经鼻内镜蝶鞍区手术的立体解剖研究方法

目的 探讨一种立体解剖学方法,研究经鼻内镜蝶鞍区手术中重要解剖结构的空间关系,为经鼻内镜蝶鞍区手术提供立体解剖学参考.方法 ①改进MicronTracker双日视觉导航仪,并检验其测量角度与距离的准确性.②依次暴露10具(20侧)去脑颅底湿标本蝶鞍区重要结构,以S点(同侧鼻棘侧缘点)和M点(上颌线中点)为基准点,鼻底平面和正中矢状面为基准平面,应用MicronTracker双目视觉导航仪测量基准点到各解剖标志连线的俯仰角、方向角和距离,并行统计学处理.③利用3D-max和AutoCAD-2008软件建立蝶鞍区解剖结构的立体模型.结果 ①改进的MicronTracker双目视觉导航仪与游标卡尺及角度转台之间的测量值差异无统计意义(P值均>0.05).②测量得到了蝶窦口、视神经-颈内动脉隐窝、球形鞍底、蝶窦后壁、斜坡中部顶点及外侧顶点等重要结构或标志的定位数据.③应用3D-max 9.0和AutoCAD-2008软件建立蝶鞍区解剖结构的立体模型.结论 应用改进MicronTracker双目视觉导航仪可得到蝶鞍区重要解剖结构定位数据,并在此基础上建立经鼻内镜蝶鞍区手术解剖结构的立体构象.     

经鼻内镜翼腭窝和颞下窝应用解剖学研究

目的探索经鼻内镜翼腭窝、颞下窝恒定的解剖标志,为手术处理该区域病变奠定基础。方法对11例尸头行鼻内镜侧颅底解剖学研究。经鼻内镜经中鼻道、蝶腭孔、上颌窦后壁入路,暴露翼腭窝及颞下窝的重要血管、神经及骨性解剖标志,并测量各解剖标志间的距离。结果经鼻内镜可恒定暴露蝶腭孔、翼管、圆孔、蝶腭神经节、眶下神经、卵圆孔、棘孔等重要侧颅底标志。鼻小柱基底到蝶腭孔、翼管、圆孔、卵圆孔、棘孔、破裂孔的距离分别为（69±3）、（73±3）、（75±3）、（90±5）、（96±4）、（88±3）mm。结论经鼻内镜可显露翼腭窝及颞下窝重要解剖结构,且各解剖结构可通过相互之间的距离及位置在鼻内镜二维平面上互相定位,以更直观、安全的处理该区域的病变。     

内镜下经鼻至岩尖区的临床应用解剖学研究

目的通过对岩尖区及其周围结构的解剖学研究,为临床内镜下经鼻至岩尖区的手术提供解剖学依据。方法:选取5例新鲜成人灌注尸头标本和10例干性成人颅骨标本,分别进行内镜解剖研究和骨性颅底解剖结构测量。(1)在5例(10侧)新鲜成人灌注尸头标本上行内镜下经鼻至岩尖区的解剖暴露观察;(2)在10例(20侧)干性成人尸头标本上进行颅底岩尖区周围解剖标志的辨认,并从颅底外面观分别测量两侧卵圆孔內缘、棘孔內缘、破裂孔內缘、破裂孔外缘、咽鼓管口、颈动脉管前界及后界的內缘至正中线的距离,进行左右侧对比及男性与女性之间的对比;测量前鼻棘至破裂孔前界、颈动脉管前界的距离。结果(1)通过对岩尖区进行内镜下及显微镜下解剖操作,辨认出岩尖区及其邻近重要结构、了解颈内动脉在岩尖区的走行,为临床内镜下经鼻至岩尖区的手术提供参考依据;(2)左右两侧卵圆孔內缘至正中线的距离分别为22.85±0.39mm、22.86±0.26mm,男性头颅与女性头颅的测量距离分别为23.01±0.24mm、22.70±0.33mm;左右两侧棘孔內缘至正中线的距离分别为30.79±0.32mm、30.69±0.71mm,男性头颅与女性头颅的测量距离分别为30.98±0.47mm、30.50±0.37mm;左右两侧破裂孔內缘至正中线的距离为11.88±0.20、11.80±0.36mm,男性头颅与女性头颅的测量距离分别为11.97±0.17mm、11.70±0.26mm;左右两侧破裂孔外缘至正中线的距离为19.59±1.03mm、19.52±1.15mm,男性头颅与女性头颅的测量距离分别为20.12±1.03mm、18.99±0.87mm;左右两侧咽鼓管口至正中线的距离为32.14±0.72mm、32.04±0.90mm,男性头颅与女性头颅的测量距离分别为32.54±0.61mm、31.64±0.76mm;左右两侧颈动脉管前界的內缘至正中线的距离为26.82±0.76mm、26.78±0.72mm,男性头颅与女性头颅的测量距离分别为27.22±0.56mm、26.38±0.64mm;左右两侧颈动脉管后界的內缘至正中线的距离为30.50±0.41mm、30.33±0.52mm,男性头颅与女性头颅的测量距离分别为30.74±0.10mm、30.10±0.35mm。左右两侧前鼻棘至破裂孔前界的距离分别为55.90±0.76 mm、55.92±0.76mm、左右两侧前鼻棘至颈动脉管前界的距离分别为75.78±0.43mm、75.81±0.43mm。结论内镜下经鼻至岩尖区是一条安全有效的手术径路,该径路的优势在于避免了传统侧方经颞骨入路潜在的丧失听力和面瘫的风险,并为岩尖区病变提供了一条天然、直接的引流通路。     

