膈神经替代喉返神经修复治疗双侧声带麻痹的应用解剖

目的　探讨膈神经干与喉返神经喉内段前支吻合治疗双侧声带麻痹的解剖学基础。方法　解剖并观察 12具 (2 4侧 )成年尸体、7只喉全切除术切除的喉体、12例 (2 4侧 )根治性颈淋巴结清扫术和 6例 (6侧 )膈神经替代修复喉返神经患者共 46侧膈神经的起源、走行、血供及毗邻关系 ,测量膈神经干相关的长度 ,图像分析仪观测 30侧膈神经、喉返神经前支相关的组织学参数。结果　颈段膈神经营养动脉均自膈神经根部进入 ,来自于颈升动脉的占 95 6 % (4 4/4 6 )。膈神经干位置较深 ,在颈根部位于颈总动脉、椎静脉外侧 ,颈内静脉及胸导管 (左 )深面 ;在胸腔入口处跨过锁骨下动脉在锁骨下静脉深面下行。膈神经起点至锁骨下静脉上缘平面及至环甲关节的距离平均 ( x±s)分别为(7 2± 1 6 )cm及 (5 5± 1 4)cm ,两者相差至少 1 5cm。膈神经干平均有髓纤维数及神经束截面积分别为喉返神经前支的 2 41及 2 15倍 ,膈神经颈段单个神经束约占 75 0 % (18/2 4)。结论　临床上在胸腔入口解剖膈神经干安全可行 ,在锁骨下静脉上缘平面切断膈神经与喉返神经前支吻合无张力     

耳内镜手术相关面神经解剖

目的为安全实施耳内镜手术,避免面神经损伤提供解剖依据。方法对12例2 4侧成人尸头样本进行解剖,暴露面神经全程,对面神经进行相关解剖测量,从外耳道、鼓窦、迷路（乙状窦）后径路用耳内镜对面神经进行观察。结果所有标本均能通过上述径路在耳内镜下完整观察面神经全程,且清晰显露面神经隐窝以及咽鼓管鼓口周围结构。面神经垂直段恰位于骨迷路中轴线位置,面神经水平段介于外半规管和镫骨头之间;面神经鼓室段和上半规管顶、外半规管上缘距离分别为（8.59±1.75）mm和（3.83±1.11）mm,面神经乳突段距后半规管下缘距离为（3.13±1.53）mm;面神经乳突段和外耳道前、后壁距离分别为（10.50±1.91）mm和（3.8 5±0.9 9）mm;鼓索神经出外耳道后壁处和面神经鼓室段之间垂直距离为（2.2 1±0.7 6）mm,鼓索神经和面神经乳突段间夹角为2 7.3 0°±5.9 7°,内耳门外侧距乳突骨质表面水平距离为（33.82±2.80）mm,内耳门上缘距岩骨上缘距离为（4.96±1.40）mm。结论耳内镜可以清晰显示显微镜难以暴露的手术区域,能清晰分辨并避免损伤面神经,在耳显微外科有广阔的应用前景。     

保留舌下神经的舌下-面神经侧端吻合术:面瘫延期治疗的新技巧

介绍了无需神经移植或舌下神经半裂开且保留舌下神经功能的舌下一面神经侧端吻合术及其结果。面瘫超过24个月的患者4例,例1、2、3为前庭神经鞘膜瘤切除术后,例4为侵及延髓髓质的成神经管瘤全切除术后。面神经功能均为House－BrackmannⅥ级。采用颅颈"S"形口,长约8cm。在乳突处向后分离,牵开胸锁乳突肌,暴露乳突前1／3,行乳突部分切除,显露颅底处面神经,用金钢钻磨开面神经管至垂直部膝段,切断鼓索神经,开放茎乳孔,折断茎突,确定茎乳孔处面神经,将面神经完全游离达腮腺,将其于近心端切断,向后下牵二腹肌,在枢椎平面暴露颈…     

