鼻内蝶筛窦切除术应用解剖研究

对６０具完整成人尸头鼻内蝶窦，筛窦切除术的应用解剖进行了研究。通过颅正中矢状切面，水平切面，设计了９条测线，２个测角和４项观察。认为中鼻甲是鼻内蝶，筛窦切除术的重要内部标志，前鼻棘是此类手术的重要外部标志，纸样板与中鼻道外侧壁（上颌窦内侧壁）处于同一垂直面。本研究提供了有关鼻内蝶，筛窦手术的解剖数据，供临床参考。     

鼻内窥镜下筛泡的应用解剖研究

目的对筛泡行应用解剖学研究,以冀为鼻内窥镜筛泡切除术确定安全的手术界限,减少并发症的发生.方法30例、60侧外观无异常经10%福尔马林固定的成人尸头(男23例,女7例),用MJ3435型带锯机,沿眉弓上缘及枕骨粗隆上1em连线水平锯开颅盖骨,去除脑组织;沿正中线矢状锯开头颅,去除鼻中隔;经眶下孔与正中剖面平行矢状锯开,用解剖刀、筛泡钳和剥离器等按鼻内窥镜下筛窦手术的体位和路径,逐层解剖并测量各解剖结构的径线,观测其变异.结果筛泡内外径8.91±2.82mm,筛泡垂直径13.92±7.08mm,筛泡骨壁厚0.23±0.10 mm,筛泡中心到下鼻甲附着缘的最小平均距离11.96±2.31mm.钩突与筛泡之间平均距离上0.68±0.36 mm,中1.71±0.78 mm,下2.81±0.58mm.结论由于筛泡变异大,了解其解剖结构的径线,对鼻内窥镜手术有重要作用.     

高频电凝在筛前筛后动脉结扎术中的应用

筛前筛后动脉结扎通常用于上述动脉所供区域的顽固性鼻出血.是一种有效的治疗方法,常常达到立竿见影的效果。自1937年首次开展,一直运用至今。但就其筛前筛后动脉切断的问题,一般都不主张[1,2]。在近些年的临床工作中,我们尝试了6例高频单极电凝灼断(或切断)筛前筛后动脉治疗顽固性鼻出血,疗效满意,无任何并发症,介绍如下。     

改良筛前动脉结扎术的解剖入路观察及临床应用

目的寻求理想的结扎筛前动脉的手术入路.方法以12具湿性尸头和20具干尸头标本为解剖材料,实地测量并以额筛缝为标志改良手术进路.将观察结果用于临床,治疗难治性鼻出血.结果筛前孔及筛前动脉距眶缘约2cm,改良手术入路并应用显微手术术野清晰,可操作性强,临床效果好.结论改良筛前动脉结扎术简单、实用、有效.     

筛动脉性鼻出血的诊治

我院1996年7月～2000年12月收治顽固性鼻出血91例,其中筛动脉性出血41例。由于筛动脉出血位置隐蔽,易被忽视及误诊。为加深对筛动脉性鼻出血的了解,现将我们的诊治体会报告如下。     

鼻内镜手术筛前动脉损伤所致眶内并发症的预防和处理

目的探讨鼻内镜手术筛前动脉损伤所致眶内并发症的原因分析、处理及预防。方法分析2例鼻内镜手术筛前动脉损伤所致眶内并发症的临床特点、处理方法及预后,进行相关文献复习,分析筛前动脉损伤的高危因素及预防措施。结果2例患者术后均出现眶压增高、球结膜水肿、视力下降,考虑为筛前动脉损伤致眶内血肿,经过及时行眶减压、电凝止血,一例患者术后视力逐渐恢复正常,另一例患者视力未能得到有效恢复。结论鼻内镜术前需仔细阅片,对于筛前动脉游离度大的病例,以及肿瘤破坏骨质包裹动脉的患者,术中需注意仔细辨认,避免损伤筛前动脉;如术中动脉损伤应及时电凝止血;术后出现眶压增高、视力明显下降者,应考虑筛前动脉损伤导致眶内血肿可能,应及时进行眶减压及筛前动脉电凝止血。     

