咽旁间隙肿瘤手术路径探讨（附46例分析）

目的：探讨咽旁间隙肿瘤切除的最佳手术路径。方法：回顾分析咽旁间隙肿瘤的临床资料及手术路径。46例中，11例经口咽路径，23例经颈侧路径，2例经颈侧腮腺路径，7例经颈－下颌骨正中裂开外旋路径，3例经颞下窝路径切除肿瘤。结果：43例完整切除肿瘤，3例大部切除。2例术中并发面神经损伤致不完全性周围性面瘫； 2例术后出现Horner′s综合征，均于术后半月内恢复；1例术中发生大出血；术后复发3例， 1例为经口咽路径切除的良性肿瘤，2例为恶性肿瘤。术后随访3～5年， 2例死亡，余均健在。结论：手术切除咽旁间隙肿瘤应根据位置的不同正确选择手术路径，充分暴露术野，辨清解剖标志。     

内镜下鼻腔泪前隐窝-上颌窦入路切除翼腭窝肿瘤

目的 探讨内镜经鼻腔泪前隐窝-上颌窦入路在翼腭窝病变手术中的应用.方法 回顾性分析2008年5月至2011年5月5例翼腭窝良性肿瘤患者的病例资料,5例患者均接受了内镜经鼻腔泪前隐窝-上颌窦入路的外科治疗.其中神经鞘瘤4例,神经纤维瘤1例.手术采用控制低血压全身麻醉,鼻内镜下泪前隐窝入路切开鼻腔外侧壁进入上颌窦,切开上颌窦后壁进入翼腭窝切除肿瘤.结果 本组5例肿瘤均获得一次性完全切除,无任何并发症.均于术后5～12 d痊愈出院.术后随访5～28个月无复发和死亡.结论 内镜经鼻腔泪前隐窝-上颌窦入路可以安全而完整地切除翼腭窝的良性肿瘤.该术式保留了鼻泪管和下鼻甲,保留鼻腔结构和功能,从而更好地降低复发率和缩短恢复时间.     

颅底-颞下区肿瘤的手术径路及手术要点

发生于颞下窝、咽旁间隙以及翼腭窝等处的肿瘤向上发展可侵及颅底和颅内,颅内肿瘤也可突破颅底进入颞下区。由于该解剖区域隐蔽、深在,四周以骨性结构为主,早期诊断困难,以致就诊时肿瘤多数己较大,治疗上还有许多困难。该区域恶性肿瘤的构成比略高于良性肿瘤,治疗以手术为主。     

侵及颞下窝和翼腭窝肿瘤的手术治疗

对3例由邻近组织的肿瘤侵犯颞下窝和翼腭窝的患者行手术治疗。2例为腮腺粘液表皮样癌侵及者，其中1例采用颈颌入路切除腮腺和颞下窝与翼腭窝肿瘤；1例是因术后复发，术中对复发灶切除后，直接暴露颅底，手术缺损用胸大肌肌皮瓣和背阔肌肌皮瓣修复。另1例是由鼻咽和腭部肿瘤侵及者，采用上颌骨掀开入路切除原发病灶，同时切除颅底肿瘤。表明，对由邻近组织肿瘤侵犯颞下窝和翼腭窝者，手术治疗时，采用上颌骨掀开入路，只要将颅底手术野予以充分暴露，就可以获得较好的治疗效果。     

颧弓颞颌径路侧颅底肿瘤切除术

目的评价经颧弓和颞颌径路切除侧颅底肿瘤的可行性和疗效.方法经颧弓和颞颌径路在手术显微镜下为侧颅底肿瘤4例行切除术.结果术后随访5年,良性肿瘤3例无复发,非霍杰金淋巴瘤1例存活.结论经颧弓和颞颌径路适用于切除侵及颞下窝、翼腭窝的侧颅底肿瘤.     

