鼻科学

20 0 4 0 70 0泪囊窝的应用解刮研究 /张涛… / /临床耳鼻咽喉科杂志 2 0 0 3,17(11) 6 5 2～ 6 5 3目的 :明确泪囊窝的解剖学特点 ,为鼻内镜下鼻腔泪囊造孔术提供参考。方法 :对 2 3具 (46侧 )成人尸头泪囊窝的骨性结构构成及骨壁的厚度和倾斜角度进行测量。结果 :泪囊窝中部的骨性构成中上颌骨额突所占比例略大于泪骨 ,且变异较大 ;泪囊窝后壁与冠状面呈大约 2 0°的倾角。结论 :在鼻内镜鼻腔泪囊造孔术中 ,应对眶壁行CT检查 ,以明确不同类型泪囊窝骨性构成情况下手术可能遇到的问题 ,防止术中眶内并发症或由于造孔过小导致术后鼻泪管…     

鼻内镜下鼻腔泪囊造孔术泪囊定位新方法的应用

目的探讨内镜下鼻腔泪囊造孔术中鼻内泪囊定位新方法的可行性。方法以枪状咬骨钳自下而上咬除泪骨前部骨质及上颌骨额突,先暴露鼻泪管而后再暴露泪囊内侧壁黏膜。结果用此法较易寻找到泪囊,不易损伤周围重要组织如筛前动脉、鼻泪管、眶纸样板、前组筛窦等,术后疗效佳,术后造孔不易闭锁。结论内镜下鼻内寻找泪囊法可行,值得推广应用。     

经眼光导纤维引导鼻内镜下鼻腔泪囊造口术治疗慢性及复发性泪囊炎的临床研究

目的:探讨鼻内镜下鼻腔泪囊造口术中鼻内泪囊定位的新方法.方法:68例慢性泪囊炎患者(包括31例复发性泪囊炎)经鼻内镜行鼻腔泪囊造口术,术中将眼内光导纤维投射到鼻腔外侧壁的光斑作为泪囊在鼻腔外侧壁的投影.结果:使用眼内光导纤维引导,泪囊定位准确,进行鼻内镜下鼻腔泪囊造口术时手术时间明显缩短,手术简化.2例2次手术者再阻塞,其余患者随访2年无复发,无并发症发生,成功率为97.06%(66/68).结论:将眼内光导纤维用于鼻内镜下鼻腔泪囊造口术中对泪囊定位的方法简单可行,值得推广应用.     

改良鼻内镜下鼻腔泪囊造口术

目的提高鼻腔泪囊造口术的成功率。方法于泪囊在鼻腔外侧壁的投影，即中鼻甲的前端，鼻丘处，“工”形切开鼻腔黏膜，形成前后二个“门”形黏膜瓣，磨开骨壁，造口约1?cm，泪囊内侧壁也做同样较小的“工”形切开，形成相似的“门”形泪囊壁瓣，将其前后分别与鼻腔黏膜瓣对应缝合，覆盖骨性造口缘，使造口表面光滑，无纤维肉芽和瘢痕组织形成，不易造成阻塞。硬膜外麻醉导管自泪点进入泪道系统，并自下鼻道鼻泪管开口及造口处拉出，形成两条通道。结果术后7?d拆除固定于造口处的导管上的高分子膨胀材料，“门”形瓣缝合处已愈合，无黏膜的上下部分骨面已有上皮爬行，造口表面黏膜红润、光滑，冲洗泪道通畅，溢泪症状消失。本组慢性泪囊炎的治愈率为97%。结论本改良鼻内镜下鼻腔泪囊造口术的造口光滑，不易形成肉芽。而硬膜外麻醉导管所形成的第二条通道，更加保证了手术的成功。     

鼻科学

不放扩张器的鼻内镜鼻腔泪囊造口术作者回顾性分析了35例鼻内镜鼻腔泪囊造口术病例,全部患者术中均未放置泪囊扩张器。作者认为鼻内镜鼻腔泪囊造口术是否放置泪囊扩张器,主要根据溢泪症状是否与反复发作的泪囊炎有关,眼科检查泪道堵塞的部位为泪囊后,手术中由暴露泪囊及造口过程是否顺利来决定。首先,按压泪囊区域发现泪囊扩张或者有脓性分泌物或黏液从泪小管口反流,尤其是下泪点反流。其次,泪小点清晰可见,尤其是下泪点。第三,术中暴露和切口泪囊后,经泪小点插入探针,如能顺利通过或有脓性分泌物流出时;如果泪囊壁     