透明化鼓索神经在胆脂瘤型中耳炎手术中保护面神经的作用探索

目的:通过观察胆脂瘤型中耳炎手术中透明化鼓索神经和透明化面神经垂直段和面神经嵴的位置关系,探讨在该手术中透明化鼓索神经是否具有定位面神经垂直段和面神经嵴高度的作用。方法:2008-2010年我科收治的118例胆脂瘤型中耳炎患者行开放式鼓室成形术,手术中结合采用根据水平半规管、砧骨窝的位置和透明化鼓索神经的方法定位面神经垂直段和面神经嵴的高度。结果:99例面神经嵴磨至鼓索神经乳突段平面,面神经垂直段未显露;9例面神经垂直段透明显露,低于鼓索神经乳突段1～2 mm,前后方向2～3 mm,位置恒定;9例患者听骨链、砧骨窝、水平半规管和面神经骨管有不同程度的破坏,面神经垂直段低于鼓索神经乳突段1～2 mm,前后方向2～3 mm;1例面神经垂直段透明显露,高于鼓索神经乳突段。结论:透明化鼓索神经乳突段在胆脂瘤型中耳炎手术中可作为定位面神经垂直段和磨低面神经嵴的标志,是对传统方法定位面神经垂直段的补充,特别对于传统定位面神经标志破坏者,定位面神经的意义尤为明显。     

腮腺区面神经鞘瘤12例临床诊治分析北大核心CSCD

目的探讨腮腺区面神经鞘瘤的临床特点和诊治方法。方法回顾分析2009年1月至2019年1月在河南省肿瘤医院收治的12例腮腺区面神经鞘瘤患者的临床资料,其中男5例,女7例,年龄23~72岁。12例患者均以腮腺区肿块为主诉就诊,其中4例患者有局部不适和疼痛感,6例患者在触诊时有不同程度的疼痛感。超声检查8例表现为腮腺区实性肿块,4例表现为混合性肿块。分析总结治疗方式、肿瘤与面神经的关系以及手术前后面神经功能情况[House-Brackmann(H-B)分级]。结果 12例患者均接受了手术治疗:8例行肿瘤及部分或全部腮腺浅叶切除术,1例行肿瘤及全腮腺切除术;3例仅行肿瘤切除,其中1例患者因肿瘤扩展到颅底不能完全切除。9例患者肿瘤发生于面神经的主干或主要分支,切除肿瘤后面神经完整;1例肿瘤发生于面神经终末支,术中部分粘连严重小分支被切断;1例复发二次手术患者,术中未发现面神经总干且找不到神经断端,故未行神经移植;1例由于术中无法将面神经的主干与肿瘤分开,神经切断后同时行神经移植术。术前面神经功能H-B Ⅰ级10例,Ⅱ级1例,Ⅴ级1例。术后随访1年复查面神经功能H-B Ⅰ级7例,Ⅱ级2例,Ⅲ级1例,Ⅳ级1例为神经移植患者,Ⅴ级1例为复发二次手术患者术后维持原状。结论腮腺区面神经鞘瘤临床少见,术前不易诊断,治疗以手术为主,术中应注意保护面神经。     

根治性腮腺切除术后的面神经功能康复

根治性腮腺切除适用于腮腺的高度恶性肿瘤及伴有面神经侵犯的复发性良性肿瘤患者,术中须将全部腮腺连同面神经一起切除,术后必将带来面部功能障碍和美容问题。为恢复术后面部功能,于1979～1996年对12例根治性腮腺切除患者进行了神经移植面神经重建。患者中男5例,女7例,手术时年龄15～38岁。术中先作耳前切口,再绕至耳垂下方,沿胸锁乳突肌前缘延长,掀起面部皮瓣,寻找并切断穿出腮腺的面神经颞支、颧支、颊支、下颌支及面神经主干,各分支远端加上标记,将腮腺、肿瘤及其中的面神经作整块切除。若肿瘤已侵犯面神经主干则进行乳突切除术,游离和松…     