内镜下经鼻泪前隐窝入路切除翼腭窝及颞下窝神经鞘瘤

目的 分析和讨论经鼻内镜下泪前隐窝入路,经上颌窦后外侧壁切除累及翼腭窝及颢下窝神经鞘瘤手术结果,探讨手术方法及适应证.方法 病例资料来自2004年至2011年住院接受经鼻内镜下泪前隐窝入路翼腭窝和颞下窝神经鞘瘤切除手术患者6例,其中男性和女性各3例,年龄29 ～ 59岁.手术前主要接受鼻窦CT扫描和MRI检查.采用全身麻醉下经鼻内镜下泪前隐窝入路进入翼腭窝和颞下窝.手术后组织病理学确认为神经鞘瘤.术后定期CT或MRI检查随访观察.结果 6例患者实现手术完整切除.平均随访19.3个月无复发,有3例在术后第1～2周出现面部上颌神经分布区域较明显麻木感,随后逐渐减轻,仅1例随访终期遗留术侧口角轻度麻木.结论 内镜下经鼻开放泪前隐窝入路切除翼腭窝和颞下窝神经鞘瘤,完整保留鼻腔外侧壁,损伤小,并发症少,为经鼻进入翼腭窝和颞下窝的创新微创入路.     

颞下窝、翼腭窝占位性病变微创手术治疗(附4例报告)

目的探讨颞下窝、翼腭窝占位性病变的微创手术治疗的可行性。方法回顾性分析2004年5月—2007年2月我科收治的内镜下经鼻入路手术治疗的4例颞下窝、翼腭窝占位性病变患者的临床资料,其中神经纤维瘤3例,神经鞘瘤1例。结果该入路术中病变暴露良好。3例1次手术完全切除,1例因术中出血过多分两次完成次全切除手术。1例出现术后脑脊液耳漏,保守治疗5天后痊愈。术后随访12～45个月无复发和死亡。结论内镜经鼻入路对经过严格选择的颞下窝、翼腭窝占位性病变能够做到安全、有效、微创切除。     

Le Fort I型截骨进路切除侵入翼腭窝、颞下窝巨大鼻咽纤维血管瘤

目的:探讨应用Le Fort I型截骨进路切除侵入翼腭窝、颞下窝的巨大鼻咽纤维血管瘤的可行性.方法:回顾性分析2000年7月～2002年1月采用Le Fort I型截骨进路手术切除3例侵入翼腭窝、颞下窝鼻咽纤维血管瘤的临床资料.结果:3例均为男性,年龄13～19岁,术前均行单侧或双侧超选择性动脉栓塞,手术均经Le Fort I型戴骨进路行肿瘤切除术,术后除1例因左眼内直肌损伤出现视物轻度重影外,无其它手术并发症.术后病理诊断均为纤维血管瘤.术后经2～18个月随访,3例病人均咬合良好,无肿瘤复发.结论:Le Fort I型截骨进路是处置侵入翼腭窝、颞下窝的巨大鼻咽纤维血管瘤的较好手术进路之一.     

Le FortⅠ型截骨进路切除侵入翼腭窝、颞下窝巨大鼻咽纤维血管瘤

目的 :探讨应用 L e Fort 型截骨进路切除侵入翼腭窝、颞下窝的巨大鼻咽纤维血管瘤的可行性。方法 :回顾性分析 2 0 0 0年 7月～ 2 0 0 2年 1月采用 L e Fort 型截骨进路手术切除 3例侵入翼腭窝、颞下窝鼻咽纤维血管瘤的临床资料。结果 :3例均为男性 ,年龄 13～ 19岁 ,术前均行单侧或双侧超选择性动脉栓塞 ,手术均经 L e Fort 型戴骨进路行肿瘤切除术 ,术后除 1例因左眼内直肌损伤出现视物轻度重影外 ,无其它手术并发症。术后病理诊断均为纤维血管瘤。术后经 2～ 18个月随访 ,3例病人均咬合良好 ,无肿瘤复发。结论 :L e Fort 型截骨进路是处置侵入翼腭窝、颞下窝的巨大鼻咽纤维血管瘤的较好手术进路之一。     

