Middle cranial fossa-infratemporal fossa tumor resection

Tumors in the middle cranial fossa (meningioma, neurofibromatosis, epithelioid cysts, etc.) can penetrate the infraorbital fossa through the skull base. Conversely, tumors of the infraorbital fossa (hemangioma, lymphangioma, schwannomas, angiofibroma, sarcoma, nasopharyngeal carcinoma, etc.) can also invade the cranial fossa. For benign tumors, the intracranial or extracranial approach should be used as soon as possible according to the location of the main body of the tumor. For malignant tumors, although some people advocate surgery only when the tumor is completely resected, most scholars still advocate early surgery in view of the following conditions: 1 In addition to nasopharyngeal carcinoma and lymphosarcoma, the malignant tumors in this region do not have radiotherapy. sensitive. 2 Even if the tumor cannot be cured completely, surgery may alleviate the patient's pain. 3 Only after surgery can you determine whether the tumor can be eradicated. Tumors in the infraorbital fossa are difficult to expose due to their deep location. Some of them belong to the surgical category of maxillofacial surgery. However, in recent years, with the rapid development of skull base surgery, domestic and foreign neurosurgeons have independently or cooperated with relevant departments, and the reports of successful removal of tumors in the cranial fossa-infratemporal fossa (sometimes involving the pterygopalatine fossa) are increasing. Continuous improvement. Treatment of diseases: neurofibromatoma meningioma Indication 1. The tumor is mainly located in the middle cranial fossa and is located in the dura mater. It can be removed through the subdural subdural approach. The medial tumor of the middle cranial fossa can take the frontal orbital approach, although it is not in the cranial fossa. The dura mater can be treated by the subdural approach. 2. There are many surgical approaches to the infratemporal fossa tumor, which can be selected according to the origin, nature, size and surrounding structure of the tumor. Maxillofacial surgeons often use warp, warp, wart- combined, warp, transanal wall, mandibular, transmaxillary sinus approach, etc., mainly in the inferior fossa and involving the midbrain For tumors, neurosurgeons use the infraorbital-anterior inferior orbital approach or intracranial and extracranial approach. 3. At the same time, the communication between the intracranial fossa and the infraorbital fossa is involved. If the intracranial and extracranial parts of the tumor are equivalent and larger, they can be resected through the intracranial or extracranial combined approach, if the main body of the tumor is in the skull. The fossa can also be removed from the intracranial part of the tumor by the underarm, and the tumor protruding into the infraorbital fossa can be separated and removed through the bone hole which is destroyed or enlarged by the skull base. Conversely, if the main body of the tumor is in the infraorbital fossa, the extracranial After the part of the tumor is excised, the portion that has grown into the skull is separated and removed through the bone hole of the skull base. Contraindications 1. A wide range of metastases that cannot be removed from the primary lesion, or a malignant tumor that originated in the infraorbital fossa but has distant metastasis is not suitable for surgery. 2. Imaging examination confirmed that the internal carotid artery was seriously violated by the tumor, the operation should be cautious; if surgery, should be fully prepared before surgery. Preoperative preparation 1. When the nature of the tumor is difficult to determine, a needle biopsy should be performed to determine whether the surgery and surgical plan. 2. If the tumor is huge and the blood supply is rich, preoperative embolization should be performed. 3. Intraoperative internal carotid artery may be damaged. It is advisable to perform carotid artery balloon occlusion test and cerebral blood flow measurement before operation. Surgical procedure 1. Excision of the cranial fossa and cerebellar incision area tumor by subdural subdural approach (1) Flap and bone flap: supine position, the affected side shoulder is raised, and the head is rotated 45° to the opposite side. It can also be used in the lateral position. The ankle (or frontal) flap and bone flap were routinely performed, and the lower part of the scale was removed until the bottom of the skull. If the tumor is in the front of the cranial fossa, the outside of the sphenoid ridge is half-ground. (2) Exposure, removal of the tumor: incision of the dura mater. The lateral fissure is separated under the microscope, and the forehead and temporal lobe are retracted with a self-sustaining retractor to reveal the tumor in the anterior middle portion of the cranial fossa. If the tumor is located in the posterior part of the cranial fossa, it is advisable to gradually lift the temporal lobe from the outside to the inside, taking care not to tear the Labbé vein. After the temporal lobe is lifted, the tumor outside the cranial fossa can be revealed. The tumor capsule is electrocoagulated to cause it to shrink, and then the basal part of the tumor