中耳手术中的面神经定位

目的结合颞骨解剖和面神经手术，明确适用于手术的面神经解剖标志。方法44具颞骨标本面神经解剖，106例周围性面神经麻痹的面神经减压手术。根据面神经周围的固定解剖标志，确定面神经位置。结果①面神经垂直段标志：水平半规管后中1／3交界处垂直线提示面神经后缘；砧骨短角上缘弧度延长线为面神经垂直段前缘；面神经与水平半规管基本在同一深度；②面神经水平段标志：位于砧骨短突之下；在水平半规管隆突前缘向前上呈30。行走；在匙突后方，面神经与匙突平行形成中上鼓室内侧面交界缘；经过匙突面神经向前上行走到膝状神经节；③膝状神经节定位：从镫骨头到匙突等距离延长线为膝状神经节位置；④鼓索神经定位：鼓索从左侧鼓沟的3点或右侧鼓沟的9点出骨管，沿鼓沟向前行走于砧骨长突外侧和锤骨颈内侧；鼓索神经从面神经发出处距离茎乳孔5—8mm；鼓索位于鼓膜紧张部与松弛部交界处。所有手术所见面神经走向符合解剖所见。结论中耳乳突的固定标志是面神经定位的参照物，其中水平半规管的位置最恒定，根据参照物确定面神经位置提高了手术的安全性。     

与人工耳蜗植入术相关的面神经垂直段应用解剖

目的　通过观测面神经垂直段解剖 ,了解与圆窗龛的关系 ,为人工耳蜗植入手术中避免面神经损伤提供参考。方法　通过对 12个成人颞骨标本解剖 ,模拟人工耳蜗植入术 ,观察和测量面神经垂直段位置与圆窗龛关系。结果　圆窗龛上缘至面神经垂直段距离 5 .49± 1.0 76mm ,圆窗上缘至砧骨短脚 5 .0 7± 2 .0 2mm ,圆窗龛平面面神经至鼓索神经距离 2 .2 5± 0 .3 8mm ,圆窗龛平面面神经垂直段至后半规管距离 2 .41± 0 .46mm。圆窗龛全貌能暴露者 7例 ,前部部分暴露 4例 ,有一例圆窗龛因面神经垂直段影响未能显示 ,未见面神经垂直段有分成两支的情况。结论　面神经垂直段前置将影响圆窗龛暴露 ,对此可考虑将面神经移位或经面神经后与后半规管之间进入后鼓室     

后鼓室解剖结构测量观察及临床意义

目的通过研究后鼓室有关解剖结构,及对后鼓室入路手术的径路进行观察、测量,为中耳相关手术入路提供理论参考依据。方法取成人30个干性颅骨的60侧颞骨,用耳科钻完成乳突腔气房“轮廓化",充分暴露后鼓室的各相关结构,在手术显微镜下进行解剖学观察,并对有关结构之间的距离进行测量。结果颞骨标本解剖观察结果,锥隆起至鼓索隆起的距离（3.22±0.41）mm、锥隆起至面神经管直线距离（3.59±0.48）mm、鼓索后小管的长度（9.44±1.65）mm;面神经管锥曲至鼓索隆起间的距离（3.34±0.42）mm、面神经锥曲至水平半规管距离（1.54±0.25）mm、面神经锥曲至后半规管距离（2.15±0.29）mm。面神经垂直段从外向内观察大部分呈后凸弧形下行,但有2例（3.33%）呈直线型垂直下行。面神经镫骨肌支全部从面神经管前壁穿出,鼓索神经自面神经管外发起9例（15%）,自面神经管下1/3处分出49例（81.67%）,自1/3处分出2例（3.33%）。结论经后鼓室进路手术开放面神经隐窝时,鼓索隆起至面神经管锥曲和至锥隆起的距离可作为开放面神经隐窝的宽度,面神经管与锥隆起可作为手术中互为寻找的依据。术中处理面神经隐窝病变时勿随意磨低锥隆起及鼓索隆起,以免损伤面神经镫骨肌支及鼓索神经。     