下鼻甲动脉的应用解剖

目的 为下鼻甲手术提供局部解剖学数据。方法 在10侧成人头颈部标本上解剖观测了鼻后外侧动脉的来源，走行，分支，分布及吻合情况。结果 蝶腭动脉大多（90%）在蝶腭孔处已分为鼻后外侧动脉和鼻后中隔动脉，二者在蝶腭孔处外径分别为0.84mm和0.98mm。鼻后外侧动脉发出下鼻甲动脉和中鼻甲动脉，其外径分别为0.70mm和0.63mm。下鼻甲动脉在中鼻甲后端附着处下方约3mm处起始后垂直下行，经中鼻道粘膜下进入下鼻甲后方，在下鼻甲近内侧面与上面交界处的粘膜下前行，沿途分支分布于下鼻甲及下鼻道，且有分支与中鼻甲动脉吻合。结论 鼻后外侧动脉是鼻腔外侧壁血供的主要来源，下鼻甲部分切除术应注意保护下鼻甲动脉，以减少术中出血及并发症的发生，提高手术效果。     

内镜鼻窦手术中眶上筛房的定位作用和筛前动脉分型的意义

目的:探讨内镜鼻窦手术中眶上筛房(SOEC)定位额窦口(FO)和筛前动脉(AEA)的作用,以及AEA内镜分型的临床意义.方法:收集116例慢性鼻窦炎患者的临床资料,筛选出伴有SOEC并完成DrafⅡ A型手术者36例(47侧),记录SOEC与FO、AEA的影像-解剖关系.根据内镜下AEA隆起范围与筛顶的关系,将其分为1...     

眶内侧壁的应用解剖研究

对６０具成人尸头的眶内侧壁进行解剖，观察筛窦外侧壁即纸样板的垂直面与中鼻道外侧壁和上凳窦内侧壁的关系，各筛孔与Ｄａｃｒｙｏｎ点的关系，测量眶内侧壁孔间的距离，以及纸样板的长度、宽度、厚度。以给鼻外筛窦及鼻内筛窦显微手术提供一系列应用数据。     

鼓岬区底转骨螺旋板的分段定位及其临床意义

目的:为耳蜗植入术提供耳蜗鼓岬区底转骨螺旋板的解剖资料,同时寻找从鼓岬表面定位骨螺旋板的方法.方法:取成人颞骨标本15例(30侧),经乳突后鼓室进路,进入鼓室;在手术放大镜下对鼓岬区骨螺旋板走行、分段及毗邻结构进行观测.结果:①耳蜗底转骨螺旋板在鼓岬区可通过位于蜗窗龛上缘及下部的转折点分成3段:钩段(1.52±0.16)mm,蜗窗前下段(3.83±0.37)mm和前行段(2.70±0.36)mm;②蜗窗前下段所在平面与面神经水平段成角为(51.00±5.97)°,且较恒定地与镫骨头后缘相交;以镫骨头后缘为一固定点,在鼓岬上画一经过此点与面神经水平段成51°的直线,可代表骨螺旋板蜗窗前下段在鼓岬上的投影,也即此段骨螺旋板在鼓岬上的投影线;③鼓岬区鼓阶宽度:蜗窗龛上缘中点处宽度为(0.36±0.06)mm;蜗窗龛前缘中点处宽度为(0.97±0.14)mm;蜗窗前下3 mm处宽度为(1.24±0.21)mm.结论:①鼓岬区骨螺旋板可通过2个转折点分成3段,即钩段、蜗窗前下段和前行段;②骨螺旋板在鼓岬上的投影线及与毗邻结构的距离可以为人工耳蜗植入术中准确定位鼓阶,避免损伤基底膜提供形态学依据.     

