胆脂瘤型中耳炎伴面神经骨管缺损的手术治疗(附48例报告)

胆脂瘤型中耳炎伴面神经骨管缺损惟一有效的治疗方法是手术。如何判断面神经骨管的缺损，术中如何既能彻底清除面神经周围的病变，又能保护好面神经，是手术治疗中的关键。1995～2003年，我们对202例慢性中耳炎患者行中耳乳突手术，其中胆脂瘤型中耳炎183例，术中发现面神经骨管有不同程度缺损48例，均为胆脂瘤型中耳炎患者。现报告如下。     

经声频共振系统导入中药治疗非化脓性中耳炎的护理体会

急性非化脓性中耳炎主要由于咽鼓管粘膜充血、水肿阻塞所致。鼓室粘膜充血后鼓室内液体渗出致音波传导阻碍、耳内阻塞感及听力下降，若治疗不及时可转化成慢性卡他性中耳炎。近3年来，我们采用经声频共振系统导入“耳聋2号”(我院研制)治疗急慢性非化脓性中耳炎，取得了较好疗效，现报告如下。     

OZFT入路显露基底动脉和岩斜坡区病变的显微解剖研究

目的 研究眶颧额颞入路对处理基底动脉和岩斜区病变的有效性。方法 10具尸体标本20侧眶颧额颞(OZFT)开颅，模拟真实手术过程进行显微解剖。结果 单纯OZFT可良好显露基底动脉顶端，结合前后床突切除，16侧开颅均成功显露基底动脉中段以上；颞下硬膜外切除岩骨前部可由中颅窝显露桥脑前外侧的岩骨斜坡区；OZFT开颅较常规颞下开颅的手术方向更趋前后，经Kawases三角，50％(10侧)的显露可低至基底动脉下端及椎动脉汇合处。结论 正确选择开颅侧别，结合前后床突切除，OZFT开颅可用于处理基底动脉中段以上的动脉瘤；结合切除岩骨前部，可用于夹闭小脑前下动脉动脉瘤等；对同时累及海绵窦及后颅窝的肿瘤，OZFT开颅也是全切肿瘤的良好选择。     

脉络膜裂的显微解剖学特点及临床应用价值

目的 探讨脉络膜裂的显微解剖学特征和经脉络裂入路的临床应用价值.方法 对12个国人成人头颅湿性标本在4-10倍显微镜下进行侧脑室区域显微解剖,观察并描述脉络膜裂的显微解剖学特点.分别打开脉络膜裂体部、房部、颞部,观察达到第三脑室、松果体区、环池的路径解剖.结果 脉络丛位于侧脑室底部内侧.脉络膜裂是位于丘脑和穹窿之间呈C...     

迷路下后进路内耳道的显微解剖研究

采用显微解剖学和传统解剖学方法，经迷路下后进路对２５具成人头颅５０例内耳道标本进行了观察，对切断前庭神经的最佳部位解剖学评估，认为经迷路下后开放内耳道为最佳进路，对中间神经的出现率和解剖部位进行了观察，并探讨了迷路动脉走行与内耳道各壁的关系。为防止在开放内耳道时损伤前庭和耳蜗，提出将单孔作为内耳道底的解剖标志。     

枕下正中经小脑延髓裂锁孔手术入路的设计及可行性

目的设计枕下正中经小脑延髓裂锁孔入路,探讨采用该入路进行第四脑室及其周边区域手术的可行性。方法6具经10%甲醛溶液固定的尸体头颅标本,于枕骨大孔下方1.0 cm,向上做长4.0 cm的切口,自枕骨大孔向上磨除枕骨成直径约2.5 cm的骨孔,“X”形打开硬膜,锐性解剖枕大池蛛网膜,牵开小脑扁桃体,显露小脑延髓裂,逐步打开脉络膜、下髓帆,观察显露的结构。结果通过调整头位和显微镜的投射角度,经该入路分离小脑延髓裂后可显露脉络膜、下髓帆,逐步切开脉络膜下髓帆可显露第四脑室底、侧隐窝及脑干侧方。结论枕下正中经小脑延髓裂锁孔入路无需切开小脑蚓部,可以安全实施第四脑室内、桥脑延髓背侧以及小脑蚓部的手术。     

