中耳胆脂瘤伴面神经受累临床特点分析

Middle Ear Cholesteatoma with Facial Nerve Involvement

目的探讨中耳胆脂瘤伴面神经受累的临床特点和诊治措施。方法采用回顾性分析方法,对2004年1月至2013年12月由本文通讯作者主刀完成、随访时间大于6个月的因中耳胆脂瘤行开放式乳突根治手术患者的临床资料进行总结,并对术中发现的面神经受累情况进行分析。入选的90例(92耳,其中双侧2例)患者中,男性46例,女性44例;左侧44耳,右侧48耳;平均年龄38岁6个月±13年5个月,平均随访时间3年5个月±2年10个月。所有患者术前均行颞骨薄层CT(水平位+冠状位)检查,部分患者同时行面神经骨管重建。手术采用开放式乳突根治术式,术中探查并记录从膝状神经节至乳突垂直段下端面神经骨管完整性,同时对术前伴有面瘫的患者行面神经减压。术前术后均采用House-Brackmann(HB)评分系统对患者的面神经功能进行评价。结果 92耳病例中,27耳(29.3%)在术中探查时发现面神经骨管部分破坏或缺失,其中位于膝状神经节+水平段(G+H)2耳(7.4%),水平段(H)19耳(70.4%),水平段+垂直段(H+V)3耳(11.1%),垂直段(V)3耳(11.1%)。4例(4耳)术前伴发面瘫,行开放式乳突根治及面神经减压术后6个月内,面神经功能逐渐改善。术前面神经功能正常的86例(88耳)中,83例(85耳)术后面神经功能正常;3例(3耳)在术后4-7d出现逐渐加重的迟发性轻度面瘫,最严重时达2-3级,发现后立即取出松解术腔填塞的碘仿纱条、予口服激素及维生素B12等对症处理,3个月复查时面神经功能均完全恢复正常(HB 1级)。结论中耳胆脂瘤伴面神经受累以水平段面神经骨管最为常见,术前高分辨CT对于预判面神经骨管完整性具有一定的参考价值。术前伴发面瘫时应尽快手术并同时行面神经减压术,乳突根治术腔填塞不宜太紧以避免压迫裸露的面神经,术后如出现即发或迟发性面瘫应立即对症处理并根据病情发展决定是否行减压术。

[Astract]Objective To study clinical features and treatment protocols of middle ear cholesteatoma with facial nerve in-volvement. Methods This was a retrospective study of patients with middle ear cholesteatoma who had undergone ca-nal-wall-down mastoidectomy by the corresponding author from January 2004 to December 2013 and with follow-ups of at least 6 months. A total of 90 patients （46 males and 44 females and 92 ears, 44 on left and 48 on right） were included in this study, with a mean age of 38 years 6 months ± 13years 5 months and a mean follow-up time of 3 years 5 months ± 2 years 10 months. Integrity of the fallopian canal was examined from geniculate ganglion to the inferior vertical segment during opera-tion. Simultaneous facial nerve decompression was performed for patients with preoperative facial paralysis. House-Brack-mann （HB） grading system was used for assessment of facial nerve function before and after operation. Results Facial nerve dehiscence or fallopian canal defects were found in 27 of the 92 ears and the most common location was in the tympanic seg-ment. Four of these patients had facial paralysis before operation which recovered gradually after surgery. Three patients had delayed mild facial weakness at 4-7 days after operation. Loosening or removal of iodoform gauzes from mastoid cavity plus ste-roid and vitamin B12 were performed immediately upon detection of facial weakness. Facial nerve functions these three pa-tients recovered gradually to normal in 3 months. Conclusions The most common location of facial nerve involvement in in the tympanic segment in middle ear cholesteatoma. Preoperative HRCT is of great value for correct diagnosis and assessment of fallopian canal integrity. Facial nerve decompression is essential for patients with facial paralysis. Over-tight packing in the mastoid cavity with iodoform gauzes should be avoided for protection of the exposed facial nerve. Immediate treatments for acute or delayed facial paralysis after operation are essential and decompression surgery may be performed when strongly indicated.