颈静脉孔及其周围区域肿瘤的外科治疗

Surgery of jugular foramen region tumors

目的探讨颈静脉孔及其周围区域肿瘤的最大限度保存功能的手术方法和手术效果。方法回顾分析1999年3月—2005年5月间手术的32例颈静脉孔区肿瘤,根据术前肿瘤性质、大小、位置、听力功能、面神经功能以及后组脑神经功能,分别采用乳突与颈部联合进路(4例)、不移位面神经的颞下窝进路(9例)、移位面神经的颞下窝进路(11例)以及颞下窝进路联合耳蜗进路(8例),分析术后功能保存情况。术中均使用脑神经监护仪,术后均复查 CT 或 MRI。结果 32例颈静脉孔区肿瘤,其中副神经节瘤13例、神经鞘膜瘤10例、脑膜瘤2例、巨细胞瘤2例、软骨肉瘤1例、黏液软骨肉瘤1例、腺样囊性癌1例、胚胎性横纹肌肉瘤1例、胆固醇性肉芽肿1例,随访时间3～60个月。26例肿瘤全切,5例近全切除、1例次全切除。术后死亡2例。5例术后脑脊液漏,2例并发颅内感染,均经保守治疗痊愈;术后1周面神经功能(House-Brackmann 分级)1～2级13例,3～4级12例,5～6级7例;术后3～60个月随访面神经功能1～2级23例,3～4级7例,5～6级2例;术后听力较术前改善4例、不变10例、减退11例,丧失7例;术后9例无后组脑神经症状,11例出现暂时性麻痹,12例出现永久性麻痹但1～3个月后10例代偿,2例未代偿。结论采用不同手术进路切除颈静脉孔区肿瘤可以达到肿瘤切除的同时最大限度保存功能,维持可接受的生活质量,手术技术及熟悉术后并发症的处理为重要因素。

Objective To evaluate the various surgical approaches in removing the jugular foramen region tumors in order to obtain the maximal functional preservation. Methods Between March 1993 and May 2005, 32 patients with jugular foramen region tumors were operated. The mastoid and neck approach, the infratemporal fossa approach with and without rerouting the facial nerve, the combined transcochlear and infratemporal fossa approach were respectively used according to the tumor type, size, auditory, facial and lower cranial nerve functions. The cranial nerve monitoring was used and a postoperative CT or MRI scanning was taken in all cases. Results In this series of 32 patients, 13 were paragangliomas, 10 schwannomas,2 meningiomas, 2 giant cell tumors, 1 chondrosarcoma, 1 mucochondrosarcoma, 1 adenoid cystic carcinoma, 1 rhabdomyosarcoma and 1 case cholestieral Granuloma. The follow-up period was 3-60 months. Total removals were achieved in 26 cases, near-total removal in 5 cases, and subtotal removal in one case. One patient died after surgery because of intracranial hemorrhage. Another patient died two year after operation because of recurrence. Postoperative cerebrospinal fluid leakage was occurred in 5 cases and meningitis in two cases. They were all treated conservatively. The facial function one week after operation was grade 1-2 in 13 cases, grade 3-4 in 12 cases and grade 5-6 in 7 cases. It changed into grade 1-2 in 23 cases, grade 3-4 in 7 cases and grade 5-6 in 2 cases. The postoperative hearing was improved in 4 cases, stable in 10 cases, deteriorated in 11 cases and totally lost in 7 cases. The lower cranial nerve function was normal in 9 cases, transient palsy in 11 cases, permanent paralysis with compensation in 10 cases and without compensation in 2 cases. Conclusion The jugular foramen region tumor could be removed with maximal function preservation by using various surgical approaches. The postoperative life quality was acceptable in most cases. Surgical techniques and postoperative complications management were fundamental in achieving a good result.