内窥镜下鼻内蝶窦手术

在鼻内窥镜下经鼻内筛窦以及经鼻腔途径进入蝶窦，克服了以往处理蝶窦的复杂手术的弊端。本文总结了经以上二途径处理４３例蝶窦病变的经验，认为此手术进路简便、安全、直视下操作、实用性强，可作为治疗蝶窦疾病的常规手术进路。     

内窥镜下鼻内蝶窦手术

在鼻内窥镜下经鼻内筛窦以及经鼻腔途径进入蝶窦，克服了以往处理蝶窦的复杂手术的弊端。本文总结了经以上二途径处理43例蝶窦病变的经验，认为此手术进路简便、安全、直视下操作、实用性强．可作为治疗蝶窦疾病的常规手术进路。     

鼻外筛—蝶窦进路鞍区肿瘤切除术的临床应用解剖研究

对５０具成人头颅标本采用经鼻外筛－蝶窦进路解剖观察的方法，测量了从Ｄａｃｒｙｏｎ点至上视结节，前鼻棘至上视结节及下视结节至蝶窦骨性开口外缘中点的距离分别为３６６８ｍｍ、６９３３ｍｍ及８０２ｍｍ。后筛窦以Ⅰ°最多（４９％），蝶上筛房占１５％。蝶窦气化良好组占７２％。筛后神经血管束行于最后筛房前壁者占２７７３％。行于最后筛房内者占３９５０％，行于蝶筛隔板内者占３２７７％。作者认为经鼻外筛－蝶窦进路比经中隔进路路线距离短，术野广等优点外，了解后筛窦、蝶窦的气化发育情况及神经血管束走行情况对选择手术进路有一定的指导意义。     

探讨开放后组筛窦、蝶窦在鼻内镜手术治疗慢性鼻窦炎中的必要性

慢性鼻窦炎、鼻息肉病变往往涉及多个鼻窦，包括额窦、上颌窦、前组筛窦、后组筛窦及蝶窦。近10余年来，鼻内镜外科技术成为治疗慢性鼻窦炎和鼻息肉的重要手段。鼻内镜下纠正鼻腔、鼻窦的解剖异常，恢复和重建鼻腔、鼻窦良好通气和引流是治疗鼻窦炎、鼻息肉的主要目的。我们发现开放后组筛窦、蝶窦与否在鼻内镜手术中治疗鼻窦炎、鼻息肉有着相同的治愈率。     

内窥镜鼻窦外科技术在蝶窦区域手术的应用

应用内窥镜鼻窦外科技术施行蝶窦区域的手术28例。采取两种进路:①经鼻内筛、蝶窦进路行全蝶筛切除术8例、蝶窦开放术12例、蝶窦占位性病变切除4例、蝶窦脑脊液鼻漏修补术2例和视神经管减压术1例,②鼻中隔蝶窦进路行垂体瘤部分切除术1例。部分手术在电视监视下进行。本文简要介绍了6种手术方式,讨论了手术适应证的选择及术中、术后并发症发生的原因以及预防和处理方法。     

鼻内镜下经鼻行蝶窦及垂体手术

鼻内镜手术的广泛开展和影像技术的进步,鼻内镜下手术治疗蝶窦及中颅窝病变逐渐增多。蝶窦及垂体病变经鼻进路手术,既往多采用经鼻中隔或经筛窦开放蝶窦,虽然手术视野能满足需要,但仍然存在创伤大。出血多,破坏鼻腔正常结构的缺点。2000年1月～2004年1月我们采用鼻内镜下经鼻腔直接入路行蝶窦及垂体手术,效果良好,现报告如下。     

鼻内蝶筛窦切除术应用解剖研究

对６０具完整成人尸头鼻内蝶窦，筛窦切除术的应用解剖进行了研究。通过颅正中矢状切面，水平切面，设计了９条测线，２个测角和４项观察。认为中鼻甲是鼻内蝶，筛窦切除术的重要内部标志，前鼻棘是此类手术的重要外部标志，纸样板与中鼻道外侧壁（上颌窦内侧壁）处于同一垂直面。本研究提供了有关鼻内蝶，筛窦手术的解剖数据，供临床参考。     