is cut off by electrocoagulation, and the intracapsular resection is performed. After most of the tumor tissue was resected and the tumor collapsed, the residual tumor and its capsule were finally separated and removed. If the tumor is located inside the middle fossa, the Labbé vein can be freed from 1 to 1.5 cm to facilitate further elevation of the temporal lobe. If the uplift is still insufficient, the inferior temporal gyrus and the middle iliac crest before the vein can be removed, so that the medial-cerebral incision area of the middle cranial fossa and the tumor located there are well exposed. The tumor resection method is the same as above. However, it should be noted that the anterior choroidal artery, posterior communicating artery, basilar artery, posterior cerebral artery and superior cerebellar artery and their branches, as well as oculomotor, trochlear and abductor nerves, are often squeezed inward and forward by the tumor. Or the rear, when separating and removing the tumor, pay attention to identification and protection. When separating the inner side of the tumor, it is important to pay attention not to hurt the brain stem. Tumors in the medial-cranial region of the cranial fossa often grow posteriorly to the cerebellopontine angle, or grow inward and downward to the slope. Therefore, after the tumor in the middle fossa is removed, the cerebellum should be cut (or partially removed), and if necessary, the sinus on the rock should be cut off, the tip of the rock removed, and the tumor under the curtain should be removed. The range of rock tip removal: the front boundary is the Meckel cavity dura mater, the posterior boundary is the anterior wall of the internal auditory canal, and the lateral boundary is the inner wall of the carotid artery. (3) Guan skull: surgery with the general ankle (or frontotemporal). 2. Excision of the cranial fossa tumor via the subdural approach (1) Flap and bone flap: The position, the flap and the method of forming the bone flap are the same as the subdural approach. (2) Excision of the tumor: The dura mater is isolated and lifted to reveal the cranial fossa from the sphenoid wing to the posterior edge of the pyramid and the tumor located outside the epidural. If the tumor is located in the anterior part of the cranial fossa, the bone flap should be in front of the frontal (frontal sacral flap). After lifting and lifting the dura mater, the sphenoid ridge is removed and the tumor is removed. When the inner dura mater of the middle cranial fossa is separated, it is restricted by the nerves and blood vessels that pass through the supracondylar fissure, round hole, foramen ovale and spinous hole. Except for the middle meningeal artery, other cranial nerves are not affected by the tumor, and the function is still good. Should not be disconnected. However, if the cranial nerve has been invaded by the tumor, the function has been lost. In order to facilitate the exposure and removal of the tumor, it can also be disconnected. After the tumor is revealed, it can be removed by block. If a part of the tumor has protruded into the infraorbital fossa and/or pterygopalatine fossa, the part of the tumor can be removed by a broken hole (eg, smaller, expandable). It is also possible to remove the sphenoid wing and expose the infraorbital fossa, remove the sphenoid wing and open the outer edge of the supracondylar and inferior iliac crest into the pterygopalatine fossa, and remove the tumor that protrudes into these areas. (3) Guan Guan: Same as above. 3. Excision of the medial tumor of the middle cranial fossa via the frontotemporal subdural approach Although the traditional infraorbital (or external) approach of the underarm is still widely used in the removal of intracranial fossa tumors, it is often not satisfactory to remove the medial tumor of the middle fossa, even if the lumbar perforating tube is discharged and over-exchanged. After the gas, it is still quite difficult to lift the leaves. To this end, many scholars have suggested that the humerus and the zygomatic arch should be temporarily removed during the craniotomy, and some of the gingival margins will be removed (the frontal approach). Here, the frontal approach is introduced. This approach can be used to remove the medial aspect of the cranial fossa and the anterior tumor of the cerebellar incision area. It is also suitable for cavernous sinus and intertrochanteric fossa tumors. (1) Flap: side lying, with the head frame fixed to the head over 40 °, and tilted to the opposite side of the lesion 35 °. The surgical bed is then raised to bring the ankle to a horizontal position. A coronal scalp incision was made, starting from the anterior fascia of the diseased side and up to 2 cm on the contralateral zygomatic arch. The scalp is turned forward along with the fascia and frontal periosteum to reveal the upper edge of the ankle and the outer edge of the ankle. The supraorbital artery and nerve are freed from the upper incision (hole), and the periosteum is separated from the dome and the posterior lateral wall. (2) Frontal iliac bone flap: After the periosteum is cut, the zygomatic arch is revealed under the periosteum. Four holes were drilled in the