颞下经岩尖-小脑幕入路手术的显微解剖研究

目的 为颞下经岩骨入路手术处理斜坡及脑干腹侧病灶提供解剖学资料。方法 模拟颞下经岩尖—小脑幕入路的手术操作,在手术显微镜下对20侧(10具)福尔马林固定的国人成年带颈头颅标本进行解剖,并观测各主要解剖结构的相互关系。结果 颞下硬脑膜外经前内侧的三叉神经压迹、外侧的岩浅大神经沟及岩上窦所形成的三角区磨削岩骨尖。其周围结构的测量结果为:上半规管垂直于岩骨嵴,位于弓状隆起下方,耳蜗位于内听道前方、岩骨颈内动脉膝后方,内听道位于上半规管与岩浅大神经夹角中央。20侧中有2侧面神经膝裸露,耳蜗至膝状神经节的距离约为3.30 mm±0.79 mm,耳蜗距颈内动脉膝约2.48 mm±1.14 mm,内听道距岩斜缝约16.03 mm±1.94 mm,颈内动脉水平段距岩上窦约10.73 mm±2.00 mm。结论 颞下经岩尖—小脑幕入路能增加岩斜坡及脑干腹侧的显露,但显露范围有限,且需一定程度的颞叶牵拉。同时可能因为不熟悉解剖而误伤耳蜗、颈内动脉及第Ⅶ脑神经、第Ⅷ脑神经,选择应用时应审慎考虑。     

颞下经岩骨前部入路的显微解剖观测及临床意义

目的　对颞下经岩骨前部入路的解剖结构进行观测 ,以指导临床应用。方法　模拟临床手术过程 ,在显微镜下对 1 0具 (2 0侧 )成年国人灌注头颅标本进行解剖观测。结果　除弓状隆起外 ,另可见中颅窝底有两个较恒定的骨性突起 ,一个位于中颅窝底的中央部 ,其对应的颅外颅底无解剖结构 ;另一个位于岩骨基底部 ,其颅外颅底对应为颞下颌关节。颈内动脉岩骨段水平部位于Kawase三角下方的骨质中 ,鼓膜张肌位于Glasscock三角下方的骨质中 ,咽鼓管位于颈内动脉岩骨段水平部和鼓膜张肌之间。上半规管延长线与岩骨嵴的交点至内耳孔前缘的距离相对恒定。结论　对中颅窝底恒定骨性突起的观测及命名 ,有利于扩大手术视野、减少对颞叶的牵拉和保护颞下颌关节。在Kawase三角中定位、显露颈内动脉岩骨段水平部 ,不会伤及鼓膜张肌和咽鼓管。熟悉解剖、术前CT扫描及术中对“蓝线”的识别 ,有助于保护骨迷路。     

耳科学

20031112颜下经岩尖一小脑幕入路手术的显微解剖研究/丁锡平…//中国耳鼻咽喉颅底外科杂志一2003,9(l)一10一12 目的:为颗下经岩骨人路手术处理斜坡及脑干腹侧病灶提供解剖学资料。方法:模拟颖下经岩尖一小脑幕人路的手术操作,在手术显微镜下对20侧(10具)福尔马林固定的国人成年带颈头颅标本进行解剖,并观测各主要解剖结构的相互关系。结果:颖下硬脑膜外经前内侧的三叉神经压迹、外侧的岩浅大神经沟及岩上窦所形成的三角区磨削岩骨尖。其周围结构的测量结果为:上半规管垂直于岩骨峙,位于弓状隆起下方,耳蜗位于内听道前方、岩骨颈内动脉膝后…     

内镜下迷路后入路小脑桥脑角区解剖学研究

目的探讨内镜下迷路后入路小脑桥脑角区解剖标志与定位方法。方法在10例（20侧）成人头颅标本上模拟内镜下迷路后入路手术,观察内听道与桥脑小脑角区各组颅神经之间的关系,并测量相关数据。结果以外半规管水平上的后半规管后缘为标志点：后半规管后缘距内耳门后缘（15.89±1.61）mm,距三叉神经下缘（27.43±3.25）mm,距舌咽神经上缘（19.39±2.57）mm;后半规管后缘-内耳门后缘连线与后半规管后缘-舌咽神经上缘连线的夹角为16.78°±2.06°,后半规管后缘-内耳门后缘连线与后半规管后缘-三叉神经下缘连线的夹角为16.25°±2.88°。结论内镜下迷路后入路小脑桥脑角区手术具有损伤小,暴露清晰,多角度观察等优点,对于显微外科手术是一种有效的辅助手段。     

