下颌骨截骨术耳后入路保留耳大神经的解剖学研究

目的：为下颌骨截骨术提供解剖学基础,建立二维坐标系,使得行下颌骨截骨美容术耳后入路时能够有效地保护耳大神经的主干及分支。方法：取常规固定头部标本20侧,取一张厚度为0.5mm的透明塑料膜,用圆规在塑料薄膜上建立直角坐标系,其最小刻度为0.2cm,将带有刻度的软塑料薄膜铺于标本的面侧区,坐标原点正对下颌角后下方的最凸点,y轴垂直于该连线（颧弓向外的最凸点与眼裂外侧点之间线段的延长线）。用油画笔将耳大神经比较完整的描点到薄膜上。最后将薄膜平铺于玻璃上,测量得出坐标参数指标。结果：耳大神经各分支的坐标值选三点,腮腺支坐标为：（34.0±2.6,-42.6±3.8）mm,（24.0±4.2,-33.0±4.5）mm,（14.0±2.8,-13.6±3.6）mm。耳后支坐标为：（34.0±2.6,-44.0±5.2）mm,（30.0±3.6,-31.0±5.6）mm,（28.0±2.8,-44.0±5.2）mm。耳垂支坐标为：（12.0±2.8,-44.0±2.6）mm,（14.0±4.6,-36.4±3.0）mm,（16.0±2.7,-31.0±4.6）mm。耳前支坐标为：（-8.0±2.8,54.0±3.4）mm,（8.0±3.6,36.2±3.4）mm,（16.0±2.7,-18.0±4.7）mm。结论：临床医生行下颌骨截骨美容术耳后入路时：①耳后切口线不低于耳廓根部后缘中点与乳突尖连线,可避免损伤耳大神经的耳后支;②游离过程中,经胸锁乳突肌鞘膜深面,紧贴胸锁乳突肌向前游离可减少耳大神经主干损伤。     

耳后隐蔽切口逆向解剖面神经在腮腺部分切除术中的临床应用

目的:探讨耳后隐蔽切口沿下颌缘支逆向解剖面神经在腮腺部分切除术中的临床疗效。方法:选取2015年1月-2018年1月收治的62例腮腺肿瘤患者进行观察,随机分为观察组和对照组,对照组采用传统“S”形手术方法,观察组采用耳后隐蔽切口沿下颌缘支逆向解剖面神经方法,术后对患者进行随访,比较两组术后面神经功能、手术并发症、切口瘢痕评分及患者对术后切口美容效果的满意度。结果:术后随访6~12个月,两组面神经功能分级情况比较,观察组面神经功能分级以Ⅰ~Ⅲ级为主,明显优于对照组,差异有统计学意义(P<0.05)。观察组涎瘘、Frey综合征、耳垂麻木以及口干等并发症发生率低于对照组,差异有统计学意义(P<0.05)。术后6个月和术后12个月观察组评分均明显低于对照组,差异有统计学意义(P<0.05)。术后12个月,观察组患者满意度大于对照组,差异有统计学意义(P<0.05)。结论:耳后隐蔽切口沿下颌缘支逆向解剖面神经的腮腺部分切除术面神经功能保护较好,并发症少,切口美容效果好,值得临床推广应用。     

腰神经后支阻滞治疗腰神经后支损伤引起的下腰腿痛

目的观察腰神经后支阻滞,治疗腰神经后支损伤后引起的下腰腿痛效果。方法选择腰神经后支损伤引起下腰腿痛病560例,随机分为治疗组和对照组,治疗2～3个月后进行随访,按照疗效评定标准进行评定。结果治疗组有效率98.0%,优良率83.0%。对照组有效率83.3%,优良率64.9%。经统计学处理两组效果有显著性差异(P<0.01)。结论腰神经后支损伤引起的下腰腿痛,选择损伤部位的腰神经后支阻滞,具有良好的治疗效果。     

耳大神经营养血管皮瓣的解剖学研究及其临床意义

目的 探讨耳大神经营养血管皮瓣的应用解剖.方法 在10例(20侧)灌注红色乳胶的成人尸体标本上,对耳大神经伴行营养血管及皮瓣的血供来源进行解剖观察.结果 耳大神经起自2、3颈神经.耳大神经的近侧段(深部)血供来源于颈升动脉发出的神经支,远侧段(浅部)的血供来源分别为枕动脉、耳后动脉、颈外动脉.耳大神经营养血管皮瓣中包含深筋膜血管网、浅筋膜血管网及皮肤血管网,并与耳大神经营养血管吻合,共同支持皮瓣的血供.结论 依据耳大神经营养血管的解剖特点,可制备近端或远端蒂耳大神经营养血管皮瓣,其血供可靠.     

