鼻科学

200708筛动脉眶内段及窦内段的应用解剖研究/鞠学红…//临床耳鼻咽喉科杂志一1 999,13(9)一399一400 目的:研究筛动脉的走行规律及局部位置关系,为筛窦手术和视神经管减压术提供参考。方法:采用显微解剖学技术对60侧成人筛动脉眶内段和窦内段进行观察和测量。结果:筛前动脉眶内     

鼻外筛窦进路视神经减压术（附3例报告）

报告经鼻外筛窦进路视神经减压术治疗视神经管内损伤３例，因就诊时间较晚，２例无改善，仅１例视力好转。手术体会：①应尽早在伤后１周内进行减压术；②显微镜下手术，保证良好的暴露与减压；③术者应熟悉视神经解剖与定位标志；④视神经骨管内壁减压范围超过管径的１／２，长度约５ｍｍ，可获减压效果，如无明显神经肿胀或淤血，不需切开神经鞘膜。     

经鼻视神经减压术相关的内镜解剖学研究

目的：研究视神经和后组鼻窦以及眼动脉的关系,寻找可靠的解剖标志,为经鼻视神经减压手术中视神经定位和有效避免损伤眼动脉提供内镜解剖学基础。方法：选用8例成人头颅标本,采用messerklinger手术方法开放后组筛窦和蝶窦。在内镜下辨认视神经-颈动脉隐窝和视神经管,观察视神经和后组鼻窦的关系,去除骨性管壁,充分开放视神经的颅口和眶口,切开视神经管硬膜层,观察视神经和眼动脉的关系。结果：本组发现在所有标本中均可以观察到颈内动脉一视神经隐窝,视神经隆起出现率仅为62％;视神经和蝶窦以及后组筛窦存在3种毗邻关系,8侧（50％）前部为后筛窦,后部为蝶窦,5侧（31％）全为蝶窦,3侧（19％）全为筛窦;视神经管颅口部眼动脉位于视神经内下方9例（56％）、下方4例（25％）和外下方3例（19％）,眼动脉在视神经下方向外侧行走,至视神经管眶口部,眼动脉位于视神经下方3例（19％）和外下方13例（81％）。结论：视神经一颈内动脉隐窝恒定出现,同时由于内镜的成像特点,该隐窝比视神经管隆起的辨认更加可靠,可以作为视神经减压手术中的首选解剖标志;眼动脉发起的位置位于视神经的下内侧,发出后向下外侧行走,行程中存在交叉关系,手术中应注意该因素,避免损伤眼动脉。     

视神经减压术的临床讨论

1　何谓视神经减压术 ,有何临床意义 ?答 :视神经分三段 ,即眶内段、视神经管段及视交叉颅内段。颅面闭合性外伤时视神经管段最易遭受损伤。视神经骨管内骨膜与神经鞘膜紧密融合一起 ,视神经在骨管内无移动余地 ,软脑膜血管丛是视神经主要供血来源 ,一旦骨管骨折或神经受损 ,便可发生缺血、水肿、压迫坏死的恶性循环 ;如早期将骨管磨开 ,切开鞘膜减压 ,即有可能恢复血运 ,消退水肿 ,保存神经功能。其机制基本同面神经减压术。2　视神经减压术有那些手术途径 ?其优缺点是什么 ?答 :临床上已采用的视神经减压术有以下 4种 :开颅减压术 :患侧额…     

中耳手术相关面神经管的解剖观测

目的：为避免中耳手术中对面神经的损伤。方法：对２０ 具（４０ 侧）成人尸头颞骨内面神经进行解剖观察。结果：①面神经裂缺率为３２．５％ （１３／４０）,迷路段、水平段、垂直段分别为５％ （２／４０）、２７．５％ （１１／４０）、７．５％ （３／４０）。②面神经垂直段与后半规管最短距离为０．６２～５．０８（２．４８±０．６３）ｍ ｍ ,鼓沟底水平面神经与鼓索神经最短距离为０～４．６２（２．１２±０．７６）ｍ ｍ ,鼓沟底水平面神经与鼓沟最短距离为２．９６～８．８２（５．８６±１．６２）ｍ ｍ 。③面神经水平段与外半规管最短距离为０～３．０２（１．９２±０．８４）ｍ ｍ ,与蹬骨底板最短距离为０．９２～４．０６（２．１４±０．９０）ｍ ｍ 。结论：熟悉颞骨内面神经解剖,可避免对面神经的损伤,减少和避免面瘫的发生     

