前篇《Head and Neck Anatomy》（可点击浏览）我们学习了头颈部解剖，本篇在前篇基础上介绍 颈静脉孔区 耳后经颞入路，其为处理颈静脉孔区病变最常用的入路。笔者学习后在标本上尝试发现该入路可方便地寻找面神经，降低面神经的损伤几率，并可保留迷路等优点。本文的讲述者是Jon Robertson教授。共118张图片。
笔者水平所限，错误之处请批评指正！
耳后经颞入路至颈静脉孔区
The Postauricular Transtemporal Approach to the Jugular Foramen
▼本集视频将展示颈静脉孔区手术入路，以及一则左侧颈静脉球瘤的病例分享，并同步结合尸头解剖，详解颈静脉孔区手术入路 解剖要点。
This presentation, to illustrate the approaches to thejugular foramen surgically, includes a case presentation of a left glomus jugularetumor with surgical footage of the case itself, as well as a cadaver dissection that demonstrates the specific anatomical landmarks inthe approach to the jugular foramen region.
▼颈静脉孔区手术显露困难，缘于其所处位置深在及周围神经血管结构遮挡，包括前方的颈内动脉、侧方的面神经、以及位于颈静脉孔后内侧缘下方的椎动脉。
Surgical accesses to the jugular foramen is difficult because of its deep location and surrounding neurovascular structures blocking its exposure, such as the internal carotid artery anteriorly, the facial nerve laterally, and vertebral artery inferior to the posteromedial marginof the jugular foramen.
▼因此，该区域的手术需做到真正意义上的“解剖性手术”，方可保护该区域错综复杂的神经血管结构。
Therefore skull base lesions of jugular foramen should be approached as a surgical anatomist would to preserve the complex neurovascular structures of this region.
▼Rhoton将颈静脉孔区的手术入路归结为三组，外侧入路经乳突（耳后经颞入路），后方入路经后颅窝（包括乙状窦后入路，或更广泛的远外侧入路及其经髁扩展），最后一种为经鼓骨的前方入路（耳前颞下-颞下窝入路及其各变型），上述入路均可联合颈部解剖，以根据需要来处理特定病变。
Rhoton has categorized approaches to the jugular foramen into three groups, a lateral group directed through the mastoid bone, this will be the postauricular transtemporal approach, a posterior group directed through the posterior fossa, this will include a retrosigmoid, or a more extensive far lateral or transcondylar variant approach, and finally an anterior group of approachs directed through the tympanic bone, this will be the preauricular subtemporal infratemporal fossa approach or variations of that. In each of these approaches, a neck dissection can be included as needed to manage the specific pathology that one is dealing with.
▼本集视频重点阐述颈静脉孔区的耳后经颞入路的应用解剖。与颈部解剖相联合，这一入路为处理颈静脉孔区病变最常用的入路。
The goal of this video is to demonstrate the surgical anatomy of the postauricular transtemporal approach to the jugular foramen region. Combined with a neck dissection, this is the most common surgical approach chosen for management of lesions involved in the jugular foramen.
▼迷路通常保留
The labyrinth is usually preserved in the exposure,
▼但根据病变具体情况，术野可向前扩展，此时需移位面神经，并牺牲中耳结构及外耳道，向内侧扩展时需磨除迷路和耳蜗。
but depending on the pathology, the surgical field may be extended anteriorly by transposing the facial nerve and sacrificing the middle ear structures and external auditory canal, or medially by removal of the labyrinth or cochlea.
▼这是右侧的颅底下表面，我们来看颈静脉孔区。耳后经颞入路联合颈部解剖，可在颅底对颈静脉孔实现270°的暴露。
We're viewing the inferior aspect of the right skull base in the region of the jugular foramen. The postauricular transtemporal approach combined with a neck dissection allows a 270 degree exposure of the jugular foramen at the skull base.
▼这一暴露范围包括前方的颈内动脉，直至颈内动脉管层面
This would include anteriorly exposing the internal carotid artery to the level of the carotid canal,
▼侧方的茎突、面神经出茎乳孔处
laterally, the styloid process, and the facial nerve at the stylomastoid foramen,
▼后方，则可显露 头外侧直肌 于颈静脉孔后缘的全部附着范围，附着处即为枕骨的颈静脉突。
and posteriorly, the full extent of the rectus capitis lateralis muscle's attachment to the posterior margin of the jugular foramen, which represents the jugular process of the occipital bone.