耳大神经阻滞联合耳颞神经阻滞在中耳显微手术低阿片化麻醉的应用

目的 探讨耳大神经阻滞(great auricular nerve block, GANB)联合耳颞神经阻滞(auriculo-temporal nerve block, ATNB)用于中耳显微手术低阿片化麻醉的效果。方法 选择择期全麻下行中耳显微手术患者64例,按随机数字表法分为两组：耳大神经阻滞+耳颞神经阻滞组(G+B组)和单纯全麻组(G组),最终每组各纳入30例。G+B组麻醉诱导前在超声引导下进行GANB和ATNB, G组行单纯全身麻醉。两组麻醉诱导方案和麻醉维持方案相同。术后使用舒芬太尼补救镇痛以维持疼痛评分<4分,用甲氧氯普胺止吐以维持恶心呕吐(PONV)评分<5分。监测麻醉诱导后1 min(T1)、手术切皮后1 min(T2)血流动力学参数(MAP、HR)变化;记录瑞芬太尼、丙泊酚用量及持续输注时间、全麻时间;进行PACU(转入后10 min)和术后4 h、12 h、24 h、48 h疼痛VAS评分、PONV评分;统计术后48 h内补救镇痛率和止吐率。结果 组间比较,G+B组瑞芬太尼用量明显减少,切皮后1 min(T2)MAP降低,PACU及术后4 h、12 h...     

耳后入路行腮腺区域性切除的临床效果分析

目的:探讨耳后入路行腮腺区域性切除的可行性及美容效果。方法:对31例腮腺下极浅叶良性肿瘤(多形性腺瘤15例,沃辛瘤11例,基底细胞腺瘤2例,脂肪瘤2例,淋巴管畸形1例)患者,采用耳后入路行腮腺区域性切除。结果:全部患者的腮腺病变被完整切除,切口愈合良好,无面神经下颌缘支麻痹,无涎液潴留、涎瘘发生及Frey征出现。经6个月～5年(平均26个月)追踪复查,肿瘤无复发,切口瘢痕隐蔽,美容效果非常好。术后有2例患者出现耳垂麻木,随访3个月后,麻木消失。结论:经耳后入路切除腮腺良性病损是可行的,可获得较理想的美容效果。     

骨间后神经终末支显微外科的解剖学研究及其临床意义

目的：对骨间后神经终末支进行解剖学研究为临床提供理论依据。方法：在放大10－16倍的视野下，观测36侧成人上肢标本中骨间后神经终末支在前臂后区、腕后区的行径、分支、分布及其毗邻关系。结果：骨间后神经终末支在前臂支配伸腕、伸指等肌肉和尺、桡骨背侧骨膜。在腕部支配指伸肌腱腱周组织、腕骨关节囊、腕背韧带及滑膜组织、骨间背侧肌肌膜和第三第四掌骨背侧的骨膜；并与尺神经深支有交通支。结论：骨间后神经终末支是支配腕后区和手背深层组织的重要感觉神经，损伤后可引起腕背痛。     

颈神经后支卡压综合征

目的：从解剖和临床两方面探讨颈神经后支卡压综合征的机制及诊治方法。方法：对１７具成人固定尸体中Ｃ１～Ｃ８颈神经后支进行解剖学研究。对２４例颈神经后支卡压综合征的患者进行了临床观察和分析。结果：（１）颈神经后支自椎间孔处发出后,穿过由项部肌群附着于颈椎关节囊的交叉纤维、上下关节突关节和内侧椎板组成的骨纤维管,然后发出关节突关节支、肌支、皮支和交通支,穿行于颈后肌群及其腱性纤维组织间。（２）临床发现保守治疗近期虽有一定疗效,但不理想。结果：颈神经后支卡压综合征的病因是以颈后肌群为主的腱性交叉纤维压迫颈神经后支所致。结经保守治疗无效的患者行颈神经后支松解术,有可能是解除颈神经后支卡压的切实有效的方法。     

