岩骨胆脂瘤的诊断与外科治疗

目的探讨岩骨胆脂瘤的病因和临床表现特点以及手术方式。方法对1986年12月～2003年4月收治的12例岩骨胆脂瘤患者(继发9例，原发3例)进行回顾性分析。结果原发岩骨胆脂瘤首发症状为面瘫及听力下降，鼓膜正常。继发岩骨胆脂瘤主要表现为耳流脓史，听力下降及面瘫，鼓膜通常有穿孔或不正常。慢性中耳炎病史及耳科手术史与继发性岩骨胆脂瘤的发生密切相关。颞骨CT可明确病变范围及与面神经的关系，能为确定手术方式提供直接的参考。继发及原发岩骨胆脂瘤的治疗原则相同：彻底清除胆脂瘤上皮。手术入路有4种：经迷路、中颅窝、迷路中颅窝联合入路、颅颈联合入路(迷路下)。1例继发胆脂瘤因反复复发而行4次手术外，其余11例随访4个月～15年无复发。吻合的3例面神经中，2例由House Brackmann分级V恢复到Ⅳ；减压及神经连续性完整的3例中2例由Ⅳ恢复到Ⅲ，1例无恢复。结论继发及原发胆脂瘤病因不相同，临床表现各具特点。手术进路的选择取决于病变部位、范围及听力状况，经迷路、中颅窝是主要入路。单纯中颅窝入路应采用术腔相对封闭的术式；其他人路应采取开放术腔式手术。

Diagnosis and surgical management of petrous apex cholesteatoma]

OBJECTIVE: To explore the etiology, diagnosis and surgical management of petrous apex cholesteatoma. METHODS: Twelve cases of petrous apex cholesteatoma (primary 3, secondary 9) were retrospectively studied. RESULTS: Primary petrous apex cholesteatoma was characterized by non otorrhea history, normal tympanic membrane appearance and the initially occurring symptoms of facial paralysis and hearing loss. In contrast, secondary petrous apex cholesteatoma was characterized by otitis media history, perforated drum, hearing loss and facial paralysis. The treatment principle for either primary or secondary cholesteatoma is to remove all the cholesteatoma. Based on the status of hearing and location and extent of cholesteatoma within temporal bone, 4 surgical approaches were taken in our study, which were translabyrinth, middle cranial fossa, combination of translabyrinth and middle cranial fossa, craniocervical combination approach (infralabyrinth approach). The complications of these surgical procedures and their management were discussed. According to result of 4 months to 15 years follow-up, there were no recurrence cases up to now, except one, which was operated 4 times as recurrence. Facial nerve anastomosis (3/12) or decompression (3/12) was performed simultaneously in the operations. The function of facial nerve partially recovered from V to IV of House and Brackmann grading in 2 out of 3 anastomosis cases and from IV to III in 2 out of 3 cases of decompression. CONCLUSION: Although there are some differences in symptoms and etiology between primary and secondary petrous apex cholesteatoma, complete surgical removal of lesion is necessary for both. Surgical approaches are decided according to location and extent of the lesion and hearing status. Our study indicated that open cavity operation had more advantage in terms of morbidity compared with the closed cavity operation, which closes the auditory canal as a blind sac.