▼我们将结合实际病例来阐述手术技巧：65岁女性，主诉为搏动性耳鸣，左侧听力无减弱。后组颅神经和面神经功能均正常。颅脑MR，提示一3cm大小的颈静脉球瘤。
The case that we're presenting for illustration of the technique is that of a 65-year-old lady who presented with pulsatile tinnitus, normal lower cranial nerve and facial nerve function, her hearing was also intact on the left side. Neuro-diagnostic studies included MR scan as well as CT scan revealing a 3-cm glomus jugulare tumor
▼颅脑CT扫描主要伴有乳突破坏及侵犯颈静脉球区域。
with destruction of the mastoid bone primarily and the region of the jugular bulb by the glomus jugulare tumor.
▼脑血管造影证实病灶血供丰富，同时由左侧颈外动脉和椎动脉供血，符合颈静脉球瘤典型表现。颅底颈内动脉未参与肿瘤的供血。
The cerebroangiogram demonstrated significant blood supply from both the left external and vertebral arteries, typical of a glomus jugulare tumor. There was no blood supply to the tumor from the internal carotid artery at the skull base.
▼术前1天，该患者进行了血管内介入栓塞治疗。
Preoperatively the patient underwent embolization the day prior to surgery.
▼手术步骤：患者采取平卧位，同侧肩膀垫高，头转向对侧。耳后部沿C形切开。
The patient was placed on supine position with an ipsilateral shoulder roll, and the head turned away from the surgeon. The postauricular area is exposed along a C-shaped incision.
▼标本解剖首先进行胸锁乳突肌的锐性切开，从乳突尖离断。将胸锁乳突肌小心牵向后方。
Our cadaver dissection begins with the sharp dissection of the sternocleidomastoid muscle from the mastoid tip. The sternocleidomastoid muscle is carefully mobilized posteriorly.
▼注意保护副神经，其穿入胸锁乳突肌上部的后内侧，层面平寰椎横突尖。
Care is taken to preserve the accessory cranial nerve, which enters the posteromedial aspect of the superior sternocleidomastoid muscle at the level of the tip of the C1 transverse process.
▼下图展示了各解剖结构的关系，包括胸锁乳突肌、二腹肌后腹、面神经、茎突。移除腮腺使得上述解剖结构能如此清晰的显露。
This Rhoton dissection shows the relationship of the anatomy of the sternocleidomastoid muscle to the posterior belly of digastric, facial nerve, and styloid process. These anatomical structures are viewed clearly in this particular dissection because the parotid gland has been removed.
▼这里特别需要注意的结构是从 茎乳孔（下图箭头）穿出的面神经，其恰位于二腹肌后腹的前方，二腹肌附着于二腹肌沟。
Aspecific anatomy to be noted in this view is the facial nerve exiting the stylomastoid foramen immediately anterior to the posterior belly of the digastric attached to the digastricgroove.
▼茎突（下图）也已清晰显露，面神经 沿 茎突的后外侧缘 穿出于 茎乳孔（下图箭头）。
Also note the styloid process can be seen clearly, and the facial nerve exiting the stylomastoid foramen along the posterolateral margin of the styloid process.
▼副神经（下图）从颈内静脉（下图）前缘跨越，进入胸锁乳突肌（下图）的后内侧部。
Note also in this view the accessory nerve crossing the anterior margin of the jugular vein to enter the posteromedial aspect of the sternocleidomastoid muscle.
▼二腹肌后腹已呈90°移位，并用线绳游离。
The posterior belly of the digastric has been mobilized with a right angle, and isolated with application of a vascular loop.
▼锐性分离二腹肌后腹，将其从乳突尖的二腹肌沟上离断，并向下翻折。
The posterior belly of the digastric muscle is sharply dissected from the digastric groove of the mastoid tip and mobilized inferiorly.
▼从二腹肌沟离断二腹肌后腹，即可显露位于茎乳孔的面神经。
Removal of the posterior belly of the digastric muscle from the digastric groove allows the exposure of the facial never at the stylomastoid foramen.
▼同时也可触及 茎突 及 三块附于其上的茎突肌群。
This also allows palpation of the styloid process and three small muscles attached to the process.
