鼻内镜下蝶窦外侧壁的应用解剖学研究

目的:通过经鼻内镜行蝶窦外侧壁尸头解剖,为临床鼻内镜下蝶窦外侧壁相关手术提供解剖学参考.方法:选取经10%甲醛防腐处理的国人成人湿性尸头10具(20侧),鼻内镜下经鼻-蝶窦手术入路,暴露蝶窦腔,在0°和30°鼻内镜下确认蝶窦外侧壁骨性隆起,观察视神经和颈内动脉与毗邻结构的关系,以直尺、量角器等测量工具分别测量视神经管和颈内动脉骨性隆起与鼻小柱、鞍底中线的距离和角度.结果:鼻内镜下可见蝶窦外侧壁上视神经管与颈内动脉骨性隆起呈"八"字形关系,向蝶窦腔凸入的程度及两者间距离因人而异,沿颈内动脉追踪可暴露海绵窦外侧壁;测得视神经管眶口内壁中点、颈内动脉骨性隆起前端到鼻小柱的平均距离分别为(75.33±5.59)mm和(81.02±5.29)mm,到鞍底中线的平均距离分别为(5.81±1.52)mm和(5.53±1.47)mm;视神经管眶口内壁中点到鼻小柱连线与鼻底的夹角平均为(53.4±4.1)°.结论:以鼻小柱及鞍底中线为参考点,在鼻内镜下经鼻-蝶窦手术径路进行的蝶窦外侧壁解剖学形态观察和相关测量数据可为临床医生提供相应指导.     

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.     

鼻内镜下扩大的经鼻腔蝶窦入路治疗鞍周病变的解剖研究和临床应用

目的：通过扩大的经鼻腔蝶窦人路的内镜解剖学研究和初步临床应用,为扩大的经鼻腔蝶窦手术适应证及范围提供理论依据。方法：在4具(8侧)已经染料动脉灌注的成人尸头上模拟扩大经鼻腔蝶窦手术入路,同时测量海绵窦旁重要结构与鞍底的距离。结果：根据蝶窦后壁的骨性结构特征将蝶窦腔分为1个中间腔、2个旁中间腔及2个外侧腔。扩大经蝶手术入路可清晰显示鞍底骨膜、硬脑膜外层、海绵窦内侧壁、海绵窦内颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍隔及视丘下部等解剖结构。临床初步用于治疗1例巨大侵入海绵窦的生长激素型垂体腺瘤患者,取得了较好的手术效果。结论：内镜扩大经鼻腔蝶窦手术入路可清晰显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗,但应熟练掌握内镜鞍周解剖学及熟练的经鼻腔蝶窦手术经验。     

蝶窦和视神经管多层螺旋CT的测量

目的 为经鼻内镜蝶窦手术、视神经管减压术提供影像解剖学基础.方法 利用螺旋CT多平面重建技术对40例鼻及鼻窦正常病例行蝶窦、视神经管有关解剖数据的影像学测量.结果 两侧视神经管各壁长度均值:内侧壁(12.08±0.62)mm,外侧壁(10.16±1.73)mm,上壁(9.16±1.17)mm,下壁(10.24±1.35)mm;两侧视神经管及蝶窦有关径线均值:视神经管颅口处左右径(5.57±0.95)mm,上下径(4.53±0.78)mm;中部左右径(4.40±0.67)mm,上下径(4.36±0.67)mm;眶口处左右径(5.09±0.85)mm;上下径(5.90±0.98)mm;鼻小柱前缘中点到蝶窦前壁中点的距离(70.8±5.4)mm;蝶窦最大左右径(17.83±4.38)mm,最大上下径(18.40±3.76)mm,最大前后径(23.19±6.73)mm.结论利用螺旋CT多平面重建技术可以准确方便的测量蝶窦和视神经管的解剖结构,对该部位的经鼻内镜手术具有重要指导价值.     

