Objective To explore better approach of resecting tumoraround the anterior skull base and reconstructing the anterior skull base.Methods In November 2004, a 49-years-old male patient with intracranial recrudescent adenoid cystic carcinoma in the anterior cranial fossa was treated using modified transcranial approach. Neurosurgeon and rhinolaryngologist cooperated to excise the tumour completely, and to reconstruct anterior skull base using the pedicle periosteum temproal musculofascial flap(15 cm×10 cm) andthe pedicle flap of aponeurosis of occipitofron talis muscle and muscular fasciae（10 cm×6 cm）.Results After operation, the wound healed by first intention. Complication, such as infection and cerebrospinal rhinorrhea, did not occur. The patient was discharged 10 days after operation, and was followed up for 8 months, no local recurrence were investigated and no scar formed over the face.Conclusion The modified transcranial approachis a relatively novel exposure that enables the skilled cranial base surgeon tosafely resect many malignant lesions previously and to reconstruct the defect of anterior skull base together.
目的:组织瓣修复缺损是头颈部肿瘤切除术中的重要手段和必要环节。本研究总结65例颊癌和口咽癌不同范围组织缺损用局部带蒂组织瓣的修复方法。方法: 回顾2001~2009年我科65例口腔颊癌及口咽癌切除术后选择腭瓣、颏下瓣、面动脉逆行皮瓣、颊脂垫颊肌复合瓣修复颊部及口咽部组织缺损,病变范围和治疗结果。结果: 65例皮瓣中,17例腭瓣全部成活,29例颏下瓣26例全部成活,2例部分坏死,1例表层皮肤坏死, 7例面动脉逆行皮瓣6例全部成活,1例坏死,12例颊脂垫或颊脂垫颊肌复合瓣全部成活11例,1例部分坏死,总成活率96.9％。31例患者术后有不同程度的张口受限,咀嚼和吞咽功能基本正常。结论: 根据颊癌和口咽癌的病变范围决定采用不同的临近带蒂组织瓣修复缺损,修复效果确切,可以明显减少手术创伤和术后并发症,尤其适用于年老及较多基础疾病患者,仍应作为头颈部肿瘤术后缺损修复的重要方法。
ObjectiveTo explore the feasibility to restore pronunciation function by repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer. Methods A retrospective study of 5 male patients with advanced laryngeal cancer between August 2019 and October 2022, aged 56-73 years, with an average age of 65 years were reviewed. The disease duration ranged from 3 to 24 months, with an average of 8 months. Tumor classification by location: 2 cases of glottic type, 2 cases of supraglottic type, and 1 case of subglottic type; TNM staging: 3 cases of T4N0M0 stage, 1 case of T4N1M0 stage, and 1 case of T4N2M0 stage; American Joint Committee on Cancer (AJCC) staging (2017): stage Ⅳ. Near total laryngectomy with partial suprahyoid epiglottis-preserved and selective bilateral neck dissection were performed before the anterior medial thigh flap was used to repair the circumferential defects. The flap size ranged from 6 cm×5 cm to 8 cm×6 cm. Four patients underwent adjuvant radiotherapy and chemotherapy after operation, while 1 patient did not receive any other adjuvant treatment such as radiochemotherapy. Results The flaps of all 5 patients survived without obvious neck infection. One patient developed a slight pharyngeal fistula after oral feeding at 1 month after operation, which healed after another week of gastric feeding. Primary healing also achieved in the thigh donor area. One patient had bilateral cervical lymph node metastasis, and 1 patient had lymph node metastasis on one side. The remaining 3 patients had no cervical nodes metastasis on both sides. All 5 patients were followed up 12-36 months, with an average of 27.6 months. Four patients had clear, audible, and hoarse voice while 1 patient (case 3) had pronunciation similar to whispering. Laryngoscopy showed that the reconstructed laryngeal inlet was fissure-shape and the reconstructed laryngo-trachea canal below the laryngeal inlet was gradually enlarged. At 1 month after operation, the gastric tube was withdrawn and the food was taken orally. There was no obvious aspiration pneumonia. The tracheostomy tube could be blocked in 4 patients for from 30 seconds to 3 minutes. Among them, 3 patients were able to make a noticeable pronunciation even when the tube was not blocked, and they were able to engage in barrier-free language communication; the tracheostomy tube could not be blocked in 1 patient who had a pronunciation similar to whispering. Preliminary voice analysis showed that the patients have a relaxed and natural pronunciation, without obvious breath-holding or air-swallowing movement, compared to patients with esophageal pronunciation. Decannulation did not achieved until the last follow-up in all 5 patients. ConclusionThe anterior medial thigh flap can repair circumferential defects after near total laryngectomy in advanced laryngeal cancer patients and achieve satisfactory pronunciation, thus can serve as an effective pronunciation rehabilitation method. The preserved part of epiglottis may play a role to prevent postoperative aspiration.