▼茎乳孔（下图箭头）位于茎突底部的后外侧缘。
Stylomastoid foramen is found at the posterolateral margin of the styloid process base.
▼需将腮腺（下图箭头）向前游离，直到暴露位于茎乳孔的面神经。
The parotid gland must be mobilized anteriorly, until expose the facial nerve at the stylomastoid foramen.
▼这里，茎突舌骨肌 已被牵开以显露 茎突。
In this view, the stylohyoid muscle has been retracted to expose the styloid process.
▼锐性分离茎突肌群。茎突舌骨肌已被沿着二腹肌后腹向下翻折。
The muscles attached to the styloid process are sharply dissected. Here the stylohyoid muscle has been reflected inferiorly along with the posteriorbelly of the digastric muscle.
▼沿着茎突底部的后外侧缘仔细松解软组织，以暴露位于茎乳孔的面神经。
The soft tissue is carefully dissected to expose the facial nerve as it enters the stylomastoid foramen, along the posterolateral aspect of the styloid base.
▼通过面神经出茎乳孔处的前方和后方可触及茎突底部。将面神经向前牵开可显示茎突全程。
The styloid base can be palpated anteriorly and posterior to the facial nerve as it enters the stylomastoid foramen.Here the facial nerve is retracted anteriorly to expose the extent of the styloid process.
▼下图可见面神经穿入腮腺后部（该部腮腺已部分切除）。腮腺若被切开，则需缝合腮腺包膜，可选用薇乔缝线间断缝合。这可避免术后腮腺涎液漏的发生。
We also see the facial nerve entering the posterior aspect of the parotid gland which has been partially removed for exposure.If the parotid gland is entered, it is important to close the capsule of theparotid,with an interrupted vicryl suture.This will help to prevent a postoperative seroma.
▼这里可见茎乳动脉，通常发自耳后动脉。茎乳动脉需予以保护，以保证面神经乳突段的血供。
Here one sees the stylomastoid artery, which typically arises from the posterior auricular artery. The stylomastoid artery should be preserved because of its blood supply to themastoid segment of the facial nerve.
▼切除茎突，方可充分暴露颈内动脉。如肿瘤包裹颈内动脉，或者颈内动脉为肿瘤供血需切除茎突。在本病例中，颈内动脉并未被肿瘤累及。因此上述步骤可以省略。
Removal of the styloid process is necessary to expose the internal carotid artery immediately below the skull base. This should be done when the internal carotid artery is encased by the tumor, or provides arterial blood supply to the tumor. The internal carotid artery was not involved by the tumor in the case we're preventing today.Therefore the step was not necessary.
▼剪断与茎突黏连的软组织
▼咬骨钳咬除茎突。
The styloid process is removed with a rongeur.
▼接下来将视野转移至下颈部，进行颈内静脉和颈总动脉的暴露。去除面静脉（下图），可暴露颈动脉分叉部。
Attention is turned to the lower neck to expose the jugular vein and the common carotidartery. Removal of the facial vein allows exposure of the carotid bifurcation.
▼舌下神经（下图）通常于颈动脉分叉部水平或稍上方进一步向内进入舌根。
The hypoglossal nerve is identified typically at the level of the bifurcation or immediately above the bifurcation, as it courses medially to the base of the tongue.
▼副神经（下图）通常位于寰椎横突尖端（下图）水平。
It is noted that the accessory nerve can typically be found at the level of the tip of the transverse process of C1.
▼在此层面，副神经可走行于颈内静脉的前方或后方。
The accessory nerve can pass either anterior or posterior to the jugular vein at this level.
▼枕动脉 被游离并切除，以利于上颈部结构的暴露。
The occipital artery is mobilized and removed in order to gain exposure of the upper cervical region.
▼向上翻折颈内静脉，以暴露颈动脉分叉部、迷走神经、舌下神经（下图）。
The jugular vein is mobilized superiorly exposing the carotid bifurcation, the vagal, and the hypoglossal nerves.
▼甲状腺上动脉（下图）位于颈外动脉起始部。
The superior thyroid artery is seen at the base of the external carotid artery.
▼牵开颈外动脉，显露颈内动脉。
The external carotid artery is retracted to allow exposure of the internal carotid artery.