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。     

鼻内镜下咽旁间隙解剖研究

目的采用鼻内镜经鼻径路对咽旁间隙区域的重要血管、神经结构进行解剖,掌握其分布的规律,以寻找用于指导手术有效的解剖标志并测量相关的数据,从而为处理该部位病变的鼻内镜手术提供解剖依据。方法对福尔马林浸泡的尸头4例（8侧）,模拟鼻内镜下鼻径路咽旁间隙进行解剖。对手术入路的安全范围进行评估,并观测手术径路的重要标志和毗邻关系,测量相应的解剖数据。结果经鼻径路咽旁间隙前为咽鼓管,外为翼内板残端,上为蝶窦底、破裂孔,下为后鼻孔下缘,内为头长肌。翼管的长度、咽鼓管峡部与颈内动脉的距离分别为（14．50±1．77）m／n、（11．04±1．08）mm。结论鼻内镜下经鼻径路可以暴露咽旁间隙的茎突前间隙部分,在该区域保护颈内动脉是关键。该径路以颈内动脉（interal carotid artery,ICA）的外口和破裂孔两点连线水平作为上界,相对安全地暴露ICA的颈段。     

经鼻内镜颅底手术解剖数据实时采集的初步研究

目的:探讨MicronTracker双目视觉导航仪在经鼻内镜颅底手术中解剖数据实时采集的可行性;为经鼻内镜颅底手术提供解剖学依据.方法:在MicronTracker双目视觉导航仪的基础上研制成功经鼻内镜手术解剖数据实时采集系统,测量67具(男32具,女35具)干颅骨相关平面及各解剖结构之间的角度和距离,并行统计学处理.结果:①经鼻内镜手术解剖数据实时采集系统运行稳定,可实时读取探针的俯仰角、方向角和针尖所及任意两点的距离.②测得主要解剖标志数据如下:额骨平面与法兰克福平面夹角男女分别为(77.7±4.7)°和(81.6±4.5)°;额骨平面与鼻底平面夹角男女分别为(78.6±5.8)°和(82.0±4.5)°.同侧鼻棘侧缘到破裂孔前缘.俯仰角男女分别为(61.3±7.6)°和(65.6±7.1)°,方向角男女分别为(7.0±2.6)°和(7.1±1.8)°,距离男女分别为(68.9±4.1)mm和(66.3±3.9)mm;同侧鼻棘侧缘到蝶窦开口,俯仰角男女分别为(40.5±9.3)°和(46.4±6.8)°,方向角男女分别为(2.1±1.8)°和(3.6±2.6)°,距离男女分别为(56.2±3.1)mm和(53.4±3.0)mm.结论:①基于MicronTracker双目视觉导航仪的鼻内镜手术实时解剖数据采集系统可实现解剖标志的快速空间定位及记录.②额骨平面和正中矢状面与鼻腔及颅底结构空间关系恒定,可作为确定鼻腔、前颅底解剖标志空间定位的基准平面.     

内镜眶上锁孔与经鼻蝶联合入路的解剖学研究

目的 研究框上锁孔入路及经鼻－蝶窦入路的内镜局部解剖学并测量有关解剖数据，探讨二者联合应用于治疗巨大鞍山区占位性病变的可行性，为颅底外科手术提供相关形态学参考数据。方法 测量100例成人颅骨标本额骨颧突距同侧和对侧前后床突的距离和角度。通过25例成人尸头，模拟内镜眶上“锁孔”入路和经鼻－蝶窦入路，观察所能达到 解剖部位，测量相关的解剖数据。结果 眶上锁孔入路可以从前方和上方达到鞍区及斜坡上段，清晰地显露垂体、垂体柄、视交叉、颈内动脉、基底动脉等结构；经鼻－蝶窦入路可从下方显露垂体及鞍膈等鞍区结构。结论 内镜眶上锁孔与经鼻－蝶窦联合入路是一种微创外科手术，二者联合应用可完成巨大鞍区占位性病变的外科治疗。     