中耳炎手术中面神经定位和辨认的临床研究

目的探讨中耳炎手术中面神经的定位和辨认。方法回顾性分析2008年1月～2010年12月185例行开放式乳突根治术或加鼓室成形术的慢性化脓性中耳炎及胆脂瘤中耳炎患者的手术资料,对术中面神经探查定位及辨认方法进行分析总结。结果①185例中,面神经探查发现58例面神经裸露;②面神经鼓室段定位标志为匙突、齿突、砧骨短突,185例中33例匙突消失,25例齿突遭到破坏,19例砧骨短突破坏或移位;乳突段定位标志为水平半规管、二腹肌脊,185例中12例水平半规管遭破坏,14例二腹肌脊被破坏;33例鼓索神经变异;③面神经与肉芽组织的关系为肉芽组织覆盖于神经表面78例,肉芽包裹神经47例,肉芽组织来自于面神经本身24例。结论中耳炎手术中面神经的定位主要根据相对固定的砧骨、水平半规管、匙突等结构,当这些结构遭破坏或观察不清时,应联合多个标志综合判断,提高面神经定位的成功率。     

Applied anatomy for the reinnervation of posterior cricoarytenoid muscle by phrenic nerve for bilateral vocal cord paralysis]

OBJECTIVE: To study the anatomic basis for the anastomosis of phrenic nerve (PN) to the anterior branch of recurrent laryngeal nerve(RLN) for the treatment of the injured bilateral RLN. METHODS: The origin and the nutritive arteries and the adjacent tissue construction of PNs in 46 cases were studied. The longest utilizable length of PNs and the distance from the root of PN to cricothyroid joint were measured. The sectional area and the number of myelinated fibers of PNs and the anterior branch of RLNs were measured by computer image processing system. RESULTS: PNs coming from C4 comprised of 93.5%, 95.6% (44/46) of the nutritive arteries came from the ascending carotid artery and got into the cervical segment of PN from its root. The common trunk of PN was very deep, to the external of the common carotid artery and the vertebral vein, and deep to the internal jugular vein and thoracic duct (left), and in the superficies of the subclavian artery and in the deep of the subclavian vein when it was crossing the thoracic entrance. The distance from the root of PN to the level of the subclavian vein and to cricothyroid joint were (7.2 +/- 1.6) cm and (5.5 +/- 1.4) cm, respectively. The former was at least 1.5 cm longer than the latter. The average number of myelinated fibers and the sectional area of the PNs were 2.41 times and 2.15 times as many as those of the anterior branch of RLNs, respectively. The single-fasciculated PNs comprised of about 75.0% (18/24)). CONCLUSION: Clinically, it may be safe and available for cutting PN off at the level of the subclavian vein. The length of PN is enough for the anastomosis of PN to the anterior branch of RLN.     

手术治疗周围性面瘫51例

目的：探讨周围性面瘫的治疗方法及影响其疗效的因素。方法：回顾性分析51例面神经麻痹患者住院治疗的临床资料。结果：随访42例。36例行面神经减压术,22例恢复至H—BⅠ～Ⅱ级;4例行面神经吻合术,2例恢复至Ⅰ～Ⅱ级,2例面神经移植术,均恢复至〉Ⅲ级。病程3个月以内与3个月以上组手术的疗效差异有统计学意义（P〈0．05）。结论：及时精确地施行手术是治疗周围性面瘫的有效方法。     

