鼻科学

991470国人成人鼻泪管的解剖学测量/倪长宝…//临床耳鼻咽喉科杂志一1999,13(2)一62~63 目的:对成人鼻泪管局部解剖有进一步认识。方法:对国人成人40具(80侧)尸头鼻腔进行解剖学测量。结果:发现鼻泪管在下鼻道的开口有5种类型,其中以裂隙型多见;有7侧存在2个开口。73侧鼻泪管及开口位置进行解剖学测量,鼻泪管平均长度14.14mm;前鼻孔内下缘交点至同侧鼻泪管开口前缘平均距离为29.00t’nm(简称孔口距);下鼻甲附着缘前端至鼻泪管开口前缘平均距离为11.07mnl;前鼻孔内下缘交点至同侧下鼻甲附着缘前端平均距离15.3om。(孔甲距)。经过计算发现“孔…     

鼻科学

951348成人鼻泪管开口的观察/李惠民…//中华耳鼻咽喉科杂志一1995,30(1)一36 观察80侧尸头鼻泪管开口的形态,可分为5种类形:裂隙形52侧,卵圆形16侧,双口形7侧,圆形3侧,类三角形2侧。同一人左右两侧鼻泪管开口形状大小及位置基本对称,开口长径最小约lmm,最大约16mm。鼻小泪管开口距下鼻甲前端最短为smm,最长为18mm;距鼻前孔内下缘交点最短为21mm,最长为37mm。图3(简文)95134,眶下血管蒂葬唇沟皮瓣的解剖与临床应用/何葆华…//中国临床解剖学杂志一1995,13(2)一103~105 观察6具n侧成人尸体标本眶下血管、神经分支走行和分布。眶下动脉出眶下…     

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。     

蝶窦开放不同方法的应用解剖学比较

目的对开放蝶窦手术入路的不同方法进行比较，为蝶窦手术提供临床解剖学标志。方法应用10具（20侧）成人头颅标本，按照不同的方法开放蝶窦，测量主要结构之间的距离，观察手术中的解剖学标志。结果前鼻孔到蝶窦前壁的距离（65．36±3．58）mm；前鼻孔到蝶鞍底部的距离（79．18±3．71）mm；鼻后孔弓到颅底的距离（21．18±4．31）mm；后鼻孔弓到蝶窦开口的距离（13．22±3．36）mm。蝶窦开口与鼻小柱基部的连线与鼻底成角35．72°±3．48°；后鼻孔弓与鼻小柱基部的连线与鼻底成角29．56°±3．61°；蝶窦前壁与颅底交界处与鼻小柱基部的连线与鼻底成角45．72°±3．63°。蝶窦前壁形状有很大变异，应根据局部结构进行定位，不同的的方法适应不同的个体。中鼻甲、上鼻甲、上鼻道是很好的定位标志。结论根据手术的目的可以选择不同的方法开放蝶窦，中鼻甲、上鼻甲以及后鼻孔弓都是定位蝶窦的恒定标志。     

上颌窦窦口的应用解剖学观测

本文观测了４８侧尸头上颌窦窦口及其周围解剖结构。发现上颌窦鼻腔开口均位于筛漏斗，其形态、大小与筛泡、钩突的发育情况有关，按形状可分为圆形或卵圆形、弯月形或肾形及月芽状或弯曲的缝隙状三类，分别占２１％、５６％、２３％；上颌窦窦腔开口均位于上颌窦内壁前囟上部；上颌窦鼻通道由窦腔开口向上或内上移行为鼻腔开口，其长度与筛泡、钩突的发育情况有关；多数上颌窦窦口上缘高于（６５％）或等于（２３％）眶底或眶内下角水平；鼻泪管后壁与上颌窦窦口前缘水平距离及与鼻底水平线夹角分别为４．２０±１．０９ｍｍ及５９±８．７°。结果提示上颌窦中鼻道开窗术或窦口开放术中，为防止发生眶损伤和鼻泪管损伤，不应咬除上颌窦自然窦口上缘及前缘组织，向下咬除时亦宜谨慎小心。此外，还讨论了上颌窦鼻腔开口类型与上颌窦炎症发生的关系。     