鼻内镜下鼻中隔正中进路行额窦底壁切除的可行性研究

目的:探讨鼻内镜下额窦底壁鼻中隔正中进路的可行性。方法:①对60例经甲醛固定的成人尸头进行CT扫描,并进行三维CT重建。②取30例尸头紧贴一侧鼻中隔沿矢状线锯开,对重要解剖标志进行相关解剖学观测。③结合CT和解剖学数据,在30例尸头上,进行鼻内镜下鼻中隔正中入路额窦模拟手术。记录模拟手术时间、手术步骤、手术过程中手术标记的寻找、鼻内镜度数的视野影响、视野中额窦各壁的可视度、手术器械的影响、鼻中隔以及嗅丝的损伤程度等等。结果:①额窦底后缘均在中鼻甲根部的前端,中鼻甲根部均附着于筛顶与筛板交界处。②中鼻甲垂直部与水平部交接点与鼻中隔相对应的点称为M点,M点到鼻骨的水平距离为(20.07±6.21)mm,M点到第一对嗅丝距离为(24.38±7.68)mm,第一对嗅丝到额窦底后缘距离为(9.57±2.73)mm,中鼻甲根部附着缘到额窦底后缘距离为(5.38±1.23)mm,额窦底壁前后径为(7.62±2.45)mm,额窦底壁左右径为(9.41±3.37)mm,额窦间隔上下径为(16.97±3.23)mm,额窦间隔前后径为(12.34±2.23)mm。③结合CT和解剖学测量,在鼻内镜下完成鼻中隔正中入路的额窦手术,模拟手术平均时间为1h45min。鼻内镜0°镜下的视野可以观察到部分额窦内侧壁、后壁和顶壁,30°镜下完成鼻中隔切除,0°镜下暴露额窦底壁并将其切除,70°镜下3例不能观测到额窦外侧壁,30例均能观测到部分额窦顶壁、内侧壁、前壁以及后壁,鼻中隔损伤范围约为2.23cm×2.59cm,嗅丝未见损伤。结论:鼻内镜下鼻中隔正中径路容易寻找额窦,以此进路进行额窦底壁切除是可行的。     

颈内动脉颅底段重要解剖标志点的影像学测量

目的了解正常成人颈内动脉岩内段各点与咽鼓管圆枕的距离,为鼻内镜颅底相关手术的安全操作提供重要的参考依据。方法选择50例正常成人颅底为研究对象,采用薄层高分辨率CT扫描和图像放大,三维重建,对颈内动脉岩内段距咽鼓管圆枕的距离进行测量,并对测量值进行统计学处理。结果咽鼓管圆枕距离同侧破裂孔距离为（17.440±0.213）mm,距离同侧颈内动脉管外口（27.322±0.271）mm,距离右侧卵圆孔（22.000±0.323）mm。男性咽鼓管圆枕与左侧卵圆孔距离为（21.122±0.314）mm,女性咽鼓管圆枕与左侧卵圆孔距离为（21.228±0.617）mm。结论该研究为鼻内镜颅底手术的安全操作提供了重要的参考依据,对术中暴露和保护岩骨段颈内动脉极为重要,能有效避免术中损伤颈内动脉造成致死性大出血。     

CT仿真内镜对蝶窦三维解剖的显示及在垂体瘤经蝶窦手术的应用

目的 探讨CT仿真内镜(CT virtual endoscopy,CTVE)显示蝶窦三维解剖的情况及在垂体瘤经蝶窦手术中的应用.方法 根据术前CT扫描数据重建蝶窦CTVE图像,并用于指导128例垂体瘤经蝶窦手术的术前计划及术中定位.结果 CTVE能显示蝶窦三维解剖结构,接近术中所见.在128例患者中,通过传输函数(tr...     

Approaches to sella turcica in endoscopic pituitary surgery

Recent advances in endoscopic sinus surgery suggested the potential for its surgical application to pituitary surgery. A number of institutions have reported the advantage of endoscope use in pituitary surgery, which is now widely accepted, but approaches to the sella vary in the literature. We retrospectively studied sella approaches in endoscopic pituitary surgery as rhinologists. Subjects included 6 cases of pituitary adenoma and 2 cases of Rathke's cleft cyst. A both-nostril transnasal transsphenoidal approach, our standard technique, was used in 6 cases. This approach consisted of elevation of mucoperiosteal flaps, resection of the vomer and sphenoid anterior wall, and opening of the sellar floor. Elevated mucoperiosteal flaps were used to close of the sella after tumor resection. All tumors were removed and no significant postoperative complications occurred. We found the both-nostril transnasal approach to be easy and time-saving and provided surgeon with a broad surgical field necessary to treat large tumors and accidental cases. Postoperative observation of the sella was easy for wide opening of the anterior wall of the sphenoid sinus. In our experience with reoperation, we quickly accessed the sella and easily removed tumors in the second operation. Our technique therefore has an advance in treatment of recurrence. The both-nostril transnasal approach involves the same procedures as median drainage of the sphenoid sinus, so our technique may have advantages in preventing mucocele of the sphenoid sinus as a late complication of transsphenoidal surgery. The transnasal transsphenoidal approach via both nostrils is preferable rhinologically.     

