颞下窝入路A型-总论
基本原理
- 通过颞骨次全切和面神经前移来暴露颞骨迷路下和岩尖、下颌窝和颞下窝后部
- 是需要联合应用耳神经外科和头颈外科手术的颅-颞-颈入路
切口及暴露范围
适应证
- 侵及颈静脉孔的肿瘤，主要C和D型颞骨球瘤
- 侵及颈内动脉和岩尖的胆脂瘤
- 起源于舌咽神经至舌下神经的颞骨肿瘤
- 从下方向上侵及颅底病变
禁忌症
- 颈动脉受累
- 颈动脉受累伴大脑侧枝循环不佳者不宜手术
- 对侧迷走神经病变
- 手术会损伤仅有具有功能迷走神经，不宜手术
- 不能完全切除肿瘤
- 神经外科不能完全切除颅内病变为相对禁忌
手术要点
- 耳后-颞-颈皮肤切口
- 盲袋封闭外耳道
- 暴露腮腺内面神经
- 暴露颈部大血管和脑神经
- 颞骨次全切
- 永久性面神经前移
- 结扎乙状窦
- 封闭咽鼓管
- 下颌骨前移
- 暴露颈内动脉
- 暴露颈静脉孔和迷路下间隙
- 脂肪填塞、颞肌瓣封闭中耳腔
并发症
- 感染
- 脑脊液漏
- 脑神经麻痹
- 面瘫
- 组织缺血坏死
- 心血管并发症
- 肺栓塞
- 脑水肿
Sanna M, Zini C, Gamoletti R, et al. Petrous bone cholesteatoma. Skull Base Surg. 1993;3(4):201-213. doi:10.1055/s-2008-1060585
Mario Sanna 《 Microsurgery of Skull Base 》中关于颞下窝A 的描述
This approach is designed to allow access to the JF area, the
infralabyrinthine and apical compartments of the petrous bone, the
vertical segment of the ICA, and the upper jugulocarotid space
SCM sternocleidomastoid muscle
SPCM splenius capitis muscle
LSM levator scapulae muscle
DM posterior belly of the digastric muscle
The approach is designed primarily for extensive extradural lesions involving these areas. The key point in this approach is the anterior transposition of the facial nerve, which provides optimal control of the infralabyrinthine and jugular foramen regions, as well as the vertical portion of the ICA
The other structures that prevent lateral access to these areas are shown:
Besides the facial nerve they include: the tympanic bone, the digastric muscle, and the styloid process.
These structures are removed to allow unhindered lateral access.
An illustration of obstacles to approaching the jugular bulb
《 Microsurgery of Skull Base 》 Mario Sanna Thieme ，2013