颞骨岩部胆脂瘤的手术治疗及面神经功能保护
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摘要
目的:通过分析总结颞骨岩部胆脂瘤(PBC)的手术策略,探讨不同面神经功能状态的保护及重建方法。方法:回顾性分析28例住院手术治疗的PBC患者临床资料,按照Sanna分类标准确定手术策略,总结面神经处理方法及术后面神经功能的恢复情况。结果:采取手术治疗的PBC患者28例,分为四型:迷路上型11例,其中3例经迷路径路,行部分半规管切除,5例经耳囊径路切除病变,保留面神经骨桥,3例经耳蜗径路切除;广泛型10例,其中2例经耳囊径路切除,8例经耳蜗径路切除;4例为迷路下型,均行岩骨次全切除术;3例为迷路下-岩尖型,其中2例行颞下窝B型手术切除,另1例经耳蜗径路切除。本组未发现孤立岩尖型病例。本研究涉及面神经手术者共14例(50%),面神经减压2例,面神经移位或部分移位2例,面神经改道吻合者2例,面神经耳大神经移植修复者3例,二期面神经舌下神经吻合者2例,另有3例因面神经长期坏死,面部肌肉萎缩,建议行远期面瘫游离血管肌肉移植,但均未接受。面神经积极处理后功能改善率为71.43%,随访未见复发病例。结论:PBC主要的治疗方式是彻底手术清除,制定合理的手术策略至关重要,面神经功能的保护优于听力,积极合理的面神经处理有利于面神经功能恢复。
Objective:To discuss the therapeutic scheme of petrous bone cholesteatoma(PBC)and the technique of facial nerve reconstruction.Method:The data of 28 patients who underwent surgery for PBC in our center were analyzed retrospectively.All patients were diagnosed radiologically with PBCs and reconfirmed pathologically after surgery.The surgical approach was discussed basing Sanna's classification of PBCs,and the facial nerve outcomes were analyzed moreover.Result:PBC cases 11 were supralabyrinthine,4 infralabyrinthine,3 infralabyrinthine-apical,10 massive and none apical.The facial nerve was involved in 50%of the cases.The translabyrinthine approach were used in 3 cases.The transotic approach was used in 7 cases in this series.The transcochlear approach type was applied in 12 cases.The Infratemporal fossa type B approach and subtotal petrosectomy were employed in 2 cases and 4 cases respectively.Active management of the nerve(rerouting,anastomosis,or grafting)was required in 14 cases,postoperative facial nerve function were inproved in 10 cases(71.43%).Conclusion:The appropriate surgery approach was vitally important to radical disease clearance in PBCs.The facial nerve preservation was preceded hearing preservation.Active facial nerve management were beneficial to facial nerve recovery.
Objective:To discuss the therapeutic scheme of petrous bone cholesteatoma(PBC)and the technique of facial nerve reconstruction.Method:The data of 28 patients who underwent surgery for PBC in our center were analyzed retrospectively.All patients were diagnosed radiologically with PBCs and reconfirmed pathologically after surgery.The surgical approach was discussed basing Sanna's classification of PBCs,and the facial nerve outcomes were analyzed moreover.Result:PBC cases 11 were supralabyrinthine,4 infralabyrinthine,3 infralabyrinthine-apical,10 massive and none apical.The facial nerve was involved in 50%of the cases.The translabyrinthine approach were used in 3 cases.The transotic approach was used in 7 cases in this series.The transcochlear approach type was applied in 12 cases.The Infratemporal fossa type B approach and subtotal petrosectomy were employed in 2 cases and 4 cases respectively.Active management of the nerve(rerouting,anastomosis,or grafting)was required in 14 cases,postoperative facial nerve function were inproved in 10 cases(71.43%).Conclusion:The appropriate surgery approach was vitally important to radical disease clearance in PBCs.The facial nerve preservation was preceded hearing preservation.Active facial nerve management were beneficial to facial nerve recovery.
引文
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[3] HOUSE J W,BRACKMANN D E.Facial nerve grading system[J].Otolaryngol Head Neck Surg,1985,93:146-147.
[4] AUBRY K,KOVAC L,SAUVAGET E,et al.Our experience in the management of petrous bone cholesteatoma[J].Skull Base,2010,20:163-167.