改良鼻内镜下泪囊鼻腔造孔术治疗慢性泪囊炎

目的:探讨改良鼻内镜下泪囊鼻腔造孔术治疗慢性泪囊炎的手术方法及其疗效。方法:通过对造孔、泪囊黏膜瓣的切开及固定方式等的改良处理,在鼻内镜下完成泪囊鼻腔造孔术治疗慢性泪囊炎22例(23眼)。结果:术后随访6～10个月,平均8个月。22例(23眼)中,21例(22眼)治愈,症状完全消失,泪道冲洗畅通,内镜检查造孔通畅;1例(1眼)症状改善不明显。总有效率95.7%(22/23)。所有患者未出现严重并发症。结论:改良鼻内镜下泪囊鼻腔造孔术治疗慢性泪囊炎明显提高了手术成功率,值得临床推广。     

鼻内镜下泪囊鼻腔造孔术造孔的处理

目的:探讨更好地处理鼻内镜下泪囊鼻腔造孔术造孔的方法。方法:102例(109眼)慢性泪囊炎患者于鼻内镜下行泪囊鼻腔造孔术,术中用银夹固定造孔,术后给予综合治疗,并随访3～73个月。结果:治愈99眼(91.0%),好转5眼(4.5%),有效率95.5%。结论:泪囊鼻腔造孔术用银夹固定造孔,术后辅以综合治疗,可有效防止造孔的狭窄、闭锁。     

鼻内镜下鼻腔泪囊造孔术的疗效观察

目的观察鼻内镜下行鼻腔泪囊造孔术的治疗疗效。方法 2011年3月-2013年9月43例(52眼)鼻内镜下行鼻腔泪囊造孔术慢性泪囊炎患者与同期54例(61眼)行传统泪囊鼻腔吻合术的患者比较,术后观察泪道通畅情况。结果术后6个月鼻内镜组43例患者中39例泪道通畅(90.70%),通畅欠佳3例(6.98%),仍堵塞1例(2.33%),有效率97.67%;传统手术组54例患者中48例泪道通畅(88.89%),通畅欠佳4例(7.41%),仍堵塞2例(3.70%),有效率96.30%,两组间有效率比较差异无统计学意义。结论鼻内镜下行鼻腔泪囊造孔术手术效果接近于传统手术,符合患者对手术的微创要求,选择合适病例,可以提高鼻内镜卞鼻腔泪囊造孔术的疗效。     

内窥镜下鼻腔泪囊造孔术

在内窥镜下进行泪囊鼻腔造孔术，因保留了泪窝上部的骨壁，避免了传统的泪囊鼻腔造孔术对泪囊及泪窝骨壁的切除，而保留泪囊的生理功能。作者对连续８１侧（男４０例，女３３例，其中８例为双侧手术，年龄２６～９３岁）下泪道阻塞病人于内窥镜下行泪囊鼻腔造孔术，术中和术后并发症发生率较传统手术低，手术效果明显优于后者，成功率保持９０％以上。此手术通常采用局麻（用副肾及２％利多卡因混合剂注射钩突前壁粘膜及泪窝内侧壁各１ｍｌ及４ｍｌ）。术中使用一个４ｍｍ３０°角的硬性内窥镜，用Ｐｌａｓｔｅｒ皮瓣刀和一对切割钳将钩突上…     

鼻内泪囊应用解剖

由于鼻内窥镜的广泛应用和发展,鼻内镜下鼻腔泪囊造口术成为治疗泪道阻塞性疾病的新兴术式,有逐渐取代鼻外进路的趋势。手术成功的关键在于准确判定泪囊窝在鼻腔外侧壁的位置,因此与之相关的鼻内泪囊应用解剖研究意义迫切。本文就鼻内泪囊应用解剖的研究方法、现状及存在问题综述如下。     

泪囊鼻腔吻合术中泪骨的定位测量

目的:探讨泪骨在泪囊鼻腔吻合术中的重要意义。方法:测量10具(男5具,女5具)成人尸头鼻腔外侧壁上泪骨的长、宽、厚,观察钩突、上颌线和M点(上颌线的中点)的解剖位置。结果:泪骨在鼻腔外侧壁位于钩突的前方,骨质菲薄,所测量的长、宽、厚的平均值分别为9.23、3.63和0.06 mm。结论:使用咬钳可以咬除泪骨,进一步开放泪囊内壁骨质,同时避免使用电钻,减小创伤。钩突、上颌线及M点可作为术中可靠的定位标志。     