经穹窿间锁孔入路行三脑室手术的可行性探讨

采用解剖学方法，在导航辅助下对16例尸头实施模拟锁孔入路手术，通过冠状缝前4Cm、后2cm范围内的6个2cm×2cm锁孔骨窗观察、比较其对三脑室的显露情况。结果顺利完成16例尸头的经穹窿间三脑室前、中和后锁孔入路手术，前锁孔入路能显露松果体区和三脑室后部，中锁孔入路能显露三脑室后大部和松果体区前下部，后锁孔入路能显露三脑室前大部，左右骨窗对三脑室显露无影响。认为经穹窿间三脑室锁孔入路技术上可行，可用于三脑室和松果体区域肿瘤的手术治疗。     

老年尸头神经内镜下经鼻扩大至斜坡区手术入路的相关研究

目的 研究老年尸头神经内镜下扩大入路至斜坡区的重要解剖结构；通过与显微镜下乙状窦前入路至斜坡区暴露部位和面积的大小进行比较,分析两手术入路的优缺点.方法 将10具尸头(＞60岁)先进行CT薄层扫面,然后在神经导航系统下精确定位于CCD中心,用穿刺针做好标记,并随机分成神经内镜和显微镜组,内镜组暴露分为鼻腔、斜坡以及硬膜阶段,观察每阶段解剖结构,硬膜阶段测量相应的数据；显微镜组暴露分为皮瓣、骨瓣、硬膜阶段,至硬膜阶段测量相应的数据,并与神经内镜组比较.结果 老年尸头神经内镜下经鼻扩大至斜坡区入路的重要解剖结构有鼻中隔、咽结节、蝶窦开口、翼管,暴露斜坡的部位是整个斜坡区及其周围,暴露面积是(486.09±62.30) mm2.显微镜下暴露斜坡的部位是一侧的中上斜坡及岩骨嵴,暴露面积是(431.06±40.30)mm2.结论 神经内镜下经鼻扩大入路至斜坡区的重要解剖结构是鼻中隔、咽结节、蝶窦开口、翼管,该手术入路对切除单纯斜坡区的肿瘤具有入路短、创伤小、术后恢复快等优点,手术风险与开颅手术相当,适用于老年斜坡区占位病变患者.     

两种改良微创手术治疗松果体区肿瘤效果分析

目的观察两种改良微创手术治疗松果体区肿瘤的效果。方法对26例松果体区肿瘤患者行微创手术，采用改良Poppen入路手术11例，其中横窦矢状窦夹角处约3cm×2cm的小骨窗7例，2cm×（4—5）cm跨矢状窦的横行骨窗4例；采用Krause入路手术15例，均经松果体区、帆间池进入三脑室。结果手术均顺利，行肿瘤全切除术21例、次全切除术3例、大部切除术2例，无死亡、感染及术后出血；术后并发小脑肿胀1例，行后颅窝减压，术后7d小脑肿胀消退；出现一过性缄默1例。结论改良Poppen入路和Krause入路用于松果体区肿瘤手术具有微创性、有效性、实用性，其中后者风险更小；肿瘤位于幕上、部分幕上兼幕下且向侧方生长较大者宜采用Poppen入路，幕下、长入三脑室和幕下兼幕上者宜采用Krause入路。     