鼻内镜下鼻中隔软骨瓣重建鼻颅底缺损

目的 探讨鼻内镜下鼻中隔软骨瓣转位重建鼻颅底缺损的可能性.方法 对30具成人湿性尸头标本进行解剖学测量,对5具冰冻保存的成人新鲜尸头标本进行鼻内镜下重建鼻颅底缺损的模拟手术实验.结果 鼻中隔软骨瓣上边长38.17～49.95 mm,平均(x±x,以下同)为(44.19±5.82)mm,鼻中隔软骨瓣下边长50.85～63.16mm,平均为(56.83±6.65)mm,鼻中隔软骨上下径长23.52～31.74 mm,平均为(27.93±3.48)mm,鼻中隔软骨前后径长16.55～24.83mm,平均为(20.83±2.12)mm.模拟手术显示以鼻中隔软骨瓣重建鼻颅底缺损的操作可行.结论 鼻颅底缺损在长(27.22±4.91)mm、宽(13.03±3.44)mm的范围时,可在鼻内镜下应用鼻中隔软骨瓣转位进行修复.     

翼腭窝和颞下窝三维影像学与经鼻内镜解剖学对照研究

目的 探讨多层螺旋CT(multislice spiral computed tomography,MSCT)测量翼腭窝和颞下窝解剖相关标志的方法及可行性.方法 对11具尸头行MSCT扫描,利用工作站确立解剖标志空间坐标,并计算解剖学数据.同时对11具尸头经鼻内镜解剖翼腭窝和颞下窝,并测量相关解剖学数据,对照影像学与鼻内镜下的共同解剖标志的形态,比较影像学和鼻内镜下解剖测量数据结果.结果 影像学方法和解剖学方法测量得到鼻小柱根部到蝶腭孔、翼管、圆孔、卵圆孔、棘孔、颈动脉管外口、破裂孔的距离((-x)±s,下同)分别为:(68.83±3.00)、(72.49±2.88)、(75.26±3.14)、(88.55±5.00)、(95.19±4.31)、(106.76±3.77)、(88.16±2.87)mm和(68.90±3.04)、(72.73±3.08)、(75.44±3.07)、(89.75±4.13)、(96.22±3.37)、(106.68±3.75)、(88.47±2.64)mm,两组数据差异无统计学意义(t值分别为-0.856、-1.134、-0.920、-1.923、-1.903、2.820、1.209,P值均>0.05).蝶腭孔、翼管、圆孔、卵圆孔、颈动脉管外口、破裂孔是鼻内镜解剖和影像学共同的解剖标志,可作为判断翼腭窝和颞下窝内神经、血管以及重要毗邻结构空间关系的解剖标志.结论 MSCT扫描三维重建测量翼腭窝和颞下窝相关标志解剖学数据可靠,可为临床个体化手术提供依据.     

鼻内镜下上颌窦入路鼻-颅底区域的解剖学分析

目的创建内镜下经上颌窦入路翼腭窝及颞下窝解剖模型,寻找内镜下咽旁间隙段颈内动脉的定位方法。方法 对100例成人行鼻、颅底CT扫描并用Mimics软件进行三维重建;在重建模型上分别测量犁骨后缘中点至颈内动脉相关解剖标志的角度和距离。同时对6具尸头于鼻内镜下经上颌窦联合入路解剖翼腭窝和颞下窝,以咽鼓管为中心向外、向后逐步暴露并定位咽旁间隙段颈内动脉。结果犁骨后缘中点至破裂孔、颈动脉管外孔、颈静脉孔的角度平均值分别为72.0°、57.6°、54.1°,犁骨后缘中点至以上各孔的距离平均值分别为13.65、31.81、32.5 mm,蝶骨角棘与颈动脉管外口前界平均距离为5.92 mm。结论鼻内镜下经鼻联合上颌窦开窗入路能充分的暴露翼腭窝和颞下窝结构。犁骨后根、蝶骨翼突、蝶骨角棘、卵圆孔和茎突是颈内动脉相关颅底解剖的重要标志;蝶骨角棘、骨性咽鼓管口为颈动脉管外口前界的重要骨性标志,术中不超越该界限有助于减少损伤咽旁间隙段颈内动脉。     

