Recently, after 15 hours of surgery and breaking through many difficulties, the Department of Otorhinolaryngology of the Third Affiliated Hospital of The University of Major Medicine and multidisciplinary successfully removed jugular venous globulinoma for a patient.
It is reported that this is the first jugular venous globulinoma surgery completed by the Third Affiliated University of Heavy Medicine, and the successful development of this type of complex and difficult surgery is of great landmark significance for the further development of the Otolaryngology Department of the hospital to the leading level in China.
The external auditory canal bleeds repeatedly and inexplicably
It is a rare jugular venous globusma
Tinnitus, hearing loss, many people may be like Mr. Chen from the longevity area, mistakenly think that this is caused by otitis media. But if the external auditory canal is still bleeding repeatedly, it may not be simple.
On April 2, 69-year-old Mr. Chen, accompanied by his family, came to the outpatient clinic of Director Li Hongtao of the Department of Otorhinolaryngology of the Third Affiliated Hospital of The University of Chongqing Medical University. "He had tinnitus, hearing loss for some time, he had otitis media all the time and had been treated at the local hospital. Who knows, since May last year, his right ear has inexplicably bled from the inside out, and the amount of bleeding is not small, but it is scary", because Mr. Chen's hearing is not good, there are some communication problems, and his wife helped him and the doctor to describe the situation.
Found that the right external ear canal was bleeding for unknown reasons, Mr. Chen and his family rushed to a hospital in Chongqing for treatment, but the condition was not effectively alleviated. Until the end of March this year, Mr. Chen's right external ear canal still repeatedly appeared inexplicable bleeding symptoms, and when he heard that Director Li Hongtao from the former Daping Hospital was good at diagnosing and treating this disease, his family immediately brought him to the clinic for treatment.
After a detailed understanding of Mr. Chen's condition, Director Li Hongtao first diagnosed and suspected that Mr. Chen was a middle ear cancer, but the inexplicable external ear canal bleeding time was long, and there may be other causes, for the sake of prudence, it is necessary to be admitted to the hospital for examination and confirm the diagnosis before formulating a treatment plan.
Finally, through the head and neck CTA, internal auditory tract enhanced magnetic resonance and other examinations, Director Li Hongtao found that Mr. Chen's tumor was located at the base of the lateral skull, the main body was in the right jugular vein foramen area, and violated the right temporal bone, breaking through the internal auditory tract, cochlea, tympanic chamber, and invading the external auditory canal outward, and the tumor was very closely related to the vertical segment of the internal carotid artery.
Director Li Hongtao said that various analyses have shown that Mr. Chen is not suffering from middle ear cancer, but is most likely a rare jugular venous globugm. After a large discussion in the department, it was initially determined that the best treatment method for C2 jugular venous globule tumor was to surgically remove the tumor.
Because the jugular venous globule grows on the internal carotid artery and the jugular venous bulb, wrapped around the internal carotid artery, if it is allowed to develop, it will destroy the internal carotid artery, resulting in a large rupture and bleeding of the internal carotid artery, which will inevitably threaten life. At the same time, if the tumor continues to develop intracranially, the patient develops intracranial hypertension. In addition, the tumor grows in the blood vessels, and there will be hemangioma body embolism and transfluent metastases.
"The surgery is very difficult." Director Li Hongtao introduced that this case is very rare, due to the large tumor body, it has invaded the adjacent structure, although he has experience in carrying out such surgery, he still thinks that Mr. Chen's condition is more difficult. However, the patient gave the doctor full trust, in order to maximize the safety of Mr. Chen's life, health and safety, Li Hongtao's team decided to do their best to treat him.
Multidisciplinary consultations are carefully planned
Preoperative angiography and embolization treatment is safe
Jugular venous spheroid tumors are divided into: stage A (small), stage B (medium), stage C (large), and stage D (huge). Stage C tumors stretch toward the submissive and rock cones and destroy the bone in this area, of which type C2: the submissive area is destroyed and invades the vertical segment of the carotid canal.
