侧颅底肿瘤的手术入路和修复重建
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摘要
目的侧颅底肿瘤的外科治疗极具挑战,本研究探讨侧颅底肿瘤开放手术入路及修复重建选择。方法 2009年8月至2018年1月,北京口腔医院头颈肿瘤团队完成的侧颅底肿瘤患者196例,纳入本研究。结果 42例为腮腺深叶或咽旁肿瘤,30例为颞下窝恶性肿瘤或交界性肿瘤,无颅内外沟通,124例为颅内外沟通肿瘤。16例应用腮腺浅叶切除后下颌支后缘入路,43例应用颌下切口-下颌骨暂时性离断入路,13例应用冠-面联合切口,面神经暂时性离断或下颌骨升支及乳突切除入路,124例颅内外沟通肿瘤采用多学科联合手术,冠-面联合切口或颞枕开颅-颅颈联合入路。155例接受了组织瓣移植修复,其中颞肌筋膜瓣59例,游离背阔肌皮瓣74例,颌下腺瓣22例。皮瓣移植成功率为100.0%。27例患者发生术后深部创口感染,术后缺损一期行组织瓣移植或颌下腺瓣填塞明显降低术后感染率。1例患者术后出现颅内感染,升级抗生素后痊愈。所有颅内外沟通患者均出现不同程度脑脊液瘘,其中58例严重患者给予腰大池引流3～7天症状消失。2例患者发生围术期死亡。结论肿瘤病理类型、发病部位、是否颅内外沟通、颌面组织缺损程度、既往治疗史等均是侧颅底肿瘤手术入路和修复重建选择需要重视的局部因素。
Objective To investigate the choice of surgical approach and reconstruction of lateral skull base tumor. Methods A total of 196 patients who underwent surgical treatment of lateral skull base tumors were included in the study. Results Forty-two cases had tumors in the deep lobe of the parotid gland or tumors in the parapharyngeal space, 30 cases were malignant tumors of the infratemporal fossa without intra-extracranial communication and 124 cases were intra-extracranial communication tumors. The retromandibular approach was used in 16 cases, mandibular transient split approach was applied in 43 cases, coronal-facial incision, facial nerve transient interruption/mandibular ramus and mastoid-resected approach were used in 13 cases. The 124 cases of combined intra-extracranial tumors were treated by coronal-facial incision or temporal occipital craniotomy-craniocervical combined approach. A total of 155 cases underwent tissue flaps reconstruction, among them 59 cases were temporalis myofascial flap, 79 free latissimus dorsi flap and 22 submandibular gland flap. The success rate of flaps was 100.0%. 27 patients developed postoperative infections, and one patient developed intracranial infection and recovered after upgrading antibiotics. All patients with intra-extracranial communication tumors showed varying degrees of cerebrospinal fluid fistula, and 58 cases of them have severe cerebrospinal fluid fistula and were cured with 3 to 7 days of drainage in the lumbar cistern. Perioperative death occurred in 2 patients. Conclusion The pathological type of the tumor, the location of the tumor, the degree of intra-extracranial communication, the type of maxillofacial tissue defect, and the history of previous treatment are noteworthy factors in the surgical approach and reconstruction of the latreal skull base tumors.
Objective To investigate the choice of surgical approach and reconstruction of lateral skull base tumor. Methods A total of 196 patients who underwent surgical treatment of lateral skull base tumors were included in the study. Results Forty-two cases had tumors in the deep lobe of the parotid gland or tumors in the parapharyngeal space, 30 cases were malignant tumors of the infratemporal fossa without intra-extracranial communication and 124 cases were intra-extracranial communication tumors. The retromandibular approach was used in 16 cases, mandibular transient split approach was applied in 43 cases, coronal-facial incision, facial nerve transient interruption/mandibular ramus and mastoid-resected approach were used in 13 cases. The 124 cases of combined intra-extracranial tumors were treated by coronal-facial incision or temporal occipital craniotomy-craniocervical combined approach. A total of 155 cases underwent tissue flaps reconstruction, among them 59 cases were temporalis myofascial flap, 79 free latissimus dorsi flap and 22 submandibular gland flap. The success rate of flaps was 100.0%. 27 patients developed postoperative infections, and one patient developed intracranial infection and recovered after upgrading antibiotics. All patients with intra-extracranial communication tumors showed varying degrees of cerebrospinal fluid fistula, and 58 cases of them have severe cerebrospinal fluid fistula and were cured with 3 to 7 days of drainage in the lumbar cistern. Perioperative death occurred in 2 patients. Conclusion The pathological type of the tumor, the location of the tumor, the degree of intra-extracranial communication, the type of maxillofacial tissue defect, and the history of previous treatment are noteworthy factors in the surgical approach and reconstruction of the latreal skull base tumors.
引文
1孙坚,沈毅,李军,等.颅颌面联合切除术后缺损的分类和修复重建.中华显微外科杂志,2014,37(5):421-426.