表面配准与解剖标志配准在鼻内镜导航手术中的应用比较

目的:评价表面配准和解剖标志配准技术在鼻内镜导航手术中应用的优劣。方法:在26例鼻内镜手术中进行导航,从准备时间、靶点误差这2方面比较其差别,并就导航手术的方便程度和应用价值进行分析。结果:26例鼻内镜手术均成功使用影像导航系统,术中均提供了准确的鼻内解剖定位,无并发症发生。表面配准组的平均准备时间为(8.5±1.9)min,解剖标志配准组为(6.5±1.7)min。表面配准组的鼻唇角靶点配准误差为(1.43±0.26)mm,中甲前端附着缘为(1.92±0.47)mm,下甲前端附着缘为(1.82±0.49)mm,下甲后端附着缘为(2.03±0.42)mm。解剖标志配准组中对应的靶点配准误差分别为(1.58±0.35)mm、(2.05±0.37)mm、(1.92±0.31)mm和(2.48±0.64)mm。术者对于导航方便程度的评价总体较高,完全不影响或略影响手术者24例(92.2%)。术者认为导航有使用价值或明显使用价值者22例(84.6%),其价值主要与靶点误差值有相关。结论:表面配准方法的精确度要优于解剖标志配准法,但解剖标志配准更简便,准备时间明显短于表面配准方法。Digipointeur导航系统使用方...     

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。     

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。     

影像导航系统在复杂鼻颅底内镜手术中的应用

目的 评价影像导航系统在复杂鼻颅底内镜手术中的作用。方法 26例中额窦复发性内翻性乳头状瘤2例,鼻腔鼻窦肿瘤侵及颅底5例,垂体腺瘤7例,创伤性视神经病12例,均应用影像导航系统行鼻内镜手术。结果 影像导航术前准备时间(包括配准、头架定位、常规器械注册等) 5～10min, 平均7min。手术区域影像标志与实体解剖标志间的误差≤1. 5mm,手术均顺利完成,术中、术后未出现并发症。结论 导航系统定位准确, 能帮助术者确定术区周围重要解剖结构,可以实时判定肿瘤切除程度, 能够最大限度地切除肿瘤, 减少并发症。尤其在有既往手术史或病变破坏了鼻鼻窦及颅底解剖标志的情况下,导航系统对术者的帮助更大,增强了术者自信心,提高了手术的安全因素,保证了肿瘤切除的彻底性。     

Comparative study on the morphology and the composition of the otoliths in the teleosts

Conclusion. Saccular otoliths of teleosts were mostly larger than utricular otoliths, which might relate to the three-dimensional movement. The large and heavy otolith may be better suited in saccules of the bottom and reef fishes. The quantities of iron in lagenar otoliths were found to be lower than those of birds. The function of the fish lagena remains to be elucidated by further studies. Objective. To evaluate the morphological characteristics and the chemical composition of the otoliths in fishes as related to behaviour and habitat. Materials and methods. We studied the morphology of the otoliths of 18 genera of fishes (81 samples) divided into 3 groups: saltwater fish (13 genera), freshwater fish except for the carp family (3 genera) and carp family fish (2 genera). The otoliths and the living environments were compared. The chemical composition was analysed using a synchrotron X-ray fluorescence analyser. Results. Bottom fishes generally have larger saccular otoliths, and migrating fishes have smaller saccular otoliths. In comparing the bottom/reef fishes and the migrating fishes in salt water, the former tended to have larger saccular otoliths. In saltwater bottom fishes the tendency was found that the thinner the head, the larger was the saccular otolith. We found significant quantities of iron, zinc and manganese in the lagenar otoliths.     

On the High Frequency Transfer of Mechanical Stimuli from the Surface of the Head to the Macular Neuroepithelium of the Mouse