New guidelines for endoscopic localization of the anterior ethmoidal artery: a cadaveric study

OBJECTIVES: To determine objective data to improve the methods of identification of the anterior ethmoidal artery during endoscopic dissection. STUDY DESIGN: Cadaveric dissection of adult human heads. METHODS: A 0 degrees, 4-mm rigid endoscope was used to guide uncinectomy and frontoethmoidectomy. The location of the anterior ethmoidal artery was first determined visually and then confirmed by passing a needle through the anterior ethmoidal foramen from the orbit into the nose in all cases. The distances were endoscopically measured using a simple ruler between two nasal landmarks and the anterior ethmoidal artery. RESULTS: Fifty-six nasal fossae in 28 cadavers were dissected endoscopically. The median distance between the artery and the "axilla" formed by the anterior attachment of the middle turbinate to the lateral nasal wall was 20 mm (range, 17-25 mm), irrespective of the side. The measurement differed by less than 2 mm between the sides in the same individual. The median distance between the artery and the "axilla" formed by the medial and lateral crura of the lower lateral cartilage (superomedial edge of the nostril) was 62 mm (range, 55-75 mm) for both sides. The artery was found to be in direct alignment with the two "axillae" formed by the middle turbinate and the nostril edge. CONCLUSIONS: The distance between the ethmoidal artery and the axilla of the middle turbinate showed the least intraindividual and interindividual variations. The tip of the endoscope (or the ruler) points directly at the anterior ethmoidal artery in the fovea ethmoidalis when its edge is aligned with the two nasal landmarks. These simple guidelines can aid the identification of the artery in endoscopic frontoethmoidectomy.     

鼻内镜下颌内动脉翼腭段应用解剖及其意义

目的通过鼻内镜经鼻腔入路对颌内动脉翼腭段及其周围区域的解剖学研究,为临床鼻内镜下颌内动脉翼腭段区域手术提供解剖学基础。方法对10具(20侧)新鲜尸头经鼻内镜下鼻腔外侧壁入路对侧颅底翼腭窝区域进行解剖学观测,正中矢状锯开标本观测内镜下解剖标志及颌内动脉翼腭段分支变异及邻近血管神经结构。结果①颌内动脉翼腭窝段变异较大,颌内动脉翼腭段按顺序发出分支占25%(5/20),眶下动脉和上牙槽后动脉共干发出占50%(10/20),分别由颌内动脉发出占40%(8/20);颌内动脉同时发出眶下动脉、腭降动脉、蝶腭动脉占10%(2/20);眶下动脉和腭降动脉共干发出占10%(2/20);翼管动脉和圆孔动脉分别由颌内动脉发出及共干发出各占50%(10/20);②鼻内镜下能够较好的控制颌内动脉及其分支,对周围结构触动少。结论掌握颌内动脉翼腭段及其周围区域的解剖可降低鼻内镜下该区域手术的并发症,对于翼腭窝手术及治疗顽固性鼻出血有重要意义。     

Endoscopic anterior ethmoidal artery ligation: a cadaver study

OBJECTIVE: The objective of this study was to investigate the radiologic and endoscopic anatomy of the anterior ethmoidal canal (AEC) and feasibility of endoscopic ligation of the anterior ethmoidal artery (AEA). STUDY DESIGN: The authors conducted a prospective analysis of computed tomography (CT) of the paranasal sinuses and endoscopic cadaver dissection. METHODS: Twenty-two cadaver heads had CT scans of the paranasal sinuses. The height of the lateral lamella of the cribriform plate was calculated and staged according to the Keros staging system. The presence of a bony mesentery, distance from AEC to the skull base, and dehiscence of the AEC were documented. Forty-four dissections were performed, the AECs identified, and AEA ligation attempted. RESULTS: The mean height of the lateral lamella was 5.4 mm on the right and 4.7 mm on the left. In all cadaver heads with asymmetry, the right lateral lamella was longer (P<.005). A Keros type 1 pattern was seen in 23%, type 2 in 50%, and type 3 in 27%. Thirty-six percent of AECs were in a bony mesentery. AEC distance from the skull base was greater on the right (P<.009). A longer lateral lamella was correlated with the artery being in a mesentery. Sixteen percent of the AECs were dehiscent. Sixty-six percent of AEAs were unable to be clipped. Twenty percent were clipped effectively, all in a mesentery. In 14%, the AEA was not effectively clipped. CONCLUSIONS: Endoscopic AEA ligation may be possible in some patients. The AEA should be in a mesentery for an effective clip to be placed and be associated with a dehiscence of the AEC. If the lateral lamella is classified as Keros grade 2 or 3, it is likely the AEC will be found in a mesentery.     

