颅底肿瘤手术入路的探讨

目的探讨涉及颅底的肿瘤切除的最佳手术入路。方法回顾性分析1992-2002年手术治疗涉及颅底的肿瘤79例。采用了11种手术入路，如面中掀翻、额冠状切开、鼻外翻、上颌骨外旋、上颌骨部分切除、眶内容剜除、下颌骨切开外旋、额 颞 耳前 颈、额 颞 耳后 颈、颞 耳后 颈、颞 口及相互组合的联合入路，彻底切除了累及颞下窝、翼腭窝、鼻窦、鼻咽部、颅底、桥脑小脑角、大脑额叶和颞叶的肿瘤。结果79例患者均彻底切除了肿瘤，5例并发脑脊液漏，均在1周内自愈，无手术死亡及严重颅脑并发症。良性肿瘤29例，其中脑膜瘤11例，神经纤维瘤9例，软骨瘤3例，骨纤维异常增殖症2例，血管瘤型脑膜瘤、海绵状血管瘤、颈静脉球体瘤、神经鞘膜瘤各1例，随访至今情况良好，19例患者存活超过5年，生存期最长1例已超过8年。恶性肿瘤50例，其中肉瘤、高分化鳞癌各3例，中分化鳞癌17例，低分化鳞癌11例，乳头状瘤恶变5例，软骨肉瘤、腺癌、恶性纤维组织细胞瘤、恶性混合瘤各2例，未分化癌、嗅神经母细胞瘤、纤维肉瘤各1例。所有病例均进行了随访，无失访患者。直接法统计3年、5年生存率分别为59．2％(29／49)、38．5％(10／26)。结论对每位患者应根据不同的病变性质和累及范围，按照最短路径，避开重要血管和神经，尽可能利用已存在的或潜在的“间隙”保护神经血管蒂及切口隐蔽的原则，设计不同的手术入路，必要时采用联合入路，可以彻底切除病变，尽量减少并发症和尽可能地避免畸形的发生。

Surgical approaches to the skullbase neoplasmas

Objective To discuss the best surgical approach to the skullbase neoplasmas. Methods~Retrospective analysis the 79 skullbase neoplasmas cases treated with surgical resection in Qilu hospital of Shandong university from 1992 to 2002. Eleven surgical approaches including midfacial degloving, frontal coronal discission, nasal eversion,maxillary swing,partial maxillary resection,total resection of orbit,mandibular swing , combination of front, temple, preauricula, post aurem, neck, and transoral approaches were used to resect the tumor which involved fossae pterygopalatina, paranasal sinuses, nasopharynx, antero, meso and posterobasilar region, lobi frontalis and lobi temporalis of cerebrum. Results Seventy-nine skullbase neoplasmas were totally removed and no one died from the operation. Although 5 cases complicated with cerebrospinal fluid leak and all recovered within 1 week,no serious cranium-cerebrum complication occurred. In 29 patients with benign tumor including 11 cases of meningioma, 3 cases of chondroma, 1 case of hemangio-meningioma, 1 case of cavernous hemangioma,2 cases of osteodyspalsia fibroas, 9 cases of neurofibroma, 1 case of glomus jugular tumor,1 case of neurolemmoma,19 have survived over 5 years and the longest one has survived over 8 years. For 50 patients with malignant tumor including ~3 cases of well-differentiated squamous cell carcinoma,17 cases of moderately differentiated squamous cell carcinoma, 11 cases of poorly differentiated squamous cell carcinoma, 1 case of undifferentiated carcinoma,2 cases of chondrosarcoma, 5 cases of canceration of papilloma, 2 cases of adenocarcinoma, 1 case of esthesioneuroblastoma,2 cases of malignant fibrohistiocytoma,1 case of fibrosarcoma, 2 cases of malignant mixed tumour, 3 cases of sarcoma survival rates of 3 and 5 years were 59.2%(29/49),38.5%(10/26) respectively. Conclusion In order to resect the tumor completely and reduce the complication and malformation as far as possible, different surgical approaches must be designed according to the pathological changes characters and involved area,and the surgeon should select the shortest approach, avoid to damage the important neurovascular structure, and resect the tumor through the natural anatomy space by the shelter incision.