内镜联合显微镜治疗婴幼儿中耳畸胎瘤1例及文献复习

Combined endoscopic and microscopic treatment of a middle ear teratoma in an infant: a case report and literature review

摘要

目的 探讨内镜联合显微镜手术治疗婴幼儿中耳畸胎瘤的临床特征、影像学表现及手术策略。方法 本例患儿以反复耳道流脓为主要临床表现。术前颞骨CT检查左侧外耳道、中耳软组织肿块伴骨质破坏，病灶经咽鼓管延伸至鼻咽部，MRI表现为T1WI等信号、T2WI高信号肿块伴局部弥散受限。全麻下行内镜联合显微镜手术，采用耳后入路乳突探查术联合鼻咽部径路完整切除肿瘤并行人工听骨链重建。术中发现鼓室内新生物，表面可见毛发，包裹听骨链。结果 术后病理确诊为成熟性畸胎瘤。随访显示鼓膜形态恢复良好，无面神经麻痹等并发症。术后随访听力未见明显改善，仍需进一步观察。文献复习共纳入16篇报道(23例)，结合本例分析显示:发病中位年龄12个月(范围:2周~12岁)，起病年龄为女性多见(87.5%，21/24)；左侧发病占87.5%(21/24)；临床表现以耳漏(87.5%)、听力下降(70.8%)和耳痛(37.5%)为主，部分患儿出现面瘫、耳后红肿、鼻咽部堵塞等表现；影像学特征为CT显示外耳道、鼓室、咽鼓管稍高密度灶伴听骨链包绕，MRI多呈T1等信号、T2高信号；病理类型以成熟型畸胎瘤为主。治疗多采用耳后径路显微镜下乳突探查肿物切除术，部分病例联合内镜技术，从咽鼓管径路取出肿物。术后随防2例复发，再次手术治疗，余预后良好。结论 婴幼儿中耳畸胎瘤具有特征性的临床表现和影像学特点，内镜联合显微镜手术可提供良好术野暴露，实现肿瘤完整切除。对于听骨链的手术时机选择仍需慎重，结合长期随访观察再行决定听骨链重建。

Abstract

Objective The aim is to explore the clinical characteristics, imaging manifestations, and surgical strategies of endoscopic combined microscopic surgery for middle ear teratoma in infants. Methods The main clinical manifestation in this paediatric patient was recurrent discharge from the ear canal. Preoperative temporal bone computed tomography (CT) revealed a soft tissue mass with bone destruction in the left external auditory canal and middle ear. The lesion extended through the Eustachian tube to the nasopharynx. Magnetic resonance imaging (MRI) showed a T1-weighted image (T1WI) iso-signal and T2-weighted image (T2WI) high signal mass with local diffusion restriction. Under general anesthesia, endoscopic and microscopic surgery were performed. A posterior auricular approach mastoid exploration was used in combination with a nasopharyngeal approach to completely remove the tumour and perform artificial ossicular chain reconstruction. During the operation, a new growth was found in the tympanic cavity, with visible hair on the surface and encapsulating the ossicular chain. Results The postoperative pathology report diagnosed the tumour as a mature teratoma. Follow-up showed that the tympanic membrane had recovered well, with no complications such as facial nerve palsy. However, hearing did not show significant improvement during the postoperative follow-up and further observation was required. A total of 16 reports (23 cases) were included in the literature review. Combined with this case, the analysis showed that: The median age at onset was 12 months (range 2 weeks-12 years), and the onset was more common in females (87.5%, 21/24); The left side was affected in 87.5% (21/24) of cases. The clinical manifestations were mainly ear discharge (87.5%), hearing loss (70.8%), and ear pain (37.5%). Some children presented with facial paralysis, postauricular redness and swelling, and nasal pharyngeal obstruction. The imaging features were as follows: CT showed slightly high-density foci in the external auditory canal, tympanic cavity, and eustachian tube accompanied by the surrounding ossicular chain. MRI mostly showed T1 iso-signal and T2 high signal. The pathological type was mainly mature teratoma. The treatment mostly adopted the microsurgical approach with tumour resection through the posterior auricular incision. In some cases, endoscopic techniques were used to remove the tumour through the eustachian tube approach. After the operation, 2 cases had recurrence and underwent reoperation, the rest had good prognosis. Conclusion Infantile middle ear teratoma exhibits characteristic clinical manifestations and imaging features. A combination of endoscopic and microscopic surgery provides good exposure of the surgical field and enables complete tumour resection. The timing of surgery for the ossicular chain still needs to be carefully considered, and the decision on ossicular chain reconstruction should be based on long-term follow-up observations.

关键词

中耳畸胎瘤 / 婴幼儿 / 内镜手术 / 显微镜手术 / 耳道流脓

Key words

Middle ear teratoma / Infant / Endoscopic / Microscopic / Purulent otorrhea

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