▼颈内动脉的显露范围向上至颅底。在该层面，可见舌咽神经（下图）从颈静脉孔内侧部穿出，跨过颈内动脉前缘。
The internal carotid artery is exposed immediately below the skull base. The 9th cranial nerve can be seen at this level crossing the anterior margin of the internal carotid artery. In this view, one can see the 9th cranial nerve exiting the medial aspect of the jugular foramen.
▼可见舌下神经、迷走神经相吻合（下图）。后组颅神经的这种吻合可见于神经恰穿出颈静脉孔的颅底附近。迷走、副、舌下神经之间均可出现上述吻合。
This view also shows the fusion of the hypoglossal and the 10th cranial nerves as they approach the jugular foramen. The fusion of the lower cranial nerves can occur immediately below the skull base as they approach the jugular foramen. This may be true of any combination of the 10th, 11th, or 12th cranial nerves.
▼下一阶段将进行乳突切除术。此处的解剖标志包括上方的乳突上嵴（下图）
Attention is turned at this stage of procedure to the mastoidectomy. The anatomical landmarks to be identified include the supramastoid crest superiorly,
▼后方的星点（下图），其可作为横窦-乙状窦转角处的标准，以暴露乙状窦；
posteriorly the asterion, which provides localization of the junction of the transverse sigmoid sinus, and exposure of the sigmoid sinus
▼这是前方的Henle嵴（下图），可定位外侧半规管。
anteriorly the spine of Henle should be noted, to provide the location of the lateral semicircular canal.
▼首先磨除三角形皮质骨区域
▼随着乳突的切除，可见该标本一个较小的乳突气房。
As mastoidectomy proceeds, it is noted that there's a small mastoid air cell space in the specimen.
▼要点在于暴露范围需足够大，需从横窦、乙状窦到颈静脉球水平。需要同时暴露乙状窦后方，及前方的硬脑膜。
It's very important that exposure is wide to include the transverse and sigmoid sinus to the level of the jugular bulb. This requires exposure of dura posterior to the sigmoid sinus as well as in the presigmoid space.
▼下图可见鼓室窦被打开。
The antrum has been exposed in the mastoidectomy.
▼该例标本存在高位颈静脉球，识别该结构的重要性在于，其与前方的面神经、颈内动脉关系密切。
Noted in this specimen is a high jugular bulb, which is important to recognize because of its relationship to the facial nerve, as well as internal carotid artery anteriorly.
▼将面神经乳突段（下图）轮廓化。
The mastoid segment of the facial nerve is skeletonized.
▼此时轮廓化的是后半规管。
Here we're drilling along the posterior semicircular canal.
▼这是鼓索神经（下图）。
The chorda tympani is identified.
▼可见面神经隐窝（下图），其位于乳突段面神经的上段和鼓索神经之间。沿着面神经隐窝可进一步开放中耳腔。
One now sees the facial recess to find between the superior aspect of the mastoid segment of the facial nerve and the chorda tympani. A drilling through the facial recess opens the middle ear space.
▼面神经乳突段的上端沿着外侧半规管下缘（下图箭头）从前向后并转而下行。
The superior aspect of the mastoid segment of the facial nerve can be seen turning below the lateral semicircular canal anteriorly.
▼继续暴露的是上半规管。
The superior semicircular canal is further defined.
▼将颈内静脉结扎后切断，并一直游离至颅底，以完全显露颈静脉孔。
After ligation and division, the jugular vein must be mobilized to the level of the skull base, in order to have full exposure of the jugular foramen.
▼可在寰椎横突尖显露 副神经。
The 11th cranial nerve is found at the level of the tip of the transverse process of C1.
▼如果副神经的走行正如该例标本所见，即从颈内静脉前方向后跨行，则需将颈内静脉移至副神经前方以继续向上游离至颈静脉孔水平。
If the 11th cranial nerve passes over the anterior margin of the jugular vein as in this case, the jugular vein must be transposed anteriorly to allow dissection of the jugular vein to the level of the jugular foramen.
▼于颈内静脉后缘松解 头外侧直肌（下图）。
The rectus capitis lateralis muscle is dissected from the posterior margin of the jugular vein.
▼从这幅Rhoton解剖图中，可见头外侧直肌（下图），起于寰椎横突上表面（下图），向上附着于颈静脉孔后缘骨质（颈静脉突）。
This Rhoton dissection shows the relationship of the rectus capitis lateralis muscle as it arises from the superior surface of the transverse process of C1, to project superiorly attaching to the posterior bony margin of the jugular foramen.