鼻额管及毗邻关系的应用解剖研究

探讨额窦、鼻额管及毗邻部位的解剖关系。方法：选国人成人干颅骨２５例５０侧,将颅骨矢状正中锯开,用直尺、游标卡尺、量角器等测量工具测量。结果：在５０侧标本中额窦未发育占１４％,额窦矢状径（ｘ±ＳＤ）为１２．９６±７．３３ｍｍ,额骨的内侧板和眶上壁骨质厚度分别为１．１５±０．７７和１．０６±０．５９ｍｍ,鼻额管长为８．４５±４．３２ｍｍ,鼻额管开口直径为５．２９±１．９ｍｍ,开口位置５０％于额隐窝,３０％于筛漏斗附近或筛漏斗内,４％于筛顶,２％在同侧上颌窦顶。额窦口距筛前动脉管为３．４±２．８３ｍｍ。结论：额窦于２岁后渐发育,也可终身不发育。国人额窦矢状径较西方人明显减少约４ｍｍ,为东方人比西方人较少合并额窦炎并发症的原因之一。额骨内侧板和眶上壁的骨质菲薄也为毗邻部位合并症发生的原因。鼻额管的狭长、开口的位置可导致额窦炎及并发症发生率的升高。筛前动脉于额窦口的后壁,此处可为术中标志。     

鼻内镜下视神经管的局部解剖与临床应用

目的：为鼻内镜下视神经管减压术的临床运用提供解剖学依据。方法：成人尸头湿性标本15例（30侧）视神经管,经鼻内镜下观察视神经管的局部解剖情况。结果：鼻内镜下测得前鼻棘到视神经管眶口内侧壁中点距离为（61．02±5．83）mm,前鼻棘到视神经管眶口内侧壁中点的角度为（45．1±4．81）°,视神经管的内侧壁最长,平均为（11．61±1．58）mm;视神经管外侧壁骨质最厚,内侧壁骨质最薄,内侧壁中又以眶口最厚。并且将观察所见应用于10例外伤性失明患者,效果满意。结论：鼻内镜下了解视神经管的局部解剖情况,对临床开展鼻内镜下视神经管减压术具有非常重要的意义。鼻内镜下视神经管减压术具有手术范围小,组织损伤轻,视野清晰,进路直接,术后处理简单,面部不留瘢痕等优点,值得临床推广应用。     

鼻内镜术致失明的预防和处理（附3例报告）

目的：探讨鼻内镜术致失明的预防和处理。方法：报告3例慢性鼻窦炎和鼻息肉患者于鼻内镜手术中损伤眼部结构和碘仿凡士林纱条填塞后并发的失明及其处理方法。结果：3例中2例因鼻内镜手术时损伤同侧眶内壁纸板和眶内组织结构,术中1例眼球变形、失明,立即行眶内视神经探查和眼内肌修复;1例出现眶周肿胀、眼睑淤血和睑结膜水肿,术后2d失明,清除眶内血肿及行视神经减压术。另1例术中筛窦填塞立即失明,抽出填塞物视力恢复。术后3例患者静脉用大剂量抗生素、糖皮质激素和神经生长因子治疗4周。随访6个月1例视力正常;1例失明,眼球萎缩;1例光感。结论：鼻内镜手术损伤眶内容物和出血,是失明的原因;术前CT检查示后筛窦呈过度气化者,术中应注意视神经骨管是否缺损;确认眶纸板损伤者一般不宜行鼻腔填塞;术后视力下降明显者应立即行视神经减压。     