skull, which were located at the outer side of the frontal bone after the 1 tibia frontal process; 2 the humerus above the iliac crest; 3 cm of the coronal suture above the iliac crest; and 4 cm of the frontal bone above the upper edge of the iliac crest. Saw the broken arch. Saw the 2-3 holes, 3-4 holes, 4 holes - the skull between the upper edges of the iliac crest. A 5 mm wide osteotome was inserted into the bone sawing slit of the upper edge of the iliac crest, at an angle of 45° to the sagittal plane, and the dome was drilled to the posterolateral side by about 2 cm. Then, it is cut inward through a hole, and merges with the above-mentioned dome-opening line. In order to cut the lateral wall of the iliac crest, the iliac crest is opened by vertically digging down through a hole to the inferior iliac crest, and then obliquely from the outer lower corner of the eyelid to the inferior iliac cleft. Finally, the skull was broken between the 1-2 holes, and the frontal iliac bone flap was turned back and down together with the diaphragm. Use the self-sustaining retractor to reinforce the periosteum and dura mater, and use a saw or a small osteotome to cut the anterior and lateral part of the sphenoidal wing and the middle cranial fossa and the posterior part of the cleft of the upper cleft. ) Take it off. The inner side of part of the sphenoid winglet is removed by high speed drilling. (3) Excision of the tumor: the dura mater is cut, and the tumor is removed by lateral fissure or underarm. Whether taking the lateral fissure or the underarm approach, it is only a short distance to reach the inside of the middle cranial fossa, the saddle and the intervertebral fossa. If you want to reach the intertrochanteric fossa, you can separate the lateral fissures widely, pay attention to protect the bungee veins of the bungee, and then pull back the hook, the distal end of the internal carotid artery and the proximal middle cerebral artery are slightly lifted, and the oculomotor nerve moves backward. Next, the Liliquist membrane was cut inside the nerve and the tumor in the intertrochanteric fossa (or the basilar artery bifurcation aneurysm) was obliquely exposed from below. (4) Guan skull: The anterior and lateral parts of the sphenoidal wing and the middle cranial fossa and the posterior part of the dome are removed and fixed, and the frontal iliac bone flap is fixed and fixed, and the scalp is finally sutured. 4. Inferior tibiofibular approach for the treatment of infraorbital fossa tumor and inferior fossa-cranial fossa communication (1) Incision: The skin incision starts from the frontal part of the forehead, and the posterior aspect of the auricle is extended to the anterior border of the sternocleidomastoid muscle. After cutting the skin and subcutaneous tissue, if the diaphragm is intact, the diaphragm will be turned forward with the flap after being disconnected from the condyle, so as not to damage the facial nerve branch. If the diaphragm has been invaded by the tumor, it should be removed together with the tumor. (2) Dislocation of the zygomatic arch: The zygomatic arch is removed from the anterior and posterior roots, and the masseter muscle is freed from the outside of the mandibular branch. (3) Mandibular retraction or resection: If the exposure is unsatisfactory, the parotid gland can be pulled to the back or removed (note that the facial nerve branch is preserved). The temporomandibular joint capsule was dissected, and the condyle was pulled outward and downward with a retractor. If the tumor is large, the mandible is still insufficient after the lower mandible. The posterior margin of the mandibular and mandibular branches can be removed, and the mandible can be temporarily removed. (4) Separation and resection of the tumor: After the tumor is exposed, it is divided into blocks or whole pieces according to the specific conditions. If some tumors invade the skull, they can be removed by the skull base defect and then removed, or enter the intracranial resection through the lower ankle bone window. (5) reconstruction and suture: the skull base dural rupture or defect, should be repaired. The mandible was restored and the temporomandibular joint capsule was sutured. For temporary mandibular disconnection, fix it with steel wire or steel plate. The zygomatic arch is reset and secured with a wire. The final layer sutures the soft tissue and skin. 5. Intracranial and extracranial combined approach for resection of the cranial fossa - inferior fossa That is, combined with the subtalar approach and the infraorbital-anterior inferior orbital approach, the intracranial and extracranial portions of the tumor were removed in one stage or in stages. complication 1. sacral laceration Due to excessive lifting of the leaves. 2. Cranial nerve injury Including the damage of the trochlear nerve, the oculomotor nerve, the trigeminal nerve and its branches. 3. Opening mouth and chewing difficulties During the operation, the temporomandibular joint capsule was opened, and the condylar process or the mandible was temporarily dissected. It may be difficult to open the mouth and chew in the early postoperative period.

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