内听道型听神经瘤的外科治疗

摘要：目的探讨和总结内听道型听神经瘤的临床显微手术技巧,以期提高手术疗效。方法回顾性分析2007年8月~2015年8月期手术的34例内听道型听神经瘤患者临床资料,探讨手术操作技巧,并总结肿瘤切除程度、术后并发症及远期随访情况。结果34例患者均采用枕下乙状窦后入路,肿瘤最大径小于10 mm 11例,介于10~20 mm之间23例;肿瘤全切34例。无一例死亡。术后3个月轻度周围性面瘫2例,听力较术前下降17例。术后随访2年以上,听力较术前下降13例。结论乙状窦后硬膜下入路是切除内听道型听神经瘤的良好办法,磨除内听道后壁及锐性分离是操作核心。     

囊性听神经瘤的显微手术策略与临床分析

目的探讨囊性听神经瘤的临床特点及其显微外科手术的治疗方法。 方法回顾性分析2013年1月~2017年12月华中科技大学同济医学院附属同济医院神经外科收治的囊性听神经瘤69例。所有囊性听神经瘤均行手术治疗,采用枕下乙状窦后入路。结果肿瘤全切61例（88.4%）,次全切除6例（8.7%）,部分切除2例（2.9%）;面神经解剖保留率为64例（92.7%）。术后2周采用面神经功能House Brackmann分级,其中Ⅰ Ⅱ级47例（68.1%）,Ⅲ Ⅳ级16例（23.2%）,Ⅴ Ⅵ级6例（8.7%）;术后后组脑神经功能障碍4例（5.8%）,术后实用听力保留患者4例（5.8%）。结论囊性听神经瘤应尽量早期积极手术,在充分保护面神经功能的前提下,力争全切肿瘤。同时术者丰富的显微外科技术,以及超声刀、激光刀、电生理监测等重要工具的应用,是保障囊性听神经瘤手术效果和保全神经功能的关键因素。     

颞下窝进路TypeB技术在颞骨岩部胆脂瘤治疗中的应用

目的探讨颞下窝径路TypeB技术在颞骨岩部巨大迷路型胆脂瘤切除中的临床应用价值。方法回顾性分析2015年8月~2017年4月北京协和医院耳鼻咽喉科收治的5例巨大迷路型颞骨岩部胆脂瘤患者的临床资料，5例患者中曾行开放式乳突根治1例，岩骨次全切除（保留听囊）1例，开放式乳突根治后再行岩骨次全切除（保留听囊）1例，入院后5例患者均接受颞下窝径路TypeB手术切除。结果5例患者均手术完整切除，显微镜下术腔无死角，检查无胆脂瘤残留。所有患者颈内动脉均有不同程度胆脂瘤包绕，均沿胆脂瘤基质与颈内动脉壁的间隙分离干净。术后均行MR+DWI随诊1~2.5年，未见复发。5例患者术后术侧均全聋。1例面神经完整者术后H B II级；2例舌下神经-面神经吻合患者,其中1例术后1年H B III级，另1例术后随访1年H B IV级；2例头痛患者术后症状均消失。5例患者术后1个月均可正常饮食。结论颞下窝径路TypeB技术可以安全、彻底切除复杂的巨大迷路型岩部胆脂瘤，未引起严重并发症。但早期反复手术失败影响对相关功能的保留和重建。     

神经导航辅助经内听道入路显微手术治疗听神经瘤

目的总结术中神经导航应用于听神经瘤的经验,探讨面听神经保留的显微外科技巧,以提高肿瘤的全切率和面听神经的保护率。方法回顾性分析应用术中神经导航技术经枕下乙状窦后-内听道入路显微外科手术治疗的31例听神经瘤。术中神经导航定位静脉窦,引导内听道后壁磨除。27例术中行脑干诱发电位监测。结果肿瘤全切31例,全切除率为100%。术中面神经解剖保留29例,面神经解剖保留率为93.6%。肿瘤切除3个月后复查,面神经功能Ⅰ～Ⅱ级27例(87.1%),Ⅲ～Ⅳ级4例(12.9%)。解剖未能保留的2例,术中均行面神经端-端吻合。无手术相关死亡病例。结论神经导航的应用有助于提高听神经瘤切除的安全性和手术疗效。熟练掌握显微手术技巧、术中神经导航和面神经电生理监测的应用是提高肿瘤全切除、面神经解剖和功能保护率的关键。     