蝶窦与筛窦骨壁抗力的评价

功能性鼻窦内窥镜手术常因损伤筛窦或蝶窦骨壁而出现各种并发症，甚至可危及生命。临床上已注意到某些部位易受损伤，为研究这些部位的抗损伤能力，对２１具尸头标本的蝶窦及筛窦骨壁进行抗力试验。测试部位包括：泪骨、筛泡内纸板、后组筛房中央纸板、筛前动脉附近的筛顶、额窦口后壁、前筛板、上筛泡气房的筛顶、筛后动脉附近的筛顶、视神经处后组筛房的后外壁（即Ｏｎｏｄｉ气房）、蝶窦内视神经管骨壁、蝶窦内颈内动脉管前壁，共计１１处。试验时采用探头表面积为１ｍｍ２的测力计，对测试的骨壁垂直加压，以克为单位记录至骨壁发生完全…     

管内段视神经损伤的诊断和疗效分析

目的分析管内段视神经损伤所致视力障碍的诊断要点、疗效及影响愈后的因素。方法对２６例（２７侧）管内段视神经损伤继发视力障碍的患者,经眶部ＣＴ检查后,在药物治疗的同时,采用鼻外开筛进路视神经减压术治疗。结果该病的眶部ＣＴ检查总阳性率为６６７％,其中视神经管骨折阳性率为８１３％,视神经水肿阳性率为５５．６％。伤后立即出现视力障碍者有效率为５７．１％,非伤后立即出现视力障碍者有效率为８３３％。术中明确发现有视神经管骨折者有效率为５６．３％,仅见视神经水肿者有效率为６６．７％。手术时机愈晚,疗效愈差。结论眶部ＣＴ检查对管内段视神经损伤具有重要诊断价值,ＣＴ检查阴性不能除外该病;疗效与视神经损伤程度和手术时机等因素有关。     

CT anatomic measurement of the optic canal and its clinical significance]

OBJECTIVE: To probe into the normal anatomy of the optic canal and its clinical significance. METHODS: The optic canals of 200 normal subjects were examined by thin layer CT scan in axial nd coronal positions. The distance and anatomic relationship with circumferentral structure were measured. RESULTS: In average: (1) The transverse diameter of the optic canal was (3.57 +/- 0.61) mm, the longitudinal diameter was (4.82 +/- 0.38) mm, the length of the inner wall was (12.62 +/- 2.59) mm, the length of the outer wall was (10.18 +/- 2.19) mm, and the length of the optic canal was (11.46 +/- 2.35) mm. The angle between optic canal and the middle line of the skull was 34.34 degrees +/- 6.48 degrees, the angle between optic canal and the intraorbital optic was 10.69 degrees +/- 6.48 degrees. The thickness of the inner wall was (0.68 +/- 0.46) mm. It showed no significant difference between the two sides of the optic canal in diameters(P > 0.05). (2) The optic canal, the superior orbital fissure and the inferior orbital fissure were respectively shown as track, crack and gorge type in CT axial pictures, while in the coronal pictures, they were respectively shown as butterfly eyes, horizontal fissure and vertical fissure type. (3) The relationship of the posterior ethmoid sinus and the optic canal was: anterocanal(42.00%), semicanal(27.5%), whole-canal(18.75%), sella turcica(9.75%) and circumcanal(2.00%). (4) The relationship of the position of the sphenoidal sinus and the optic canal was: I degree sphenoidal sinus(20%), II degree (63%) and III degree (17%). (5) The incidence of the bony defect of the inner optic canal wall was 25.5%. The range of the defect was (5.07 +/- 2.52) mm. CONCLUSION: It's a reliable way to show the relation of the optic canal and circumcanal by CT, and it is of important value in operation.     

眶-筛-蝶联合径路视神经减压术的临床应用

目的 :探讨提高视神经管内段损伤疗效的方法。方法 :采用眶 筛 蝶联合径路对 5 2例视神经管内段损伤进行减压术治疗 ,全程松解视神经。结果 :术后视力得到不同程度恢复者 2 2例 ,视力改善率为 42 .3%。其中继发性视力损伤 2 3例 ,视力提高者占 73.9% ;原发性视力损伤 2 9例 ,视力提高者占 17.2 %。随访 6个月 ,视力恢复至 0 .0 5～ 0 .6。结论 :眶 筛 蝶联合径路视神经减压术进路短 ,视野宽 ,便于操作 ;且解剖标志清楚 ,易定位 ,更安全 ,更适合筛、蝶窦发育不良 ,骨质增生者。     

