Temporal bone tumor resection

Primary malignant tumors of the ear and tibia are rare, accounting for about 1/20000 of otologic patients. According to clinical manifestations and treatment methods, they can be divided into two groups: 1 tumors confined to the ear or only the external auditory canal. 2 Invade the tumor of the middle ear and mastoid. The former is usually partially removed from the otolaryngology department. Squamous cell carcinoma is the most common in this group of tumors, accounting for 60%, sarcoma (mainly rhabdomyosarcoma in childhood) accounting for 12%, adenocarcinoma accounting for 11%, and other basal cell carcinoma, malignant paraganglioma and melanoma. . The treatment of middle ear and mastoid malignancies is quite tricky and the prognosis is poor. However, because there is no other more effective method than surgical resection, the radiotherapy effect is not certain, and it is very difficult to obtain sufficient dose of radiation for tumors growing in the dense tibia without causing complications. Patients should still seek surgical treatment. It has been reported that the 5-year survival rate of patients with middle ear and mastoid malignancies after radical resection of the tibia can reach 27%. Since the 1950s, many authors have continued to improve the technique of radical patella resection based on the work of Campbell (1951), Parsons, and Lewis (1954), making it the primary treatment for malignant tumors of the tibia. At present, the commonly used patella resection does not include the rock tip, so it is actually a subtotal resection. Hilding and Selker also cut the rock tips together. Graham et al. even included the internal carotid artery within the scope of resection. Treatment of diseases: temporal lobe tumor Indication 1. The middle ear and mastoid malignant tumors that may be removed should be treated with radical humeral resection. 2. Patients with local lymph node metastasis, plus radical resection of the neck. Contraindications 1. The tumor has a wide range or extends inward to invade the midline structure of the skull base. 2. There has been a distant transfer. 3. The tumor is associated with severe local infection. Preoperative preparation 1. Carefully analyze the patient's clinical and imaging (CT, MRI, DSA, etc.) data to understand the exact extent of the tumor and its relationship with adjacent structures, and pay attention to the patency of the cerebral artery ring and the contralateral sigmoid sinus. 2. Patients with squamous cell carcinoma and adenocarcinoma are often accompanied by local chronic infection. They should be treated before surgery, do bacterial culture and drug sensitivity test, and preventive application of sensitive antibiotics before and during surgery. 3. Lumbar puncture is placed in the tube so that the cerebrospinal fluid can be drained during the operation. 4. Prepare the skin on the thigh or abdominal wall so that the skin can be skinned if necessary. 5. Regarding preoperative radiotherapy, opinions differ. Some people think that it can prevent intraoperative tumor cell planting; others think it may cause some complications. Generally not used. Surgical procedure 1. Radical humeral resection (1) Incision: It is in the shape of "C", starting from the temporal region, extending back and forth around the auricle, and then going forward along the neck. After cutting the skin, it is separated forward under the skin. If the tumor is in the deep or middle ear of the external auditory canal, the auricle can be preserved, but the external auditory canal should be transversely cut as far as possible. The auricle and the flap should be turned forward together, and the inner and outer ends of the external auditory canal should be sutured respectively. If the tumor has affected the superficial part of the external auditory canal, the auricle should be removed together with the tumor, and the skin incision should be corrected accordingly. Separation continued under the skin, revealing the parotid gland, temporomandibular joint, mastoid, and sternocleidomastoid muscle. Take lymph nodes for frozen section examination, such as confirming local metastasis, plus radical resection of the neck. (2) ankle bone flap: the humerus is separated and pulled forward to reveal the scales of the tibia. A hole is drilled in the humerus above the zygomatic arch, and a low-level ankle free bone flap is made through this, and the height is no more than 3 cm. After the appropriate amount of cerebrospinal fluid was released through the lumbar puncture tube, and the mannitol solution was intravenously instilled, the dura mater of the cranial fossa was separated and lifted, and the middle mening artery was cut off by electrocoagulation to reveal the rock bone. If the dura mater has been invaded by the tumor, it should be removed and the defect repaired with fascia. If the dura mater on the inside of the spine is found