颅中窝径路切除小听神经瘤保护面听神经功能的研究

目的 探讨经颅中窝径路切除内听道内小听神经瘤手术对面神经和听神经功能的保护.方法 2004年1月至2013年2月共13例患者接受经颅中窝径路切除内听道内的小听神经瘤,其中男6例,女7例,年龄38 ～ 54岁;瘤体大小为0.8～1.5cm.听神经功能评价根据美国耳鼻咽喉头颈外科学会的标准分为A、B、C、D四级,面神经功能的评估参照House-Brackmann (HB)分级标准,比较患者手术前和手术后1个月时的面听神经功能.结果 13例患者手术顺利,无死亡病例,其中12例患者肿瘤全切,1例近全切除.患者术前听力评估A级10例、B级2例、C级1例,术后复查,2例患者听力由A级下降至B级,1例由B级升至A级,1例由B级下降至C级,术后听力A级保存率为80％(8/10).12例患者术前面神经功能为HB Ⅰ级,术后仍为Ⅰ级,术后面神经功能Ⅰ级保留率为100％(12/12);1例面神经功能Ⅱ级患者术后下降为Ⅲ级.术后随访0.5～5年,均未出现严重并发症.结论 颅中窝径路内听道内小听神经瘤切除术可有效保留听神经和面神经功能,手术切除可以考虑作为小听神经瘤患者的常规治疗手段.     

听神经瘤枕下乙状窦后锁孔入路的临床探讨

目的 探讨改良听神经瘤枕下乙状窦后入路的手术方法，预防并发症，减少手术损伤。方法 对12例听神经瘤采用单侧枕下乳突后小“J”形皮肤切口，枕下乙状窦后“锁孔”入路显微手术切除肿瘤，后颅窝开颅术改咬骨窗为开骨瓣术。结果 10例肿瘤全切除，1例全切除；面神经解剖保留9例，术后2－9个月复查面神经House-Brackmann（H－B）Ⅰ-Ⅱ级、Ⅲ－Ⅳ级，Ⅴ级1例。术后见明显并发症。结论 改良枕下乙状窦后“锁孔”入路是一种有效、安全、便捷的微创手术入路。它的优点是解剖复位、创伤小、并发症少，并有利于美容。     

肌电图监护下大型听神经瘤的显微手术及面神经保留

目的 介绍经枕下-乙状窦后入路大型听神经瘤显微手术切除及面神经保留技巧。方法对32例大型听神经瘤在面肌肌电图监护下行显微手术切除。结果所有32例病人均行肿瘤全切，面神经解剖保留率为96．88％。根据House-Brackmann面神经功能分级标准，面神经功能保留率术后6个月为Ⅱ级52．38％、Ⅲ级42．86％、Ⅳ级4．76％；术后1年为Ⅱ级66．67％、Ⅲ级28．57％、Ⅳ级4．76％。结论对大型听神经瘤，在面肌肌电图监护下通过显微手术技术，可以全切肿瘤同时保留面神经解剖的完整。     

听神经瘤手术的初步体会

目的探讨听神经瘤切除术的方法及效果。方法采用经迷路进路手术切除听神经瘤4例,经乙状窦后进路手术切除听神经瘤6例,对其临床资料进行回顾性分析。结果肿瘤全切除8例,次全切除1例,近全切除1例,面神经功能保留9例,术后短期并发症4例,无死亡病例。结论依据听力情况及肿瘤大小来决定手术进路,术中面神经监测、熟悉的解剖及良好的显微手术技巧是保证肿瘤全切、减少面神经损伤和并发症的关键。     

咬肌神经联合颞骨内面神经转位治疗听神经瘤术后面瘫

目的探讨咬肌神经联合颞骨内面神经转位手术,治疗听神经瘤术后完全性面瘫的临床效果和手术适应证。方法回顾分析北京中日友好医院耳鼻咽喉科 2018年1月—2019年1月收治的 10例听神经瘤术后伴有重度以上感音神经性聋的完全性面瘫患者。所有患者均行咬肌神经联合颞骨内面神经转位手术治疗。结果术后1年面神经功能评估,1例恢复到H B Ⅱ级,9例恢复到H B Ⅲ级,手术前后面瘫分级经t检验差异具有统计学意义（P<0.01）。4例出现自发性微笑,6例为社交性微笑,无明显手术并发证。结论咬肌神经联合颞骨内面神经转位手术,避免了耳大神经损伤,减少了神经吻合口,临床疗效显著,值得进一步深入研究。     