鼻内窥镜下鼻腔泪囊吻合术的有关前组筛窦应用解剖

目的：为鼻内窥下鼻腔泪囊吻合术提供解剖学指导。方法：对１６具（３２侧）成人尸头的前组筛窦解剖进行研究,同时观察了钩突与眶内仙壁的毗邻结构关系。结果：根据前组筛窦与泪囊窝的解剖关系将前组筛窦分为三种类型：Ⅰ型为前组筛房前界达泪囊窝的后泪嵴;Ⅱ型为前组筛房前界达泪窝的泪颌缝;Ⅲ型为前组筛前界超过泪凳缝达前泪嵴。其中Ⅰ型占３１．２％,Ⅱ型占５０．％,Ⅲ型占１８．８％,结论：对不同类型的鼻泪管阻塞的患者,     

The maxillary line: anatomic characterization and clinical utility of an important surgical landmark

OBJECTIVES: The maxillary line is a mucosal projection along the lateral nasal wall that serves as a landmark for endoscopic sinus and orbital procedures. The anatomic relations of this structure are not well described. We sought to define the anatomy of the maxillary line and explore its clinical utility. STUDY DESIGN: Cadaver dissection/case series. METHODS: Twenty-five cadaveric nasal specimens were dissected. Extranasal and intranasal measurements of structures including the lacrimal crests, sac and duct, the suture line between the maxillary and lacrimal bones, and the maxillary sinus ostium were taken. The mid-point of the maxillary line, termed the "M point," was used for reference. The distance from the nasal sill to the M point was measured in 30 consecutive clinic patients. RESULTS: The maxillary line corresponded intranasally to the junction of the uncinate and maxilla and extranasally to the suture line between the lacrimal bone and maxilla within the lacrimal fossa. This suture was approximately half way between the anterior and posterior crests. Axially, the plane of the M point corresponded to the superior margin of the maxillary sinus ostium posteriorly (average 10 mm) and was just inferior to the lacrimal sac-duct junction anteriorly. In live subjects, the M point was approximately 3.9 cm from the nasal sill in women and 4.8 cm in men. CONCLUSION: Understanding the conserved relationships of the maxillary line and M point with adjacent nasal and orbital structures will ensure the complete removal of the uncinate process during uncinectomy and promote safe and ample exposure of the lacrimal sac during endoscopic dacryocystorhinostomy.     

Endoscopic inferior dacryocystorhinostomy

Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.     

Endoscopic “retrograde” dacryocystorhinostomy: A fast route to the lacrimal sac

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line.However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery).In the present study, a variation of “classic” endoscopic DCR, named “retrograde” endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.     

鼻腔泪囊造口术的泪囊鼻内解剖研究

目的：探讨鼻腔泪囊的解剖结构及其与毗邻的关系,为鼻内镜下鼻腔泪囊造口术提供解剖学指导。方法：对15具（30侧）成人尸头的泪囊投影在鼻腔外侧壁上的解剖特点进行研究,同时观察了内眦韧带与泪囊的解剖关系。结果：泪囊在鼻腔外侧壁上的解剖位置投影大部（2／3）位于中鼻甲附着处（中鼻甲腋）前端上方,小部位于其下方;泪囊小部分（1／3）位于泪总管开口上方水平,大部位于该口下方;内眦韧带几乎横压于泪囊中部。中鼻甲腋可越过泪囊后界（11侧）或中线（1侧）。使用以内眦韧带为基准点的泪囊鼻外定位法,30侧标本全部定位于泪囊投影区较中心的位置。结论：建议术前行泪囊碘油造影CT检查,手术造口中心位置约为中鼻甲附着处以上1.5～2．0mm处稍前方。泪总管开口与泪囊的解剖关系恒定,术中使用激光光纤行泪道探查,并以透过鼻腔外侧壁上的光斑为定位标志相对精确,以内眦韧带为基准点的泪囊鼻外定位法准确度亦高。     

鼻内镜及影像学定位在鼻腔泪囊造口术中的应用

目的 探讨鼻内泪囊的解剖及影像学定位在泪囊手术中的临床应用价值.方法 对20例(26眼)慢性泪囊炎患者术前进行CT泪囊造影三维重建,确定泪囊大小及影像学定位;术中以上颌线作为定位开放泪囊的参考标志,行鼻内镜下鼻腔泪囊造口术.结果 CT泪囊造影片能清晰显示泪囊大小以及与周围结构的关系,并可任意径线及角度适时测量.术中以上颌线作为手术进路的标志均能准确开放泪囊,20例(23眼)中,大泪囊10眼术后无造口闭塞,治愈率100%;中泪囊11眼术后有1眼仍有少量流泪,但较术前明显好转,治愈率90.9%;小泪囊2眼中有1眼术后仍有明显流泪,内镜检查发现造口粘连、阻塞,治愈率50%.结论 术前计算机三维重建泪囊造影对鼻内镜下鼻腔泪囊造口术具有重要应用价值.上颌线可以作为泪囊手术进路的参考标志之一.     