▼椎动脉恰位于头外侧直肌的后内侧。椎动脉被其周围静脉丛包绕，穿出于横突孔。
The vertebral artery surrounded by the venous plexus exits the foramen transversarium, immediately posteromedial to the rectus capitis lateralis muscle.
▼显露寰椎横突（下图箭头）。从寰椎横突上缘处锐性离断头外侧直肌，将其分块切除直至颈静脉孔后缘。
The transverse process of C1 is defined. This muscle is sharply dissected from thesuperior margin of the transverse process of C1, and then removed in a piecemeal fashionto the posterior margin of the jugular foramen.
▼切除头外侧直肌 是暴露颈静脉孔后缘的必要步骤。
Removal of the rectus capitis lateralis muscle is necessary in order to expose the posterior margin of the jugular foramen.
▼在切除头外侧直肌时，需注意避开椎动脉（下图），后者穿出横突孔的位置，恰位于头外侧直肌的后内侧。
As one removes the rectus capitis lateralis muscle, one must be careful to avoid the vertebral artery, which exits the foramen transversarium, posteromedial to the rectus capitis lateralis muscle.
▼将颈内静脉与后组颅神经分离，直至颈静脉孔水平。
The lower cranial nerves are separated from the jugular vein, to the level of the jugular foramen.
▼切除残余的骨质和颈静脉孔区纤维环。
Residual bone and the fibrous ring of the jugular foramen are removed.
▼切开颈内静脉，经颈静脉孔至颈静脉球。
The jugular vein is opened though the jugular foramen into the jugular bulb area
▼并进一步切除乙状窦外侧壁。
followed by the removal of the lateral wall of the sigmoid sinus.
▼在实际手术中，若肿瘤累及颈静脉孔及颈静脉球区，需首先结扎颅底处的上段颈内静脉（下图箭头）
In an actual case where tumor would involve the jugular foramen or jugular bulb region, one must isolate this region initially by ligating the jugular vein immediately below the skull base
▼随后结扎乙状窦，结扎部位为横窦-乙状窦转角以远，以及结扎岩上窦汇入转角处（下图箭头）。分别行上述结扎从而离断乙状窦，对于岩上窦的保护非常重要，也是防止Labbe静脉血栓形成的重要措施。
followed by ligation of the sigmoid sinus distal to the junction of the transverse sigmoid sinus and the entry of the superior petrosalsinus into that junction.This isolation of the sigmoid sinus in jugular bulb region by ligation of the respective venous structures,is very important in order to preserve the superior petrosal sinus and avoid potential thrombosis of the vein of Labbe.
▼结扎乙状窦的手术技巧包括用4-0丝线间断缝合，逐步将外侧壁缝合于内侧壁上。重复缝合数针，以完全闭合乙状窦。
The technique of ligation of the sigmoid sinus involves individual 4-0 silk sutures that pass from the outer wall of the sinus, attaching it to the inner wall of the sinus. And this is done in a serial fashion to cause occlusion of the sinus.
▼减少操作中出血的方法，可压闭乙状窦近端，即采用骨腊填塞于骨缘下方，直至横窦-乙状窦转角处。
In order to prevent bleeding during this procedure, the proximal portion of the sinus can be occluded by using bone wax packed underneath the edge of bone extending over the junction of the transverse sigmoid sinus.
▼本人采用的间断缝合逐步闭合乙状窦的方法，可避免开放后颅窝硬脑膜，减少术后脑脊液漏的风险。
The reason that the technique of placing individual sutures to ligate the sigmoid sinus as I've described, is to prevent opening the posterior fossa dura, and with a potential of having a cerebrospinal fluid leakage from opening the dura.
▼需注意的是，绝大多数颈静脉球瘤正如该例，肿瘤仅位于硬膜外，并未进入后颅窝，而真正广泛累及进入后颅窝的病例，如今已非常罕见了，因为越来越多的肿瘤在早期体积较小时已被诊断。
You must remember that in this case as in a significant number of glomus jugulare tumor cases, this tumor is an extradural tumor, and the posterior fossa is not violated, unless the tumor has significant extension into the posterior fossa, which in these days is really quite uncommon because most of these tumors are identified when they're typically median size or smaller tumors.