颅底外侧面分区新方法——交叉斜线法

1994年我们对50例成人干颅骨进行测量［l］，并将交叉斜线法颅底外侧面的分区应用于临床及教学，收益很大。介绍如下：1分区方法将颅骨翻转，使顾底外侧面向上，以双侧上颌骨第2磨牙外缘到对侧枕骨键外缘两点问做交叉斜线并延长，可将颅底外侧面分为4个区；即颅底前区。相对应的两个硕底侧区和颅底后区卜］，交叉斜线的交点至枕骨大孔前缘约13mn，至犁骨后缘约匕．smxn，前角及后角为93．60土6．49，两侧角为86．40土6．49，以交点为中心，以两侧乳突尖为远点，将两点间距离三等分划弧线，可将颅底侧区分为侧1区、侧2区和侧3区（图1）o颅底…     

内镜下迷路后入路小脑脑桥角及内耳门区手术的实验解剖

目的 测量比较内耳门后唇至乙状窦前、后缘的距离;迷路后间隙与乙状窦距外耳道后壁距离的相关性,为经迷路后入路内镜下小脑脑桥角区及内耳道微创手术提供解剖学依据.方法 10％甲醛固定的成人头颅标本（正常完整颅底）15例（30侧）,性别不限,乳突轮廓化,迷路骨骼化,乙状窦全程解剖.①测量内耳门后唇至乙状窦前、后缘的距离;②测量...     

翼管的高分辨率CT(HRCT)研究

目的：探讨翼管高分辨率ＣＴ（ＨＲＣＴ）正常及病理的表现。方法：回顾性分析１００例正常成年人翼管和７２例病变累及翼管的病例。结果：正常成年人右侧翼管长度１４．００ｍｍ（１７．０１～１１．００ｍｍ）,左侧翼管长度 １４．００ｍｍ（１８． ０５～１１． ０３ｍｍ）,男女两者无明显差异（ Ｐ＞０． ０５）;翼管前口宽度 ２．００ｍｍ（０．８０～４．００ｍｍ）,后口宽度１．４０ｍｍ（０．５０～２．８０ｍｍ）;８５％翼管向前内走向,两侧翼管前部距离２５ｍｍ（１７～３１ｍｍ）,后部距离２７ｍｍ（１９～３５ｍｍ）;翼管与蝶窦下壁前后的距离分别为２．４ｍｍ和３．０ｍｍ,以上三组数值均有显著差异（ Ｐ＜ ０． ０５）,但男女之间无明显差异（ Ｐ＞０． ０５）。正常成人翼管与鼻窦关系：位于有完整分隔的蝶窦下５５％,蝶窦内３１％,不对称分隔或无分隔下８％,上壁缺如与蝶窦交通６％。病变累及翼管病理改变分三种类型：扩大１０例（１３．９％）;狭窄１７例（２３,６％）。消失４５例（９９．５％）。结论：ＨＲＣＴ能很好显示翼管骨性结构,准确认识翼管正常表现及与邻近结构关系,可以发现翼管早期病变并指导临床治疗。     

扩大鼻内镜上颌窦手术视野的解剖学研究

目的:通过对鼻腔和上颌窦相关解剖结构的观测,寻找扩大鼻内镜上颌窦手术视野的解剖学方法,为获得满意的手术视野提供指导。方法:以30例(60侧)经4%甲醛固定的成人尸头(男21例,女9例)为研究对象,去除鼻腔外侧壁的黏膜,保留各个重要骨性结构的完整性,以骨性鼻泪管和下鼻甲骨附着缘为标志,观察测量相关结构的解剖特点以及与周围毗邻结构的位置关系。通过解剖学观测,寻找影响鼻内镜下扩大上颌窦手术视野的解剖学因素。结果:骨性鼻泪管前界上、中、下端到上颌窦前壁与内侧壁交界的水平距离分别为0、(1.90±1.03)、(3.29±1.04)mm;骨性鼻泪管前下端到下鼻甲前缘的水平距离为(5.13±0.62)mm,到鼻底的垂直距离为(16.89±0.97)mm,左右侧测量数据差异无统计学意义。去除的骨质范围:下鼻甲附着缘以上部分上下径为(9.43±1.72)mm,前后径由上往下为(9.76±0.83)、(11.39±0.50)、(12.85±0.66)mm,下鼻甲附着缘以下部分上下径为(13.52±0.83)mm,前后径由上往下为(19.89±1.37)、(16.59±0.77)、(12.48±0.91)mm。结论:鼻内镜下中鼻道入路的上颌窦手术视野,受上颌窦口前方的骨性鼻泪管、上颌骨额突及下方的下鼻道外侧壁骨质的影响而无法充分显露,同过去除窦口周边无用的骨质而保留重要结构,可以扩大内镜下中鼻道入路上颌窦手术的视野,利于彻底清除上颌窦内底壁、前壁的病变。     