鼻内镜下治疗儿童蝶筛窦炎性疾病

以往认为，蝶窦炎性疾病发病率较低，临床报道不多，而有关儿童蝶窦炎性疾病的报道更少，在鼻内镜手术开展以前，尚无可靠有效的治疗措施。近年来，随着影像学的发展及鼻内镜的广泛应用，蝶窦炎的发病率逐渐增多，临床确诊率大为提高，治疗措施迈上了一个新台阶。我科自2000年6月～2003年6月收治儿童蝶窦炎性疾病12例，全部采用鼻内镜手术开放蝶或蝶筛窦，清除病灶，报道如下。     

鼻外筛——蝶窦进路视神经管减压术

头面部创伤所致的视神经挫伤临床上以视神经管段损伤最为多见，本文对９例外伤性视神经挫伤病人进行鼻外筛－蝶窦进路视神经管减压术治疗，其中３例视力有所恢复，６例无效。作者认为对伤后视力下降者应作急症手术处理，以鼻外筛－蝶窦进路为最好，减压必须充分。     

慢性蝶窦炎

蝶窦炎因其特殊的解剖部位及无独特临床症状，往往被临床医师忽视，以往报道少，本组分析了５８例蝶窦炎，其特异的临床症状不明显，由于ＣＴ、ＭＲＩ和鼻内窥镜的广泛应用，使本病诊断已不困难，鼻内窥镜下的手术处理，患者痛苦少，操作简单，本组大部分病例（５３例）为继发于鼻腔及筛窦病变的蝶筛窦炎，孤立性蝶窦炎５例，在临床上比较少见。     

Surgical anatomy of the optic nerve and the internal carotid artery in the lateral wall of the sphenoid sinus. An anatomic study of the cranial base]

The optic nerve and the internal carotid artery lying in the cavernous sinus contact the bony wall of the sphenoid sinus, and can easily be injured during surgery. The maxillary sinus, the sphenoid sinus and the ethmoid cells were opened on both sides during ten resections of the skull base. After removing the bony part of the lateral wall of the sphenoid sinus the following measurements were performed: the distance between the optic nerve and the frontal dura; the distance between the optic nerve and the internal carotid artery; the length and width of the optic nerve and the internal carotid artery in the area contacting the bony wall of the sphenoid sinus. This study illustrates the regularity of the structures of the posterior nasal wall. Landmarks are offered for finding the orbital aperture of the optic canal. The necessity of orientation by landmarks is emphasized.     

经鼻视神经减压术相关的内镜解剖学研究

目的：研究视神经和后组鼻窦以及眼动脉的关系,寻找可靠的解剖标志,为经鼻视神经减压手术中视神经定位和有效避免损伤眼动脉提供内镜解剖学基础。方法：选用8例成人头颅标本,采用messerklinger手术方法开放后组筛窦和蝶窦。在内镜下辨认视神经-颈动脉隐窝和视神经管,观察视神经和后组鼻窦的关系,去除骨性管壁,充分开放视神经的颅口和眶口,切开视神经管硬膜层,观察视神经和眼动脉的关系。结果：本组发现在所有标本中均可以观察到颈内动脉一视神经隐窝,视神经隆起出现率仅为62％;视神经和蝶窦以及后组筛窦存在3种毗邻关系,8侧（50％）前部为后筛窦,后部为蝶窦,5侧（31％）全为蝶窦,3侧（19％）全为筛窦;视神经管颅口部眼动脉位于视神经内下方9例（56％）、下方4例（25％）和外下方3例（19％）,眼动脉在视神经下方向外侧行走,至视神经管眶口部,眼动脉位于视神经下方3例（19％）和外下方13例（81％）。结论：视神经一颈内动脉隐窝恒定出现,同时由于内镜的成像特点,该隐窝比视神经管隆起的辨认更加可靠,可以作为视神经减压手术中的首选解剖标志;眼动脉发起的位置位于视神经的下内侧,发出后向下外侧行走,行程中存在交叉关系,手术中应注意该因素,避免损伤眼动脉。     

Interpretation of Anatomic Variations of Computed Tomography Scans of the Sinuses: A Surgeon's Perspective

Four hundred computed tomography (CT) scans of patients undergoing endoscopic sinus surgery were studied with particular attention to anatomic variations. Six specific variations were identified that may predispose the surgeon to inadvertent penetration of the orbit or anterior cranial cavity. These anatomic variants are: 1. lamina papyracea lies medial to the maxillary sinus ostium; 2. maxillary sinus hypoplasia; 3. fovea ethmoidalis abnormalities, such as low or sloping fovea and encephaloceles; 4. lamina papyracea dehiscence resulting in herniation of orbital content into the ethmoids; 5. sphenoid sinus wall variations such as septa attached to the carotid covering, and penetration of the sphenoid by the internal carotid artery or optic nerve; 6. sphenoethmoid cells (Onodi cells), the most posterior ethmoid cells pneumatizing lateral and superior to the sphenoid and intimately associated with the optic nerve.     