▼在这标本中，乙状窦、颈静脉球、颈内静脉内容物被去除。移除的最后一部分灌注染料是位于髁导静脉内的，该静脉汇入颈静脉球后缘。
In this specimen, the contents of the sigmoid sinus, jugular bulb and jugular vein are removed. The last portion of the latex material removed is from the condylar emissary vein coming into the posterior margin of the jugular bulb region.
▼暴露颈静脉球内侧壁，即可见数个源自岩下窦的静脉通道。切除累及颈静脉孔或颈静脉球区域的肿瘤，保留颈静脉球内侧壁非常重要，以保护后组颅神经。
Exposure of the medial wall of the jugular bulb, reveals the multiple venous channels representing the inferior petrosal sinus drainage. In removing tumors involving the jugular foramen or jugular bulb region, it is very important to leave the medial wall of the jugular bulb intact, to protect the lower cranial nerves.
▼下方还可见髁导静脉。
One also notes the condylar emissary vein immediately inferior.
▼一旦完成乙状窦结扎，下一个手术步骤即为显露肿瘤，本例中，肿瘤主要累及乳突骨质和颈静脉球。迷路和耳蜗并未累及，中耳也未被累及。这里切除的是累及乳突的肿瘤（下图）。
Once we've ligated the sigmoid sinus, the next stage of the operative procedure is to approach the tumor, which in this case is primarily involving the mastoid bone and the region of the jugular bulb.The labyrinth as well as the cochlea are not involved with tumor, nor is the middle ear invaded by the tumor mass. At this level we're removing a tumor involving the mastoid bone.
▼术中出血明显减少，这归功于术前的栓塞。
The bleeding that one sees is obviously significantly reduced because of the preoperative embolization.
▼但仍需通过骨腊、明胶海绵、速即纱控制出血，保证术野的清晰。尽量少用双极电凝，因为大部分出血是静脉性而非动脉性。
But bleeding that is encountered should be controlled with either application of bone wax, cottonoid pledgets, or surgicel, until the anatomy is defined. We tend to avoid using bipolar cautery because majority of the bleeding that is encountered is actually venous as opposed to arterial.
▼在这一阶段，可见已被结扎的、包含有肿瘤的颈内静脉，大致位于寰椎横突水平。沿着颈静脉孔后缘至纤维环进行松解。
At this stage of operative procedure, you see the jugular vein containing a tumor which has been ligated, at the level of the transverse process of C1 roughly. The dissection is carried along the posterior margin of the jugular foramen to the level of the fibrous ring.
▼在进行这一松解步骤时，可清晰见到已被栓塞的动脉：咽升动脉，是颈静脉球瘤主要的供血来源。
As we dissect along the posterior margin of the jugular vein to the level of the fibrous ring, we encounter significant arterial vessels which have been embolized. This represents the ascending pharyngeal artery, which is a significant blood supply to the glomus jugulare tumor.
▼现在我们正松解并切开纤维环，开放颈静脉孔后外侧缘。
Here we are mobilizing and cutting the fibrous ring to open the jugular foramen along the lateral and posterior margin.
▼此时将颈内静脉切开，即可见其内的肿瘤，其具有该类肿瘤的典型表现。颈静脉球瘤通常起源于颈静脉球顶，可同时位于静脉腔内外。
At this stage we're opening the jugular vein which you can see, is filled with glomus tumor, which is typical of this particular pathology as you recall. Glomus jugulare tumors typically arise at the dome of the jugular bulb and can be found both extra- as well as intra luminal.
▼在本例中也是如此，肿瘤不仅累及颅外的颈内静脉，同时完全侵犯了颈静脉球区域，并侵蚀乳突骨质，直至迷路、中耳和耳蜗下方水平。
This is the case in this particular situation,where tumor fills not only the jugular vein extending below the skull base, but completely fills that region of the jugular bulb with invasion of the mastoid bone at the level primarily below the labyrinth as well as the middle ear space and cochlea.
▼在颈静脉球水平，肿瘤粘连主要存在于颈静脉球顶以及部分的内侧静脉壁上部。
As the tumor is removed at the bulb level, there is attachment of the tumor primarily at the region of the dome of the jugular bulb, as well as partially on the medial wall superiorly in that region.
▼分块切除肿瘤，逐步向上至颈静脉球。
The tumor is removed in a piecemeal fashion extending up into the region of the bulb.