腮腺良性肿瘤切除术中腮腺导管和面神经颊支解剖关系的观察

目的观察研究腮腺导管与面神经颊支的解剖关系,为术中用腮腺导管作为面神经探查标记物提供解剖依据。方法在腮腺良性肿瘤切除术中观察和测量42例患者的腮腺导管和面神经颊支的解剖关系,包括深浅、成角和距离关系。结果在深浅关系上,颊支位于腮腺导管浅面占69.05%（29/42）,同层面占14.29%（6/42）,深面占16.67%（7/42）。从二者走形角度上,基本平行占76.19%（32/42）,明显成角的占23.81%（10/42）。以出腮腺处测量距离来看,上颊支位于腮腺导管上0.2~1.0 cm,平均（0.61±0.13）cm;下颊支位于导管下0.2~1.5 cm,平均（0.77±0.27）cm。结论腮腺导管与面神经上下颊支解剖关系相对恒定,可以用于腮腺肿瘤术中寻找解剖面神经的标志物。     

面神经减压术治疗周围性面瘫的临床分析

目的：探讨面神经减压术治疗周围性面瘫的效果和时机。方法：周围性面瘫患者57例,分别在2个月以内和2个月以后行面神经减压术,采用组间χ^2。检验进行疗效对比。结果：2个月以内组治愈率显著高于2个月以上组（P〈0．05）。结论：面神经减压术是治疗周围性面瘫的有效手段,早期行面神经减压术可明显提高治愈率。     

Total-length invasion of the facial nerve by parotid carcinoma ex pleomorphic adenoma

A case of parotid carcinoma extending along the facial nerve up to the internal auditory canal is presented. Total parotid resection with neck dissection was performed, as well as resection of the ear canal, eardrum, ossicles, and transmastoid and translabyrinthine facial nerve, and obliteration using the fascia lata and fatty tissue. This was followed by adjuvant radiotherapy. The facial nerve showed continuous swelling along its length with lump formation at the site of the geniculate ganglion and the internal acoustic canal. Pathological examination revealed the salivary duct carcinoma subtype of carcinoma ex pleomorphic adenoma. Within the facial nerve, the epineurium, perineurium and endoneurium were affected throughout its length. Preoperative MRI with a contrast medium revealed the site of lump formation on the facial nerve, though it did not reveal the consecutive spread of the tumor along the nerve trunk. CT of the temporal bone is strongly recommended for detection of swelling of the temporal bone segment of the nerve trunk, which could provide confirming evidence of invasion by a parotid carcinoma.     

Protection of facial nerve anastomosis with a vein graft

When a cut nerve, which has been repaired, does not function properly it is usually due to the regenerating axons failing to cross the site of the anastomosis. The axonal regrowth may be blocked either by the presence of granulation tissue between the cut ends of the nerve, or to poor stabilization of the nerve stumps with resultant movement and torsion. In the past, many substances have been utilized to protect these anastomosis, most with unfavorable results. The most popular material used today for nerve protection is silastic sheeting which appears to offer some protection without having any major undesirable side effects. Gibb in a previous article, suggested that autogenous vein may be an excellent material for the protection of facial nerve anastomosis. It is readily available, easily tailored and completely physiologic. We felt his proposal had merit, but that it first should be evaluated in an animal model before embarking on a clinical trial. Eighteen dog facial nerves were severed. In six animals (control group) the nerve was repaired with three 7/0 silk sutures in neurolemmal sheath. In the second six, after the nerve sheath was repaired, a section of post auricular vein was wrapped around the anastomosis, being held in place with 7/0 silk sutures. In the remaining six animals, prior to repairing the severed nerve, a tube-like section of post-auricular vein was slipped around the proximal segment of the nerve, then after the nerve anastomosis was completed, the vein tube was pulled down over the anastomosis and held in place with 7/0 silk suture. Animals in each group were sacrificed at one, two and three months, in addition, three animals in each group were kept until maximum return of facial function occurred. Clinical evaluation revealed that the animals which had their nerve anastomosis protected with the vein tube or vein sheeting, had more complete return of facial function than the control group. Histological sections showed the vein still to be identifiable during the first two postoperative months, after this is became lost in the general fibrous reaction that occurred around the anastomosis. There was no difference between the groups in the amount of granulation tissue or fibroblasts in the area of the anastomosis. It appears that a careful anastomosis of the neurolemmal sheath will prevent granulations from entering the nerve as effectively as the vein tube; however, we felt that the additional stabilizing effect of the vein tube contributed to the improved results in the sheated animals. It appears that autogenous vein is a safe substance for the protection of facial nerve anastomosis, and is suitable for clinical use.     