蝶窦、视神经管多层螺旋CT三维重建后的影象解剖学测量

目的：为经鼻内镜蝶窦手术、视神经管减压术提供影象解剖学基础。方法：利用螺旋CT三维重建技术对40例(80侧)鼻、鼻窦正常的受试者行蝶窦、视神经管有关解剖数据的影象学测量。结果：两侧视神经管各壁长度均值为：内侧壁12.08±0.62?mm，外侧壁10.16±1.73?mm,上壁9.16±1.17?mm,下壁10.24±1.35?mm。两侧视神经管及蝶窦有关径线均值为：视神经管颅口处：左右径5.57±0.95?mm，上下径4.53±0.78?mm；中部：左右径4.40±0.67?mm，上下径4.36±0.67?mm；眶口处：左右径5.09±0.85?mm，上下径5.90±0.98?mm；鼻小柱前缘中点到蝶窦前壁中点的距离：7.08±0.54?cm；蝶窦最大左右径：17.83±4.38?mm，最大上下径：18.40±3.76?mm，最大前后径：23.19±6.73?mm。结论：螺旋CT三维重建技术可以准确有效地测量蝶窦、视神经管的解剖结构，对经鼻内镜手术具有重要指导价值。     

视神经管局部解剖与鼻内镜下解剖的结合研究

目的:为鼻内镜下视神经管减压术的临床运用提供解剖学依据。方法:10具(20侧)成人湿性尸头,从正中矢状位锯开,以直尺、量角器等测量工具测量视神经管与前鼻棘间的距离和角度;5具(10侧)(含儿童尸头2具)湿性尸头经鼻腔行鼻内镜下视神经管眶口至颅口段解剖,观察视神经管及其相关解剖标志。结果:大体标本观察,均可见到视神经管与颈内动脉呈“八”字形关系,测得视神经管内侧壁长度平均(9.12±1.89)mm,视神经管眶口直径平均(4.12±0.53)mm,前鼻棘到视神经管眶口内壁中点距离平均(61.22±6.23)mm,前鼻棘到视神经管眶口内壁中点的角度平均(45.3±4.5)°。鼻内镜下观察,沿视神经管眶口向后,可见到不同程度的一条反光带,即视神经管,7侧(70%)可见到明显的隆起,3侧(30%)无明显隆起,无法按照隆起形状判断视神经管。结论:结合大体解剖观察与鼻内镜下解剖观察,有助于准确识别鼻内镜下的视神经管,从而提高鼻内镜下视神经管手术的准确性。     

Computer-aided three-dimensional reconstruction and measurement of the optic canal and intracanalicular structures.

OBJECTIVE: To reconstruct the human optic canal and its inner structures and to provide detailed knowledge of this region for optic nerve decompression. METHODS: Six optic canals and their inner structures were reconstructed using a computer-aided three-dimensional reconstruction system. Quantitative measurement of the canal wall thickness, bony canal transverse area, optic nerve transverse area, dural sheath transverse area, subarachnoid space transverse area, and subarachnoid space volume was done using the computer morphometric analysis system. The detailed spatial relationship among intracanalicular structures was also carefully identified on the three-dimensional models. RESULTS: The thinnest portion of the canal was the middle part of the medial wall (0.45 +/- 0.14 mm) and the narrowest space was in the middle part of the optic canal (the transverse area was 18.21 +/- 1.20 mm2). The volume of subarachnoid space that can be considered the compensatory space for distention incurred by the hemorrhage, optic nerve edema, or hematoma was 21.16 +/- 4.31 mm3. At the cranial opening, the middle part, and the orbital opening, its transverse area was 4.45 +/- 0.46 mm2, 2.68 +/- 0.54 mm2, and 1.23 +/- 0.34 mm2 respectively. CONCLUSIONS: Because the compensatory space was limited, even a tiny amount of blood or swelling of the nerve may cause optic nerve compression. Because the compensatory space for distention gradually decreases from cranial end to orbital end, the middle part and the anterior part of the optic canal and dural sheath are critical in optic nerve decompression.     

