国人颈静脉孔区神经血管的显微解剖研究-颞下窝径路、乙状窦后径路应用解剖学

通过模拟颞下窝手术径路和乙状窦后径路对30侧头部标本进行解剖.获得国人颈静脉孔区神经、血管的解剖参数.①面神经的行程和有关结构的参数:鼓乳裂外端-茎乳孔12.96±163mm,二腹肌嵴前端-茎乳孔9.09±1.67mm,面神经水平段12.58±1.61mm,垂直段15.88±1.55mm,茎乳孔-腮腺段18.45±1.76mm.②颈静脉球的有关参数:颈静脉球的穹隆顶骨壁厚度4.32±2.28mm,颈静脉窝与颈动脉管的骨壁厚4.92±2.03mm,颈静脉球-后半规管壶腹端3.81±2.94mm,颈静脉球-面神经垂直段8.80±2.66mm.③颈内动脉岩骨段的有关参数:颈内动脉垂直段9.73±1.04mm,水平段18.00±2.04mm,水平段与脑膜中动脉的距离6.80±2.00mm,鼓膜张肌腱与水平段及膝部的距离2.20±1.20mm.以咽鼓管、鼓膜张肌腱、脑膜中动脉为标志定位颈内动脉的水平段,颞下窝径路具有暴露好,可变通的特点.以上述解剖参数,对颈静脉孔区肿瘤的彻底切除、减少合并症、避免死亡病例的发生,均有一定参考意义.     

颈静脉孔区薄层断层解剖学研究

目的 为临床颈静脉孔区影像学诊断提供断层解剖学依据。方法 利用生物塑化技术，将9例颈静脉孔区及相邻结构制成3个方位（横断、冠状位及矢状位）的薄层断层标本，观察各重要神经、血管在各方位上的出现范围、走行与毗邻关系。结果 在横断面上颈静脉孔连续5－6个层面显示，冠状断面连续7－8个层面显示，矢状断面连续10－11个层面显示。双重要层面的结构作了描述。结论 生物塑化薄片对颈静脉及相关神经、血管能够连续显示并准确分辨，对颈静脉孔区的影像诊断及手术有较高的价值。     

颈静脉孔区肿瘤的影像学特征分析

目的探讨颈静脉孔区肿瘤的影像学特征,对颈静脉孔区常见肿瘤进行鉴别诊断,指导外科手术治疗。方法回顾性分析中南大学湘雅医院神经外科1998年4月~2011年5月38例颈静脉孔区肿瘤的影像学资料。结果38例颈静脉孔区肿瘤中神经鞘瘤25例,颈静脉球瘤8例,脑膜瘤5例,38例均行颅底CT、MRI平扫增强检查及显微手术治疗。主要首发症状有耳鸣、听力下降、头痛、行走不稳、吞咽困难、声音嘶哑等。颈静脉球瘤呈典型的“盐椒征”、强化明显,颈静脉孔扩大、边缘极不规则;神经鞘瘤常呈不均匀强化、部分囊性变,颈静脉孔扩大、边缘规则;脑膜瘤“脑膜尾征”典型,颈静脉孔扩大不明显、边缘骨质增生硬化较不规则、偶可见钙化。结论颈静脉孔区不同类型肿瘤有其特有的影像学特征,影像学检查可清晰显示肿瘤与相邻结构改变,有利于神经外科医生制定合适的治疗策略。     

颈静脉孔神经鞘瘤（附5例报告）

本文报告了经手术治疗的颈静脉孔神经鞘瘤５例，其临床表现与波及的颅神经有关，但多有听神经受损症状，术前易误诊。ＭＲＩ对诊断有助，该肿瘤为良性，及时手术全切疗效满意。     