前庭神经鞘膜瘤囊性变的治疗策略

摘要：目的分析前庭神经鞘膜瘤囊性变治疗策略的影响。方法回顾性分析2006年1月~2013年12月收治前庭神经鞘膜瘤697例,其中根据内听道及桥小脑角增强MRI发现为前庭神经鞘膜瘤束性变患者96例,同时从剩余601例中随机抽取96例作为实体肿瘤组,比较两组患者临床特性、术中特点和手术效果。结果前庭神经鞘膜瘤囊性变的临床进展明显较实性肿瘤快速,且听力症状较实性肿瘤患者严重,突发性耳聋率较高29（30.2%）,囊性肿瘤与面神经粘连较实体肿瘤严重,术后短期两组面神经功能差异无统计学意义（P>0.05）,但术后1年随访时CVS组面神经功能良好率明显低于SVS组（30.2% vs 44.8%,P=0.037）。两组在术后并发症发生率、死亡率、复发率方面无差异。结论前庭神经鞘膜瘤囊性变应首选手术切除,对于周围薄壁型囊性肿瘤,如剥离困难无法全切除,应以保留面神经功能为先,采取近全切除等措施,提高术后患者生活质量。     

Distance from acoustic neuroma to fundus and a postoperative facial palsy.

OBJECTIVE/HYPOTHESIS: Generally, patients with small acoustic neuroma have less facial palsy after its removal. The middle cranial fossa approach is mainly applied to the small acoustic neuroma and tumor size does not influence the prognosis of facial palsy. The internal auditory canal cannot be fully opened in the middle cranial fossa approach, and the facial nerve is tightly attached in the fundus. According to these anatomical factors, we hypothesized that acoustic neuromas located away from the fundus might be removed with less facial nerve damage. We investigated the distance between the acoustic neuroma and fundus and its clinical relationship. STUDY DESIGN: Retrospective study of 45 patients with acoustic neuroma who underwent a middle cranial fossa approach. METHODS: The distance between the acoustic neuroma and fundus and the tumor diameter were measured on T2-weighted and contrast-enhanced magnetic resonance images, respectively. These data were compared with the postoperative facial nerve function. RESULTS: The mean distance was 3.0 +/- 1.8 mm (range, 0-10 mm), and the mean diameter was 11.3 +/- 3.7 mm (means +/- standard deviation; range, 4-20 mm). Neither the distance nor the diameter had any correlation to the degrees of postoperative facial palsy either immediately or at 3 months after surgery. CONCLUSIONS: As far as the nerve was anatomically preserved, postoperative facial nerve function seemed to be influenced by factors other than surgical manipulation among small acoustic neuromas. Although the tumor fills in the fundus, it may not influence postoperative facial nerve function and also may not interfere with indication of the middle cranial fossa approach for removal of the acoustic neuroma.     

神经电生理监测下听神经瘤显微手术中面神经的保护

目的总结分析术中神经电生理监测结合显微手术操作技巧在听神经瘤手术中预防面神经损伤的作用。方法选取我科2011～2012年施行乙状窦后入路显微手术的大型及中型听神经瘤（肿瘤直径≥2.4 cm）患者62例,术中应用神经电生理监测技术对手术进行综合监护,同时密切留意骨性解剖、蛛网膜解剖、神经与血管解剖关系。术后随访6个月,评估肿瘤切除程度并根据House-Brack-mann面神经功能分级对患者面神经功能进行评估。结果肿瘤全切除58例（93.5%）,次全切除4例（6.5%）;无围手术期死亡患者。面神经功能评定：Ⅰ级57例（91.9%）,Ⅱ级5例（8.1%）。结论对于大型和中型听神经瘤患者,术中进行综合电生理监护,同时操作时注意典型的解剖位置与熟练的显微手术技术,可达到较高的肿瘤全切除率,并尽可能地保全面神经功能。     