筛动脉眶内段及窦内段的应用解剖研究

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：筛前动脉眶内段长（５．１６±１．２４）ｍ ｍ ,管径为（０．５６±０．１７）ｍ ｍ ;筛后动脉眶内段长（９．０８±２．２９）ｍ ｍ ,管径为（０．３７±０．１４）ｍ ｍ 。筛动脉的周围有致密结缔组织构成的筋膜鞘,该鞘包绕与之并行的筛神经和筛静脉,筋膜鞘在筛动脉窦内段亦存在。筛动脉窦内行程有三种类型：走在骨管内;走在筛房顶壁和筛粘膜之间;部分走在骨管内。结论：在筛窦手术或视神经管减压术中,正确寻找和处理筛动脉有重要意义     

Transnasal endoscopic medial maxillectomy as the initial oncologic approach to sinonasal neoplasms: the anatomic basis

OBJECTIVE: To demonstrate an anatomic basis for endoscopic medial maxillectomy with excision of the lateral nasal wall to the nasal floor, including the inferior turbinate, and nasolacrimal duct. Transnasal endoscopic medial maxillectomy involves complete resection of the lateral nasal wall with boundaries that are inferior to the nasal floor; superior to the cribriform plate and fovea ethmoidalis; anterior to the anterior maxillary wall, including the nasolacrimal duct; and posterior to within 5 mm of the eustachian tube. Transnasal endoscopic medial maxillectomy provides exposure for endoscopic resection of the orbital wall, pterygopalatine fossa, pterygoid plates, nasopharynx, and anterior skull base when indicated. DESIGN: Volumetric analysis of the maxillary sinus was performed on axial and coronal computed tomographic scans of 19 adult patients for a total of 38 maxillary sinuses. SETTING: Tertiary care medical center. PATIENTS: Nineteen adult patients with tumors of the head (but outside the sinonasal region). INTERVENTIONS: Radiographic analysis. MAIN OUTCOME MEASURES: The total volume of the maxillary sinus, volume above and below the superior attachment of the inferior turbinate, and volume anterior to the nasolacrimal duct were measured. RESULTS: The mean (SD) total volume of the maxillary sinus was 20.1 (4.2) cm(3), whereas its volume inferior to the superior attachment of the inferior turbinate was 12.9 (3.7) cm(3) and anterior to the nasolacrimal duct was 1.1 (0.6) cm(3). The mean (SD) volume of the maxillary sinus inferior to the superior attachment of the inferior turbinate was 64% (12%), whereas the nasolacrimal duct obscured the transnasal anterior exposure of the maxillary sinus. CONCLUSION: Without excision of the lateral nasal wall inferiorly to the nasal floor and anteriorly, including the nasolacrimal duct, over half of the maxillary sinus would be inaccessible for procedures directed at neoplasms within the maxillary sinus.     

鼻内鼻窦手术损伤泪道的解剖学分析

为了减少或避免易内鼻窦手术损伤泥道，在20具成人尸头标本上，观测泪道与鼻腔外侧壁的毗邻关系。发现前筛气房与泪囊窝关系密切，气房侵及泪骨占87．5％；鼻泪管与钩突上端游离线之间距离为6.74±1．72mm，距离筛漏斗前界3．44±0．75mm，距上颌窦鼻内开口为5．50±3．73mm。鼻泪管开四位于下鼻道前端鼻甲附着处。研究表明，前筛房、钩突切除和上颌窦鼻内开窗手术范围，如果过于向前，容易损伤泪道。     

Nasolacrimal obstruction after inferior meatus nasal antrostomy

Transient epiphora following rhinoplasty or intranasal procedures is a common occurrence. Permanent nasolacrimal duct obstruction, however, is rare. This article documents four cases of nasolacrimal duct obstruction following intranasal antrostomy. Three patients were cured by dacryocystorhinostomy and a fourth refused surgery. The anatomy of the nasolacrimal duct in the inferior meatus has considerable variation. Although the duct typically opens in the inferior meatus immediately under the insertion of the inferior turbinate, the orifice can be a single hole, a slit, multiple holes, or a trough, and can be located anywhere from 30 to 40 mm dorsal to the anterior nares. We review the embryology and anatomy of the nasolacrimal orifice in the nose and make recommendations for safe surgery in the inferior meatus.     