改良外鼻锥体侧翻术在颅底肿瘤手术中的应用

目的:介绍改良外鼻锥体侧翻术在颅底肿瘤手术的临床应用。方法:回顾性研究改良外鼻锥体侧翻术治疗的20例颅底肿瘤的诊断及外科手术治疗结果。结果:20例颅底肿瘤均累及鼻腔、双侧筛窦、蝶窦及眶内侧壁。侵犯翼腭窝、颞下窝2例,侵犯颅内者2例;均行改良外鼻锥体侧翻术治疗,其中2例鼻咽纤维血管瘤患者同时行额颞颧开颅及大部分上颌骨移位手术;2例行颅面联合入路手术。术后10例患者行放疗。患者术后无手术并发症,随访8～60个月,有6例肿瘤复发。结论:改良外鼻锥体侧翻术是治疗鼻腔、筛窦、蝶窦肿瘤累及颅底的一种安全、有效的外科治疗方法;在肿瘤向翼腭窝、颞下窝及颅内侵犯时应辅以其他手术入路。     

颞下窝肿瘤的外科治疗

目的 :探讨颞下窝肿瘤的手术进路及手术方法。方法 :根据肿瘤病变的性质及范围采用耳前上、耳后下、改良Ferguson Weber及下颌骨下 4种手术进路。 结果 :手术结果按Kaplan Meire生存率计算 ,其 2年生存率良性肿瘤为 10 0 % ,恶性肿瘤为 4 7.1%。结论 :应根据肿瘤部位、性质与相邻解剖关系选择合适的手术进路 ,以保证手术能安全、有效及顺利进行     

咽旁隙肿瘤的诊断及治疗

目的 了解咽旁隙解剖特征，提高咽旁隙肿瘤诊治水平。方法回顾分析近9年收治的45例咽旁隙肿瘤病人临床表现、影像学特征、外科径路、手术所见及手术后并发症，全部病人随访8个月～9年。结果良性肿瘤40例(其中神经源性肿瘤28例)，恶性肿瘤5例。术前CT或MRI能明确肿瘤的大小、位置、扩展范围、以及与周围结构的关系。术后出现伸舌偏斜2例，口角偏斜1例，Hoiner综合征4例，右上肢曲屈障碍1例，3例术后肿瘤复发再次手术治愈。结论原发性咽旁隙肿瘤以神经源性肿瘤多见，MRI和/或CT检查是诊断咽旁隙肿瘤及术前确定手术方案的基础，且MRI检查优于CT。根据病变的部位及特性，手术可选择经口径路、颈侧径路或颈侧联合径路切除肿瘤。     

Surgical policy in patients with basally advanced form of juvenile nasopharyngeal angiofibroma

The authors has modified surgical policy in a basicranially extending form of juvenile nasopharyngeal angiofibroma (JNA) which is classified into tumors of stage I, II and III. Basally advanced tumors were diagnosed in 28 of 40 JNA patients: basicranially extended tumor (n=12, 30%), stage I tumor invading nasopharynx, nasal cavity, sphenoid sinus (n=4, 14.3%), stage II tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses (n=9, 32.1%), stage III tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses, infratemporal fossa, orbit, maxillary sinus and parapharyngeal space (n=15, 53.6%). Differential surgical treatment according to Owens (stage I tumors), Denker (stage II tumors), Moure (stage III tumors) provides radical removal of the tumor in the majority of the patients (87.7%) and therefore is an effective therapy of surgical treatment of the above patients.     