2韩正学,李金忠,李华,等.游离组织瓣移植重建颅内外沟通性缺损的临床研究.中华神经外科杂志,2012,28(8):772-774.
3 de Almeida JR,Witterick IJ,Gullane PJ,et al.Physical morbidity by surgical approach and tumor location in skull base surgery.Head Neck,2013,35(4):493-499.
4 Yang B,Su M,Li H,et al.Use of submandibular gland flap for repairing defects after tumor resection in the infratemporal region.JCraniomaxillofac Surg,2015,43(1):87-91.
5 Frederick JW,Sweeny L,Carroll WR,et al.Outcomes in head and neck reconstruction by surgical site and donor site.Laryngoscope,2013,123(7):1612-1617.
6 Shen Y,Ma C,Wang L,et al.Surgical Management of Giant Cell Tumors in Temporomandibular Joint Region Involving Lateral Skull Base:A Multidisciplinary Approach.J Oral Maxillofac Surg,2016,74(11):2295-2311.
7 Guo Y,Guo C.Maxillary-fronto-temporal approach for removal of recurrent malignant infratemporal fossa tumors:Anatomical and clinical study.J Craniomaxillofac Surg,2014,42(3):206-212.
8 Guo Y,Guo C,Zhang L,et al.Extracapsular dissection of the parapharyngeal space for a pleomorphic adenoma:a 10-year review.Br J Oral Maxillofac Surg,2014,52(6):557-562.
9 Guo R,Guo YX,Feng Z,et al.Application of a computer-aided navigation technique in surgery for recurrent malignant infratemporal fossa tumors.J Craniofac Surg,2015,26(2):e126-e132.
10 de Almeida JR,Vescan AD,Gullane PJ,et al.Development of a disease-specific quality-of-life questionnaire for anterior and central skull base pathology-the skull base inventory.Laryngoscope,2012,122(9):1933-1942.
11郭传瑸.累及颅底的咽旁颞下区肿瘤手术入路选择.中华口腔医学杂志,2006,41(8):467-469.
12 Casani AP,Cerchiai N,Dallan I,et al.Benign tumours affecting the deep lobe of the parotid gland:how to select the optimal surgical approach.Acta Otorhinolaryngol Ital,2015,35(2):80-87.
13 Macía G,Picón M,Nu?ez J,et al.The use of free flaps in skull base reconstruction.Int J Oral Maxillofac Surg,2016,45(2):158-162.
2韩正学,李金忠,李华,等.游离组织瓣移植重建颅内外沟通性缺损的临床研究.中华神经外科杂志,2012,28(8):772-774.
3 de Almeida JR,Witterick IJ,Gullane PJ,et al.Physical morbidity by surgical approach and tumor location in skull base surgery.Head Neck,2013,35(4):493-499.
4 Yang B,Su M,Li H,et al.Use of submandibular gland flap for repairing defects after tumor resection in the infratemporal region.JCraniomaxillofac Surg,2015,43(1):87-91.
5 Frederick JW,Sweeny L,Carroll WR,et al.Outcomes in head and neck reconstruction by surgical site and donor site.Laryngoscope,2013,123(7):1612-1617.
6 Shen Y,Ma C,Wang L,et al.Surgical Management of Giant Cell Tumors in Temporomandibular Joint Region Involving Lateral Skull Base:A Multidisciplinary Approach.J Oral Maxillofac Surg,2016,74(11):2295-2311.
7 Guo Y,Guo C.Maxillary-fronto-temporal approach for removal of recurrent malignant infratemporal fossa tumors:Anatomical and clinical study.J Craniomaxillofac Surg,2014,42(3):206-212.
8 Guo Y,Guo C,Zhang L,et al.Extracapsular dissection of the parapharyngeal space for a pleomorphic adenoma:a 10-year review.Br J Oral Maxillofac Surg,2014,52(6):557-562.
9 Guo R,Guo YX,Feng Z,et al.Application of a computer-aided navigation technique in surgery for recurrent malignant infratemporal fossa tumors.J Craniofac Surg,2015,26(2):e126-e132.
10 de Almeida JR,Vescan AD,Gullane PJ,et al.Development of a disease-specific quality-of-life questionnaire for anterior and central skull base pathology-the skull base inventory.Laryngoscope,2012,122(9):1933-1942.
11郭传瑸.累及颅底的咽旁颞下区肿瘤手术入路选择.中华口腔医学杂志,2006,41(8):467-469.
12 Casani AP,Cerchiai N,Dallan I,et al.Benign tumours affecting the deep lobe of the parotid gland:how to select the optimal surgical approach.Acta Otorhinolaryngol Ital,2015,35(2):80-87.
13 Macía G,Picón M,Nu?ez J,et al.The use of free flaps in skull base reconstruction.Int J Oral Maxillofac Surg,2016,45(2):158-162.