本文選題：中耳膽脂瘤　切入點(diǎn)：開放式乳突根治術(shù)　出處：《中華耳科學(xué)雜志》2014年03期

【摘要】：目的探討中耳膽脂瘤伴面神經(jīng)受累的臨床特點(diǎn)和診治措施。方法采用回顧性分析方法,對(duì)2004年1月至2013年12月由本文通訊作者主刀完成、隨訪時(shí)間大于6個(gè)月的因中耳膽脂瘤行開放式乳突根治手術(shù)患者的臨床資料進(jìn)行總結(jié),并對(duì)術(shù)中發(fā)現(xiàn)的面神經(jīng)受累情況進(jìn)行分析。入選的90例(92耳,其中雙側(cè)2例)患者中,男性46例,女性44例;左側(cè)44耳,右側(cè)48耳;平均年齡38歲6個(gè)月±13年5個(gè)月,平均隨訪時(shí)間3年5個(gè)月±2年10個(gè)月。所有患者術(shù)前均行顳骨薄層CT(水平位+冠狀位)檢查,部分患者同時(shí)行面神經(jīng)骨管重建。手術(shù)采用開放式乳突根治術(shù)式,術(shù)中探查并記錄從膝狀神經(jīng)節(jié)至乳突垂直段下端面神經(jīng)骨管完整性,同時(shí)對(duì)術(shù)前伴有面癱的患者行面神經(jīng)減壓。術(shù)前術(shù)后均采用House-Brackmann(HB)評(píng)分系統(tǒng)對(duì)患者的面神經(jīng)功能進(jìn)行評(píng)價(jià)。結(jié)果 92耳病例中,27耳(29.3%)在術(shù)中探查時(shí)發(fā)現(xiàn)面神經(jīng)骨管部分破壞或缺失,其中位于膝狀神經(jīng)節(jié)+水平段(G+H)2耳(7.4%),水平段(H)19耳(70.4%),水平段+垂直段(H+V)3耳(11.1%),垂直段(V)3耳(11.1%)。4例(4耳)術(shù)前伴發(fā)面癱,行開放式乳突根治及面神經(jīng)減壓術(shù)后6個(gè)月內(nèi),面神經(jīng)功能逐漸改善。術(shù)前面神經(jīng)功能正常的86例(88耳)中,83例(85耳)術(shù)后面神經(jīng)功能正常;3例(3耳)在術(shù)后4-7d出現(xiàn)逐漸加重的遲發(fā)性輕度面癱,最嚴(yán)重時(shí)達(dá)2-3級(jí),發(fā)現(xiàn)后立即取出松解術(shù)腔填塞的碘仿紗條、予口服激素及維生素B12等對(duì)癥處理,3個(gè)月復(fù)查時(shí)面神經(jīng)功能均完全恢復(fù)正常(HB 1級(jí))。結(jié)論中耳膽脂瘤伴面神經(jīng)受累以水平段面神經(jīng)骨管最為常見,術(shù)前高分辨CT對(duì)于預(yù)判面神經(jīng)骨管完整性具有一定的參考價(jià)值。術(shù)前伴發(fā)面癱時(shí)應(yīng)盡快手術(shù)并同時(shí)行面神經(jīng)減壓術(shù),乳突根治術(shù)腔填塞不宜太緊以避免壓迫裸露的面神經(jīng),術(shù)后如出現(xiàn)即發(fā)或遲發(fā)性面癱應(yīng)立即對(duì)癥處理并根據(jù)病情發(fā)展決定是否行減壓術(shù)。
[Abstract]:Objective to investigate the clinical features, diagnosis and treatment of middle ear cholesteatoma with facial nerve involvement. The clinical data of patients with middle ear cholesteatoma undergoing open mastoidectomy for more than 6 months were summarized, and the facial nerve involvement found during the operation was analyzed. There were 46 males, 44 females, 44 left ears and 48 right ears. The mean age was 38 years, 6 months, 13 years and 5 months, and the mean follow-up time was 3 years, 5 months, 2 years and 10 months. Some of the patients underwent facial nerve bone canal reconstruction at the same time. Open mastoidectomy was performed. The integrity of facial nerve bone canal from the geniculate ganglion to the vertical segment of the mastoid process was explored and recorded during the operation. At the same time, facial nerve decompression was performed in patients with facial palsy before and after operation. House-Brackman 's nerve scoring system was used to evaluate the facial nerve function before and after operation. Results in 92 cases, 27 ears were found to be partially damaged or missing during intraoperative exploration. Among them, 7. 4 ears were located in the horizontal segment of the geniculate ganglia, 70.4 ears were located in the horizontal segment, 3 ears were located in the vertical segment of the horizontal segment and 11. 1% in the vertical segment) and 4 cases had facial palsy before operation. The patients were treated with open mastoidectomy and decompression of the facial nerve within 6 months after operation. The facial nerve function was improved gradually. 83 cases (85 ears) with normal facial nerve function before operation (83 cases with 85 ears) and 3 cases with normal facial nerve function (3 ears) with progressive aggravation of delayed mild facial paralysis at 4 to 7 days after operation, which reached 2-3 grade at the most serious stage. Immediately after discovery, take out the iodoform gauze that is filled in the cavity of the loosening operation. Oral administration of hormone and vitamin B12 showed that the facial nerve function was completely restored to HB1 grade after 3 months reexamination. Conclusion Middle ear cholesteatoma with facial nerve involvement is the most common in horizontal facial nerve bone canal. Preoperative high resolution CT scan has certain reference value for predicting the integrity of bone canal of facial nerve. Surgery and decompression of facial nerve should be performed as soon as possible before operation and radical mastectomy should not be too tight to avoid the compression of the exposed facial nerve. Immediate or delayed facial palsy should be treated immediately and decompression should be performed according to the development of the disease.
【作者單位】： 中國(guó)醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院北京協(xié)和醫(yī)院耳鼻喉頭頸外科;中國(guó)醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院北京協(xié)和醫(yī)院放射科;
【基金】：十二五國(guó)家科技支撐計(jì)劃資助項(xiàng)目課題(項(xiàng)目/課題編2012BAI12B00/2012BAI12B01)
【分類號(hào)】：R764.21;R745.12

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