颞下经岩骨前部手术入路的解剖学研究

目的：研究颞下经岩骨前部入路(Kawase入路)的解剖特点。方法:10例20例成人尸头标本在手术显微镜下进行显微解剖和测量。结果：岩骨前部切除后可暴露位于前外例的颈内动脉管水平段，以及颈内动脉管和内听道之间的耳蜗基底转。岩骨前部切除可分别在岩尖上面和内侧面开出面积为2．6cm^2和1．9cm^2的骨窗。与颞下经小脑幕入路相比，暴露范围在斜坡面向下扩大至斜坡上部、在脑干面扩大至椎基底动脉连接部和桥延沟水平。此入路暴露的岩斜坡区硬脑膜主要由脑膜垂体干和咽升动脉供血。结论：Kawase入路可同时暴露中后颅窝，其对后颅窝的暴露范围局限于岩斜坡区上半部。     

半规管手术的基础与临床

近年来 ,由于基础研究的不断深入 ,人们对内耳解剖和生理的认识不断提高 ,临床上应用半规管手术治疗内耳疾病的范围也不断扩大。本文就半规管手术的基础研究和临床应用情况作一简介。1　半规管手术的实验依据Ｈａｒａ等 (1 993 )报道 ,在迷路外淋巴间隙中存在迷路界膜 (ｍｅｍｂｒａｎｅｌｉｍｉｔａｕｓ) ,界膜将迷路分隔为上部 (三个半规管和椭圆囊 )和下部 (球囊和耳蜗 )。它在迷路上、下部之间起着屏障作用 ,限制上、下部外淋巴液中的物质相互弥散。由于界膜的存在 ,我们可以在迷路上部给药而不影响下部 ,反之亦然。在膜性半规管周围的…     

改良迷路入路内听道手术应用解剖

目的探讨能保存面神经功能及听力的改良迷路入路听神经瘤手术方法,为其提供解剖学标志及参数。方法20具成人尸头模拟改良迷路入路进行手术,切除上半规管弓、后半规管弓,保留上半规管壶腹、后半规管壶腹、外半规管、前庭,测量术野暴露范围及内听道的暴露长度。结果上半规管壶腹至乙状窦内侧硬脑膜之间的最短距离为(10.4±2.0)mm;外半规管后下缘至乙状窦内侧硬脑膜之间的最短距离为(6.4±1.0)mm;颈静脉球至颅中窝硬脑膜之间的最短距离为(13.8±3.3)mm;内听道暴露长度为(5.8±0.9)mm,占全长的60.4%。结论改良迷路入路可以较好地显露内听道内侧及小脑脑桥角,同时有可能保留听力;外半规管后下缘可作为寻找内听道的标志。     

部分迷路切除的应用解剖学观察及意义

目的探讨经部分迷路切除手术到达内听道和桥小脑角区的应用解剖及临床意义。方法对25个成人湿尸头经乳突分别切除上半规管和后半规管,再向深部削除岩部骨质,观察对岩尖、内听道及桥小脑角区暴露情况。结果选择性切除上半规管或／和后半规管的迷路部分切除术可到达岩尖和暴露部分内听道,不损及面神经和蜗神经,桥小脑角区显露改善。结论部分迷路切除人路可用于某些岩尖、桥小脑角或内听道占位病变的治疗。     

前庭学

20031139成人骨半规管的观察和测t/于海玲…//青岛医药卫生一2003,35(3).一169~1 71 目的:对成人骨半规管进行解剖观察和测量,以期为临床内耳疾病的诊疗和手术提供解剖学基础。方法:制作26侧成人颖骨骨迷路标本进行观察和测量。结果:(l)半规管长度以后半规管最长,上半规管次之,外半规管最短;(2)半规管横断面呈椭圆形,其弓顶处管腔纵径大于横径;(3)三个半规管弓除外半规管弓在同一平面上外,前、后半规管弓均不在同一平面上,而呈不同程度的扭曲;(4)同侧三半规管之间并非相互垂直。结论:本研究结果为骨迷路结构研究增添了新的内容,为临床内耳手…     

