颅底咽旁间隙肿瘤的CT、MRI影像学特征及手术入路的选择

发布时间：2018-01-18 09:45

本文关键词：颅底咽旁间隙肿瘤的CT、MRI影像学特征及手术入路的选择　出处：《安徽医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的探讨颅底咽旁间隙肿瘤的CT、MRI影像学特征,为选择不同的手术入路提供重要依据。方法回顾性分析2002年1月-2014年12月安徽医科大学第一附属医院耳鼻咽喉头颈外科经病理明确诊断的63例颅底咽旁间隙肿瘤的临床资料,观察不同肿瘤的CT、MRI影像学特征(各肿瘤类型的形态、体积、性质、有无包膜、与周围组织的关系及有无转移)并分析讨论手术入路的选择依据。结果本组病例中,良性肿瘤56例,恶性肿瘤7例。神经源性肿瘤31例(49.2%),涎腺源性肿瘤为21例(33.3%)、副神经节瘤4例包括颈动脉体瘤3例(4.8%)和迷走体瘤1例(1.6%)、鼻咽癌颅底咽旁间隙转移4例(6.3%)、扁桃体癌2例(3.2%)、腮腺深叶粘液表皮样癌1例(1.6%)。本组病例中,神经源性肿瘤与涎腺源性肿瘤均位于咽旁间隙,CT扫描多表现为圆形或者类圆形边界清楚、包膜完整的肿块,其中部分涎腺源性肿瘤表现为略呈分叶状,部分肿瘤内部可见坏死囊变区。由于二者CT表现无特征性,术前一般通过在CT或MRI上通过甄别肿瘤病灶与腮腺深叶的关系及颈动脉鞘、二腹肌后腹受肿瘤推压移位情况鉴别诊断。颈动脉体瘤CT或MRI上表现为软组织肿块,边界清楚,形态规则,增强扫描可见明显强化,其特征性改变是颈内外动脉分离,呈高脚杯状改变,MRI上可见瘤体内部丰富的血管流空影,即“胡椒盐征”。7例恶性肿瘤CT或MRI表现为不规则肿物低信号,部分病例合并颈部多发性肿大淋巴结影,可融合,增强扫描可见部分强化,可伴有坏死。本组63例病例均全麻下手术切除,手术入路如下:31例神经源性肿瘤中的6例采用单纯内镜切除;31例神经源性肿瘤中的10例及2例颈动脉体瘤采用颈侧入路,其中6例联合鼻内镜入路;1例迷走体瘤、1例颈内动脉体瘤、1例扁桃体癌及2例巨大涎腺源性肿瘤采用下颌骨外旋入路切除。其他下颌骨不同处理入路切除22例,方式包括下颌骨前上牵拉入路、半侧下颌骨切除入路、下颌骨升支离断再复位入路及下颌骨升支部分切除入路。上颌骨外旋入路切除6例,为神经源性肿瘤4例及伴张口困难的鼻咽癌2例;眶颧入路切除2例,均为侵犯前中颅底的颅底咽旁间隙神经鞘瘤。所有肿瘤均完整切除,颅底咽旁缺损修复根据缺损大小及有无骨质破坏采用胸大肌皮瓣、舌瓣、自体帽状筋膜瓣以及颏下瓣等修复。术后3例出现声音嘶哑;3例发生Horner综合征;2例复发鼻咽癌术后张口困难明显改善。12例气管切开患者的10例于术后半年内拔除气管套管。33例涉及上下颌骨不同入路的患者均未出现明显影响进食的咬合关系错乱。恶性肿瘤术后综合治疗,术后随访2-14年,良性肿瘤未见复发,恶性肿瘤中死亡3例,为扁桃体腺样囊腺癌1例及复发鼻咽癌2例。结论:CT、MRI影像学可提供颅底咽旁间隙肿瘤的一些影像学特征,正确认识并利用影像学提供的这些特征如肿瘤的形态、密度、与周围组织关系、增强扫描后瘤体的强化情况以及瘤体内部情况等特征,对提高颅底咽旁间隙肿瘤的早期诊断和鉴别诊断具有重要意义。术前有效利用和评估这些特征有助于选择合适的手术入路及提高手术效率和安全性,降低手术并发症。
[Abstract]:Objective to investigate the skull base tumors in the parapharyngeal space CT, MRI imaging, for the choice of surgical approach. The method provides an important basis for the retrospective analysis of clinical data of 63 patients with skull base of Otolaryngology Head and neck surgery, January 2002 -2014 year in December in the First Affiliated Hospital of Medical University Of Anhui definite pathological diagnosis of tumors in the parapharyngeal space, observed tumor CT MRI, imaging features (the type of tumor morphology, size, nature, there is no capsule, the relationship with the surrounding tissue and metastasis) and discuss the selection basis of surgical approach. Results in this group of cases, 56 cases of benign tumor, malignant tumor in 7 cases. 31 cases of neurogenic tumor (49.2%), salivary gland tumors in 21 cases (33.3%), including 4 cases of paraganglioma of carotid body tumor in 3 cases (4.8%) and aberrant body tumor in 1 cases (1.6%) of nasopharyngeal carcinoma, skull base parapharyngeal metastasis in 4 cases (6.3%), 2 cases of tonsillar cancer (3.2%), the deep lobe of the parotid gland mucus table 1 cases of dermoid cancer (1.6%). In this group of cases, neurogenic tumors and salivary gland tumors were located in the parapharyngeal space, CT scan showed round or oval clear boundary, encapsulated mass, which showed some salivary neoplasm slightly lobulated, necrotic or cystic part of the tumor inside area. Because the two CT showed no specific features, preoperative general through CT or MRI through the relationship between the carotid sheath and screening tumor lesions and the deep lobe of the parotid gland, two pbdm by shifting the differential diagnosis of carotid body tumor. CT or MRI showed soft