Utility of sphenoid mucosal flaps in transnasal transsphenoidal surgery

CONCLUSIONS: Use of a sphenoid mucosal flap in transsphenoidal surgery decreased the incidence of postoperative cerebrospinal fluid (CSF) leaks and promoted wound healing of the sphenoid sinus. OBJECTIVES: To evaluate the effectiveness of sphenoid mucosal flaps for the reconstruction of the sellar floor after transsphenoidal surgery. PATIENTS AND METHODS: Patients who underwent transnasal transsphenoidal surgery were reviewed. Data on materials used for the sellar reconstruction, presence of postoperative CSF leaks, duration of lumbar drainage and local wound complications of the sphenoid sinus were collected. RESULTS: Sphenoid mucosal flaps were used in 46 cases but not in 22 cases. An intersinus septal mucosal flap was most commonly used. Total mucosal covering was possible in 43 cases, partial covering in 3 cases and no covering in 22 cases. Postoperative CSF leaks occurred exclusively in six patients with partial or no mucosal covering. The duration of lumbar drainage was shorter in patients with a total mucosal covering than in those with a partial or no mucosal covering (average 4.3 days vs 11.7 days, p=0.003). Local wound complications of the sphenoid sinus occurred more frequently in patients with no mucosal covering than in patients with a mucosal covering (5/22, 22.7% vs 1/46, 2.1%, respectively, p=0.012).     

蝶窦外侧壁相关结构的CT和MRI对比研究

目的 :对正常人蝶窦外侧壁相关结构的CT和MRI进行对比研究 ,为该区域疾病诊断和鉴别诊断提供理论依据。方法 :对 2 5例正常人行冠状和水平位高分辨率CT扫描。对 2 0例正常人行MRI冠状、水平位SET1 WI和FSET2 WI扫描。结果 :①蝶窦气化分为蝶骨体气化类型和蝶骨体突起气化类型。前者分 3型 :甲介型 (2 % ) ,鞍前型 (2 0 % ) ,鞍型 (78% )。后者分 4型 :蝶骨小翼气化型 (38% ) ,蝶骨大翼气化型 (40 % ) ,翼突气化型(34% ) ,鞍背气化型 (6 % )。②蝶骨外侧骨壁最薄 (<1mm)处位于视神经管内壁 (96 % )、蝶筛隐窝层面骨壁(86 % )、颈内动脉管层面骨壁 (6 6 % )。③过度气化的蝶窦可使圆孔 (6 4 % )和翼管 (44 % )突入蝶窦腔内。结论 :临床应对视神经管周围不同气化类型给予充分重视     

Endoscopic approach to lesions of the sphenoid sinus, orbital apex, and clivus

OBJECTIVE: The expanding role of endoscopic management of sinonasal disorders includes approaches to the skull base. In this report, we review our experience approaching lesions of the sphenoid sinus, orbital apex, and clivus via a transnasal endoscopic technique. DESIGN: A retrospective, case series review of 15 patients presenting with skull base lesions approached via an endoscopic approach was performed. Emphasis was placed on analyzing the preoperative planning strategy and the surgical technique. SETTING: Academic referral center. RESULTS: We reviewed the medical records of 15 patients who underwent an endoscopic approach to the sphenoid sinus, orbital apex, or clivus. Ten patients presented with lesions of the sphenoid sinus and clivus. The lesions in this patient group included metastasis to the cavernous sinus and clivus (3); fibrous dysplasia (2); plasmacytoma of the clivus (2); and 1 patient each with cholesterol granuloma, meningoencephalocele, and recurrent teratoma. Five patients presented with lesions of the orbital apex. These included invasive fungal sinusitis (2), mucopyocele (2), and pseudotumor (1). Image-guided surgical navigation was used in each case, and all approaches consisted of entirely endoscopic transnasal techniques. CONCLUSIONS: Endoscopic approaches to the skull base are possible because of advancements in technology now available to the rhinologic surgeon. This report highlights the preoperative strategies and surgical techniques used in approaching lesions of the sphenoid sinus, orbital apex, and clivus. These extended techniques should provide a more direct, less invasive, and more cost-effective method for approaching select skull base lesions.     