经迷路下径路切除岩尖病变显微解剖学

目的探讨经迷路下入路切除岩尖病变之手术入路,为手术入路提供解剖学标志和依据。方法①应用30例干颞骨标本依次测量颈内动脉膝部到面神经管垂直段的距离、面神经管到岩尖的距离以及颈内动脉到岩锥后面的距离。并在干颞骨标本上磨出该手术路径;②应用10具(20侧)经10%甲醛固定成人尸头湿标本,在手术显微镜下模拟迷路下入路切除岩尖气房,分别测量后半规管最低点到颈静脉球最高点骨板之间距离,面神经管垂直段和乙状窦骨板之间距离。结果①干颞骨标本测量:面神经管垂直段到颈内动脉膝部距离为(13.26±1.66)mm,面神经管垂直段到岩尖的距离为(34.48±1.07)mm,颈内动脉膝部到岩部后面的距离为(9.68±1.53)mm;②湿标本模拟手术测量:面神经管垂直段中点到乙状窦前壁距离为(6.42±2.65)mm,后半规管骨管到颈静脉球距离为(5.76±3.38)mm。能够完成迷路下手术入路的13侧。结论经迷路下入路手术切除岩尖病变能够保护内耳道、耳蜗、迷路不受损伤,保存听力,是一个具有临床应用意义的手术途径。     

Three-dimensional reconstruction and measurement of the human membranous semicircular canal

The planar relationship of the human semicircular canals was determined by Blanks et al. at a series of points measured from the dissected bony labyrinth of the human skull. The relationship of membranous canal planes have not, however, been measured from the human temporal bone. We reconstructed 3 semicircular canals by computer-aided 3-dimensional analysis and measured the angles formed between pairs of 3 osseous and membranous canal planes of temporal bones. Five temporal bones in adults were used for this study. Results indicated angles formed between pairs of ipsi-lateral canal planes of both the bony and membranous labyrinth. Angles formed between the horizontal-anterior, anterior-posterior, and posterior-horizontal canal planes of the bony labyrinth were 89.64 +/- 1.82 (mean +/- SD), 90.95 +/- 1.25, and 94.02 +/- 3.77 degrees. The same angles measured from the membranous labyrinth were 90.12 +/- 2.64, 90.18 +/- 2.75, and 91.48 +/- 6.32 degrees. Differences between the angles formed between bony and membranous canal planes were 2.11, 6.05, and 3.26 degrees in the anterior, horizontal, and posterior canal. Pairs of membranous canal planes were nearly perpendicular without exception, but pairs of osseous canal planes had a larger deviation from 90 degrees. This suggested that membranous canals could successfully be constructed in adequate alignment for canal function in the large perilymphatic space within osseous semicircular canals.     

Three-dimensional reconstruction of the human semicircular canals and measurement of each membranous canal plane defined by Reid's stereotactic coordinates

OBJECTIVES: Equations for estimating the planar relationships of the human semicircular canals were devised by Blanks et al from a dissected bony labyrinth in a human skull. However, a similar study on the membranous semicircular canal planes has never been published. METHODS: In this study, the angle between each membranous canal plane and Reid's stereotactic horizontal plane was measured on serial histologic sections of 7 temporal bones from Japanese adults. We reconstructed the 3 semicircular canals by computer-aided 3-dimensional analysis. The angles between each pair of both bony and membranous canal planes were measured. RESULTS: In the bony labyrinth, the angles between the 2 canal planes of the lateral-anterior, anterior-posterior, and lateral-posterior pairs were 90.51 degrees +/- 2.98 degrees (mean +/- SD), 91.70 degrees +/- 1.85 degrees, and 94.52 degrees +/- 3.32 degrees, respectively. The angles between the 2 membranous canal planes of the lateral-anterior, anterior-posterior, and lateral-posterior pairs were 90.05 degrees +/- 4.74 degrees, 91.03 degrees +/- 2.93 degrees, and 91.92 degrees +/- 5.22 degrees, respectively. CONCLUSIONS: The data from our study of the membranous labyrinth showed that the angles between each canal plane and the others were much closer to 90 degrees than was found by Blanks et al for the bony labyrinth.     