▼侵犯颈静脉球上方和迷路下方骨质内的肿瘤，循着之前切除的肿瘤予以仔细清除，包括之前从颈静脉球剥离的肿瘤和已经肿瘤化的颈内静脉。
The bone involvement above the level of the bulb and below the labyrinth, is carefully removed following definition of that tumor that has been removed from the bulb as well as the jugular vein itself.
▼肿瘤切除后，瘤腔贴覆 速即纱 防止渗血。
The tumor has been removed and the tumor bed is packed with surgicel for hemostasis.
▼这一幅Rhoton解剖图，展示了颈静脉孔和颈静脉球内侧壁
This Rhoton dissection in a normal specimen shows the medial wall of the jugular foramen and bulb region
▼以及被内侧壁覆盖着的后组颅神经
and the lower cranial nerves that are covered by the medial wall,
▼下图箭头示岩下窦和髁导静脉汇入颈静脉球的入口。
with the various venous channels that represent the inferior petrosal sinus and condylar emissary drainage into the jugular bulb.
▼关颅：可取前腹部脂肪进行颅底缺损修补。
Closure of the cranial defect is accomplished by utilizing a fat graft taken from the anterior abdomen.
▼ 钛网颅骨成形也可确保脂肪的固定，保证颅底的修复。
The graft is held firmly in place by titanium mesh cranioplasty,which closes the cranial defect.
▼胸锁乳突肌可缝合于钛网上，随后逐层缝合颈部各层软组织。
The sternocleidomastoid muscle can be attached to the titanium mesh, and the soft tissue of the neck dissection closed in a layer fashion.
▼术后，该患者听力、后组颅神经和面神经功能均正常。搏动性耳鸣完全缓解。
Post-op the patient's hearing, lower cranial nerve and facial function were normal. The pulsatile tinnitus was no longer present.
▼术后2月行头颅MR复查未见肿瘤残余。
A two-month post-op follow-up MR scan of head showed no residual glomus tumor.
▼颈静脉孔区最常见的良性肿瘤绝大多数为化学感受器瘤、神经鞘瘤、脑膜瘤。罕见肿瘤为脊索瘤和软骨肉瘤，或其他恶性肿瘤。
Benign tumors of the most common pathology effecting the jugular foramen region the majority are chemodectoma,neurinomas, or meningiomas. Rarely chordomas and chondrosarcomas may involve the jugular foramen,as well as other malignant tumors.
▼肿瘤的病理类型、对颈静脉孔区神经血管的侵犯范围，决定了手术入路的选择。
耳前颞下-颞下窝入路（下图）适用于肿瘤累及颈内动脉和颈静脉孔前部。
The type of pathology and extent to which it involves the neurovascular structures of the jugular foramen region will determine the selection of an approach to the jugular foramen. A preauricular subtemporal infratemporal approach will be necessary for management of tumors involving the internal carotid artery and the anterior jugular foramen.
▼乙状窦后联合远外侧经髁入路（下图）适用于肿瘤侵犯后颅窝或枕骨大孔区。
The retrosigmoid approach involving a far lateral transcondylar exposure is needed for jugular foramen tumors occupying the posterior fossa or foramen magnum.
▼本次讲解主要针对颈静脉孔区最常用的手术入路，即耳后经颞入路联合颈部解剖。
Our presentation is focused on the most common approach to the jugular foramen, the postauricular transtemporal approach combined with a neck dissection.
▼我们强调需充分掌握颈静脉孔区和颈动脉区的应用解剖。对颅底外侧面颈静脉孔区进行270°暴露的理念，进行了详尽的阐述。
This presentation has emphasized a thorough understanding of the surgical anatomy of the jugular foramen region and the carotid space.The concept of exposing the jugular foramen below the skull base in an 270 degree fashion has been shown in a stepwise fashion.
▼颈静脉孔区的手术需做到真正意义上的“解剖性手术”，方可保护复杂的神经血管结构，提高手术疗效。
Skull base lesions in the jugular foramen should be approached as a surgical anatomise to preserve the complex neurovascular structures of this region, and improve one's surgical outcome.
▼对于该区域复杂解剖知识的进一步学习，请观看Rhoton教授讲解的《远外侧入路与颈静脉孔区解剖》《头颈部解剖》（可点击浏览）
For further study of this region in order to understand the complex anatomy, please review Dr.Rhoton's lecture on the jugular foramen.