颈静脉孔区肿瘤临床表现及影像学分析

目的探讨颈静脉孔区肿瘤的临床特点、影像学特征。方法回顾性分析2006年5月-2009年12月32例颈静脉孔区肿瘤的临床及影像学资料,术前32例患者均行颞骨薄层CT和头颅MRI平扫加增强扫描,22例怀疑颈静脉球瘤患者于术前24dx时内行血管造影和肿瘤供血血管栓塞。32例颈静脉孔区肿瘤有31例行肿瘤全切手术,1例怀疑颈静脉球瘤患者因乙状窦血栓性静脉炎导致患者反复发热未行手术治疗。术后病理诊断颈静脉球瘤21例,神经鞘瘤10例。结果32例颈静脉孔区肿瘤主要临床表现为耳鸣、听力下降和周围性面神经麻痹。颈静脉球瘤的特征性表现为侵蚀性骨质破坏及“盐和胡椒”征：神经鞘瘤表现为压迫性骨质改变、多发囊变并中度强化。结论CT与MRI的合理结合应用,有助于病变的临床诊断和鉴别,有利于下一步手术方案的选择。     

颈静脉孔区的CT研究

颈静脉孔区位置深在、结构紧密、解剖及毗邻关系复杂。随着影像技术的不断发展，对该区影像解剖研究也越来越深入，为临床提供了更准确、客观的影像学依据。对颈静脉孔区肿瘤的诊断，多层螺旋CT已经成为极为必要的检查手段。这一区域肿瘤最主要的影像表现是颈静脉孔扩大。     

经迷路下-颈静脉突入路切除颈静脉孔区神经鞘瘤

目的回顾经迷路下-颈静脉突入路手术切除颈静脉孔区神经鞘瘤的病例,探讨该入路的临床价值。方法回顾总结2例经迷路下-颈静脉突入路手术切除的颈静脉孔区神经鞘瘤的临床资料,并复习相关文献。结果2例肿瘤均得到完全切除。术后1例患者出现短暂轻度的后组脑神经损害及面神经不全损害表现（House Brackmann Ⅱ级）;1例患者原先后组脑神经损害表现改善,无面神经损害表现,听力保留;术后均无脑脊液漏发生。术后随访6个月,2例患者面神经或后组脑神经损害均逐渐恢复或代偿,无肿瘤复发。结论经迷路下-颈静脉突入路操作简便,能在保护迷路的基础上充分暴露颈静脉孔区,适用于主体位于颈静脉孔内并向颅内脑池明显扩展的神经鞘瘤的手术切除。     

经颞下窝径路切除颈静脉孔区神经鞘瘤1例

患者,男,３２岁。以“伸舌偏斜１年,声音嘶哑８个月,吞咽困难６个月”为主诉于１９９２年５月６日入院。曾在外院以“多发性神经炎”治疗无效。体检：舌右侧萎缩,伸舌舌尖偏右。咽反射迟钝,有唾液积聚,软腭右侧活动度小,悬雍垂左偏。间接喉镜下见右侧声带固定于旁中位。右侧胸锁乳突肌瘦小,耸肩右侧活动度小。颅底位Ｘ线平片、断层及ＣＴ均未发现病变;ＭＲＩ见右侧颈静脉孔扩大,可见２．８ｃｍ×２．３ｃｍ×５．０ｃｍ之肿块,血管受压前移,肿块边界清楚,呈长柱状,枕骨大孔前缘右侧受累（图１）。诊断：右侧颈静脉孔区新生物…     

侧颅底肿瘤术中颈静脉球的静脉窦回流临床研究

目的观察侵犯颈静脉球的侧颅底肿瘤术中的静脉窦回流关系。方法回顾性分析我院自2010年1月至2013年6月收治的7例侵犯颈静脉球的侧颅底肿瘤,其中颈静脉球体瘤5例;侵犯颈静脉球的颞骨鳞癌1例;后颅窝脑膜瘤1例。手术方式采用颞下窝入路,以填塞法或者结扎法控制乙状窦,于颈部结扎颈内静脉。切开颈静脉球,填塞汇入的静脉窦开口,并连同受累静脉壁一起切除肿瘤。结果颈静脉球内静脉窦汇入关系如下:单口汇入4例;双口汇入者2例;数个小口汇入者1例。颈静脉球体瘤完整切除3例,部分切除2例,术后出现暂时性后组颅神经麻痹者1例;中耳癌1例完整切除;脑膜瘤1例完整切除。结论了解颈静脉球及邻近血管腔的静脉窦回流关系,并予以填塞,对于侵犯颈静脉球的侧颅底肿瘤手术切除和出血控制有着重要的意义。     

Clinical Presentation and Management of Jugular Foramen Paraganglioma

Objectives

Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.