Endoscope-Assisted Cerebellopontine Angle Surgery

Objective To report experiences with use of otoendoscopy in cerebellopontine angle (CPA) surgeries. Methods Twenty five cases of CPA surgeries performed between November 2002 and December 2008 in which microscope enabled otoendoscopy was used were reviewed.The 25 cases included 19 cases of acoustic neuroma, 3 cases of CPA facial nerve tumors, 1 case of trigeminal neurinoma, a case of glossopharyngeal neuralgia and 1 case of hemifacial spasm. Endoscopy was used in all cases together with monitoring of brainstem auditory responses and facial electromyography. Postoperative hearing and facial nerve function were evaluated and compared to pre-op-erative levels. Results Endoscopy provided improved visualization of local anatomy, revealed hidden lesions and reduced unnecessary anatomical distortions. Total resection was achieved in 18 of the 19 acoustic neuroma cases, Facial nerve anatomical integrity was preserved in all 19 cases. One week postoperative House-Brackmann grading was Ⅰ in 3 cases, Ⅱ in 10 cases and Ⅲ in 6 cases. Facial nerve function continued to improve in some cases at 3 months. Total tumor resection was achieved in all 3 patients with facial neurinoma. The facial nerve was sacrificed in 2 of the 3 cases with primary faciohypoglossal nerve anastomosis. Facial nerve function was Grade Ⅱ and Grade Ⅲ one year after surgery, respectively. In the case with anatomically preserved facial nerve, postoperative facial nerve function was initially Grade Ⅲ and improved to Ⅱ at 3 months. The tumor was completely resected in the trigeminal neurinoma patient with a Grade Ⅲ postoperative facial nerve function which improved Grade Ⅱ three months later. Seventeen of the 19 patients with acoustic neuroma retained hearing postoperatively, of these 12 maintained preoperative levels of hearing. Preoperative hearing capacity was preserved in 2 of the 3 patients with facial nerve tumors, but lost in patients with other tumor types. Glossopharyngeal neurotomy (n=1) and mi-crovascular deeompression(n=1) resulted in satisfactory symptom relief and no recurrence at 5- and 3-year follow up, respectively. Conclusions Otoendos aope-aided technique greatly helps surgical management of CPA and in-ternal auditory canal lesions and other disorders. This minimally invasive technique overcomes many shortcomings inherent to the traditional retrosigmoid approach.     

Sporadic acoustic neuroma in pediatric patients

OBJECTIVE: Sporadic acoustic neuroma, usually occur between the ages of 40 and 70 years, are very rare in children. We review the experiences of 10 cases of sporadic (non-NF2) acoustic neuromas in pediatric patients. METHOD: During last 26 years 2000 skull base procedures were performed in the Otorhinolaryngology Unit of the Ospedali Riuniti di Bergamo. Among these almost 900 cases were acoustic neuromas. Only 10 were at or under the age of 18 years. RESULTS: The age of the youngest patient in our series was 12 years. Deafness were the commonest presentation and were seen in eight patients. It varied between 10 and 65 dB sensorineural hearing loss. Among these eight cases, two patients have sudden onset of hearing loss. Two patients presented with dizziness. The duration of complaints were between 2 months and 5 years in these patients. The diameter of the tumors varied widely with minimum of 10 mm to maximum up to 60 mm. Five patients each underwent resection of the tumor by translabyrinthine and retrosigmoid approach, respectively. The minimum postoperative follow-up was 3 years and maximum was 22 years in our series. Postoperatively seven cases the facial nerve recovered to grade I, and one each to grade II and grade VI of House-Brackmann classification. All five cases who underwent retrosigmoid approach had moderate (40 dB) to total sensorineural hearing loss postoperatively. The youngest patient with largest tumor diameter of 60 mm developed transient hemiparesis in the immediate postoperative period and he recovered fully in due course. CONCLUSION: We found preservation of facial nerve function is more easier than hearing in this group of patients.     

A Review of Facial Nerve Outcome in 100 Consecutive Cases of Acoustic Tumor Surgery

Objective To determine the facial nerve outcomes at a tertiary neurotological referral center specializing in acoustic neuroma and skull base surgery. Study Design Retrospective review of 100 consecutive patients in whom acoustic neuromas were removed using all of the standard surgical approaches. Methods Functional facial nerve outcomes were independently assessed using the House‐Brackmann facial nerve grading system. Results The tumors were categorized as small, medium, large, and giant. If one excludes the three patients with preoperative facial palsies, 100% of the small tumors, 98.6% of the medium tumors, 100% of the large tumors, and 71% of the giant tumors had facial nerve function grade I‐II/VI after surgery. Conclusion Facial nerve results from alternative nonsurgical treatments must be compared with facial nerve outcomes from experienced surgical centers. Based on the facial nerve outcomes from our 100 consecutive patients, microsurgical resection remains the preferred treatment modality for acoustic tumors.     