颞下窝A型入路的显微解剖研究

目的通过观察颅骨标本颈静脉孔及周围重要结构和在尸头标本上模拟颞下窝A型入路,获得相关的国人解剖学数据,为临床应用提供参考。方法选取10例颅骨标本测量颈静脉孔大小及与周围重要结构间距离;应用10例尸头标本对颞下窝A型入路的相关结构进行显微解剖研究和测量。结果 1颈静脉孔外口距茎突根（4.17±1.99）mm、距茎乳孔（6.06±1.71）mm、距舌下神经管（2.41±1.23）mm;2面神经鼓室段长度（9.66±1.41）mm、乳突段长度（16.08±2.15）mm、面神经锥段距外半规管（1.08±0.41）mm;3颈静脉球距面神经乳突段（6.56±1.81）mm、距后半规管弓峰下缘（3.67±1.27）mm;4岩骨内颈内动脉垂直段长度（10.36±2.31）mm、水平段长度（19.41±2.02）mm;5后半规管弓峰下缘距寰椎横突（31.22±1.93）mm、乙状窦垂直臂距下颌关节（19.17±1.51）mm、乳突尖距岩尖（53.91±4.82）mm。结论颞下窝A型入路可充分暴露颞下窝后部及迷路下区特别是颈静脉孔区,适用于切除迷路下区及颈静脉孔周围病变。     

Model experiment of benign paroxysmal positional vertigo mechanism using the whole membranous labyrinth

Whole membranous labyrinths of bullfrogs were used in order to replicate the human vestibule. The posterior semicircular canals (PSCs) were exposed, leaving the remaining membranous labyrinth encapsulated in the otic capsule. Vibration was applied to the surface of the bony capsule using a conventional surgical drill in order to dislodge the otoconia from the utricle. The position of the preparation was controlled so that the dislodged otoconia were attached to the cupular surface. This was regarded as a cupulolithiasis model. The action potentials changed instantaneously according to the gravitational force on the cupula. When the otoconia were dislodged and held within the PSC lumen, the position of the whole preparation was changed so that the otoconia moved back and forth within the canal lumen. This is a model of canalolithiasis. The action potentials changed in combination with the otoconial movement after a latent period. Both cupulolithiasis and canalolithasis are potentially valid mechanisms of benign paroxysmal positional vertigo (BPPV). However, canalolithiasis is the most likely mechanism of BPPV, which is usually characterized by nystagmus of short duration and long latency. A vibratory stimulus was able to detach the otoconia from the utricle, suggesting that mechanical insult could be a possible etiology of BPPV.     

Labyrinthine fistula after cholesteatomatous chronic otitis media

OBJECTIVES: To report on cases of labyrinthine fistula diagnosed in an ear, nose, and throat department and to study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of two types of cholesteatomatous labyrinthine fistulae-the extensive fistula that erodes both the bony and membranous labyrinths and the bone fistula that affects only the bony labyrinth. STUDY DESIGN: Retrospective case review. PATIENTS: Fifty-four patients with cholesteatomatous chronic otitis media with labyrinthine fistulae. SETTING: Tertiary referral center. INTERVENTIONS: Diagnosis and treatment. MAIN OUTCOME MEASURES: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae. RESULTS: The incidence of labyrinthine fistulae was 7% in all patients who underwent surgery for chronic otitis media. The bone type (66%) is more common than the extensive type (33%). Compared with bone fistulae, the outcome for extensive fistulae is more severe in terms of hearing loss, vertigo, and facial palsy. In terms of preoperative diagnosis, computed tomography imaging ensured early diagnosis in 89% of extensive cases and in 28% of bone cases. For extensive fistulae, the surgical technique was more radical, requiring an open technique in 66% of cases versus 22% of the bone fistulae cases. The most common location is the lateral semicircular canal (61%). CONCLUSIONS: The breach in the membranous labyrinth is consistent with a more aggressive pathology, causing more severe pre- and postoperative symptoms. Preoperative computed tomography is more sensitive for diagnosing extensive fistulae, which also require a more radical treatment.     