Endoillumination-guided intranasal microscopic dacryocystorhinostomy for difficult cases

PURPOSE: This prospective study explores the efficacy of a combined approach by intranasal microsurgical dacryocystorhinostomy and fiberglass endoillumination of the tear passage for difficult cases of lacrimal sac or nasolacrimal duct obstruction. METHODS: Microscopic dacryocystorhinostomy was performed in 67 patients with lacrimal obstruction and for revision of external dacryocystorhinostomy. Improved endonasal visualization by microscope and combination with endoillumination of the tear passage allows instant identification and opening of the lacrimal nasal sac without skin incision. Silicon tubes were used for bicanalicular intubation. The patients were prospectively observed for at least 1 year. RESULTS: The operation was well tolerated by all patients. In 95%, a persistently open tear passage was successfully established. No serious complications were observed. CONCLUSION: Endoillumination of the lacrimal sac is useful for locating the sac precisely and refining the endonasal operation technique.     

Eosinophilic fungal rhinosinusitis of the lacrimal sac

OBJECTIVES/HYPOTHESIS: Chronic sinusitis is a condition affecting millions of individuals each year. Recent findings indicate that chronic rhinosinusitis is a response to fungi mediated by the eosinophil in some of these individuals. We report a case of eosinophilic fungal rhinosinusitis of the lacrimal sac, an entity not previously reported. STUDY DESIGN: Case report. METHODS: A 69-year-old man presented with a 1-cm cystic lesion in the right-side medial canthal region. This lesion was fluctuant, and mucoid material was freely expressed from the medial canthal area. Endoscopic examination revealed bilateral nasal polyps anteriorly and superiorly with mucopurulent drainage from both maxillary sinuses. He had undergone three prior sinus surgeries and two prior lacrimal cannulations elsewhere. A computed tomography scan showed opacification of both maxillary sinuses, ethmoid sinuses, and the left sphenoid sinus and moderate thickening in the frontal sinuses. There was significant soft tissue prominence in the area of both lacrimal fossae with erosion into the medial orbit. The patient underwent bilateral endoscopic revision ethmoidectomies, middle meatal antrostomies, sphenoidotomies, frontal sinusotomies, and endoscopic right-side dacryocystorhinostomy at the Department of Otorhinolaryngology, Mayo Clinic (Rochester, MN). RESULTS: At the time of surgery, massive amounts of thick mucoid material were aspirated from both lacrimal regions. The aspiration of the lacrimal duct on the left side was sufficient treatment, whereas the dacryocystorhinostomy was necessary to decompress the cyst of the face on the right side. The material aspirated was allergic mucin, and the patient met the criteria for diagnosing eosinophilic fungal rhinosinusitis. The patient was started on a regimen of antifungal nasal irrigations postoperatively and has done well in follow-up. CONCLUSIONS: Although never previously reported, eosinophilic fungal rhinosinusitis can occur in the lacrimal sac. It is important to recognize this so that the underlying disease process can be treated appropriately.     

泪囊鼻内解剖研究及临床应用

目的探讨鼻内镜下鼻腔泪囊造口术的泪囊鼻内表面定位。方法对15具(30侧)成人尸头的泪囊在鼻腔外侧壁上的投影位置进行解剖学测量;并指导临床应用于32例(39侧)慢性泪囊炎鼻泪管阻塞患者的鼻内镜下鼻腔泪囊造口术。结果解剖学测量泪囊大部分(2／3)位于中鼻甲腋上方,小部分(1／3)位于中鼻甲腋下方;泪囊大部分(2／3)位于总泪小管口下方,小部分(1／3)位于总泪小管口上方;内眦韧带横压于泪囊的中部,几乎与总泪小管平行。施行手术的32例(39侧),术后随访半年以上,治愈28例(35侧,89．8％),好转2例(2侧,5．1％),无效2例(2侧,5．1％),总有效率94．9％。结论以中鼻甲腋前上0．2 cm为手术造口中心点,中鼻甲腋前上0．8 cm为上界,腋前下0．4 cm为下界,作弧形黏膜切口及1．2 cm×1．0 cm骨孔,此为鼻腔泪囊造口的最佳位置;利用枪状镊依据鼻外内眦韧带定位泪囊造口的中心点亦不失为一简易可取的方法。