Methods

Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications.

Results

Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications.

Conclusion

Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.     

A Hearing Preservation Technique for the Resection of Extensive Jugular Foramen Tumors

Objective To describe a modified surgical approach for patients who maintain hearing function with jugular foramen tumors that extend to the posterior cranial fossa and the neck. Study Design A retrospective review of 6 patients with jugular foramen tumors that were resected by a combined suboccipital and infralabyrinthine–transcervicomastoid approach. Methods A combined suboccipital and infralabyrinthine–transcervicomastoid approach is characterized as follows: 1) There is no ablation of ear structures except the infralabyrinthine mastoid bone; the auricle is retracted anteriorly while preserving the bony wall and skin of the ear canal. 2) After superficial parotidectomy, a limited length of nerve VII from the intratemporal vertical segment is rerouted to divisions of the parotid portion. 3) The tumor is removed along with the internal jugular vein and sigmoid sinus, then the extended intracranial mass is resected through an additional suboccipital approach. Results Five of the 6 patients had complete removal of all gross tumors. There were no major complications or mortalities. The preoperative levels of hearing were preserved in 5 of the 6 patients. Favorable facial function in the immediate postoperative period was noted in 4 of the 6 patients. Incomplete paralysis of 2 patients recovered eventually. Conclusion We propose that a combined suboccipital and infralabyrinthine–transcervicomastoid approach to the jugular foramen can provide sufficient exposure to resect most dumbbell‐shaped tumors, and it could be the initial treatment of choice for patients with remnant hearing.     

Morphometric Study of the Paranasal Sinuses in Normal and Pathological Conditions

Prospective and retrospective morphometric CT (axial and coronal) research was performed with 100 healthy persons and 163 patients (145 males, 118 females, mean age 50 years, range 1-88 years). The patients were classified into the following groups: chronic sinusitis (n=85), polyposis (n=25), mucoceles (n=13), benign tumors (n=20) and malignant tumors (n=20). After initial calibration with the scale (in cm) displayed on the CT image, each paranasal sinus was outlined following its bone inner surface. The data were processed with a high-resolution analysis system, and volumes were calculated using an integration areas rule. The ethmoid, maxillary and sphenoid sinuses exhibited an increase in volume for a period of up to 15 years, afterwards maintaining similar values. The frontal sinus grows in a monomodal pattern (peak at 30 years). The volumetric results (mean and standard deviation) in the normal adult group were as follows: maxillary sinus 13.07 cm³ (6.8), ethmoid 5.5 cm³ (2.0), sphenoid 3.5 cm³ (2.6) and frontal 3.7 cm³ (3.6). Primary frontal and maxillary sinus hypoplasia appeared in 3.9% and 1.3% of cases, respectively. The anatomic variations were as follows: concha bullosa 8.3%, Haller cells 3.2% and Onodi cells 8.3%. The sinusitis values (adults) were greater than those in the normal group: 14.4 cm³ (7.3), 6.8 cm³ (2.9), 2.9 cm³ (1.9) and 4.2 cm³ (5.2), with the exception of the sphenoid, but the difference was not statistically significant. Finally, we propose a new classification for paranasal sinus tumors (benign and malignant), volumetric T (vT), taking into account the morphometric tumoral volume and the mean volumetric value of normal sinuses.     