与乙状窦相关的螺旋CT影像三维定量测量

目的 为岩骨后人路手术及手术中准确定位与乙状窦相关结构提供影像解剖依据,减少手术并发症的发生.方法 收集2007年10月至2008年10月在辽宁医学院第一附属医院行螺旋CT颅底三维重建而无颅底疾病的成年人数据资料119例(238侧),其中男80例(160侧),女39例(78侧);年龄19-69岁.在ADW4.2重建工作站上利用多平面重建技术重建出轴位和冠状位图像,通过旋转显示出所要测量的解剖结构.定量测量与乙状窦相关的解剖结构间的距离,分析性别和侧别等因素对结果的影响以及各测量结果之间的关系,并将测量结果与文献中的尸头标本和干性颅骨标本上测量的数据对比,进行统计学分析.结果 解剖结构间螺旋CT影像的定量测量以(x)±s(以下同)表示,乙状窦沟宽(11.14±2.13)mm,乙状窦沟深(6.04±1.67)mill,乙状窦沟底至乳突外表面的距离(9.74±2.95)mm,乙状窦沟前缘至外耳道后壁的距离(12.98±2.71)mm,后半规管最后部至乙状窦沟前缘的距离(9.87±2.60)mm,后半规管最后部至岩骨后壁的距离(3.18±1.30)mm,外半规管长轴后端至岩骨后壁的距离(5.46±1.38)mill,外半规管长轴后端至乙状窦沟前缘的距离(13.17±2.59)mm,外半规管至颈静脉球窝顶垂直距离(6.69±3.08)mm,面神经垂直段至颈静脉窝最短距离(5.32±2.13)mm.CT测量结果与文献中尸头标本和干性颅骨标本上测量的数据比较,无明显差异.乙状窦沟前缘至外耳道后壁的距离与外半规管至颈静脉球窝顶的垂直距离、面神经垂直段至颈静脉球窝最短距离、乙状窦沟底至乳突外表面的距离呈现出正相关趋势(r值分别为0.284、0.145、0.208,P值均<0.05).结论 利用多平面重建,多排螺旋CT定量测量的结果可以代表实际的相关解剖结构间的距离;重建图像能准确显示颞骨的解剖特征和变异,从而为手术入路的选择及术中准确定位有关结构提供依据.乙状窦前置时,乙状窦更易发生外移,面神经垂直段至颈静脉球距离更短;乙状窦前置的程度与颈静脉球的高度呈正相关趋势.     

Important factors for the hearing loss caused by the triple semicircular canal occlusion in guinea pigs.

HYPOTHESIS: Dynamic recording of the auditory brainstem response is helpful in verifying harmful procedure(s) to hearing during triple semicircular canal occlusion (TSCO) surgery. The damage to the membranous semicircular labyrinth is the single major contributor to hearing loss caused by TSCO. BACKGROUND: Posterior semicircular canal occlusion has been recognized as an efficient method of eliminating vertigo without causing a significant hearing impairment. Recently, TSCO has also been explored for its potential to treat vertigo of various causes. In limited animal studies, varied hearing impairments have been documented after TSCO. However, the major factor(s) causing hearing loss in TSCO is/are unclear. METHODS: Triple semicircular canal occlusion was performed on 36 guinea pigs in total. The cochlear function of the guinea pigs was monitored by observing the auditory brainstem response. The impact of membranous labyrinth damage on hearing was verified by a between-group comparison. RESULTS: Hearing loss during TSCO was accumulated in every step of semicircular canal manipulation. Generally, perilymph leak was found to cause a slight hearing loss that was predominately recovered during surgery. However, transaction of the membranous labyrinth usually caused a more significant hearing loss that was not recovered during the surgery. In addition, the magnitude of hearing loss seemed to be increased with the elongation of the surgery. However, the hearing can be largely recovered after the surgery even in animals with transaction of the membranous labyrinth. CONCLUSION: Hearing loss caused by TSCO can be greatly reduced by avoiding damage to the membranous labyrinth and by shortening the operation time.     

Transport of heat in caloric vestibular stimulation. Conduction, convection or radiation?

Experiments in temporal bone specimens were carried out under strictly controlled conditions: temperature (37 degrees C) and humidity kept constant; standardized irrigation of the external ear canal by an automated system (in 15 s, 50 ml of water, 11 degrees C above temperature of specimen), thermistor probes of 0.2 mm diameter placed in different parts of the specimens. In the intact temporal bone such an irrigation causes a rise in temperature with a gradient from the external ear canal across the bony bridge to the lateral semicircular canal as expected with heat conduction. After removal of the bony bridge, which is the main route for heat conduction, the rise in temperature in the lateral semicircular canal is greater and faster than in the intact specimen. This effect again is drastically reduced by placing a reflecting shield between tympanic membrane and labyrinth. In the intact middle ear inserting a reflecting shield or filling the cavity with gel also reduces the heat transfer to the labyrinth, although the bony routes for heat conduction are left untouched. The experiments prove that radiation plays an important part in heat transfer in caloric stimulation.