Infratemporal fossa approach for jugular body tumor resection

Advantages and disadvantages of this operation (1) Advantages: 1 Enter the path width of the labyrinth and the tip of the humerus, and expose the stroke in the entire rock bone of the internal carotid artery; 2 Diversion of the facial nerve is beneficial to the open approach and possible preservation of facial nerve function; 3 Easy control Bleeding from the sinus; 4 may reach the first stage of wound healing and avoid the risk of infection. (2) Disadvantages: The middle ear cavity disappears, resulting in permanent sounding paralysis. Due to facial nerve diversion, causing nerve ischemia, temporary facial paralysis or facial muscle weakness may occur. Surgical features (1) The facial nerve is permanently moved forward. (2) The zygomatic arch is displaced. (3) The tympanic cavity disappears and the eustachian tube is permanently blocked. (4) The external ear canal is closed in a blind bag to avoid the risk of postoperative infection, and may cause the initial healing of the wound in the shortest time. (5) It may protect the inner ear function (the inner ear function is intact before surgery). Treatment of diseases: arteriovenous hemangioma Indication 1. Tumor invasion of the labyrinth zone and rock cone: C1 tumor invades the jugular vein bone and jugular bulb; C2 carotid artery vertical segment destruction; C3 rock cone and carotid artery horizontal segment destruction. 2. Tumor invasion into the skull <2cm. 3. Tumor invasion into the skull > 2cm, can cooperate with brain surgery and maxillofacial surgeons to complete the operation, but take a greater risk. Contraindications 1. Tumor invading the brain > 2cm, invasive brainstem and other important parts, no good surgical conditions, when the blood source is insufficient. 2. Invasion of intracranial tumors, rapid development after radiotherapy. 3. The general condition cannot tolerate prolonged surgery, or older people (>70 years old). 4. It is estimated that there are no postoperative complications and no rescue conditions. Preoperative preparation 1. Learn more about the condition, with typical symptoms and signs. 2. X-ray film, tomography, CT examination, MRI examination, digital subtraction angiography, to determine the tumor location, size, invasion and destruction range and blood supply. 3. Co-disciplinary consultation with members of the surgical department and nurses, blood bank personnel, anesthesiologists, etc. to discuss surgical procedures, anesthesia and resuscitation, blood transfusion and blood supply preparation, team members of the surgery, command, supply security, etc. . 4. General anesthesia, routine preparation (blood, urine, stool), liver, kidney function, cardiopulmonary examination, etc. 5. Carotid artery compression training for one and a half months, until each time of compression for half an hour without adverse reactions. 6. Apply antibiotics 3 days before surgery. 7. Prepare blood 2000 to 10000ml according to different conditions. 8. 1d hair shaved before surgery, local disinfection dressing. 9. 2 days before surgery, it is possible to perform superselective vascular embolization in digital subtraction angiography to reduce intraoperative bleeding, and provide good conditions for rapid resection of the tumor. Surgical procedure Incision The head and neck behind the ear are combined with a large S-shaped incision, which is 5 cm above the auricle tip and down to the plane of the tongue. 2. Flap Flip the flap forward on the diaphragm surface. A muscle periosteal flap is cut out from the surface of the mastoid, and the external auditory canal is completely traversed inside the flap. After the musculoskeletal flap is turned forward and moved into the external auditory canal, the inner end of the external auditory canal is closed, so that the external auditory canal becomes a blind tube. 3. Exposure of large blood vessels and nerves in the neck The jugular vein of the sternocleidomastoid along the neck incision is firstly ligated and cut, and then the carotid sheath is found deep in the neck, and the common carotid artery, the external jugular artery and the internal carotid artery and the internal jugular vein are separated. The IX, X, XI, and XII cranial nerves were separated, and the posterior parotid gland was separated, and the facial nerve stem was separated into the parotid gland. The external carotid artery (ligated on the superior thyroid artery) and its branches were ligated, and the sternum was cut. The mastoid muscle and the second abdominal muscle. Protect large blood vessels and cranial nerves. 4. The electric drill grinds off the outer wall of the mastoid, the mastoid cavity is contoured, and the outer semicircular canal and the posterior semicircular canal, the anterior sigmoid sinus and the facial tympanic cavity and the mastoid segmental canal are clearly seen, from the knee ganglion to the stem cavity The 1/2 circumference of the facial nerve tube reveals the facial nerve, and the tumor range is clearly defined. Then the sigmoid sinus plate is removed to expose the meninges 2 to 3 mm, the meninges are cut open, the sigmoid sinus is ligated, and the small bones are removed. 5. Facial nerve displacement and ligation of the internal jugular vein; a bone groove is made in the anterior tympanic cavity and the gingival root to displace the facial nerve into the bone groove. After ligation of the internal jugular vein, the jugular vein was dissected to determine the extent of the tumor. At the same time, carefully open the internal carotid artery with an electric drill and protect it. 6. Remove the tumor and try to avoid touching it before removing the tumor, otherwise it will cause serious bleeding. After determining the extent of the tumor, the tumor was electrocoagulated and the tumor was removed, along with part of the jugular bulb. The rock surface was polished with diamonds to reveal normal bone. The sinus ostium of the rock is filled with muscle mass to stop bleeding. In the process of removing the tumor, the internal carotid artery should be protected. Do not damage, and the cranial nerve should be protected. 7. Remove the tumor that invades the skull. If the tumor invades the skull, the sigmoid sinus part and the pyramid part should be removed. At the same time, the meninges adhering to the tumor should be removed. After the removal, the dural suture and repair should be performed. The sacral muscle flap and the thoracic cavity should be used. The locking mastoid muscle flap is filled and sutured. In the operation, if the facial nerve is surrounded by the tumor, the facial nerve cannot be separated, and it should be removed together with the tumor. If there are conditions, facial nerve transplantation should be performed. Unconditional one can make the proximal end of the hypoglossal nerve and the distal end of the facial nerve anastomosis. 8. Suture the incision layer to suture the subcutaneous tissue and skin, place the silicone tube drainage strip in the operation cavity, and pressurize the dressing. complication 1. The main complications are basically the same as "sacral resection", which may include wound bleeding, meningitis, intracranial hematoma, cerebral edema, cerebrospinal fluid leakage and pneumonia. Temporary and permanent peripheral facial paralysis and transsexual paralysis or sensorineural hearing loss or dizziness can occur. 2. Ingestion difficulties, hoarseness and cough. The reason is that the IX and X brain nerves may be damaged during the operation, causing pharyngeal muscles and vocal cord paralysis. It usually lasts for 3 to 6 weeks after it occurs. 3. If the internal carotid artery is damaged during operation, the internal carotid artery ligation is performed. If the carotid artery is not trained for 1.5 months, the hemiplegia after ligation can occur, the incidence can be as high as 45% to 50%, and the mortality rate is up to 4 % to 7%.