鼻咽癌放疗后局部复发挽救性手术入路的探讨

目的探讨鼻咽癌放疗后鼻咽部复发挽救性手术入路的方法和效果。方法1998年1月—2003年1月对13例鼻咽癌放疗后鼻咽部复发进行挽救性手术治疗。手术采用经口腔硬腭入路2例，鼻锥内翻入路2例，上颌骨外旋入路5例，经颞下窝入路4例，术后随访2～5年。回顾性分析4种不同的手术路径与方法、适应证以及治疗效果。结果T1和T2a各2例患者经硬腭入路和鼻锥内翻入路，随访生存均达3年以上。3例T2b和2例13上颌骨外旋入路，分别在术后2个月、2年死亡，1例术后复发光敏治疗后带瘤生存13个月死亡；2例健在，随访分别达2年和4年。T44例经颞下窝入路，术后咬殆）功能均有影响，术后1年内死亡3例，1例随访2年健在。13例均无术中并发症，术后发生鼻咽部颅底骨坏死、脑脊液漏并发颅内感染、上消化道大出血各1例，2年生存率54％（7／13）。结论根据鼻咽复发肿瘤的部位、侵犯范围，以尽可能小的创伤获得足够的显露的原则选择手术入路。T1和他病变可外科手术根治，手术效果良好。肿瘤侵犯咽旁组织和中耳者，预后较差，手术可以减轻患者痛苦，延长生命。     

颞骨和颞下窝联合入路侧颅底肿瘤切除术

探讨安全和彻底摘除广侵侧颅底及其相邻区的肿瘤的手术入路和方法。方法通过颞骨和颞下窝联合入路,应用显微外科技术摘除肿瘤,并尽可能维护或重建颅底和颅神经。     

Robotic skull base surgery: preclinical investigations to human clinical application

OBJECTIVE: To develop a minimally invasive surgical technique for the treatment of parapharyngeal space and infratemporal fossa skull base neoplasms using the technical and optical advantages of robotic surgical instrumentation. DESIGN: A robotics skull base surgery program at the University of Pennsylvania, Philadelphia, was initiated in the fall of 2005. Six experimental procedures focusing on developing approaches to the parapharyngeal space and infratemporal fossa were performed on a total of 2 cadavers and 1 mongrel dog. Based on the preclinical work, transoral robotic surgery (TORS) was then performed in February 2007 on 1 human patient with a parapharyngeal to infratemporal fossa cystic neoplasm as part of a large prospective human trial. SETTING: In each cadaver and in the dog, a TORS approach to parapharyngeal space and infratemporal fossa was performed bilaterally and in an approved training facility using the da Vinci Surgical System. For the human surgical case, a TORS approach was evaluated on one side for a benign neoplasm. The human patient underwent TORS of the parapharyngeal space and infratemporal fossa under an institutional review board-approved prospective clinical trial. PATIENTS: For the human clinical trial, a TORS approach was evaluated for a patient with a benign neoplasm of the parapharyngeal space and infratemporal fossa. MAIN OUTCOME MEASURES: The ability to access and dissect tissues within the various areas of the parapharynx and infratemporal fossa was evaluated, and techniques to enhance visualization and instrumentation were developed. RESULTS: Using TORS approaches permitted excellent access, visualization, and tissue dissection within the parapharyngeal space and infratemporal fossa in both the cadaver and canine experiments. In the first known human surgical case, TORS was used to remove a parapharyngeal space and infratemporal fossa cystic neoplasm. Wide visualization, followed by complete resection using the identical techniques developed in the preclinical models, was achieved. The robotic procedure allowed adequate and safe identification of the internal carotid artery and cranial nerves, and excellent hemostasis was achieved with no complications during or after surgery. CONCLUSIONS: The TORS approaches provided excellent 3-dimensional visualization and instrument access that allowed successful parapharyngeal space and infratemporal fossa surgical resections from cadaver models to the first known human patient application. Robotic surgery for the skull base holds potential as a minimally invasive approach to skull base neoplasms; however, continued development and investigation is warranted in a prospective human clinical trial before final conclusions can be drawn as to the full advantages and limitations of this approach.     