Surgical anatomy of the optic nerve and the internal carotid artery in the lateral wall of the sphenoid sinus. An anatomic study of the cranial base]

The optic nerve and the internal carotid artery lying in the cavernous sinus contact the bony wall of the sphenoid sinus, and can easily be injured during surgery. The maxillary sinus, the sphenoid sinus and the ethmoid cells were opened on both sides during ten resections of the skull base. After removing the bony part of the lateral wall of the sphenoid sinus the following measurements were performed: the distance between the optic nerve and the frontal dura; the distance between the optic nerve and the internal carotid artery; the length and width of the optic nerve and the internal carotid artery in the area contacting the bony wall of the sphenoid sinus. This study illustrates the regularity of the structures of the posterior nasal wall. Landmarks are offered for finding the orbital aperture of the optic canal. The necessity of orientation by landmarks is emphasized.     

High-resolution computed tomography analysis of the greater palatine canal

BACKGROUND: The greater palatine foramen injection is effective for minimizing bleeding during sinus surgery. The correct depth is important to minimize risk of orbital penetration. This study analyzed the length of the greater palatine canal using high-resolution computed tomography (HRCT). METHODS: HRCT sinus scans from 100 adults were analyzed. One thousand two hundred measurements were performed by three observers. RESULTS: The mean distance of the greater palatine foramen to the orbital floor was 40+/-3 mm in men and 37+/-3 mm in women (range, 32-46 mm). The mean distance of the greater palatine foramen to the sphenopalatine foramen was 28+/-2 mm in men and 27+/-2 mm in women (range, 23-33 mm). CONCLUSION: The greater palatine foramen injection is an appropriate method to minimize bleeding during endoscopic sinus surgery. The authors recommend an injection depth of 25 mm in adults to minimize the risk of intraorbital complications.     

Danger areas of the posterior nasal base: anatomical, histological and endoscopic findings

In 52 cadaveric half-heads and endoscopic sphenoethmoidectomy was performed. Subsequently an anatomical preparation with registration of specific data like bulging of the optic canal, thickness of the bony wall covering the optic nerve and the internal carotid artery was achieved, followed by histological sections in specially selected cases. Thus the two key areas of major surgical hazard in the posterior rhinobasis could be clearly demonstrated: the immediate topographic relation of the optic canal and the internal carotid artery to the lateral wall of the sphenoid sinus and the cells of the posterior ethmoid, respectively. Onodi cells of varying degrees were found in 42% of all cases. The thickness of bony wall over the maximum bulging of the optic canal averaged 0.28 mm. Bony dehiscences could be demonstrated in 12% of the cases. The technique of data acquisition, the anatomical and histological findings as well as their clinical and surgical relevance are discussed.     

嗅相关神经的临床解剖学观测

目的:了解嗅神经的正常走行及其与视神经、鼻窦之间的关系,为临床开展相关手术提供解剖学资 料,并为预防鼻窦手术中嗅神经损伤提供解剖学依据。方法:在16例32侧成人尸头上对嗅神经、嗅束、嗅球进行 解剖测量,并观察其与视神经、鼻窦之间的关系。结果:嗅束的长度为(29.32±2.11)mm,中点处宽度为(3.36± 0.83)mm,嗅束中点内侧距前颅底中线垂直距离为(5.48±1.02)mm,嗅束与矢状线之间夹角为(21.32±3.28)°, 嗅球长度为(10.43±2.35)mm,宽度为(5.12±0.62)mm;84.4%(27/32)的嗅束后端与蝶窦、前中部与筛窦顶相 邻,9.4%(3/32)嗅束仅与筛窦顶相邻,6.3%(2/32)嗅束与额窦顶相邻,所有嗅束都在视神经管内口处与视神经 交叉向前内行走,嗅球前缘与筛泡前缘基本在同一水平。结论:嗅束基本都在眶内侧颅底行走,鼻内手术时应注 意不要损伤鼻窦顶部,术中可以筛泡来定位嗅球位置,结合嗅束与矢状线之间夹角可以大致给嗅束定位,对于防 止手术损伤嗅神经具有一定意义。行前颅底手术上抬大脑额叶时应注意防止拉断嗅丝。