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Analysis of the Effect of Facial Nerve Processing in the Surgery of Paraganglioma of the Lateral Skull Base Area
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摘要:
目的 总结肿瘤累及颈静脉孔区的侧颅底副神经节瘤切除术中与术后面神经功能相关的操作要点。 方法 回顾性分析2015年8月至2021年1月北京协和医院诊治的累及颈静脉孔区的侧颅底副神经节瘤患者临床资料。根据肿瘤与面神经的关系，术中对面神经进行不同方式的处理。对不同处理方式患者的术后面神经功能进行总结。 结果 共纳入30例累及颈静脉孔区的侧颅底副神经节瘤患者。Fisch分型为C1型3例，C2型6例，C2De1型2例，C2Di1型2例，C3De1型7例，C3Di1型5例，C3Di2型3例，C4De1型1例，C4Di1型1例。术前面神经功能House-Brackmann(HB)分级Ⅰ~Ⅱ级22例，Ⅲ级2例，Ⅳ级3例，Ⅴ级2例，Ⅵ级1例。经术后MRI检查证实，30例患者肿瘤均彻底切除。术后中位随访886 d，均未见复发。肿瘤未触及面神经15例，术中均行面神经前移，其中术后HB分级Ⅰ~Ⅱ级13例，Ⅲ级2例。肿瘤部分粘连面神经2例，术中均成功将面神经与肿瘤分离，其中术后HB分级Ⅰ~Ⅱ级1例，Ⅲ级1例。肿瘤包绕面神经13例，其中1例术中将面神经与肿瘤分离，术后HB分级Ⅲ级；余12例术中均未能将面神经与肿瘤分离，其中3例同期或分期行面神经重建，术后HB分级Ⅰ~Ⅱ级1例，Ⅲ级2例，余9例未行面神经重建，术后HB分级均为Ⅵ级。 结论 对于侧颅底副神经节瘤患者，若病变未累及面神经，单纯对面神经进行游离、移位，对其功能的影响较小；若面神经被肿瘤包绕，则很难将其从肿瘤中分离，术后发生面瘫的可能性较大。 Abstract:Objective To summarize the key points of the operation related to the facial nerve function after surgery of paraganglioma involving the jugular foramen in the lateral skull base. Methods We retrospectively analyzed the clinical data of patients with lateral skull base paraganglioma involving jugular foramen that were diagnosed and treated in Peking Union Medical College Hospital from August 2015 to January 2021. According to the relationship between the tumor and the facial nerve, the facial nerve was treated in different ways during the operation. The postoperative facial nerve function of patients with different treatments is summarized. Results A total of 30 patients with lateral skull base paraganglioma in the jugular foramen area were included. The Fisch classification of these patients was as followed: C1(n=3), C2(n=6), C2De1(n=2), C2Di1(n=2), C3De1(n=7), C3Di1(n=5), C3Di2(n=3), C4De1(n=1), C4Di1(n=1). Preoperative facial nerve function assessed by House-Brackmann (HB) grade: grade Ⅰ-Ⅱ (n=22), grade Ⅲ (n=2), grade Ⅳ (n=3), grade Ⅴ(n=2), grade Ⅵ(n=1). All tumors were completely resected, which was verified by post-operational MRI. No recurrence was observed during the medium follow-up of 886 days. All of the postoperative nerve function refers to the results of the last follow-up. Anterior facial nerve rerouting was performed in 15 cases whose tumor did not invade the facial nerve. The postoperative facial nerve function was HB grade Ⅰ-Ⅱ in 13 cases and HB grade Ⅲ in 2 cases. The tumors were adhesive to the facial nerve in 2 cases. The tumors and the facial nerve were successfully separated in both cases; one achieved HB grade Ⅰ-Ⅱ, while the other was HB grade Ⅰ-Ⅱ postoperatively. In 13 cases, the tumor wrapped the facial nerve. Among those patients, the tumor was separated from the facial nerve in 1 case, with the postoperative facial nerve function of HB grade Ⅲ. In the remaining 12 cases, the facial nerve was resected together with the tumor. Facial nerve reconstruction was performed in 3 cases in the same or the second surgery. The postoperative facial nerve function was HB gradeⅠ-Ⅱ in 1 case and HB grade Ⅲ in the other 2 cases. The postoperative facial nerve function in the remaining 9 cases that did not receive facial nerve reconstruction was HB grade Ⅵ. Conclusions In patients with lateral skull base paraganglioma, anterior facial nerve rerouting has a slight effect on the function of facial nerve, if the tumor does not invade the facial nerve. It is difficult to separate the tumor and the facial nerve, if the facial nerve is wrapped by the tumor, and the rate of postoperative facial nerve paralysis is higher in these cases. -
Key words:
- paraganglioma /
- jugular foramen /
- glomus jugulare tumor /
- lateral skull base /
- facial nerve
作者贡献：张立芹负责撰写论文初稿；赵杨、田旭参与资料收集；高志强、冯国栋负责研究设计及论文审校。利益冲突：无 -
图 2 颈静脉孔区副神经节瘤患者术前及术后影像学资料
A~C.术前颞骨增强MRI示右侧颈静脉孔区大小约3 cm×4 cm占位，强化明显，肿物侵入颅内，硬脑膜移位超过2 cm，侵犯颈静脉球，与右侧小脑、颈内动脉垂直段及水平段关系密切，未至破裂孔，肿瘤分型为C3Di2型；D.术前颞骨增强CT示右侧颈静脉孔区骨质破坏；E~H.术后2年颞骨增强MRI示右侧颈静脉孔区术后改变，术腔可见等信号(术腔填塞脂肪)，未见增强，提示肿瘤未复发，右侧乙状窦、颈静脉球、颈内静脉均未显影(术中见肿瘤侵犯乙状窦、颈静脉球，予结扎乙状窦，切除颈静脉球)，右侧颈内动脉垂直段及水平段显影好
表 1 30例侧颅底副神经节瘤患者术中面神经处理方式及术后面神经功能恢复情况
肿瘤与面神经的关系 处理方式 术前面神经功能HB分级 术后面神经功能HB分级(末次随访时) 术后中位随访时间(d) 肿瘤未触及面神经(n=15) 面神经前移(n=15) Ⅰ~Ⅱ级14例，Ⅲ级1例 Ⅰ~Ⅱ级13例，Ⅲ级2例 1153 肿瘤部分粘连面神经(n=2) 分离肿瘤和面神经(n=2) Ⅰ~Ⅱ级2例 Ⅰ~Ⅱ级1例 679 Ⅵ级1例 309 肿瘤包绕面神经(n=13) 分离肿瘤和面神经(n=1) Ⅰ级1例 Ⅲ级1例 1954 离断面神经，面神经和肿瘤一起切除，未行面神经重建(n=9) Ⅰ~Ⅱ级3例，Ⅲ级1例，
Ⅳ级3例，Ⅴ级1例，Ⅵ
级1例Ⅵ级9例 850 未能将肿瘤与面神经分离，离断面神经，同期或分期行耳大神经-面神经重建(n=3) Ⅴ级1例 Ⅰ~Ⅱ级1例 1150 Ⅰ~Ⅱ级2例 Ⅲ级2例 HB：House-Brackmann 
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