CAJ | 학술논문

目的探讨分析中耳乳突手术导致医源性面神经损伤的原因、部位以及手术修复方法和预后效果.方法选择中耳乳突手术后立即发生周围性面神经麻痹,并经再次手术探查、修复的42例医源性面神经损伤病例,按House-Brackmann法对面神经功能进行分级,根据探查时所见,分析发生面神经损伤的原因和部位；依据面神经损伤的部位和范围,分别采用面神经减压、吻合、耳大神经移植、面神经-舌下神经吻合术等进行修复治疗；对于随访1年以上、资料齐全的28例患者,根据手术前后面神经功能的分级进行比较,分析治疗效果和预后.结果开放式乳突根治术是引起面神经意外损伤的最常见的中耳乳突手术,损伤部位以面神经鼓室段、锥段最多见.主要病理改变包括:面神经水肿9例(21.4％)；面神经鞘膜损伤10例(23.8％)；面神经纤维部分断裂4例(9.5％)；面神经完全断裂17例(40.5％)；未见明显病变2例(4.8％).面神经修复方法包括:面神经减压24例(57.1％),端-端吻合2例(4.8％),改道吻合2例(4.8％),耳大神经移植吻合10例(23.8％),面神经-舌下神经吻合4例(9.5％).随访1年以上,资料完整的28例患者预后与疗效分析:面神经减压17例,术前面神经功能Ⅳ级4例,Ⅴ级12例,Ⅵ级1例,术后1年面肌功能恢复至Ⅰ级4例,Ⅱ级11例,Ⅲ级2例；耳大神经移植5例,术前面神经功能均为Ⅴ级,术后恢复至Ⅱ级3例,Ⅲ级2例；面神经-舌下神经吻合4例,面神经功能从Ⅴ级恢复至Ⅲ级；改道和端-端吻合各1例,面神经功能均由V级恢复至Ⅱ级.结论面神经鼓室段和锥段是中耳乳突手术时最容易损伤的部位；根据损伤程度和范围的不同,行面神经减压、吻合、耳大神经移植、面神经-舌下神经吻合术可以使患者获得较好的预后效果.
목적 탐토분석중이유돌수술도치의원성면신경손상적원인、부위이급수술수복방법화예후효과.방법 선택중이유돌수술후립즉발생주위성면신경마비,병경재차수술탐사、수복적42례의원성면신경손상병례,안House-Brackmann법대면신경공능진행분급,근거탐사시소견,분석발생면신경손상적원인화부위；의거면신경손상적부위화범위,분별채용면신경감압、문합、이대신경이식、면신경-설하신경문합술등진행수복치료；대우수방1년이상、자료제전적28례환자,근거수술전후면신경공능적분급진행비교,분석치료효과화예후.결과 개방식유돌근치술시인기면신경의외손상적최상견적중이유돌수술,손상부위이면신경고실단、추단최다견.주요병리개변포괄:면신경수종9례(21.4％)；면신경초막손상10례(23.8％)；면신경섬유부분단렬4례(9.5％)；면신경완전단렬17례(40.5％)；미견명현병변2례(4.8％).면신경수복방법포괄:면신경감압24례(57.1％),단-단문합2례(4.8％),개도문합2례(4.8％),이대신경이식문합10례(23.8％),면신경-설하신경문합4례(9.5％).수방1년이상,자료완정적28례환자예후여료효분석:면신경감압17례,술전면신경공능Ⅳ급4례,Ⅴ급12례,Ⅵ급1례,술후1년면기공능회복지Ⅰ급4례,Ⅱ급11례,Ⅲ급2례；이대신경이식5례,술전면신경공능균위Ⅴ급,술후회복지Ⅱ급3례,Ⅲ급2례；면신경-설하신경문합4례,면신경공능종Ⅴ급회복지Ⅲ급；개도화단-단문합각1례,면신경공능균유V급회복지Ⅱ급.결론 면신경고실단화추단시중이유돌수술시최용역손상적부위；근거손상정도화범위적불동,행면신경감압、문합、이대신경이식、면신경-설하신경문합술가이사환자획득교호적예후효과.
Objective To discuss the causes,sites,management strategies and curative effects of accidental facial nerve paralysis in the middle ear surgery.Methods Forty two cases with peripheral facial nerve paralysis following middle ear surgery who underwent surgical exploration and reanimation were analyzed.Facial nerve decompression,primary end-to-end anastomosis,interpositional nerve grafts with the great auricular nerve and nerve substitution of facial-hypoglossal anastomosis were applied to restoration of the facial nerve function.The facial nerve function was graded according to House-Brackmann(HB)Grade.Results The most common operation complicating iatrogenic facial nerve injury was mastoidectomy,and the common sites of the injured facial nerve were the tympanic segment and pyramid segment.The facial nerve exploration showed facial nerve edema in nine cases(21.4％),injury of the facial nerve sheath was observed in 10 cases(23.8％),partial nerve fibers transection was found in four cases(9.5％),total nerve fibers transection was detected in 17 cases(40.5％)and two cases(4.8％)with facial nerve anatomical integrity.Facial nerve re-animation methods include facial nerve decompression in 24 cases(57.1％),end-to-end anastomosis in two cases(4.8％),end-to-end anastomosis after nerve transfer in two cases(4.8％),interpositional nerve grafts with the great auricular nerve in 10 cases(23.8％)and facial-hypoglossal nerve anastomosis in four cases(9.5％).The facial nerve function was graded according to House-Brackmann Grade before and after surgery.Twenty eight patients were followed up more than one year.For the 17 cases who received facial nerve decompression,four cases recovered to House-Brackmann Grade Ⅰ,11 casesrecovered to House-Brackmann Grade Ⅱ,two cases recovered to House-Brackmann Grade Ⅲ.For the five cases who underwent the great auricular nerve grafting,three cases recovered to House-Brackmann Grade Ⅱ,two cases recovered to House-Brackmann Grade Ⅲ.For the four cases who received facial-hypoglossal nerve anastomosis recovered to House-Brackmann Grade Ⅲ.For the two cases who underwent the end-to-end anastomosis recovered to House-Brackmann Grade Ⅱ.Conclusions The tympanic segment and pyramid segment are more vulnerable to be injured during mastoid surgery.The injured facial nerve should be explored and repaired.The methods include facial nerve decompression,end-to-end anastomosis,end-to-end anastomosis after nerve transfer,interpositional nerve grafts with the great auricular nerve and facialhypoglossal nerve anastomosis.