经口咽入路显微外科治疗颅颈区畸形

目的：探讨颅颈区畸形经口咽入路显微直视减压手术的方法和疗效。方法：本组58例颅颈区畸形患者，以颅底陷入为主的枕骨大孔区先天畸形42例(16例伴有颅后窝容积减小、小脑扁桃体下疝及脊髓空洞症)．慢性环枢椎脱位11例．齿状突骨折及脱位5例。采用经口咽入路显微镜直视下切除齿状突、斜坡下部及增生结缔组织，解除其对延髓、颈髓的压迫；围手术期行气管切开、颅骨牵引、植骨固定等。结果：术后随访O．5～7年，症状明显好转47例，减轻7例，无效3例，死亡1例。结论：采用显微外科技术经口咽入路治疗颅颈区畸形，可降低术后并发症和致残率；重视围手术期处理可预防术后伤口感染和脑脊液漏；二期植骨能增加颈椎稳定性。     

慢性中耳炎鼓索神经的病理学研究

对6例尸头（正常组）及因慢性中耳炎（COM）接受中耳手术的45例患者（病变组）病变侧鼓索神经进行光镜和电镜检查。根据肉眼观察的鼓索神经形态将病变组分为三组：A组为鼓索神经无病变组织侵蚀，B组为鼓索神经被肉芽组织，严重水肿粘膜和（或）胆脂瘤包绕，C组为由于病变严重或在原来的中耳手术中鼓索神经已被切断。病变组鼓索神经光镜和电镜下的检查结果与正常组比较有明显差异，B组鼓索神经有髓纤维数明显低于A组。认为慢性中耳炎引起可引起鼓索神经病变，中耳病变越重，其鼓索神经损伤也越严重。     

Intraoperative Facial Nerve Monitoring During Cochlear Implant Surgery: An Observational Study

Iatrogenic facial nerve injury is one of the most severe complications of cochlear implantation (CI) surgery. Intraoperative facial nerve monitoring (IFNM) is used as an adjunctive modality in a variety of neurotologic surgeries. The purpose of this retrospective study was to assess whether the use of IFNM is associated with postoperative facial nerve injury during CI surgery. The medical charts of 645 patients who underwent CI from 1999 to 2014 were reviewed to identify postoperative facial nerve palsy between those who did and did not receive IFNM. Four patients (3 children and 1 adult) were found to have delayed onset facial nerve weakness. IFNM was used in 273 patients, of whom 2 had postoperative facial nerve weakness (incidence of 0.73%). The incidence of facial nerve weakness was 0.54% (2/372) in the patients who did not receive IFNM. IFNM had no significant effect on postoperative delayed facial palsy (P = 1.000). All patients completely recovered within 3 months after surgery. Interestingly, all 4 cases of facial palsy received right CI, which may be because all of the surgeons in this study used their right hand to hold the drill. When right CI surgery is performed by a right-handed surgeon, the shaft of the drill is closer to the inferior angle of the facial recess, and it is easier to place the drilling shaft against the medial boundary (facial nerve) when the facial recess is small. The facial nerve sheaths of another 3 patients were unexpectedly dissected by a diamond burr during the surgery, and the monitor sounded an alarm. None of these 3 patients developed facial palsy postoperatively. This suggests that IFNM could be used as an alarm system for mechanical compression even without current stimulation. Although there appeared to be no relationship between the use of monitoring and delayed facial nerve palsy, IFNM is of great value in the early identification of a dehiscent facial nerve and assisting in the maintenance of its integrity. IFNM can still be used as an additional technique to optimize surgical success.     

面肌痉挛显微血管减压术中责任血管的解剖分析对手术疗效的影响

目的分析面肌痉挛（hemifacial spasm，HFS）患者颅内责任血管与面神经之间的解剖关系，为HFS显微血管减压术（microsurgical neumvascular decompression，MVD）提供解剖学依据。方法回顾性分析106例经显微血管减压术治疗的面肌痉挛患者的临床资料。术前均行三维时间飞越法磁共振血管造影（3D-TOF-MRA）检查，了解面神经受压迫是否存在责任血管及其来源与走向。采用枕下乙状窦后小脑下外侧入路显露面神经脑干段，仔细观察责任血管及其来源后将其推移，在责任血管与脑干之间放置Teflon减压垫棉。结果3D-TOF-MRA检查显示面神经被微小血管压迫的阳性率达92％。术中发现全部病例均有明确的责任血管，其中小脑前下动脉占66％（70／106）。34例患者中发现面神经根区（root exit zone，REZ）存在明显的压迫切迹。术后104例抽搐症状立即完全消失；2例抽搐症状明显好转，3个月内延迟治愈，总有效率为100％。结论血管压迫可能是面肌痉挛的主要病因。术中REZ的显露、准确判断责任血管、面神经REZ的充分减压，以及垫棉的大小和放置的位置等，是影响手术疗效的重要因素。     