下颌外旋切除咽及颅底肿瘤

目的 探讨咽及颅底肿瘤切除的最佳手术入路。方法 １３例咽及颅底肿瘤中，鼻咽部２例，口咽部４例，咽旁间隙５例，咽旁颞下区２例。均采用下颌骨切开外旋入路进行了根治性切除。同期行咽后淋巴结清扫术５例，改良根治性颈清扫术２例，咽部缺损以胸大肌皮瓣整复５例。恶性肿瘤术后均接受了辅助性放射治疗。结果 １３例患者中恶性肿瘤１０例，良性肿瘤３例。１２例切口愈合良好，１例术后胸大肌皮瓣感染坏死，延缓愈合。１例吞咽困     

头皮半冠状联合下颌下切口治疗颞下窝肿瘤

目的 探讨颞下窝肿瘤切除的手术进路和手术方法.方法 根据肿瘤的性质和大小,对1998年10月～2006年6月收治的9例患者,全部采用头皮半冠状切口联合下颌下切口进路进行手术治疗.结果 全部9例患者,3例良性肿瘤手术后3年随访无1例复发;6例恶性肿瘤患者手术后均进行50 Gy～70 Gy的放射治疗,经过最长3年随访,1例因肿瘤再次复发大出血而死亡,1例带瘤生存,1例1年后失访,3例未见有明显复发.结论 颞下窝肿瘤位置较深,发现较晚,瘤体较大,采用头皮半冠状切口联合下颌下切口进路进行手术,肿瘤相对较易切除彻底,风险小,安全,并能有效修复遗留死腔.     

Facial translocation approach in the management of central skull base and infratemporal tumors

OBJECTIVES/HYPOTHESIS: The objectives were to systematize the indications of various types of facial translocation and to present a technical modification to avoid some sequelae of this approach. STUDY DESIGN: Retrospective analysis was made of patients treated with different types of facial translocation approach to resect nasopharyngeal, infratemporal, and sinonasal tumors. METHODS: Thirty-nine patients underwent facial translocation approaches for neoplasms originally involving the nasopharynx (27) infratemporal fossa (7), and nasal cavity (5). Of the 21 malignant tumors, 2 were stage T2, 5 were stage T3, and 14 were stage T4. From the entire series of patients, 10 received a unilateral medial translocation, 3 a bilateral medial translocation, 25 a standard facial translocation, and 1 an extended medial facial translocation. RESULTS: Fifteen patients (38%) developed some kind of complication, such as wound infection (nine cases) and osteomyelitis and cerebrospinal fluid leak (five cases each). Two patients died as a result of postoperative complications (5.2%). Overall 5-year survival for malignant tumors was 43%. Neither the histological appearance of the tumor nor the T stage influenced the survival of patients. Survival of patients with intracranial involvement was significantly decreased compared with patients with involvement of other areas (P =.0003). CONCLUSION: The facial translocation approach offers an excellent exposure in tumors with large degree of involvement of the nasopharynx, infratemporal fossa, nasal cavity, and maxillary sinus. More limited osteotomies are indicated in smaller tumors. The use of midfacial degloving minimizes the number of sequelae of these approaches.     

咽旁隙和颞下窝肿瘤的外科治疗进展

咽旁隙的原发肿瘤约占头颈部肿瘤的0.5%~1%,绝大多数为良性,涎腺肿瘤和神经源性肿瘤最常见。颈侧入路和经颈-腮腺入路手术是处理咽旁隙肿瘤的主要方法。颞下窝内原发肿瘤较少,且恶性居多。该区域手术可采用颞下窝入路,上颌骨外旋入路、下颌骨外旋入路等。随着内镜辅助下经鼻、经口入路手术技术的进步和机器人手术、影像导航系统的发展,咽旁隙和颞下窝肿瘤的外科治疗呈微创化趋势。耳鼻咽喉科、头颈外科、口腔颌面外科和神经外科等相关专业的多学科合作和内镜辅助下的微创手术是该区域肿瘤外科治疗的发展方向。