Microanatomy and surgical approaches to the infratemporal fossa: an anaglyphic three-dimensional stereoscopic printing study.

Objective: The infratemporal fossa (ITF) is a continuation of the temporal fossa between the internal surface of the zygoma and the external surface of the temporal bone and greater wing of the sphenoid bone that is sitting deep to the ramus of the mandible. The principal structure to understanding its relationships is the lateral pterygoid muscle. Other important structures are the medial pterygoid muscle, the maxillary artery, the pterygoid venous plexus, the otic ganglion, the chorda tympani nerve and the mandibular nerve. In this study, we describe the microsurgical anatomy of the ITF, as viewed by step-by-step anatomical dissection and also through the perspective of three lateral approaches and one anterior surgical approach. Methods: Eight cadaver specimens were dissected. In one side of all specimens, an anatomical dissection was done in which a wide preauricular incision from the neck on the anterior border of the sternoclidomastoid muscle at the level of the cricoid cartilage to the superior temporal line was made. The flap was displaced anteriorly and the structures of the neck were dissected followed by a zygomatic osteotomy and dissection of the ITF structures. On the other side were the surgical approaches to the ITF. The combined infratemporal and posterior fossa approach was done in two specimens, the subtemporal preauricular infratemporal fossa approach in two, the zygomatic approach in two, and the lateral transantral maxillotomy in two. The anatomical dissections were documented on the three-dimensional (3D) anaglyphic method to produce stereoscopic prints. Results: The lateral pterygoid muscle is one of the principal structures to enable understanding of the relationships into the ITF. The tendon of the temporal muscle inserts in the coronoid process at the ITF. The maxillary artery is the terminal branch of the external carotid artery that originates at the neck of the mandible and runs into the parotid gland. In our dissections the maxillary artery was lateral to the buccal, lingual, and inferior alveolar nerves. We found the second part of the maxillary artery superficial to the lateral pterygoid muscle in all specimens The anterior and posterior branches of the deep temporal artery supply the temporal muscle. In two cases we found a middle deep temporal artery. The different approaches that we used provided different views of the same anatomical landmarks and this provides not only safer surgery but also the best choice to approach the ITF according with the pathology extension. Conclusions: The ITF is a complex region on the skull base that is affected by benign and malignant tumors. The study through different routes is helpful to disclose the relationship among the anatomical structures. Although the authors have shown four approaches, there are a variety of approaches and even a combination of these can be used. This type of anatomical knowledge is essential to choosing the best approach to treat lesions in this area.     

Recognition and management of phaeochromocytoma

Phaeochromocytomas are catecholamine-secreting neuroendocrine tumours arising from the chromaffin cells in the adrenal medulla. These tumours may be identified incidentally, as part of a workup for multiple endocrine neoplasia or during unrelated surgery. Better understanding of catecholamine physiology and advances in preoperative preparation has significantly reduced surgical mortality from around 40% to less than 3%. Surgery is the definitive treatment in most cases and laparoscopic resection is associated with reduced hospital stay and earlier mobilisation. Phaeochromocytomas are of particular interest to anaesthetists as it presents a unique haemodynamic challenge both before and after adrenal resection. In this article we describe the physiology of these tumours, their diagnosis and perioperative management.     

腹膜后副神经节瘤25例临床分析

目的 探讨腹膜后副神经节瘤的诊断和治疗,提高其早期诊断及手术切除率.方法 对25例原发性腹膜后副神经节瘤患者行手术治疗.结果 25例中术后病理诊断良性肿瘤19例,恶性肿瘤为6例,完全切除19例,大部切除3例,其中围手术期死亡l例,无法切除3例,术后复发3例中再手术2例肿瘤完全切除,1例放弃手术.结论 腹膜后副神经节瘤早期临床表现缺乏特异性,诊断目前主要靠影像学检查,围手术期处理至关重要,手术完整切除仍是治疗的主要手段,对复发性肿瘤应争取再次手术.     

