颅脑外伤后顽固性脑脊液耳漏的手术策略和技巧研究  

Surgical strategies and techniques in the management of refractory cerebrospinal fluid otorrhea

作　　者：张斌[1] 李峰[1] 张良文[1] 杨扬[1] 朱树干[1] 

机构地区：[1]山东大学齐鲁医院神经外科,山东济南250012

出　　处：《山东大学耳鼻喉眼学报》2015年第6期17-21,共5页Journal of Otolaryngology and Ophthalmology of Shandong University

摘　　要：目的探讨颅脑外伤后顽固性脑脊液耳漏手术治疗的技巧和策略。方法采用颞下中颅底-乳突后联合入路,对11例颅脑外伤后中颅窝底缺损所致脑脊液耳漏且保守治疗无效的患者施行手术修补。结果 1无需行乳突探查5例。因乳突为粉碎性骨折,在取下骨瓣前先行钛板固定2例。另外4例乳突粉碎骨折严重,术中将事先收集的颅骨碎屑回植到乳突缺损内,取头最长肌加生物胶加固;2术中发现有颅底广泛骨质缺损6例,脑组织疝入缺损中或乳突黏膜暴露广泛;3修补探查过程发现听骨链完整者3例,缺失2例,部分听小骨（锤骨）缺失2例,术中未探查听骨链者4例。术后随访2~11年,无复发。结论 1当合并复杂性骨折时,通过幕上幕下联合,经颞下中颅底-乳突后联合入路,无疑是明智的选择,尤其是不稳定骨折累及乳突的患者;2对颅底骨折复杂而听力完全丧失的脑脊液耳漏患者,除了封闭外耳道外,尚需进行鼓室及咽鼓管填塞封闭,以防止假鼻漏的情况发生;3颈内动脉岩段与鼓室及咽鼓管关系密切,脑脊液耳漏修补手术中应避免手术误伤或骨折片意外伤及颈内动脉。Objective To explore the surgical strategies and techniques in the management of refractory cerebrospinal fluid （CSF）otorrhea.Methods Combined subtemporal trasnscranial and transmastoid approach was performed to re-pair the middle cranial fossa defects in 11 patients with posttraumatic CSF otorrhea.Results （1）Mastoid probe was not required in 5 cases.Due to comminuted fractures of mastoid process,2 cases needed titanium plate fixation before the bone flaps were removed.In the other 4 cases with serious mastoid fracture,the pieces were collected and refilled back to the defect,and fixed together with longissimus by biological glue.（2）The brain tissues herniation and/or ex-posed mastoid mucosa via large skull base defects were observed intraoperatively in 6 cases.（3）The ossicular chain was intact in 3 cases,disappeared in 2 cases,and not inspected in 4 cases;the otosteon （malleus）was missed in 2 ca-ses.No recurrence was recorded during the follow-up of 2-11 years.Conclusion （1）A combined supra-infratentorial approach,with an incision incorporating both the middle skull base and mastoid process,is advisable for the manage-ment of CSF otorrhea with complex fractures,especially with unstable fractures involving the mastoid process.（2） Postoperative rhinorrhea could be prevented by tamponade of tympanic cavity,especially,the eustachian tube,in addi-tion to obliteration of the external auditory canal during surgical repair of CSF leaks in patients with complex fractures and hearing loss.（3）Inadvertent injury to petrous segment of the internal carotid artery should be avoided during surgi-cal manipulations near tympanic cavity and eustachian tube.

关 键 词：颅脑外伤 脑脊液耳漏 颅底重建 手术策略 

分 类 号：R765.240.5[医药卫生—耳鼻咽喉科]