鼻内镜下鼻泪管前径路和后径路切除上颌窦良性病变

目的 探讨鼻内镜下上颌窦内侧壁入路切除上颌窦良性病变的手术径路及手术方法的可行性及疗效.方法 2003年6月至2010年8月,采用鼻内镜下经鼻腔鼻泪管前径路和鼻泪管后径路的多种方式切除上颌窦良性病变139例,其中内翻性乳头状瘤43例、真菌性上颌窦炎63例、上颌窦囊肿28例、出血坏死性息肉3例、骨瘤2例.所有病例术前行CT检查,可疑内翻性乳头状瘤患者同步行MRI检查.鼻泪管前方径路采取3种方式:梨状孔入路、泪前隐窝入路(包括解剖鼻泪管和不解剖鼻泪管2种方式)、梨状孔鼻泪管人路,共治疗97例;鼻泪管后方径路也采取3种方式:下鼻甲翻转、双蒂下鼻甲、单蒂下鼻甲,共治疗42例.观察患者术后疗效.结果全部病例在鼻内镜下经鼻彻底清除病变,保护了鼻泪管,保留了下鼻甲,无一例发生鼻泪管损伤和下鼻甲坏死.术后鼻塞、头痛、闷胀不适、异味、牙疼和麻木感等症状逐步消失.9例感觉鼻腔干燥,经鼻腔冲洗等处理后1个月左右逐渐消失.随访6 ～79个月,骨瘤和出血坏死性息肉未见复发.所有真菌性上颌窦炎患者术中均可见窦腔黏膜明显水肿、增厚,术后3个月左右逐渐消失,无一例复发.2例上颌窦囊肿患者术后10个月和18个月在上颌窦其他部位再发,但囊肿小且无临床症状未作处理.内翻性乳头状瘤患者有3例复发,1例术后17个月上颌窦口上方局限性肿物突出,病理示乳头状瘤复发,门诊予以清理后随访1年未见复发;1例于术后15个月前筛处复发,行筛窦广泛切除后随访3年未见复发;1例术后26个月上颌窦后外侧壁局部复发,二次行蒂在前方单蒂下鼻甲方式手术,术后1年再次复发,行鼻内镜下Denker手术,随访18个月未见复发征象.所有病例术后3个月上颌窦创面上皮、瘢痕覆盖,下鼻甲形态良好,下鼻道开窗者较术中明显瘢痕变小,且引流通畅无闭锁.结论鼻内镜下鼻泪管前、后径路上颌窦手术可以减小创伤,充分暴露窦腔视野,并为术后内镜复查和复发后的处理提供了视窗;保留下鼻甲避免了鼻腔外侧壁去除过多而导致的术后干燥、结痂、头痛等并发症.     

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.     

Nasolacrimal duct orifice cysts in adults: a previously unrecognized, easily treatable cause of epiphora

BACKGROUND: Epiphora is a common problem evaluated by ophthalmologists and otolaryngologists. It is typically the result of obstruction at some level of the nasolacrimal system, either the canaliculi, sac, or duct. Multiple etiologies exist, including scarring from infection or trauma, tumors, or masses. Cysts of the nasolacrimal duct orifice (dacryocystoceles) in the inferior meatus have been described in neonates, usually presenting as obstructive nasal masses shortly after birth. Nasolacrimal duct orifice cysts have not been described in the adult population in the medical literature. PATIENTS: Three patients were identified with epiphora as a result of cysts in the inferior meatus at the opening of the nasolacrimal duct. All patients presented with constant epiphora and were referred for dacryocystorhinostomy by an ophthalmologist or an otolaryngologist. None of the patients had a previous history of nasolacrimal duct (NLD) surgery. One patient had previous endoscopic sinus surgery for nasal polyps. Cysts were identified by nasal endoscopy of the inferior meatus in all patients. RESULTS: All patients underwent endoscopic resection of the inferior meatus cyst to relieve the obstruction of the NLD. Two procedures were performed under general anesthesia and one under intravenous sedation. All patients had complete relief of epiphora and have had no evidence of recurrence of the symptoms or the cyst in 4 to 10 months follow-up. CONCLUSIONS: NLD orifice cysts are easily correctable causes of epiphora. Routine inferior meatus endoscopy should be routinely performed in patients with epiphora to identify whether on not this pathology is present prior to performing dacryocystorhinostomy.     

