颅底骨巨细胞病变的外科治疗
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摘要
目的总结联合颞下窝进路Type B+D切除对于广泛侵犯颅底的骨巨细胞瘤和巨细胞修复性肉芽肿的临床效果,探讨其技术要点和临床应用价值。方法回顾性分析2014年12月至2018年7月在北京协和医院耳鼻咽喉科5例因颞骨巨细胞瘤或巨细胞修复性肉芽肿行联合颞下窝进路Type B+D患者的临床资料。术后行MRI+DWI随访。其中2例为骨巨细胞瘤,3例为巨细胞修复性肉芽肿。5例患者中3例既往有肿物切除史,分别于术后6、18和20月复发。病变均累及乳突、颞颌关节和翼突,其中1例侵入颅内,并有内听道、耳蜗的破坏。肿物的平均大小为42*46mm。结果 4例患者均1期手术完整切除病变,显微镜下病变无残留,1例一期切除颅外部分,二期切除侵入颅内部分,术后均无脑脊液漏的发生。术后随诊8-51月,未见复发。5例患者2例术前面神经功能正常,术后3月内恢复正常,2例术前H-B II,术后为H-B II级,1例术前H-B V级,术后1年恢复为H-B III级。除1例术前已有耳蜗破坏,其余4例均保留了耳蜗功能。2例术前听力正常,术后由于封闭外耳道为重度传导性听力下降,1例术前为轻度传导性听力下降,术中重建了鼓室和听力,术后3月为轻度传导性听力下降,另外2例术前有不同程度的迷路破坏分别为重度混合性听力下降和极重度感音神经性听力下降,术后听力同术前。5例患者术后1周左右(平均6天)恢复饮食。结论颞下窝联合进路Type B+D技术可以安全、彻底切除广泛侵犯颞骨和颞下窝的巨大骨巨细胞瘤及巨细胞修复性肉芽肿,术中面神经及耳蜗功能得到较好的保护。巨大骨巨细胞瘤及巨细胞修复性肉芽肿经彻底切除,术后长期随访无复发,对饮食无明显影响。
Objective To review clinical outcomes in surgical treatment of temporal bone giant cell reparative granuloma(CGRG) and giant cell tumor(GCT) via combined infratemporal fossa approach type B and D. Methods Data from 5 patients diagnosed with CGRG(n=3) and GCT(n=2) and treated with resection via combined infratemporal fossa approach B and D from December 2014 to July 2018 were retrospectively reviewed. Three cases had a history ofprevious tumor resection, followed by recurrence at 6, 18 and 20 months postoperatively, respectively. The mastoid process, temporomandibular joint and pterygoid process were involved in all 5 cases, and the tumor invaded the brain with destruction of internal auditory canal and cochlea in 1 case. The mean tumor size was 42 x 46 mm. All patients were followed up regularly by CT and MRI postoperatively. Results Complete tumor resection with no residual lesion under the microscope was achieved in a single stage operation in 4 cases, while resection was staged for resection of extra and intra-cranial lesion in 1 case. There was no recurrence during the 8-51 months followup. Facial nerve function was normal before surgery and returned to normal within 3 months after surgery in 2 cases; was H-B II before surgery and remained at H-B II after surgery in 2 cases; and was H-B V before surgery and improved to H-B III 1 year after surgery in 1 case.Cochlear function was preserved in all cases except the one with cochlear destruction before surgery. Hearing test was normal preoperatively and showed conductive loss postoperatively in 2 cases, due to ear canal closure; showed mild conductive loss preoperatively which remained unchanged at 3 months postoperatively due to tympanum reconstruction in1 case; showed severe mixed or profound sensorineural loss preoperatively due to labyrinth/cochlea damage and no postoperative improvement in the rest 2 cases. All patients returned to normal diets within about 1 week(mean = 6 days) after surgery. Conclusion Safe and complete removal of GCT and GCRG involving the infratemporal fossa and temporal bone can be achieved via the combined infratemporal fossa approach type B+D, with facial nerve and cochlear function preserved and no long-term recurrence or significant impact on oral feeding.