Vestibular macular sensors are activated by a shearing motion between the otoconial membrane and underlying receptor epithelium. Shearing motion and sensory activation in response to an externally induced head motion do not occur instantaneously. The mechanically reactive elastic and inertial properties of the intervening tissue introduce temporal constraints on the transfer of the stimulus to sensors. Treating the otoconial sensory apparatus as an overdamped second-order mechanical system, we measured the governing long time constant (Τ_L) for stimulus transfer from the head surface to epithelium. This provided the basis to estimate the corresponding upper cutoff for the frequency response curve for mouse otoconial organs. A velocity step excitation was used as the forcing function. Hypothetically, the onset of the mechanical response to a step excitation follows an exponential rise having the form Vel_shear = U(1-e^−t/TL), where U is the applied shearing velocity step amplitude. The response time of the otoconial apparatus was estimated based on the activation threshold of macular neural responses to step stimuli having durations between 0.1 and 2.0 ms. Twenty adult C57BL/6 J mice were evaluated. Animals were anesthetized. The head was secured to a shaker platform using a non-invasive head clip or implanted skull screws. The shaker was driven to produce a theoretical forcing step velocity excitation at the otoconial organ. Vestibular sensory evoked potentials (VsEPs) were recorded to measure the threshold for macular neural activation. The duration of the applied step motion was reduced systematically from 2 to 0.1 ms and response threshold determined for each duration (nine durations). Hypothetically, the threshold of activation will increase according to the decrease in velocity transfer occurring at shorter step durations. The relationship between neural threshold and stimulus step duration was characterized. Activation threshold increased exponentially as velocity step duration decreased below 1.0 ms. The time constants associated with the exponential curve were Τ_L = 0.50 ms for the head clip coupling and T_L = 0.79 ms for skull screw preparation. These corresponded to upper −3 dB frequency cutoff points of approximately 318 and 201 Hz, respectively. T_L ranged from 224 to 379 across individual animals using the head clip coupling. The findings were consistent with a second-order mass-spring mechanical system. Threshold data were also fitted to underdamped models post hoc. The underdamped fits suggested natural resonance frequencies on the order of 278 to 448 Hz as well as the idea that macular systems in mammals are less damped than generally acknowledged. Although estimated indirectly, it is argued that these time constants reflect largely if not entirely the mechanics of transfer to the sensory apparatus. The estimated governing time constant of 0.50 ms for composite data predicts high frequency cutoffs of at least 318 Hz for the intact otoconial apparatus of the mouse.     

Observations on the stria vascularis of the guinea pig cochlea and the changes resulting from the administration of the diuretic furosemide

An electron microscope examination of the stria vascularis of guinea pigs and the structural changes occurring after administration of furosemide has been made. The use of ruthenium-red, which stains cell coats, has shown that the stria is impermeable to the passive diffusion of material from both the endolymph and the spiral ligament. The first changes after administration of furosemide are observed 4 hours after injection; small spaces develop between the cells. After 5–6 hours the spaces have enlarged but the tight junctions between marginal cells remain intact. The intermediate cells show signs of atrophy. In severely affected animals the intermediate cells have so shrunk that the spaces are very large and the marginal cells clearly resolved. These latter cells show no structural damage. In this severely affected tissue it is seen that the blood vessels are entirely surrounded by marginal cell extensions. It is suggested that the intermediate cells may have a regulatory function. The damage appears to be recoverable, since 6 hours after injection the spaces have decreased in size although some signs of intermediate cell atrophy are still apparent.     

胃镜联合食管镜取出胃内异物1例

患者,男,49岁,因＂反复中上腹疼痛6年＂于2012年6月12日就诊于我院消化内科。患者有反复胃痛、胃部不适症状,长期按胃病治疗效果不佳。既往有吸毒史、丙型肝炎病史。6年前患者毒瘾发作时曾吞入牙刷,在当地医院复查未发现异物,未进一步诊治。     

Contact between the tectorial membrane and the cochlear sensory hairs in the human and the monkey

European Archives of Oto-Rhino-Laryngology - The surface structure of the organ of Corti and the overlying tectorial membrane were studied in human and monkey cochleas under a scanning electron...     

膈神经与面神经吻合的解剖学研究

目的:探讨膈神经移位与面神经干吻合的解剖学基础。方法:解剖11具22侧成年尸体头颈部,观察并测量:①膈神经根与面神经总干腮腺区分叉处之间的距离;②膈神经干在颈部可利用长度;③面神经总干腮腺区分叉处游离至水平半规管下缘可利用长度,面神经总干腮腺区分叉处游离至水平半规管下缘较游离至茎乳孔处增加的面神经干可利用长度;④面神经总干腮腺区分叉处至水平半规管下方切断处膈神经干及面神经干神经移位后并列放置重合长度。结果:①膈神经根与面神经总干腮腺区分叉处之间的距离为(7.2±0.9)cm。②膈神经起点至锁骨下静脉上缘平面为(7.2±1.6)cm。③面神经总干腮腺区分叉处至水平半规管下方切断处的长度2.7~3.5 cm,较面神经干自茎乳孔下方切断增加1.0~1.5 cm。④神经移位后重合长度为0.4~1.8 cm。结论:在锁骨下静脉上缘平面切断20侧标本膈神经可与自乳突内切取的面神经干无张力吻合,两侧膈神经不能与自乳突内切取的面神经干无张力吻合。