tissue mass with clear boundary form, rules, enhanced scan showed obvious enhancement, the characteristic changes of internal carotid and external carotid, a goblet shape change, MRI showed tumor abundant internal flow void vessels, namely "salt and pepper" sign.7 cases of malignant tumors in CT or MRI showed irregular low mass Signal fusion shadow, multiple lymph nodes were combined with the neck, enhanced visible enhancement, accompanied by necrosis. Resection of 63 cases in this group were under general anesthesia surgery, the surgical approach is as follows: 31 cases of neurogenic tumors in 6 cases were treated with endoscopic resection; 31 cases of neurogenic tumors in 10 cases and 2 cases of carotid body tumor by transcervical approach, among which 6 cases were combined with nasal endoscopic approach; 1 cases of aberrant tumor, 1 cases of carotid body tumor, 1 cases of tonsil carcinoma and 2 cases of salivary gland tumors with large mandibular swing approach for resection of mandible in the other. Physical approach resection in 22 cases, including pull into the road before the mandibular distraction, hemimandibular approach, and then reset the fragmented broken mandible ascending approach and mandibular ramus resection approach. The maxillary swing approach for resection in 6 cases, 2 cases of neurogenic tumor and 4 cases with trismus nasopharyngeal carcinoma; orbitozygomatic Approach of resection in 2 cases, both the anterior and middle skull base of skull base invasion of parapharyngeal space neoplasms. All tumors were resected completely, parapharyngeal skull base defect repair according to the defect size and no bone destruction by pectoralis major myocutaneous flap, tongue flap, flap and autologous cap submental flap repair occurred in 3 cases. Hoarseness occurred in 3 cases; Horner syndrome; trismus 2 cases of recurrent nasopharyngeal carcinoma after surgery significantly improved.12 cases of tracheotomy patients in 10 patients within six months after the removal of the tracheal tube.33 cases involving mandible in different way patients showed no obvious effects of occlusal relationship eating disorder. After the resection of malignant tumors in comprehensive treatment. Patients were followed up for 2-14 years, no recurrence of benign tumor, 3 cases died of malignant tumors, 1 cases of tonsil adenoid cystic carcinoma and recurrent nasopharyngeal carcinoma in 2 cases. Conclusion: CT can provide some images of skull base tumors in the parapharyngeal space features of MRI imaging, is To understand and learn these features provide such as tumor morphology, using image density, relationship with surrounding tissue, after enhancement tumor enhancement and tumor internal conditions and other characteristics, it has important significance to improve the early diagnosis and differential diagnosis of basicranial parapharyngeal tumor. Preoperative evaluation and effective use of these features help to choose the appropriate surgical approach and improve the operation efficiency and safety, reduce the complications.

【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.6

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