内镜经唇下上颌窦入路切除侧颅底肿瘤的临床应用研究

发布时间：2018-01-27 00:22

本文关键词： 颅底内镜侧颅底肿瘤唇下上颌窦入路　出处：《北京协和医学院》2017年硕士论文　论文类型：学位论文

【摘要】：目的随着手术技术的不断提高和辅助设备的日益完善,内镜手术作为切除颅底中线区肿瘤的重要手段已获得广泛认可。不仅如此,颅底内镜手术范围现正在向侧颅底延伸,但目前还仅局限于经鼻入路,而鼻腔结构毁损严重、并发症繁多以及侧颅底外侧区显露受限等是这一入路致命的缺点。结合基础解剖研究和临床实践探索,我们尝试应用经唇下上颌窦入路内镜手术切除侧颅底肿瘤,探讨该入路个性化的手术适应证、手术方法、利弊得失及其可能的拓展、演变,以期规避上述缺点。方法2014年10月至2016年12月间,尝试经唇下上颌窦入路内镜手术切除9例侧颅底肿瘤,统计每例手术上颌窦前壁开窗面积、术中出血量、病灶切除率、手术时间、并发症、随访效果,并对每一例手术计划的个性化设计剪裁、具体手术操作的要点、调适以及该入路可能的联合策略及其拓展演变逐一进行探讨。结果所有病例一般状况良好,KPS评分70分以上。所有病例肿瘤均累及翼腭窝,侵及颞下窝5例,侵入颅内中颅窝底4例。上颌窦开窗面积2.5×1.5cm2-3×2.5cm2,平均5.11cm2。瘤体体积为4.14—182.7cm3,平均54.2cm3。MRI增强扫描:除1例囊性肿物外,所有病例肿瘤明显强化,提示血供丰富,与术中所见基本相符。手术时间80—428min,平均210min;出血量100-2500ml,平均717ml;除1例非何杰金氏淋巴瘤因包裹颈内动脉、海绵窦内多组颅神经而予近全切除外,其余病例术程顺利。术后影像学复查显示:8例肿瘤全切,1例近全切;病理:神经鞘瘤5例,恶性神经纤维性肿瘤1例,表皮样囊肿1例,非霍奇金淋巴瘤1例,脊索瘤1例。随访3-26个月,平均9.7个月,无复发与死亡病例,所有患者均有不同程度的术侧面部麻木。结论相较经鼻入路,经唇下上颌窦前壁入路内镜手术暴露侧颅底翼腭窝、颞下窝肿瘤路径最短、角度更直接、操作更灵便,稍加拓展便可显著增加外侧颞下窝的术野显露和操作空间,且完全避免了鼻内并发症,不失为侧颅底肿瘤内镜治疗较为理想的手术入路;若再巧妙联合经典的经鼻入路,则几可实现全颅底肿瘤内镜手术全覆盖。
[Abstract]:Objective with the continuous improvement of surgical techniques and the improvement of auxiliary equipment, endoscopic surgery as an important means of removing tumors in the midline of the skull base has been widely recognized. Endoscopic skull base surgery is extending to the lateral skull base, but at present it is limited to transnasal approach, and the nasal cavity structure is severely damaged. Multiple complications and limited exposure of the lateral base of the skull are fatal shortcomings of this approach. Combined with basic anatomical research and clinical practice exploration. We try to use translabial maxillary sinus endoscope to remove lateral skull base tumor, and discuss the indication, operative method, advantages and disadvantages, possible expansion and evolution of this approach. Methods from October 2014 to December 2016, 9 cases of lateral skull base tumors were resected by endoscope through sublabial maxillary sinus, and the area of fenestration of anterior wall of maxillary sinus was counted. Intraoperative bleeding volume, focal resection rate, operative time, complications, follow-up results, and for each case of personalized design of the operation plan tailoring, the key points of the specific operation. The adjustment and the possible joint strategy and the development of the approach were discussed one by one. Results all cases were in good condition and KPS score was more than 70. The pterygopalatine fossa was involved in all cases. There were 5 cases of infratemporal fossa and 4 cases of infratemporal fossa. The fenestration area of maxillary sinus was 2.5 脳 1.5 cm ~ (-3) 脳 2.5 cm ~ (2). The mean volume of tumor was 4.14-182.7cm ~ (-3), the average value was 54.2 cm ~ (3). MRI enhanced scan: all the tumors except one cystic tumor were obviously enhanced. The results showed that the blood supply was abundant, which was consistent with the intraoperative findings. The operative time was 80-428 mins with an average of 210 mins. The blood loss was 100-2500ml (mean 717ml); Except for one case of non-Hodgkin 's lymphoma which was wrapped in the internal carotid artery, except for multiple groups of cranial nerves in cavernous sinus, the procedure of operation was smooth. Pathology: schwannoma in 5 cases, malignant nerve fiber tumor in 1 case, epidermoid cyst in 1 case, non-Hodgkin 's lymphoma in 1 case, chordoma in 1 case. There was no recurrence or death, all patients had different degrees of lateral numbness. Conclusion compared with the nasal approach, the lateral pterygopalatine fossa was exposed by endoscope through the anterior wall of the maxillary sinus under the lip, and the tumor path of the subtemporal fossa was the shortest. Angle is more direct, easy to operate, a little expansion can significantly increase the lateral infratemporal fossa of the surgical field exposure and operation space, and completely avoid intranasal complications. It is an ideal approach for endoscopic treatment of lateral skull base tumors. If combined with classical transnasal approach skillfully, the whole skull base tumor can be completely covered by endoscopic surgery.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.4

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