Modified transnasal endoscopic medial maxillectomy with medial shift of preserved inferior turbinate and nasolacrimal duct

Although transnasal endoscopic medial maxillectomy (TEMM) is effective for the treatment of inverted papilloma (IP) in maxillary sinus (MS), it involves resection of the inferior turbinate (IT). TEMM also involves resection of the nasolacrimal duct (ND) in many cases to gain better access. Therefore, we developed a novel procedure in which the preserved IT and ND are shifted medially for a complete resection of IP in the MS. Incision was made in the mucosa of the lateral wall along the anterior margin of the IT. After removal of the medial maxillary wall except the ND and the lateral nasal mucosa, the anterior lateral mucosa of the nose, including the IT and the ND, was shifted in the medial direction to allow wider access to the MS. The tumor was removed together with the attachment through the anterior side of the ND. This modified TEMM was performed in 10 patients with IP. The IT and ND were preserved in all patients. We have not observed epiphora after this surgery. The advantages of the novel approach presented herein include: 1) preservation of the IT, ND, and lateral nasal mucosa; 2) wide access to the MS by shifting the IT, ND, and lateral nasal mucosa in the medial direction; and 3) direct access to the MS through anterior space of the ND, resulting in easier operation with a straight endoscope and instruments. This approach is a safe and effective method to obtain wide and straight access to the MS and to resect IP in the MS.     

鼻内镜下泪前隐窝入路治疗上颌窦良性病变

目的经鼻内镜下泪前隐窝入路治疗上颌窦良性病变,并探讨其适应证、并发症及手术方式。方法回顾性分析43例经鼻内镜下泪前隐窝入路治疗上颌窦良性病变的病例,其中术前及术后病理确诊的上颌窦内翻性乳头状瘤15例,窦内病变镜下检出菌丝或孢子的真菌性上颌窦炎8例,上颌窦囊肿12例,上颌窦后鼻孔息肉6例,上颌窦异物2例。所有病例手术前均行鼻窦冠状位或水平位CT扫描。患者在局麻下以下鼻甲前缘为中心切口,解剖内移鼻泪管-下鼻甲瓣经泪前隐窝进入上颌窦腔处理上颌窦内病变,复位鼻泪管-下鼻甲瓣,缝合手术切口并行下鼻道开窗。结果 43例患者术中均完全清除窦内病变,术后随访6～24个月,下鼻甲形态愈合良好,术腔上皮化,无溢泪、面部麻木等并发症。2例上颌窦内翻性乳头状瘤术后6个月局部复发,原手术入路切除,随访1 8个月无复发。3例术后鼻腔粘连,局部分离,随访12个月无复发。结论经鼻内镜下泪前隐窝入路进入上颌窦是一种微创、安全、有效的处理上颌窦良性病变的手术方式,可作为鼻内镜下经中鼻道行上颌窦自然口开窗无法彻底切除窦内病变组织的首选治疗方法。     

Inferior turbinate arterial supply: histologic analysis and clinical implications

OBJECTIVE: To study the arterial architecture of the normal inferior turbinate. DESIGN: A prospective, nonrandomized, histologic study. MAIN OUTCOME MEASURES: Fourteen samples were removed at autopsy and during septoplasty operations, processed in the usual manner, stained with hematoxylin-eosin, and investigated microscopically. The analysis included data on the number, location within or outside the bone, the mean area, wall thickness, and distance the arteries traverse from the point of entrance into the bone to the point of exit into the soft tissue. RESULTS: One to three arteries enter the inferior turbinate posteriorly. In 7 of 14 inferior turbinates (50%), the arteries lie within the bone and in 2 (14%) within the soft tissue, and in 5 (36%), a mixed pattern was observed. The arteries run along a mean of 1.2 +/- 0.49 cm before piercing the bone into the soft tissue and split off to one to six branches. The mean area and the mean wall thickness of the arteries at the entrance into the bone posteriorly were significantly greater than that of the arteries emerging from the bone and entering the soft tissue anteriorly (0.099 +/- 0.056 mm2 vs 0.051 +/- 0.022 mm2 [p < .01] and 0.116 +/- 0.042 mm vs 0.083 +/- 0.031 mm [p < .05], respectively). The inferior mucosal layer lacks major arteries. CONCLUSION: Given the data presented here, the excision of the inferior mucosal layer and the anterior portion of the inferior turbinate bone distal to the point of arterial exit constitute a relatively low risk for postoperative arterial bleeding.