Objective To review clinical outcomes in surgical treatment of temporal bone giant cell reparative granuloma(CGRG) and giant cell tumor(GCT) via combined infratemporal fossa approach type B and D. Methods Data from 5 patients diagnosed with CGRG(n=3) and GCT(n=2) and treated with resection via combined infratemporal fossa approach B and D from December 2014 to July 2018 were retrospectively reviewed. Three cases had a history ofprevious tumor resection, followed by recurrence at 6, 18 and 20 months postoperatively, respectively. The mastoid process, temporomandibular joint and pterygoid process were involved in all 5 cases, and the tumor invaded the brain with destruction of internal auditory canal and cochlea in 1 case. The mean tumor size was 42 x 46 mm. All patients were followed up regularly by CT and MRI postoperatively. Results Complete tumor resection with no residual lesion under the microscope was achieved in a single stage operation in 4 cases, while resection was staged for resection of extra and intra-cranial lesion in 1 case. There was no recurrence during the 8-51 months followup. Facial nerve function was normal before surgery and returned to normal within 3 months after surgery in 2 cases; was H-B II before surgery and remained at H-B II after surgery in 2 cases; and was H-B V before surgery and improved to H-B III 1 year after surgery in 1 case.Cochlear function was preserved in all cases except the one with cochlear destruction before surgery. Hearing test was normal preoperatively and showed conductive loss postoperatively in 2 cases, due to ear canal closure; showed mild conductive loss preoperatively which remained unchanged at 3 months postoperatively due to tympanum reconstruction in1 case; showed severe mixed or profound sensorineural loss preoperatively due to labyrinth/cochlea damage and no postoperative improvement in the rest 2 cases. All patients returned to normal diets within about 1 week(mean = 6 days) after surgery. Conclusion Safe and complete removal of GCT and GCRG involving the infratemporal fossa and temporal bone can be achieved via the combined infratemporal fossa approach type B+D, with facial nerve and cochlear function preserved and no long-term recurrence or significant impact on oral feeding.
引文
1 Wei-Ying D,Chao T,Li L.Case Reports of a Giant Cell Reparative Granuloma and a Giant Cell Tumor on Temporal Bone[J].Chinese Medical Journal(English Edition),2018,131(18):2254.
2 Freeman J,Oushy S,Schowinsky J,et al.Invasive Giant Cell Tumor of The Lateral Skull Base:A Systematic Review,Meta-analysis and Case Illustration[J].World Neurosurgery,2016,96:47-57.
3 Kaya?,Benzer M,Turhal G,et al.Giant Cell Tumor of the Temporal Bone and Skull Base:A Case Report[J].Journal of International Advanced Otology,2018,14(1):151-154.
4 Fisch U,Mattox D,Glitsch I B I.Microsurgery of the skull base[J].Journal of the Royal Society of Medicine,1989,82(11):698.
5 Fisch U,Fagan P,Valavanis A.The infratemporal fossa approach for the lateral skull base[J].Otolaryngol Clin North Am,1984,17(3):513-552.
6 Fisch U.The infratemporal fossa approach for nasopharyngeal tumors.[J].Laryngoscope,2010,93(1):36-44.
7 Sabit I,Schaefer S D,Couldwell W T.Modified infratemporal fossa approach via lateral transantral maxillotomy:A microsurgical model[J].Surgical Neurology,2002,58(1):21-31.
8 Sekhar L N,Schramm V L,Jones N F.Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms[J].Journal of Neurosurgery,1987,67(4):488-499.
9 Tamura R,Miwa T,Shimizu K,et al.Giant Cell Tumor of the Skull:Review of the Literature[J].Journal of Neurological Surgery Part A Central European Neurosurgery,2015,77(03):239-246.
10 Harris A E,Beckner M E,Leon B,et al.Giant cell tumor of the skull:a case report and review of the literature[J].Surgical Neurology,2004,61(3):274-277.
11 Fricton J R,Schiffman E L.Reliability of a Craniomandibular Index[J].Journal of Dental Research,1986,65(11):1359-1364.
12 Ma Y,Liu L,Huang D,et al.Diagnosis and treatment of giant cell granuloma of the temporal bone:Report of eight cases[J].Acta Otolaryngol,2012,132(6):657-662.
13 Liu J,Zhong D,Liu L,et al.[Giant cell reparative granuloma of the skull][J].Acta Oto-Laryngologica,2000,121(4):523-528.
14 Jain S,Sam A,Yohannan D I,et al.Giant cell tumor of the temporal bone--an unusual presentation.[J].Clinical Neurology&Neurosurgery,2013,115(5):646-648.
15刘军,黄德亮,韩东一,等.颞骨巨细胞修复性肉芽肿[J].中华耳科学杂志,2004,2(1):34-36.Liu J,Huang DL,Han DY,et al.Giant cell reparative granuloma in temporal bone[J].Chinese Journal of Otology,2004,2(1):34-36.
16 Starc M T,Delara F A,Meltzer D E.Giant Cell Tumor of the Temporal Bone[J].2016.
17 Venkatesh M D,Vijaya N,Girish N,et al.Giant cell tumor of temporal bone:A case report.[J].Medical Journal Armed Forces India,2012,68(4):392-394.
18 Cochrane E.Giant cell tumor of the temporal bone-a case report[J].Bmc Ear Nose&Throat Disorders,2005,5(2):211-212.
19 Jain S,Sam A,Yohannan D I,et al.Giant cell tumor of the temporal bone--an unusual presentation.[J].Clinical Neurology&Neurosurgery,2013,115(5):646-648.
20 Zhang M,Garvis W,Linder T,et al.Update on the infratemporal fossa approaches to nasopharyngeal angiofibroma[J].Laryngoscope,1998,108(11):1717-1723.
21冯国栋,杨华,刘庆松,等.颞下窝进路Type B技术在颞骨岩部胆脂瘤治疗中的应用[J].中国耳鼻咽喉颅底外科杂志,2018,6(24):509-512.Feng GD,Yang H,Liu QS,et al.Application of Infratemporal fossa approach type B in the treatment of petrous bone cholesteatoma[J].Chinese Journal of Otorhinolaryngology-Skull Base Surgery,2018,6(24):509-512.