Minimally Invasive Sacral Neuromodulation Implant Technique

PURPOSE: Sacral neuromodulation is a novel treatment for selected urinary and bowel dysfunctions. A new method is described for electrode implantation, the "minimally invasive sacral neuromodulation implant technique." METHODS: After the percutaneous nerve evaluation test, a small longitudinal incision (3 cm) is made, and a catheter cannula segment is inserted through the sacral foramen beside an insulated needle. The electrode is introduced into the catheter cannula, which is then removed and fixed to the sacrum by means of small anchors. The proximal part of the lead is tunneled into the subcutaneous tissue, reaching the pocket made to accommodate the neurostimulator. RESULTS: This procedure was performed in ten patients (5 male; mean age, 50.4 years). In four patients a single electrode was implanted, and in six patients two electrodes were implanted. The minimally invasive technique was significantly faster, saving a mean time of 20 minutes for each electrode. The incision made directly on the sacral foramen was significantly reduced (3 vs. 12 cm), avoiding the wide, blunt dissection of subcutaneous fat tissue. Application of the catheter cannula allowed the electrode to be introduced easily and correctly. The electrode anchors never failed: no cases of lead displacement or suboptimal position of the electrode occurred. A unilateral, sterile subcutaneous seroma occurred in one of the ten patients. CONCLUSIONS: The minimally invasive sacral neuromodulation implant technique seems to be a safe procedure-making sacral neuromodulation implant easier, faster, and safer, in as much as complications could be potentially reduced.     

大型听神经瘤显微手术治疗

目的探讨大型听神经瘤的显微手术经验。 方法回顾性分析解放军九六〇医院神经外科自2002年1月至2015年12月收治的47例大型听神经瘤患者,均行枕下乙状窦后入路显微外科切除术,采用术后House-Brackman面神经功能分级评价面神经功能并观察术后并发症。 结果肿瘤全切除者47例,面神经解剖保留者45例。术后House-Brackman面神经功能分级Ⅰ~Ⅱ级27例,Ⅲ~Ⅳ级17例,V级3例。术后38例患者恢复良好,8例出现术后不良反应,1例死亡。 结论采用显微外科手术技术可以切除大型听神经瘤并获得面神经解剖的保护,临床疗效良好。     

Otogenic brain abscess--a case report

Brain abscess is one of the life-threatening complications of otitis media. Mortality and morbidity have decreased with the advent of antibiotic therapy. More frequently encountered in cases of acute otitis media in the preantibiotic era, in recent years otogenic brain abscess was noticed almost only in patients of chronic otitis media with cholesteatoma. A case of brain abscess in a 49-year-old female was initially diagnosed as a headache. A high resolution computed tomography (HRCT) scan of the temporal bones later revealed that there were two abscesses over the right side temporal lobe. A modified radical mastoidectomy was performed. Cultures of the middle ear cholesteatoma later grew Pseudomonas aeruginosa and Strenotrophomonas maltophilia. Antibiotic therapy was carried on for three months postoperatively. The patient improved but retained a conductive hearing loss.     