小听神经瘤的手术治疗策略

目的　总结小听神经瘤的手术治疗效果,探讨小听神经瘤手术治疗策略。方法　回顾分析在我科手术治疗的26例小听神经瘤患者临床资料。1例术前听力分级为B者,行颅中窝入路;其余25例术前听力分级均为C与D者,行迷路入路听神经瘤切除术。回顾分析术前术后的面肌力弱、平衡障碍、耳鸣等情况,分析术中蜗神经的解剖完整性保存、肿瘤控制及复发情况、并发症发生率,以及患者获益情况。结果　25例（96.2%）达到肿瘤全切除,1例因与面神经粘连过于紧密,做近全切除。术后随访时间6个月～7年,随访19例,7例失访。无死亡、颅内感染病例。术后脑脊液耳漏1例,二次手术进行咽鼓管封堵,脑脊液耳漏消失。面神经解剖保存率100%,蜗神经解剖保存率88%。19例随访者中术后17例（89.5%）具有良好面神经功能,HB I与II级;另2例面瘫,HB III级。经颅中窝入路患者,术后听力C级。19例随访者中术前眩晕6例,术后5例（83.3%）眩晕消失,1例与术前相同。另13例术前无眩晕者,术后12例仍无眩晕与平衡障碍,1例出现体位改变时头晕或者快走时走路不稳。术前耳鸣15例,术后5例（33.3%）耳鸣消失或减轻,8例（53.3%）耳鸣程度与术前相同,2例耳鸣加重。术前4例无耳鸣,术后仍没有耳鸣。结论　小听神经瘤是否手术需要考虑患者年龄,合并全身疾病、症状的严重程度,肿瘤生长速度,采取个性化治疗策略。对于没有实用听力者,推荐经迷路入路切除肿瘤,术中尽量保存蜗神经完整性,为人工耳蜗植入重建听力创造条件。     

大型听神经瘤的显微手术技巧及面神经保护

目的探讨大型听神经瘤的显微手术技巧、效果及术中面神经的保护。方法回顾性分析解放军总医院耳鼻咽喉头颈外科2010年1月~2010年12月收治的采用显微外科手术治疗30例大型听神经瘤患者的临床资料。其中男性18例,女性12例;年龄19～71岁,平均39.6±4.2岁;病程3个月～2年。主要临床表现为桥小脑角综合征和颅内压增高征,首发症状表现为耳鸣、听力下降12例,头痛、恶心、呕吐10例,行走不稳4例,面部麻木7例,三叉神经痛2例,面瘫6例。30例术中均行面神经监测,显微镜下切除肿瘤,术毕刺激面神经的脑干端对术后面神经功能进行预测。结果本组30例大型听神经瘤全切除28例,次全切除1例,部分切除1例。术中面神经完整保留29例(96.67%),无死亡病例。肿瘤切除后,面神经刺激阈值的大小与术后面神经功能存在明显的相关性。刺激阈值越小,术后面神经功能越好。结论熟练地采用显微外科技术选择合适的手术入路可明显提高肿瘤的全切除率和面神经的解剖及功能保留率。手术入路的正确选择,娴熟的显微外科操作技术,术中应用面神经监测技术,能有效地保护桥小脑角周围的重要结构及面神经功能,并可预测术后面神经功能。     

舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫

摘要：目的探讨舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫的效果。方法6例小脑脑桥角肿瘤切除术后面瘫患者均行舌下神经-面神经侧端吻合术。所有患者术后每3个月随访1次,评估House Brackmann(H B)分级和舌下神经功能。结果术后1年H B III级2例,H B Ⅳ级3例, H B V级1例。静态面部张力4例患者在吻合术后6个月改善明显,1例患者在吻合术后 9个月改善,1例患者在吻合术后1年改善。所有患者均未出现术侧舌肌瘫痪萎缩,发音和吞咽功能均正常。结论舌下神经-面神经侧端吻合术可改善小脑脑桥角肿瘤切除术后面瘫患者的面部张力和面肌功能,借助神经监护可尽量减小对舌肌功能的影响。