22 Kim S M,Paek S H,Lee J H.Infratemporal fossa approach:the modified zygomatico-transmandibular approach[J].Maxillofac Plast Reconstr Surg,2019,41(1):3.
23 Woodford R,Chaudhary N,Wolf A,et al.A Modified Retromaxillary Approach to the Infratemporal Fossa:Three Case Studies[J].Journal of Oral&Maxillofacial Surgery,2015,73(4):769-780.
2 Freeman J,Oushy S,Schowinsky J,et al.Invasive Giant Cell Tumor of The Lateral Skull Base:A Systematic Review,Meta-analysis and Case Illustration[J].World Neurosurgery,2016,96:47-57.
3 Kaya?,Benzer M,Turhal G,et al.Giant Cell Tumor of the Temporal Bone and Skull Base:A Case Report[J].Journal of International Advanced Otology,2018,14(1):151-154.
4 Fisch U,Mattox D,Glitsch I B I.Microsurgery of the skull base[J].Journal of the Royal Society of Medicine,1989,82(11):698.
5 Fisch U,Fagan P,Valavanis A.The infratemporal fossa approach for the lateral skull base[J].Otolaryngol Clin North Am,1984,17(3):513-552.
6 Fisch U.The infratemporal fossa approach for nasopharyngeal tumors.[J].Laryngoscope,2010,93(1):36-44.
7 Sabit I,Schaefer S D,Couldwell W T.Modified infratemporal fossa approach via lateral transantral maxillotomy:A microsurgical model[J].Surgical Neurology,2002,58(1):21-31.
8 Sekhar L N,Schramm V L,Jones N F.Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms[J].Journal of Neurosurgery,1987,67(4):488-499.
9 Tamura R,Miwa T,Shimizu K,et al.Giant Cell Tumor of the Skull:Review of the Literature[J].Journal of Neurological Surgery Part A Central European Neurosurgery,2015,77(03):239-246.
10 Harris A E,Beckner M E,Leon B,et al.Giant cell tumor of the skull:a case report and review of the literature[J].Surgical Neurology,2004,61(3):274-277.
11 Fricton J R,Schiffman E L.Reliability of a Craniomandibular Index[J].Journal of Dental Research,1986,65(11):1359-1364.
12 Ma Y,Liu L,Huang D,et al.Diagnosis and treatment of giant cell granuloma of the temporal bone:Report of eight cases[J].Acta Otolaryngol,2012,132(6):657-662.
13 Liu J,Zhong D,Liu L,et al.[Giant cell reparative granuloma of the skull][J].Acta Oto-Laryngologica,2000,121(4):523-528.
14 Jain S,Sam A,Yohannan D I,et al.Giant cell tumor of the temporal bone--an unusual presentation.[J].Clinical Neurology&Neurosurgery,2013,115(5):646-648.
15刘军,黄德亮,韩东一,等.颞骨巨细胞修复性肉芽肿[J].中华耳科学杂志,2004,2(1):34-36.Liu J,Huang DL,Han DY,et al.Giant cell reparative granuloma in temporal bone[J].Chinese Journal of Otology,2004,2(1):34-36.
16 Starc M T,Delara F A,Meltzer D E.Giant Cell Tumor of the Temporal Bone[J].2016.
17 Venkatesh M D,Vijaya N,Girish N,et al.Giant cell tumor of temporal bone:A case report.[J].Medical Journal Armed Forces India,2012,68(4):392-394.
18 Cochrane E.Giant cell tumor of the temporal bone-a case report[J].Bmc Ear Nose&Throat Disorders,2005,5(2):211-212.
19 Jain S,Sam A,Yohannan D I,et al.Giant cell tumor of the temporal bone--an unusual presentation.[J].Clinical Neurology&Neurosurgery,2013,115(5):646-648.
20 Zhang M,Garvis W,Linder T,et al.Update on the infratemporal fossa approaches to nasopharyngeal angiofibroma[J].Laryngoscope,1998,108(11):1717-1723.
21冯国栋,杨华,刘庆松,等.颞下窝进路Type B技术在颞骨岩部胆脂瘤治疗中的应用[J].中国耳鼻咽喉颅底外科杂志,2018,6(24):509-512.Feng GD,Yang H,Liu QS,et al.Application of Infratemporal fossa approach type B in the treatment of petrous bone cholesteatoma[J].Chinese Journal of Otorhinolaryngology-Skull Base Surgery,2018,6(24):509-512.
22 Kim S M,Paek S H,Lee J H.Infratemporal fossa approach:the modified zygomatico-transmandibular approach[J].Maxillofac Plast Reconstr Surg,2019,41(1):3.
23 Woodford R,Chaudhary N,Wolf A,et al.A Modified Retromaxillary Approach to the Infratemporal Fossa:Three Case Studies[J].Journal of Oral&Maxillofacial Surgery,2015,73(4):769-780.