侧颅底应用解剖学研究

目的 通过对侧颅底解剖学结构的观察与测量,为临床侧颅底手术的定位、导航提供解剖学依据。方法 10%甲醛浸泡的成人尸头10个(20侧),观测颈静脉球区域神经血管、颈内动脉毗邻的解剖关系。结果 颈静脉球,其形态可分为隆起型和低平型,舌咽神经多位于颈静脉球前内侧者,迷走神经和副神经多位于颈静脉球内侧者,颈内动脉岩骨段距离鼓膜张肌的长度平均为2.2mm,距离下颌神经和脑膜中动脉的平均长度分别为6.9mm和6.8mm。结论 侧颅底血管和神经分布密集,术者了解侧颅底血管和神经的解剖关系,有利于手术中安全扩大手术视野,避免术中损伤血管、神经。     

经鼻鼻内镜下泪囊造口定位的解剖与临床研究

目的调查经鼻内镜下鼻腔泪囊造口术的解剖定位资料。方法经鼻内镜下解剖16具湿性成人尸头32侧泪囊,确定泪囊鼻腔造口的最佳解剖位置标志;并结合2例手术失败病例和12例尚未行手术的慢性泪囊炎病例的相关影像学资料,对比分析最佳解剖定位数据。结果泪囊上、下点与鼻小柱和鼻翼交界点及"中鼻甲腋"(即中鼻甲前端位于鼻腔外侧壁的附着处)的距离分别为33.0±3.3mm、44.6±4.9mm和6.8±1.4mm、3.2±1.6mm;2例手术失败病例的泪囊鼻腔开口位置较低。结论手术中,应在中鼻甲腋前上方定位鼻腔内泪囊开口。     

Endoscopic ligation of the anterior ethmoidal artery: a cadaver dissection study

Anterior ethmoidal artery (AEA) ligation may be necessary in cases of severe epistaxis not controllable with traditional therapy. Endoscopic endonasal ligation of the AEA is not used frequently; there are few studies in the literature for standardization of the endoscopic technique for this vessel.Aim: To demonstrate the feasibility of periorbital AEA ligation in a transethmoidal endoscopic approach.Methods: A prospective study where 50 nasal cavities were dissected. After anterior ethmoidectomy and partial removal of lamina papyracea, the periorbital area was carefully dissected along a subperiosteal plane to identify the AEA. The vessel was exposed within the orbit and dissected.Results: Data on technical difficulties, complications, the learning curve and anatomical variations were gathered.Conclusion: An endonasal endoscopic approach to the AEA within the orbit was shown to be feasible. Identifying the artery is not difficult, and this technique avoids external incisions. This approach appears to be an excellent alternative for approaching the AEA. Further clinical studies are needed to demonstarte the benefits of this technique.     

与鼻内窥镜下鼻腔泪囊造孔术有关的前筛窦应用解剖

本文对６０具成人尸头有鼻内窥镜鼻腔泪囊造孔术的前筛窦解剖进行了研究，根据前筛窦与泪囊窝的解剖关系将前筛窦气房气化范围分为三度，结果为属Ｉ度者有２３．３３％，Ⅱ度者有５７．５０％，Ⅲ度者有１９．１７％。这种分度法对鼻内鼻腔泪囊造孔术具有临床指导意义。     

Adenocarcinoma of the ethmoidal and nasal mucosa: lateral rhinotomy as a more conservative approach

Malignant neoplasms of the nasal cavity and paranasal sinuses are infrequent. In relation to salivary gland carcinomas of the naso-ethmoidal region and, due to its poor prognosis, a radical en bloc resection followed by radiotherapy is mandatory to control the disease. Surgically, naso-ethmoidal tumors must be managed by means of a combined craniofacial approach or using a lateral or total rhinotomy, a transpalatal or a transantral approach. We suggest the use of lateral rhinotomy for tumors of moderate size located homo-laterally, without involvement of the orbits, the cribriform plate, sphenoidal sinus or the clivus. A wide approach with minimal aesthetic and functional consequences is obtained by means of this method.