保留腮腺咬肌筋膜的"肿瘤+腮腺部分切除术"治疗(研究组),比较两组患者的疗效、并发症发生率及复发率。结果:术后随访6~48个月,两组患者的复发率无显著性差异(P>0.05)。研究组术后并发症发生率显著低于传统组(P<0.05)。结论:改良腮腺部分切除术手术创伤小,术后并发症少,在直径<4 cm的腮腺浅叶良性肿瘤手术中,具有很高的临床应用价值。     

腮腺内下颌后静脉与面神经关系的解剖学研究

为了腮腺外科避免损伤面神经,本文对３１具成年尸体（５７例）腮腺内下颌后静脉与面神经关系进行了解剖学研究。结果：下颌后静脉宽５．６ｍｍ±１．０ｍｍ。有５０例（８７．８％）下颌后静脉位于面神经上、下干（或上、中、下干）内侧;有７例（１２．３％）下颌后静脉位于面神经上干内侧,进而转向下干外侧。依据下颌后静脉横过面神经不同部位,又分成若干亚型。其中较为常见者为下颌后静脉在面神经总干分叉点与下干分支点之间的内侧横过（３３．３％）。在２６具双侧解剖的尸体中,有４例（１５．４％）下颌后静脉与面神经关系左、右侧不同。     

Preoperative determination of the location of parotid gland tumors by analysis of the position of the facial nerve.

PURPOSE: This study examined the usefulness of anatomic lines in predicting the intraparotid course of the facial nerve. Materials and Methods: To make the comparison, 3 lines were drawn on 69 transverse sections of 5 cadaver heads. Then, the shortest and the longest distance from the lines to the facial nerve were measured. RESULTS: Of the tested lines, the one that connects the most dorsal point on the ipsilateral half of a vertebra to the dorsal side of the retromandibular vein had the shortest distance to the facial nerve. It also ran more parallel to the facial nerve than the other 2 lines. CONCLUSIONS: Because the line that connects the most dorsal point on the ipsilateral half of a vertebra to the dorsal side of the retromandibular vein best predicts the intraparotid course of the facial nerve, it might be useful in assessing whether parotid tumors are located in the superficial or deep lobe.     

Comparison of Preauricular Approach Versus Retromandibular Approach in Management of Condylar Fractures

Aim

The aim of the study is to compare the two extra oral approaches to the TMJ viz preauricular and retromandibular approach in management of condylar fractures of mandible.

Methods and Materials

Patients with fractured dislocation and displacement of mandible condyle in medial direction were managed by preauricular approach. Patients with lateral displacement of mandibular condyle were managed by retromandibular approach. OPG, Reverse towne??s, and C.T. scan were taken in all the cases prior to surgery to assess the pattern of displacement.

Results

In our study both approaches have given excellent access and visibility to the condylar fractures but with limitations in each technique. Minimal intraoperative and postoperative complications were encountered in both approaches. The duration of the procedure for preauricular approach was much longer when compared with retromandibular approach. Facial nerve weakness was common in patients treated with preauricular approach, which they improved over a period of time and had complete recovery. Postoperative scar was imperceptible in all cases and good cosmetic results were seen with both approaches. Mouth opening, mandibular movements and occlusion were more or less same in both the approaches while pain and clicking was common in preauricular approach.

Conclusion

Both approaches have good results in managing condylar fractures with retromandibular approach having ease of access and ease of fixation. So one can always give preference to retromandibular approach over preauricular approach in managing the condylar fracture except in some cases where preauricular approach is the only option like anteromedial dislocation or complete medial dislocation of condylar segment. Situations, where patients who reported very late for the surgery with resultant scarring of the tissue, in those cases preauricular approach is the only option.     

The retromandibular transparotid approach: Our clinical experience

Introduction

Mandibular condylar fractures are very common. There is general agreement that an intracapsular fracture requires conservative treatment, but the treatment of extra-capsular fractures is controversial. Extraoral approaches have different advantages and disadvantages. The possibility of damage to the facial nerve is always present but, in our experience, always recovers in a short time.

Materials and methods

From June 2008 to June 2009, we admitted 25 patients with mandibular condylar fractures to our department. Nineteen patients received a retromandibular transparotid approach to identify and stabilize the condylar fracture site. None of them developed infection.

Surgical technique

A 2 cm incision extending in the retromandibular hollow is the first step. Initial dissection in a forward and upward in the direction of the SMAS layer is mandatory to gain good mobility of the soft tissue flaps. Blunt dissection through the parotid gland is performed between the marginal and buccal branches of the facial nerve. Periosteal elevation of all the lateral surface of the mandible provides good exposure of the bony surfaces and mobilization of the soft tissues.

Conclusions

We believe that this approach is a safe and time sparing alternative to the intraoral endoscopic approach     

Analysis of the retroauricular transmeatal approach: a novel transfacial access to the mandibular skeleton

In 2005 experimental work was published about the successful surgical management of fractures of the condylar head through a retroauricular approach. There were two reports in German, and later publications have not mentioned this route to open reduction and internal fixation of such fractures. The approach was studied in Germany but was poorly described and illustrated; later reports in English do not mention this route to the mandible. The aim of this study was to illustrate the retroauricular transmeatal approach, and briefly to review current surgical approaches to the mandibular skeleton and their technical variants. We exposed the mandibular skeleton by a retroauricular transmeatal route with transection of the external ear, dissection of the parotid gland, isolation of the retromandibular vein, and protection of the frontal branch of the facial nerve and the auriculotemporal nerve within the substance of the anteriorly retracted flap. Although we cannot draw any significant conclusions, the retroauricular transmeatal approach ensures extremely low risk of injury to the facial nerve, and leaves an invisible scar. The morbidity is low in terms of facial nerve lesions, vascular injuries, aesthetic deformity, auditory stenosis, salivary fistulas, sialocele and Frey syndrome. We think that further prospective clinical trials are needed better to assess and eventually develop this approach.     

Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures

Condyle fractures represent 20% to 30% of all mandibular fractures and are thus among the most common facial fractures. The fracture pattern can vary greatly and may occur anywhere along the line from the sigmoid notch to the mandibular angle. The main problems are access, difficulty in repositioning the extremely slender fragments, and fixation of the condyle.Eighty-seven patients were diagnosed with condylar neck or condylar base fractures from January 2007 to December 2009 in the Department of Oral & Maxillofacial Surgery of Kyung Hee University Dental Hospital. In this study, we included 35 patients who underwent open surgery and a total of 28 patients who were treated using a retromandibular transparotid approach.Surgical treatment aims were anatomic repositioning and rigid fixation of the fragments, occlusal stability, rapidly return to function, maintenance of vertical ramus dimension, no airway compromise, and reduced long-term temporomandibular joint dysfunction. Considering the high rate of occurrence of condylar fracture and the importance of the condylar as a growth center of the mandible, extraoral approaches for the open reduction of condylar fractures are considered effective and can be used widely.Short access route, easy reduction, short operating time, and stable postoperative occlusion are the advantages of the retromandibular transparotid approach. Also, there was no permanent damage from facial nerve injury, salivary leakage, or preauricular hypoesthesia. Therefore, the retromandibular transparotid approach is considered a safe and effective method for patients with a condylar neck or condylar base fracture classified according to the Strasbourg Osteosynthesis Research Group's classification, who require surgical treatment with an extraoral approach.