耳内镜辅助下桥小脑角手术

目的探索耳内镜在桥小脑角(CPA)手术中的应用.方法自2002年11月以来采用耳内镜结合显微镜开展CPA微创手术12例,手术均采用全麻下乙状窦后入路,并行面神经肌电位和听性脑干诱发电位术中监测.听神经瘤7例,桥小脑角面神经肿瘤2例,三叉神经鞘瘤1例,对肿瘤病例内镜主要用于检查内耳道底部有否残留病灶,探查面神经位置和走行,分离残留瘤体.舌咽神经痛1例,内镜下显露CPA和内听道口,显露后组颅神经,并确认舌咽神经,将其游离,用微型剪将之切断.半面痉挛1例,用30°内镜观察内听道口的解剖和后组颅神经的位置,在不牵拉小脑的情况下寻找对面神经形成压迫的责任血管.面神经功能按House-Brackmann分级标准评价.结果所有病例均顺利完成,无死亡病例,无并发后组颅神经损伤.听神经瘤7例,6例全切,1例绝大部分切除,残留脑干表面和内听道内的少许囊壁;均保留面神经解剖结构完整,术后一周面神经功能Ⅰ级2例,Ⅱ级3例(术后3个月Ⅰ级),Ⅲ级2例(术后3个月分别为Ⅰ级和Ⅱ级).面神经鞘瘤2例,肿瘤均全切,1例保留面神经解剖结构完整,术后面神经功能Ⅲ级,术后3个月Ⅱ级,另1例面神经连同肿瘤一起切除,一期面神经-舌下神经吻合,术后1年面神经功能Ⅱ级.三叉神经鞘瘤1例,肿瘤全切,术后一周面神经功能Ⅲ级,术后3个月Ⅱ级.听神经瘤7例术前有残余听力4例,术后有1例保存术前听力;面神经肿瘤2例,术后保存残余听力1例;其余肿瘤病例术后均未保存听力.舌咽神经切断术后症状完全消失,随诊6个月未复发.面神经微血减管压并梳理术后症状明显好转,间断轻度抽搐,面神经功能Ⅱ级,随访1年仍只为轻度抽搐.结论耳内镜与手术显微镜有机结合,达到桥小脑角手术微创的目的,既可清除病变,又能最大限度地保存功能.但耳内镜目前还只是一种辅助的手段,仍有一定局限性,需进一步完善.

Endoscope-assisted cerebellopontine angle surgery

Objective To evaluate oto-endoscope technique using in the surgery of cerebellopontine angle(CPA). Methods Twelve patients conducted with surgery of CPA under microscope with oto-endoscope- assisted in our department from Nov. 2002 to Dec. 2004 were reviewed. Of this series, there were 7 cases of acoustic neuroma(AN), 2 cases of facial nerve tumor in CPA, 1 case of trigeminal neuroma(TN), 1 case of glossopharyngeal neuralgia and 1 case of hemifacial spasm. Rigid ear endoscope was used to resect the remains of tumors inside the Internal Auditory Cannal(IAC). House-Brackmann grade system was used to evaluate the facial nerve function. Results The operation of all patients was successful, and there was no dead case and no severe complication accrued in this series. The tumors were resected completely in 6 cases of AN, 2 case of facial nerve tumor and 1 case of TN, but sub totally removed in 1 cases of AN. Of all 12 patients, 7 cases of AN, 1 case of TN, 1 case of facial nerve had obtained anatomic preservation of the facial nerves. According to House-Brackmann grade system, for AN patients 7 days after operation, there were Grade I in 2 patients, Grade II in 3 patients (Grade I after 3 months), and Grade III in 2 patients (Grade I and Grade II after 3 months, respectively), and for TN patient with Grade III but Grade II after 3 months. For patients with facial nerve tumor, the facial nerve function was Grade III in one case (Grade II post-operation 3 months) and Grade III in the other case post-operation one year with facial nerve-hypoglossal anastomosis. For 10 tumor cases, two patients were preserved the hearing level as same as that of preoperation. The symptom disappeared after surgery for the case of glossopharyngeal neuralgia patients, and for the hemificial spasm case, suffering was alleviated generally after operation. Conclusion Endoscope conbined with the microscope could play an important role to expose the anatomical structure in CPA and the tumor within the ICA to get the aim of minimal-invaded surgery, as well as to overcome the short point of the traditional approach of restrosigmoid. However, the technique of endoscope is expected to be improved for more practical in CPA surgery.