咬肌神经-面神经吻合治疗面瘫的解剖学研究

目的通过对咬肌神经与面神经进行显微解剖学研究,为咬肌神经-面神经吻合治疗面瘫提供解剖学依据与安全有效的操作方法。方法对20例(左右两侧,共40侧)湿性头颅标本面神经和咬肌神经及周围毗邻结构进行详细的显微解剖学研究,总结咬肌神经的分段与定位标志并分别对咬肌神经与面神经各段的走行、分支、长度及横径进行观察与测量。结果咬肌神经恒定出现于颞下颌前三角(由颧弓下缘、下颌颈前缘、咬肌浅层后缘围成)内,且距离下颌骨髁突颈前缘8.52±1.35mm～9.00±1.58mm,距离颧弓外侧面深度为15.20±1.07mm～15.73±1.28mm;根据临床应用特点,咬肌神经可分为三段,分别为M1段(自卵圆孔至颧弓下缘)、M2段(自颧弓下缘至发出第一分支处)、M3段(自发出第一分支处至咬肌神经主干末端);咬肌神经M2段中点横径为1.12±0.18mm～1.18±0.18mm,面神经各分支中点横径在1.00±0.15 mm～1.39±0.23mm之间。结论咬肌神经M2段长度适宜且横径与面神经各分支横径相匹配,咬肌神经-面神经吻合术治疗面瘫具有解剖学上的可行性。同时咬肌神经解剖位置恒定,在颞下颌前三角内可安全有效地进行解剖,该三角是术中定位咬肌神经的可靠标志。     

人工耳蜗植入术相关结构的解剖测量

目的通过对人工耳蜗植入手术相关的解剖结构进行观察、测量,为人工耳蜗植入手术提供理论参考。方法对10个尸头20侧颞骨标本进行解剖,模拟人工耳蜗植入术,在手术显微镜下观察、测量与人工耳蜗植入手术相关的解剖数据。结果镫骨头下缘与耳蜗底回切开点之间的距离为2.154±0.173mm,镫骨头下缘与圆窗龛之间的距离为2.470±0.582mm,圆窗龛与耳蜗底回切开点的距离为1.422±0.369mm,镫骨头下缘与耳蜗第二回切开点之间的距离为3.238±0.151mm,镫骨头下缘与匙突之间的距离为2.831±0.269mm,匙突与耳蜗第二回切开点之间的距离为1.338±0.132mm,面神经垂直段与圆窗龛的距离为4.830±1.152mm,面神经与鼓索神经在圆窗平面的距离为2.480±0.274mm,卵圆窗与圆窗的距离为1.820±0.452mm,耳蜗底回前缘与颈内动脉管的距离为1.856±0.372mm。结论人工耳蜗植入手术中切开耳蜗底回的位置位于圆窗龛前方约1.422mm,镫骨头下缘约2.154mm处;耳蜗第二回切开点位于匙突下约1.338mm处;卵圆窗与圆窗、面神经与鼓素神经间的平均距离的测量为术中寻找圆窗龛、避免损伤面神经等重要结构提供了参考。     

Certain Anatomical Relations and the Precise Morphometry of the Infraorbital Foramen–Canal and Groove: An Anatomical and Cephalometric Study

Objectives To determine and to standardize the certain anatomical relations, and the precise size, course, and location of the infraorbital foramen, canal, and groove for facilitating surgical and invasive procedures. Study Design This anatomical study consisted of two main steps, namely, the examination of skulls and the cephalometric analysis of the skulls. Measurements of the skulls and of the radiograms were performed. Methods Thirty‐five adult bony heads (70 sides) were studied regarding the localization and dimensions of the infraorbital groove (IOG), infraorbital canal (IOC), and infraorbital foramen (IOF) as well as their relationships with different anatomical landmarks. The cephalometric analysis of the skulls was measured for evaluating the relationships of certain anatomical points and the distances of the skulls in the cephalometric analysis. For this purpose, 13 different distances and two angles were measured on anteroposterior and lateral craniographies. Differences between data of skull and cephalogram measurements were analyzed by the Student t test. The Pearson correlation test was used in the statistical analysis of the 15 values in the cephalogram. Results Examination of the 70 sides of the 35 bony heads revealed that the shape of the IOF was oval in 34.3%, round in 38.6%, and semilunar in 27.1% of all skulls. The IOF was single in 94.3% and double in 5.7% of the cases. The average distance from the IOF to the infraorbital margin and to the lateral process of the canine tooth in vertical direction and to the lateral nasal border in horizontal direction were 7.19 ± 1.39 mm, 33.94 ± 3.15, and 17.23 ± 2.64 mm, respectively. In cephalometric analysis, when S‐N (the distance between the center of the sella turcica and the nasion) and N‐ANS (the distance between the nasion and the anterior nasal spine) distances were used as independent parameters for the linear analysis, the correlation of the three values for both independent parameters were statistically significant. Conclusion While the IOF has no statistically significant changes with regard to the size of the skull, expressive changes take place in the course and the length of the IOG and IOC. Meticulous preoperative evaluation of the IOF and the route of the infraorbital nerve are necessary in patients who are candidates for maxillofacial surgery and regional block anesthesia. If these measurements are taken into account, there will be little surgical risk, and this will be helpful in identifying the extent of the operative field.     