A quantitative study of nerve fibers in the human facial nerve

Summary The facial and intermediate nerves were quantitatively evaluated in seven patients who died from systemic malignancies not involving the facial nerve. In addition, five of the specimens were also qualitatively evaluated by measuring the total and axon diameters of the facial and intermediate nerve fibers. In two cases the facial nerve fibers were counted at five different levels. The total number of myelinated nerve fibers in the facial nerve varied from 7500 to 9370. The total number of myelinated nerve fibers in the intermediate nerve varied between 3120 and 5360. The peak diameter of the facial nerve axon was between 4 and 6 m, and was between 2 and 3 m in the intermediate nerve. When comparing nerve segments at different anatomical levels, the largest amount of nerve fibers was found at the level of the middle mastoid portion. However, this number did not reach the amount of nerve fibers counted in the internal acoustic meatus.Prof. H. Spoendlin died in November 1991 after a lengthy illness     

舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫

摘要：目的探讨舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫的效果。方法6例小脑脑桥角肿瘤切除术后面瘫患者均行舌下神经-面神经侧端吻合术。所有患者术后每3个月随访1次,评估House Brackmann(H B)分级和舌下神经功能。结果术后1年H B III级2例,H B Ⅳ级3例, H B V级1例。静态面部张力4例患者在吻合术后6个月改善明显,1例患者在吻合术后 9个月改善,1例患者在吻合术后1年改善。所有患者均未出现术侧舌肌瘫痪萎缩,发音和吞咽功能均正常。结论舌下神经-面神经侧端吻合术可改善小脑脑桥角肿瘤切除术后面瘫患者的面部张力和面肌功能,借助神经监护可尽量减小对舌肌功能的影响。     

Facial nerve in parotidectomy: a topographical analysis

OBJECTIVE: Establish normative data concerning parotidectomy and facial nerve dissection and determine the relationship between the length of the facial nerve dissected during parotidectomy and subsequent facial nerve paresis. STUDY DESIGN: Prospective mapping of facial nerve during parotidectomy and comparison with postoperative facial nerve function. METHODS: A prospective observational study of 78 patients who underwent 79 parotidectomy procedures. During each procedure, various topographical measurements were recorded. These measurements included the distance from the tragal pointer to the main trunk of the facial nerve, the distance to the pes anserinus, and length of each segmental branch dissected. In addition, a designation of the patient's tumor location was made by drawing a line from the ear canal to the nasal spine. Tumors above this line were designated anatomic zone A and those below the line were designated anatomic zone B. Finally, facial nerve function was quantified at a 1-week follow-up visit using the House-Brackmann Scale. RESULTS: The distance from the main trunk of the facial nerve to the tragal pointer was significantly (P < .000) less than the previously accepted standard of 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Results of an independent t test and logistic regression (P = .01, both) indicated that patients with temporary facial nerve paresis had a significantly greater amount of nerve dissected than patients without temporary facial nerve paresis. Patients with short-term facial nerve dysfunction had significantly (P < .01) more total nerve dissected (136.73 mm vs. 94.73 mm) than patients without short-term facial nerve dysfunction. Patients with nerve dissection lengths at the third quartile (130.0 mm) were 3.8 times more likely to experience temporary facial nerve paresis than patients with nerve dissection lengths at the first quartile (64.5 mm). CONCLUSIONS: The axiom that the main trunk of the facial nerve is located 1 cm from the tragal pointer may need to be modified to less than 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Facial nerve paresis after parotidectomy is associated with the length of the facial nerve dissected during the procedure. The greater the length of facial nerve dissected, the higher the chance of facial nerve paresis, albeit temporarily, in this particular series of patients.