颞骨岩部胆脂瘤切除术及面神经保护和修复

Protection and Repair of Facial Nerve during Resection of Petrous Bone Cholesteatoma

目的分析总结颞骨岩部胆脂瘤的外科治疗、术中面神经功能的保护及修复方法及疗效。方法回顾性分析解放军总医院2000年1月至2012年12月79例手术治疗的颞骨岩部胆脂瘤病例,按House-Brackmann法对面神经功能进行分级,根据术中探查所见,依据面神经损伤的部位和范围分别采用面神经减压、吻合、耳大神经移植、面神经-舌下神经吻合术等方法进行修复;随诊1年以上,资料齐全的48例患者,根据手术前后面神经功能的分级进行比较,分析治疗效果。结果 79例岩部胆脂瘤患者经过手术切除病灶,术中发现面神经受累部位以迷路段最为多见。面神经损伤修复方法:面神经减压48例(60.76%);面神经端端吻合5例(6.33%);面神经改道吻合3例(3.80%);耳大神经移植修复面神经3例(3.80%);面神经舌下神经吻合10例(12.66%)。剩余10例术中面神经未处理。随访1年以上,资料完整的48例患者预后:面神经减压:29例,术前面神经功能Ⅰ级13例,Ⅱ级1例,Ⅲ级7例,Ⅳ级2例,Ⅴ级4例,Ⅵ级2例;术后Ⅰ级22例,Ⅱ级2例,Ⅲ级1例,Ⅳ级3例,Ⅴ级1例。端端吻合:4例;术前Ⅰ级1例,Ⅴ级3例;术后Ⅱ级1例,Ⅲ级3例。改道吻合:3例;术前Ⅴ级1例,Ⅵ级2例;术后:Ⅲ级2例,Ⅳ级1例。耳大神经移植:2例;术前均为Ⅴ级;术后:Ⅳ级1例,Ⅴ级1例。面神经舌下神经吻合术:7例;术前Ⅴ级4例,Ⅵ级3例;术后:Ⅲ级1例,Ⅳ级4例,Ⅴ级2例。3例术中未处理面神经病例,面神经功能无变化。结论颞骨岩部胆脂瘤术中需仔细保护面神经,发现面神经损伤后应及时修复,依据损伤程度和范围的不同,采取不同的修复方式可以使患者获得较好的预后效果。

Objective To discuss issues of facial nerve protection during surgery and recovery of facial nerve function after surgery. Methods This was a retrospective study on 79 cases treated for petrous bone cholesteatoma from 1/1/00 to 31/12/12 by PLA General Hospital otolaryngologists. Facial nerve decompression, primary end-to-end anastomosis, great auricu-lar nerve grafting or facial-hypoglossal anastomosis were adopted for restoration of facial nerve function. Facial nerve func-tion was assessed according to House-Brackmann（H-B） Grade. Results The most common location of facial nerve injury was in the labyrinth segment. Facial nerve re-animation methods included facial nerve decompression （n=48）, end-to-end anas-tomosis （n=5）, rerouting （n=3）, greatre auricular nerve grafting （n=3）, facial-hypoglossal nerve anastomosis （n=10）, and others （n=10）. The facial nerve function was assessed before and after surgery. 48 patients were followed up more than 1 year.Among them,29 patients underwent facial nerve decompression , 22 recovered to H-B I, 2 recovered to H-BⅡ,1 re-covered to H-BⅢ,3 recovered to H-BⅣ, and 1 recovered toⅤ. Of the 4 patients who underwent end-to-end anastomosis, 1 recovered to H-BⅡand 3 recovered to H-BⅢ. Of the 3 patients who underwent facial nerve rerouting, 2 recovered to H-BⅢ,and 1 recovered to H-BⅣ. Of the 2 patients treated with greater auricular nerve grafts, 1 recovered to GradeⅣ, and 1 recovered to Grade Ⅴ. Of the 7 patients receiving facial-hypoglossal nerve anastomosis treatment, 1 recovered to GradeⅢ,4 recovered to GradeⅣ,and 2 recovered to GradeⅤ. Facial function remained unchanged in the 3 cases with no treatment. Conclusions During petrous bone cholesteatoma surgeries, surgeons should protect the facial nerve carefully. When facial nerve injury is noticed, various methods can be used for immediate repair.