Foramen Thyroideum: A Comparative Study in Embryos,Fetuses, and Adults

The incidence and characteristics of foramen thyroideum (FT) in embryonic and/or fetal larynges have not been established. In the present study, 90 adult larynges and 53 embryonic-fetal larynges were studied. The incidence of FT during the embryonic-fetal period (57%) was statistically different from the adult period (31%) (P = 0.005). All the FT found in the adult period contained vessels and/or nerves, while in the embryonic and fetal period only 63% presented neurovascular elements (P < 0.001). The origin of FT in the embryonic period and its persistence during adult life is discussed.     

经口内定位面神经颊支与咬肌神经的相关解剖研究

目的针对内镜手术特点,研究经口内镜下面神经颊支咬肌神经吻合术可行性和安全性,定位面神经颊支、咬肌神经的解剖特征,为经口内镜下面神经颊支咬肌神经吻合提供解剖基础。方法对国人10具固定成人尸头(20侧)及3具新鲜成人尸头(6侧)进行解剖,在尸头上观察颞骨外面神经、咬肌神经与周围解剖的毗邻关系,测量面神经颊支咬肌神经吻合术相关的解剖数据。结果在固定标本、新鲜标本中,腮腺导管口至上颊支发出点的距离分别为58.19±4.37 mm, 55.54±4.66mm;腮腺导管口至咬肌神经第一段之间的距离分别为43.94±2.20mm, 41.76±2.75mm;腮腺导管口至咬肌神经第二段之间的距离分别为35.69±4.39 mm, 33.54±2.63mm;上颊支发出点至咬肌神经第一段之间距离分别为21.60±2.57 mm, 19.90±2.32mm;上颊支发出点至咬肌神经第二段之间距离分别为22.45±1.78 mm, 21.61±2.90mm;下颌骨升支前缘至上颊支发出点距离分别为37.59±4.16 mm, 40.53±2.13mm;下颌骨升支前缘至咬肌神经第一段距离分别为27.78±5.92 mm, 26.95±2.02mm;下颌骨升支前缘至咬肌神经第二段距离分别为20.57±6.90 mm, 22.48±3.63mm;腮腺导管口至上颊支发出点连线与水平线的夹角分别为23.75±1.71°,25.29±2.95°;腮腺导管口至咬肌神经第一段连线与水平线的夹角分别为37.75±3.86°,39.00±2.76°;腮腺导管口至咬肌神经第二段连线与水平线的夹角分别为30.25±9.42°,36.33±3.72°;下颌骨升支前缘至上颊支发出点连线与水平线的夹角分别为23.15±2.58°,24.17±2.71°;下颌骨升支前缘与咬肌神经第一段连线与水平线的夹角分别为49.30±4.69°,52.83±4.62°;下颌骨升支前缘与咬肌神经第二段连线与水平线的夹角分别为50.25±5.12°,50.33±3.62°。结论利用口内腮腺导管口、上颌骨升支前缘可定位面神经的上颊支、咬肌神经的第一段第二段;在内镜及相关特殊器械辅助下行面神经颊支咬肌神经吻合在理论上是安全可行的。