[5] SANNA M,PANDYA Y,MANCINI F,et al.Petrous bone cholesteatoma:classification,management and review of the literature[J].Audiol Neurootol,2011,16:124-136.
[6] SANNA M,DE DONATO G,TAIBAH A,et al.Infratemporal fossa approaches to the lateral skull base[J].Keio J Med,1999,48:189-200.
[7] HEMBD A,NAGARKAR P,PEREZ J,et al.Correlation between Facial Nerve Axonal Load and Age and Its Relevance to Facial Reanimation[J].Plast Reconstr Surg,2017,139:1459-1464.
[8] CRUZ FILHO N A,AQUINO J E,OLIVEIRA L F.Facial nerve grafting and end-to-end anastomosis in the middle ear:tympanic cavity and mastoid[J].Braz J Otorhinolaryngol,2013,79:441-445.
[9] AUBRY K,KANIA R,SAUVAGET E,et al.Endoscopic transsphenoidal approach to petrous apex cholesteatoma[J].Skull Base,2010,20:305-308.
[10]TABUCHI K,YAMAMOTO T,AKUTSU H,et al.Combined transmastoid/middle fossa approach for intracranial extension of middle ear cholesteatoma[J].Neurol Med Chir(Tokyo),2012,52:736-740.
[11]YAWN R J,WRIGHT H V,FRANCIS D O,et al.Facial nerve repair after operative injury:Impact of timing on hypoglossal-facial nerve graft outcomes[J].Am J Otolaryngol,2016,37:493-496.
[12]BIGLIOLI F,FRIGERIO A,COLOMBO V,et al.Masseteric-facial nerve anastomosis for early facial reanimation[J].J Craniomaxillofac Surg,2012,40:149-155.
[13]BIGLIOLI F.Facial reanimations:part II--long-standing paralyses[J].Br J Oral Maxillofac Surg,2015,53:907-912.
[2] SANNA M,ZINI C,GAMOLETTI R,et al.Petrous bone cholesteatoma[J].Skull Base Surg,1993,3:201-213.
[3] HOUSE J W,BRACKMANN D E.Facial nerve grading system[J].Otolaryngol Head Neck Surg,1985,93:146-147.
[4] AUBRY K,KOVAC L,SAUVAGET E,et al.Our experience in the management of petrous bone cholesteatoma[J].Skull Base,2010,20:163-167.
[5] SANNA M,PANDYA Y,MANCINI F,et al.Petrous bone cholesteatoma:classification,management and review of the literature[J].Audiol Neurootol,2011,16:124-136.
[6] SANNA M,DE DONATO G,TAIBAH A,et al.Infratemporal fossa approaches to the lateral skull base[J].Keio J Med,1999,48:189-200.
[7] HEMBD A,NAGARKAR P,PEREZ J,et al.Correlation between Facial Nerve Axonal Load and Age and Its Relevance to Facial Reanimation[J].Plast Reconstr Surg,2017,139:1459-1464.
[8] CRUZ FILHO N A,AQUINO J E,OLIVEIRA L F.Facial nerve grafting and end-to-end anastomosis in the middle ear:tympanic cavity and mastoid[J].Braz J Otorhinolaryngol,2013,79:441-445.
[9] AUBRY K,KANIA R,SAUVAGET E,et al.Endoscopic transsphenoidal approach to petrous apex cholesteatoma[J].Skull Base,2010,20:305-308.
[10]TABUCHI K,YAMAMOTO T,AKUTSU H,et al.Combined transmastoid/middle fossa approach for intracranial extension of middle ear cholesteatoma[J].Neurol Med Chir(Tokyo),2012,52:736-740.
[11]YAWN R J,WRIGHT H V,FRANCIS D O,et al.Facial nerve repair after operative injury:Impact of timing on hypoglossal-facial nerve graft outcomes[J].Am J Otolaryngol,2016,37:493-496.
[12]BIGLIOLI F,FRIGERIO A,COLOMBO V,et al.Masseteric-facial nerve anastomosis for early facial reanimation[J].J Craniomaxillofac Surg,2012,40:149-155.
[13]BIGLIOLI F.Facial reanimations:part II--long-standing paralyses[J].Br J Oral Maxillofac Surg,2015,53:907-912.