In order to accurately formulate the treatment plan, on April 12, the department of otorhinolaryngology, anesthesiology, radiology, critical care medicine, neurosurgery, and cardiovascular surgery conducted a multidisciplinary MDT consultation, and the expert team discussed in depth and detail, and clarified the surgical steps, estimated time and response plan.
"However, the blood supply to this jugular venous globule is unusually abundant." Director Li Hongtao said that in addition to the external carotid artery, the tumor blood supply artery is also clearly demarcated from the internal carotid artery, and the possibility of blood supply is not ruled out. In order to ensure the safety of the operation and avoid intraoperative bleeding, they also made a full response plan before the operation. On April 13, Director Li Hongtao, Deputy Chief Physician Zhang Min, Attending Physician Tan Yun, and Physician Li Mingming of the Department of Otorhinolaryngology, with the cooperation of Ji Jianwen, Deputy Chief Physician of Neurosurgery, and Li Fuping, Director of Cardiovascular Surgery, performed angiography and interventional embolism for Mr. Chen. Through contrast, the interventional team identified the blood vessels that supply blood to the tumor, the pharyngeal artery supplies blood to the medial side of the tumor, and the posterior occipital artery provides blood supply to the lateral tumor. Subsequently, the blood supply of the external carotid artery was coagulated by embolization, and the two blood vessels of the pharyngeal ascending artery and the stem and milk artery in the branches of the external carotid artery were precisely embolized.
"This provided an opportunity for safe surgery the next day, and I was more confident that I would not be so worried about heavy bleeding." Director Li Hongtao said so.
High-difficulty surgery is completed in 15 hours
Postoperative care awaits discharge
At 8:00 a.m. on April 14, according to the pre-formulated surgical plan, Director Li Hongtao led Zhang Min, Tan Yun and Li Mingming to start this high-difficulty operation that attracted the attention of the whole hospital on time.
For patients with intravenous compound anesthesia, first make an incision about 10 cm long in the left abdomen, take the fat size of the fist; then from 2 cm above the upper pole of the right ear chakra, 5 cm from the posterior groove of the ear to the tip of the mastoid, extend from the tip of the mastoid to the level of thyroid cartilage, make a question mark incision of about 30 cm long, and then close the opening of the external auditory canal; separate the internal facial nerve of the parotid gland; extend the incision and ligature the external carotid artery, etc.; preliminary mastoid profiling... The first part of the naked eye opening surgery under the shadowless lamp, from 8 a.m. to 12 noon, was relatively smooth.
Next is the second part, which is operated under the microscope: anterior removal of the facial nerve of the facial expression movement, blocking and pressing the closure of the jugular vein supply, pressing the sigmoid sinus; exposing the Eustachian tube and blocking it; removing the wall of the cervical artery and exposing the vertical segment of the internal carotid artery; removing the stem process to reveal the temporal mandibular fossa... Although all the delicate movements were done on blood vessels about 2-3 mm thick, the surgical team also successfully completed within the expected 5 hours.
The third part is to remove the tumor and fill the cavity. This part is still operated under the microscope, and it is necessary to cut the tumor while stopping the bleeding and protecting the nerves. Moreover, during the operation, it was found that the tumor was particularly tightly adhered to the carotid artery wall, and the experienced surgical team slowly peeled off in an orderly manner, and finally took 6 hours to complete the tumor resection, facial nerve anastomosis, adipose tissue tamponade, and incision suture.
In the early morning of April 15, after 15 hours of hard work by the surgical team, the operation finally ended smoothly, and the amount of bleeding was only 300 ml. After the operation, After Mr. Chen was sobered up with anesthesia, he was sent to the intensive care department with endotracheal intubation to continue treatment; the next day, he was transferred back to the ward to give anti-infection, anti-thrombosis and extraintestinal nutrition treatment; on the third day, he began to get out of bed, go to the toilet, activities... Through the meticulous treatment of the medical team working together, Mr. Chen is speeding up his recovery and will be discharged from the hospital after his condition stabilizes.