腰神经后外侧支的解剖学研究

目的：为探讨腰神经外侧支在其行程中是否受压的有关解剖因素。方法：在20具成人尸体标本上，观察腰神经后外侧支的走行、分段，固定点及与其有关的解剖结构；测量了臀上皮神经在出管点及入臀点处的外径，并以坐标方法确定体表定位。结果：腰神经后外侧支的行程中有四个段，六个固定点，臀上皮神经在出管点及入臀点处的直径T12、L1-4均数分别为1.28mm、1.51mm，体表定位在距横坐标下方13mm处作一水平线与距纵坐标外侧62-77mm处作两条垂直线的四个交点区域内。结论：在腰神经后外侧支的行程中存在多处受压的解剖因素，其中以入臀点处更明显。这为临床治疗臀上皮神经性腰腿痛提供了解剖学基础。     

带耳大神经的胸锁乳突肌肌瓣在腮腺癌手术修复中的应用

目的探讨腮腺深叶癌根治手术切除后,面部凹陷畸形及面神经缺损进行功能性修复的新方法,并评价临床疗效。方法对12例腮腺深叶癌侵袭周围骨质的患者,采取开放面神经管,将癌瘤、腮腺、受累面神经及周围骨质(包括乳突、茎乳孔、茎突及下颌升支后缘)扩大切除,利用面神经管内段正常的神经干断端与胸锁乳突肌肌瓣相连的耳大神经进行吻合,同时利用胸锁乳突肌肌瓣填充凹陷畸形。结果开放面神经管利用耳大神经胸锁乳突肌肌瓣功能性修复的方法,9例腮腺区凹陷畸形明显恢复常态,2例因肿瘤复发再次手术切除留有明显凹陷畸形,1例因局部感染,组织液化,肌肉萎缩,出现凹陷。面神经功能完全恢复,恢复时间最短为12周,最长20周,平均163周。同时提高了肿瘤的局部控制率。结论开放面神经管腮腺癌根治术,用耳大神经-胸锁乳突肌肌瓣即时修复,既达到了面部凹陷畸形的整复,又实现了面神经的功能性修复,同时减少肿瘤的局部复发,符合功能外科修复的发展要求,是一种临床应用效果比较理想的方法。     

Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study

BACKGROUND: The great auricular nerve (GAN) is frequently sacrificed during parotidectomy and causes sensory disturbance of the auricle. Our study is to investigate whether GAN preservation can improve the sensory recovery. METHODS: Patients undergoing superficial or total conservative parotidectomy for benign tumours were recruited consecutively from November 1998 to September 2001. Different sensory methods (light touch, two-point discrimination and sharp pain) of the auricle were evaluated by a designated physiotherapist preoperatively as well as at 1, 3, 6 and 12 months postoperatively. The patients and the physiotherapist were blinded to the integrity of the GAN. Long-term subjective assessment was also carried out beyond 2 years postoperatively. RESULTS: A total of 21 patients were recruited for the study. GAN were preserved in 10 patients. The mean follow up was 16 months (12-42 months). There was no difference in sex distribution, type of operation and pathology of parotid tumour between the two groups. No postoperative mortality occurred and postoperative morbidity did not differ between the two groups. Patients with GAN preserved had significantly better light touch and sharp pain recovery at 1 year postoperatively. Subjective assessment of sensory dysfunction also favoured GAN preservation. CONCLUSION: Great auricular nerve preservation minimizes the postoperative sensory disturbance and should be considered whenever tumour clearance is not compromised.     