Utility of sphenoid mucosal flaps in transnasal transsphenoidal surgery

Conclusions. Use of a sphenoid mucosal flap in transsphenoidal surgery decreased the incidence of postoperative cerebrospinal fluid (CSF) leaks and promoted wound healing of the sphenoid sinus. Objectives. To evaluate the effectiveness of sphenoid mucosal flaps for the reconstruction of the sellar floor after transsphenoidal surgery. Patients and methods. Patients who underwent transnasal transsphenoidal surgery were reviewed. Data on materials used for the sellar reconstruction, presence of postoperative CSF leaks, duration of lumbar drainage and local wound complications of the sphenoid sinus were collected. Results. Sphenoid mucosal flaps were used in 46 cases but not in 22 cases. An intersinus septal mucosal flap was most commonly used. Total mucosal covering was possible in 43 cases, partial covering in 3 cases and no covering in 22 cases. Postoperative CSF leaks occurred exclusively in six patients with partial or no mucosal covering. The duration of lumbar drainage was shorter in patients with a total mucosal covering than in those with a partial or no mucosal covering (average 4.3 days vs 11.7 days, p=0.003). Local wound complications of the sphenoid sinus occurred more frequently in patients with no mucosal covering than in patients with a mucosal covering (5/22, 22.7% vs 1/46, 2.1%, respectively, p=0.012).     

Surgical measurement to sphenoid sinus for the Chinese in Asia based on CT using sagittal reconstruction images

The objective this study was to measure the changes of sphenoid sinusin the Chinese in AsiausingCT sagittal thin-slice reconstruction images, and to clarify the three-dimensional anatomical features of sphenoid sinus with its surrounding structures, relevant to the performing of the endoscopic sphenoidotomy. The sagittal reconstruction images were obtained from 178 CT images of 89 cases of normal adult participants (54 males and 35 females) with sphenoid sinus. We took the high-resolution axial CT images, from all the subjects, of the thickness by 0.625 mm, and reconstructed 1-mm-thick gapless sagittal CT images to measure the distance of all the sellar and pre-sellar types on the three-dimensional reconstructable sagittal plane under the bone window (4,000 at its width, and 400 at its level) in the CT images. The length of mean vertical line from the center of sphenoid ostium to the roof of sphenoid sinus of Non Onodi cell type is 10.6 ± 1.5 mm, and of Onodi cell type is 3.3 ± 1.5 mm. The length of vertical line from the center of sphenoid ostium to the lowest level of the bottom of sphenoid sinus is 12 mm ± 3.7 mm. The length of mean horizontal line from the sphenoid ostium to the posterior wall of sphenoid sinus is 18 ± 1.5 mm or 28 ± 2.5 mm. The mean horizontal line from the lowest point of the sella to the anterior wall of sphenoid sinus is 17.5 ± 1.3 mm in length. The mean horizontal distance from anterior wall to posterior wall of sphenoid sinus of Non Onodi cell type lining skull base is 10.1 ± 1.0 mm, and of Onodi cell type, is 5.2 ± 4.3 mm. The longest horizontal distance from the anterior wall to the posterior wall of sphenoid sinus is 22.0 ± 7.7 mm. The present study provides atomical information about sphenoid sinus of the Chinese in Asia with some surgical distance measured between the sphenoid ostium and the surrounding structures, which is essential to avoid the complications during surgery.     

鼻中隔偏曲与球型鼻甲泡的关系

目的：探讨鼻中隔偏曲与球型鼻甲泡的关系。方法：分析972例患者的鼻窦冠状位CT片,观察鼻中隔偏曲和球型鼻甲泡的发生率,并把鼻中隔偏曲分为高位偏血和低位偏曲,测量鼻中隔偏曲角度（SDA）和球型鼻甲泡的横径,探讨鼻中隔偏曲与球型鼻甲泡的关系。结果：182例鼻中隔偏曲患者的球型鼻甲泡发生率为17．03％,790例无鼻中隔偏曲患者的球型鼻甲泡发生率为14．05％,2组间差异无统计学意义（P〉0．05）。60例高位偏曲患者的球型鼻甲泡发生率为33．33％,122例低位偏曲患者的球型鼻甲泡发生率为9．02％,2组间球型鼻甲泡发生率有显著性差异（P〈0．01）。20例高位偏曲伴球型鼻甲泡组SDA平均值为14．55°±3．61°,偏曲凹侧球型鼻甲泡横径均值为（5．93±1．88）mm,两者之间无相关性（P〉0．05）。11例低位偏曲伴球型鼻甲泡组SDA平均值为13．36°±2．42°,偏曲凹侧球型鼻甲泡横径均值为（4．86±1．40）mm,两者之间无相关性（P〉0．05）。结论：鼻中隔高位偏曲与球型鼻甲泡的发生有关,尤其是凹侧易出现球型鼻甲泡。球型鼻甲泡大小并不随SDA增大而增大。     

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...