to be involved, the tumor cannot be completely removed, and surgery should be discontinued. (3) Separation of the masseter muscle area of the parotid gland: the sternocleidomastoid muscle and the second abdominal muscle are cut off at the attachment of the mastoid. Confirm the 9th to 12th cranial nerves, carotid artery and internal jugular vein. The bone on the surface of the sigmoid sinus is removed by high-speed drilling until the jugular foramen. Find the facial nerve and dissect it to the distal end until it is inside the parotid gland. The parotid gland is removed from the shallow and deep leaves, and the facial nerve branches are preserved. The facial nerve is cut off in the proximal side of the trunk. (4) The mandibular condyle resection and the internal carotid artery of the rock segment are exposed: the masseter muscle is removed from the zygomatic arch, and the sacral root is sawn. Cut the temporomandibular joint capsule, expose the condylar neck of the mandible, and traverse it with a micro drill. Be careful not to damage the deep internal maxillary artery. After the condylar resection, the socket is removed and the carotid canal of the eustachian tube and its medial side is revealed. Open the eustachian tube and carotid artery, and separate the vertical part of the internal carotid artery of the rock segment, taking care not to injure the artery. On the outside of the neck, the veins and the veins continue to remove the tibia from the direction of the styloid process. Peel off the muscles on the styloid process and bite the styloid process. (5) Incision in front of the rock bone: return to the bottom of the skull and confirm the arched bulge on the front surface of the rock. The shallow nerve is cut off, the posterior part of the horizontal section of the carotid artery is ground, and the internal carotid artery is completely free. The inner auditory canal was removed, the dura mater of the inner auditory canal was separated, and the seventh and eighth cranial nerves were cut. The rock bone is ground (chiseled) between the inner side of the arcuate bulge and the outer side of the inner auditory canal until it passes through the inner ear. (6) Complete free resection of the humerus: under the base of the skull, between the slightly inner side of the styloid process and the outside of the jugular bulb, with an appropriate wide and narrow osteotome (or micro drill), upward and slightly inward, chiseled (grinding) The rock bone merges with the above-mentioned bone in front of the rock. Use the osteotome to gently pick up the center of the humerus near the inner auditory canal, so that the tibia (together with the tumor) that needs to be removed is completely free and carefully removed. Indicates the condition after the patella resection. (7) Reconstruction and suture: The eustachian tube and the internal auditory canal were closed with bone wax and fascia, respectively. If the dura mater in the middle and posterior fossa is damaged, it should be tightly sutured, and the cavity left behind after the resection of the humerus should be filled with the diaphragm or sternocleidomastoid. The sublingual nerve was cut off as far as possible, and the sublingual nerve-face nerve end anastomosis was performed with 10-0 line. Suture the subcutaneous tissue and skin. If the auricle is removed together with the tumor, the pectoralis major myocutaneous flap can be used to repair the defect; or a reduction can be made in the posterior area of the defect, the skin in the defect area is sutured, and the thick section of the incision is taken to repair the layer. 2. Radical neck resection The carotid artery and internal jugular vein were separated until the base of the skull, and the external carotid artery was ligated. The soft tissue and lymph nodes of the masseter muscle region of the parotid gland were separated and removed. The posterior margin of the zygomatic arch and mandibular branch was removed, and the soft tissue was removed from the infraorbital fossa and parapharyngeal space until the posterior wall of the maxilla, the outer pterygoid, the sphenoidal wing and the cervical vertebral body. complication 1. Internal carotid artery injury is the most serious complication, which may occur when the carotid artery is opened. 2. Hearing loss and facial paralysis are the inevitable consequences of radical patella resection. Although sublingual-face nerve anastomosis is performed, there is still facial paralysis within a considerable period of time after surgery. 3. The cerebrospinal fluid leakage is caused by poor repair of the dura mater in the middle and posterior cranial fossa or poorly blocked eustachian tube and internal auditory canal. 4. Zhangkou and chewing disorders are the results of mandibular condyle resection. 5. Infections include local infections and intracranial infections, which are more common in patients with local infections before surgery.