应用耳后动脉分支皮瓣翻转修复耳甲部皮肤软组织缺损

目的：探讨一种耳甲部皮肤软组织缺损的修复方法。方法：自2009年1月～2013年3月,对6例耳甲部皮肤软组织缺损患者采用耳后动脉分支皮瓣转移修复。结果：术后皮瓣均100%成活,5例获得3个月～6个月随访,皮瓣色泽、质地与受区匹配,随访期间无肿物复发。结论：耳后动脉分支皮瓣修复耳甲部缺损,术后感觉良好,耳廓无变形,供区瘢痕隐蔽,是一种理想的手术方法。     

Injuries of the great auricular nerve in rhytidectomy

The great auricular nerve is most frequently injured in the course of rhytidectomy. Frequency of such injuries is many times higher than that of all other nerves combined. Estimate of such frequency cannot be obtained because many surgeons pay little attention to this complication. Patients often accept the discomfort of anesthesia of the external ear as a normal sequel of the operation, although an occasional neurotic patient may complain of the sensation of having his ear cut off. If the proximal end of the cut nerve becomes attached to the skin flap, neuroma will cause a trigger point on the lateral part of the neck. This may lead to a bizarre complaint of migraine-like pain on the side of the face. Two patients with neuroma of the great auricular nerve were seen, 1 and 2 years, respectively, after rhytidectomy. Diagnosis was confirmed by an operation. Repair of this nerve, either at the time of the operation or several years later, has a very favorable prognosis.The anatomy of this nerve and the precautions necessary to avoid injury during rhytidectomy will be discussed.     

A prospective controlled double-blind trial of great auricular nerve preservation at parotidectomy

BACKGROUND: Earlier reports of the advantages of preservating the posterior branches of the great auricular nerve (GAN) at parotidectomy were conflicting. This prospective study was aimed at clarifying the controversy. METHODS: Eighty-one patients in a university otolaryngology department were recruited. The posterior branches were preserved whenever initial dissection showed that tumor clearance would not be compromised. Touch-pressure sensation was monitored in predefined territories supplied by the GAN using a Semmes-Weinstein aesthesiometer, preoperatively and postoperatively. Minimal pressure thresholds obtained were compared between the two groups. RESULTS: Preservation of the GAN was achievable in 69% of patients; sensory deficit was transient. With the GAN divided, measurable sensory depression occurred up to 2 years after surgery. The difference is statistically significant. Patients' subjective assessment of numbness also conformed to these trends. Additional time taken for preservation of the GAN was about 10 minutes. CONCLUSIONS: The posterior branches should always be preserved if tumor clearance is not compromised.     

Adenoid cystic carcinoma of the parotid gland: Anastamosis of the facial nerve with the great auricular nerve after radical parotidectomy

Adenoid cystic carcinoma of the parotid gland is a rare and slowly growing, but highly malignant tumor. Surgical resection of a malignant parotid tumor should include resection of the facial nerve when the nerve is involved in the tumor. Facial nerve reconstruction is required after nerve resection. A 14 year-old female presented with complaints of painless enlargement of the right parotid gland and facial asymmetry. Physical examination revealed a firm mass in the region of the parotid gland as well as right facial paralysis. Biopsy obtained from the mass showed an adenoid cystic carcinoma of the parotid gland. A radical parotidectomy with a modified radical neck dissection was carried out. Grafting material for the facial reconstruction was harvested from the great auricular nerve. The proximal main trunk and each distal branch of the facial nerve were coapted with the greater auricular nerve. The patient received radiotherapy after surgery and was seen to achieve grade IV facial function one year after surgery. Thus, the great auricular nerve is appropriate grafting material for coaptation of each distal branch of the facial nerve.     

旋后肌肌支移位术的解剖学研究

目的 通过对桡神经旋后肌肌支和骨间后神经的显微解剖,为旋后肌肌支移位术提供解剖学依据,并设计旋后肌肌支移位术的最佳手术入路.方法 选择13侧甲醛固定成人上肢标本,解剖肘以远桡神经及各肌支,记录旋后肌肌支及骨间后神经的形态特征、分布情况和直径.结果 旋后肌肌支一般有3支,旋后肌Frohse弓近端2支,旋后肌肌管内1支,管外肌支恒定,可直接与骨间后神经缝合,且口径匹配.结论 旋后肌肌支可用来移位修复骨间后神经,为臂丛神经中下干损伤患者提供一种新的神经移位方式.