前列腺副神经节瘤1例报告并文献复习

目的:提高对前列腺副神经节瘤的认识和诊治水平。方法:报告确诊前列腺副神经节瘤1例,肿瘤组织行神经元特异性烯醇化酶(NSE)、嗜铬A、突触素(Syn)、S-100和前列腺特异性抗原(PSA)免疫组化染色。结合文献复习,总结其临床、病理和治疗情况。结果:这1例前列腺副神经节瘤以血精就诊。行前列腺根治切除术,病理检查符合副神经节瘤组织学特征,免疫组化染色:NSE、嗜铬A、Syn、S-100阳性,PSA阴性。随访42个月,排尿和排便通畅,疗效满意,无转移和复发。结论:前列腺是肾上腺外副神经节瘤极少见的位置,临床非常罕见。前列腺副神经节瘤的临床和病理特征具有特殊性,需病理确诊,治疗宜手术完整切除肿瘤,术后应密切随访。     

前列腺副神经节瘤1例报道并文献复习

目的:探讨前列腺副神经节瘤的临床表现、病理特征、治疗和预后。方法:报道前列腺副神经节瘤1例,患者男,39岁,主因"反复血精1年余"入院,误诊为前列腺癌后,行耻骨上前列腺根治性切除术,完整切除肿瘤。结果:术后病理确诊为前列腺副神经节瘤,本例前列腺副神经节瘤为无功能性,免疫组化:NSE(+)、CGA(+)、S100(+)、CK(-)、Desmin(-)。术后血压平稳,2周后拔尿管出院。随访48个月至今未复发。结论:前列腺副神经节瘤缺乏特异的临床特征表现,易误诊,只有靠切除术后病理和免疫组化才能确诊。由于其非常罕见,相关治疗缺乏成熟的经验,故需要进一步研究。     

Surgical management of carotid body tumours: a 24-year surgical experience

BACKGROUND: Carotid body tumours (CBT) are rare tumours, best treated by complete surgical resection. However, there is no uniform agreement on the method of resection. The aim of this study was to review our 24 years' experience of meticulous subadventitial excision of CBT. METHODS: A retrospective study, from March 1980 to September 2004 of patients with CBT was undertaken, detailing presentation, diagnosis and treatment and postoperative complications. RESULTS: Twenty-five patients (six men and 19 women) with an age range of 23-72 years had been operated on, and all were treated by surgical excision. All patients had neck mass. No patient had a positive family history. Angiography was the main method of diagnosis. All of the patients had unilateral tumours. There was no postoperative permanent neurological deficit. Temporary neurological problems developed in only four patients. External carotid artery was ligated in three patients to facilitate excision of the tumour. Surgical care limited blood loss to an average of 480 mL. CONCLUSIONS: Subadventitial excision, carried out meticulously, allowed complete resection to be achieved in all of the patients with minimal morbidity and no surgical mortalities. This method is therefore recommended. Facilities for shunting and arterial repair should always be available.     

Juxtacondylar Approach in Temporal Paraganglioma Surgery: When and Why?

As it became clear that patients with paraganglioma (PGL) syndromes had a higher risk of multifocal tumors, we changed our surgical strategy to avoid the possibility of bilateral cranial nerve paralysis. The juxtacondylar approach offers advantages for some jugular foramen tumors, including types C and D temporal PGLs. This approach allows exposure of the jugular foramen without skeletonizing or transposing the facial nerve. It improves the surgeon's ability to distinguish between the pars vascularis and the pars nervosa at the jugular foramen, and it helps to save functioning of the lower cranial nerves. There is already considerable experience using the juxtacondylar approach for patients suffering from schwannomas and meningiomas involving the jugular foramen. Some limitations have been noted for using the juxtacondylar approach with jugular PGLs that are related to their vascular nature. In this article we demonstrate its use for the management of eight patients with locally advanced temporal PGLs and how it can be combined with an infratemporal fossa approach.     

Clinical Presentation and Management of Jugular Foramen Paraganglioma

Objectives

Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.

Methods

Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications.

Results

Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications.

Conclusion

Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.     

CARNEY'S TRIAD

A 26 year old female presented with partial expression of Carney's triad. This is the first Australian report of the condition. The role of surgery and the need for vigilance to detect the occurrence of the complete triad are stressed.