经面静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘

目的探讨经面静脉途径治疗海绵窦区硬脑膜动静脉瘘（arteriovenous fistula，AVF）的方法和疗效。方法回顾性分析经面静脉途径（导管置入股静脉-面静脉-角静脉-眼上静脉-海绵窦）治疗7例海绵窦区硬脑膜AVF的病例资料，其中5例患者岩下窦闭塞；1例患者岩下窦开放，但其AVF所在的海绵窦和岩下窦之间无交通；1例患者的瘘与岩下窦相通。对该患者先行经岩下窦栓塞海绵窦后部，然后再经面静脉途径栓塞海绵窦前部。其他6例患者只经面静脉途径行栓塞治疗。结果血管造影显示，7例患者的角静脉和眼上静脉的走行清晰，其中有1例眼上静脉闭塞的患者，由于导管无法置入闭塞的眼上静脉，导致经静脉途径治疗终止。其余6例患者经面静脉入路用弹簧圈栓塞海绵窦治疗后，4例达到完全栓塞，2例临床症状明显好转。结论相对其他静脉途径而言，经股静脉-面静脉入路是血管内治疗海绵窦区硬脑膜AVF的一种很有价值的方法，即使该入路对术者手术技能要求较高，但仍然不失为一种安全和有效的血管内治疗方法。     

Cochlear implant challenges encountered in tuberculous otitis media

Tuberculous otitis media (TOM) is rare in ENT department, and is frequently misdiagnosed as otitis media. Thus early systemic treatment is very important for TOM. We reported a case report with TOM to highlight development of the disease and difficulties in clinical treatment in late stage of TOM. Implantation of ossified and eroded cochlea poses many unique challenges to both the surgeon and programming team. With thorough preparation and complete knowledge about characters of specific issues, implantation would be performed successfully, and patients with ossified cochlear could benefit from cochlear implantation.     

Inner ear and facial nerve complications of acute otitis media,including vertigo

Acute otitis media is one of the most common diagnoses made in children in the United States. Intracranial and extracranial (intratemporal) complications have greatly decreased in the antibiotic era, but still remain a challenge when they arise. This article addresses two intratemporal complications with significant associated morbidity: facial nerve paralysis/paresis, and labyrinthitis. Epidemiology, pathology, clinical diagnosis, and treatment options are discussed, focusing on an evidence-based approach to diagnosis and management. In addition, the future of treatment and current questions regarding otitis media are briefly discussed.     

A permanent transvenous lead system for an implantable pacemaker cardioverter-defibrillator. Nonthoracotomy approach to implantation.

A transvenous lead system for implantable defibrillators would obviate a surgical thoracotomy and reduce the morbidity and mortality associated with implantation. We evaluated the clinical performance of a new nonthoracotomy lead system that included a defibrillation lead in the coronary sinus. At the time of defibrillator implantation, transvenous defibrillation leads were inserted percutaneously through the left subclavian vein into the right ventricular apex (RVA), superior vena cava (SVC), and distal coronary sinus (CS) under fluoroscopic guidance. A subcutaneous patch electrode (SQ) was also available if required. The first single- or dual-pathway electrode configuration that successfully terminated three of four ventricular fibrillation episodes using 18 J or less was implanted. Eleven men and three women aged 39-77 years (60.0 +/- 10.1 years) with left ventricular ejection fraction ranging from 16% to 63% (33.4 +/- 13.1%) were evaluated. Nine presented with ventricular tachycardia, three had ventricular fibrillation, and two had both. A totally transvenous lead system (RVA/CS/SVC) was implanted in seven patients (50%) with a mean defibrillation threshold of 15.6 +/- 2.9 J (10-18 J). Four patients received a partial transvenous lead system (RVA/CS/SQ). An effective nonthoracotomy lead system was not found in three patients; they received epicardial electrodes. After cumulative follow-up of 73 patient-months, nine patients remain alive and free of problems related to the implanted nonthoracotomy leads. One patient died of respiratory failure 3 months after defibrillator implant, and the leads from another patient were removed at 9 months because of bacterial infection. A transvenous lead system that includes a defibrillation lead in the coronary sinus is a safe, reliable, and, at least in the short term, effective nonthoracotomy approach for automatic defibrillator implantation.