ObjectiveTo explore the feasibility of reconstruction of phonatory function by using a tubular free flap from upper-lateral upper arm to repair the laryngotracheal circumferential defect after near-total laryngectomy for laryngeal cancer. Methods A retrospective study was conducted on 7 patients who underwent near-total laryngectomy between June 2021 and October 2023, aged from 48 to 70 years (median, 59 years), 6 males and 1 female. The disease duration ranged from 1 to 11 months, with a median of 6 months. Pathological diagnosis of preoperative biopsy was squamous cell carcinoma. Tumor classification: glottic type in 5 cases, supraglottic type in 1 case, transglottic type in 1 case; TNM staging: T4N0M0 in 6 cases, T4N2M0 in 1 case; American Joint Committee on Cancer (AJCC) staging in 2017 was stage Ⅳ. Preoperative MRI angiography of upper arm was performed to investigate the blood supply in the upper and lateral regions of the upper arm. After near-total laryngectomy and bilateral neck lymph node dissection, the area of the laryngotracheal defect was measured. A free flap measuring 7.0 cm×5.0 cm to 8.0 cm×7.0 cm was harvested from the upper-lateral upper arm, rolled into a tube shape, and connected between the stump of the cervical trachea in the neck root and that of the epiglottis at the tongue base. Four patients received adjuvant radiochemotherapy, 1 patient received radiochemotherapy and targeted therapy, 2 patients adopted no further adjuvant treatment. Results All 7 patients were followed-up 1-2 years (mean, 1 year and 3 months). Four patients had primary wound healing, 2 patients had minor pharyngeal fistulas that healed after dressing change, 1 patient experienced pharyngeal fistula because of flap necrosis and the wound still healed without secondary surgery. All patients took food orally within 1 month after operation, and the tracheal cannula was retained. Six patients with survived flap gradually adapted to their new pronunciation mode and obtained satisfactory phonatory function from 15 days to 2 months after operation. Four patients had slight aspiration after operation. Till the end of the follow-up, all patients survived and no local recurrence or distant metastasis had been observed. The motor function of the upper arm was not affected, only partial sensory loss occurred in the area near the incision. The scar of the incision could be covered by the short sleeve so as to obtain a better aesthetic effect. ConclusionUsing a tubular free flap from upper-lateral upper arm to repair the laryngotracheal circumferential defect after near-total laryngectomy for laryngeal cancer can achieve satisfactory phonatory restoration while preserve the motor function and aesthetics of the donor site.
ObjectiveTo investigate the correlation between the anterior talofibular ligament (ATFL) injury and the pathological changes of the anterior tibiotalar fat pad (ATFP) based on MRI. Methods The clinical and imaging data of 217 patients with ankle sprain who met the selection criteria between January 2019 and March 2024 were retrospectively analyzed. There were 113 males and 104 females with an average age of 38.2 years ranging from 18 to 60 years. Patients were divided into mild group (n=106), moderate group (n=63), and severe group (n=48) according to the degree of ATFL injury. There was no significant difference in gender, side, and body mass index among the 3 groups (P>0.05). The age of the mild group was significantly older than that of the moderate and severe groups (P<0.05). The imaging parameters including the longest and shortest sagittal axis, the largest thickness, the longest and shortest transverse axis, the ATFP area, the area of ATFP high-signal region, and the anterior distal tibial angle (ADTA) were measured according to the MRI and X-ray films of patients. According to the morphology of ATFP, the patients were divided into type Ⅰ (n=128), type Ⅱ (n=73), and type Ⅲ (n=16) based on the severity of the lesions. The distribution of ATFP types, ATFP area, area of ATFP high-signal region, and the ratio of area of ATFP high-signal region to ATFP area at the same level were statistically analyzed and compared among different ATFL injury groups. Additionally, radiographic parameters were compared across different ATFP types. Spearman rank correlation analysis was used to assess the relationships between ATFP area, area of ATFP high-signal region, and the ratio of area of ATFP high-signal region to ATFP area at the same level with patient baseline data. Through analysis of the area under curve (AUC) of ROC, optimal variables were selected for quantification to predict ATFL injury. Results There were significant differences in ATFP types among different ATFL injury groups (P<0.05). The mild group had a higher proportion of type Ⅰ, the moderate group had a higher proportion of type Ⅱ, and the severe group had higher proportions of both typeⅡ and type Ⅲ. No significant difference was found in ATFP area among the different ATFL injury groups (P>0.05). However, the area of ATFP high-signal region and the ratio of area of ATFP high-signal region to ATFP area at the same level were significantly lower in the mild group compared to the moderate and severe groups (P<0.05). Except for the longest sagittal axis, maximum thickness, and longest transverse axis, which were significantly smaller in ATFP types Ⅱ and Ⅲ compared to type Ⅰ (P<0.05), there was no significant difference in the remaining radiographic parameters among the different ATFP types (P>0.05). Spearman rank correlation analysis revealed that ATFP area was negatively correlated with patient gender (P<0.05), while area of ATFP high-signal region and the ratio of area of ATFP high-signal region to ATFP area at the same level were negatively correlated with patient age (P<0.05). Through analysis of the AUC for the response variable ATFP injury, the combined diagnostic AUC of ROC for the reciprocal of the maximum thickness and the reciprocal of the area of ATFP high-signal region was 0.839 (asymptotic P<0.001). The corresponding cutoff value when the Youden index reached its maximum was 0.570 3. ConclusionAs the severity of ATFL injury increases, the ATFP undergoes gradual morphological and functional changes. Classification based on ATFP types can assist in assessing the level of ATFL injury, thereby aiding in the prevention of post-traumatic osteoarthritis.