The prevalence of an Onodi cell in adult Thai cadavers

Endoscopic sinus surgery in patients who have an Onodi cell (sphenoethmoid cell) carries a high risk for optic nerve injury. We meticulously dissected 65 embalmed cadaver adult half-heads and attempted to identify an optic canal bulge in each with a nasal endoscope. Our aims were to determine the prevalence of an Onodi cell in adult Thai cadavers, to ascertain the prevalence of an overriding ethmoid cell, and to measure the length of an overriding ethmoid cell's superior and posterior extensions in relation to the anterior sphenoid wall. Moreover, we attempted to determine the minimum amount of bone thickness between an Onodi cell and the optic nerve. We found that an Onodi cell was present in 39 of the 65 specimens (60.0%). We also found that an overriding ethmoid cell was present in 14 specimens, which accounted for 21.5% of the total number of specimens and 36.8% of 38 Onodi cell-positive specimens (the presence or absence of an overriding ethmoid cell was not recorded in one of the 39 Onodi cell-positive specimens). The distance of the overriding ethmoid cell's superior and posterior extensions from the anterior sphenoid wall ranged from 3 to 13 mm (median: 7) and from 4 to 16 mm (median: 9.5), respectively. Measurements of the minimum amount of bone thicknesses between each Onodi cell and optic nerve ranged from 0.03 to 0.54 mm (median: 0.08). Our study demonstrated that the prevalence of an Onodi cell in adult Thai cadavers was as great as the prevalence reported in the only other gross anatomic dissection study performed in Asia and much higher than rates generally reported in Western countries.     

Surgical anatomy of the natural ostium of the sphenoid sinus

OBJECTIVES: This study was undertaken to measure the distance and the angle between the anterior part of nasal cavity and the natural ostium of the sphenoid sinus. The anatomical location of the natural ostium according to the direction of surgeon's operating view toward the anterior wall of the sphenoid sinus was also analyzed. STUDY DESIGN: This study used careful cadaver dissection under a surgical microscope. METHODS: One hundred sagittally sectioned adult cadaveric heads were used. We measured the distances and angles for identifying the natural ostium of the sphenoid sinus using several reference points such as the limen nasi, the sill, and the posteroinferior end of the superior turbinate. In addition, we tried to identify whether the location of the natural ostium is medial or lateral to the posterior end of the superior turbinate. RESULTS: The natural ostium of the sphenoid sinus was located at an angle of 35.9 degrees with a distance of 56.5 mm from limen nasi and at an angle of 34.3 degrees with a distance of 62.7 mm from nasal sill. It was located approximately 1 cm above the posteroinferior end of the superior turbinate and at a medial aspect to the posterior end of the superior turbinate in 83% of specimens. CONCLUSIONS: We speculate that the posteroinferior end of the superior turbinate is the best landmark for identifying the natural ostium of the sphenoid sinus. Furthermore, the natural ostium should ideally be searched from a superior and medial aspect in relation to the posteroinferior end of the superior turbinate.     

The relationship between the sphenoid and the posterior ethmoid sinuses and the optic nerves in Turkish patients

The sphenoid and the posterior ethmoid sinuses are surrounded by more vital structures than any other sinus. With the widespread acceptance and expanding role of endoscopic sinus surgery, a proper understanding of the anatomy of the sphenoid and the posterior ethmoid sinuses is achieved. We reviewed 100 CT studies of the paranasal sinuses belonging to patients examined for a chronic inflammatory disease of the nasal cavity and the paranasal sinuses. The relationship between the optic nerves and the paranasal sinuses is classified into four discrete categories. Type 1 with a proportion of 64% is observed to be the most often localized optic nerve. Type 2 is detected in 22% of the cases; types 3 and 4 are both 7% of the total number. A bony dehiscence was detected in 13.5% of the total cases, while it was observed in 39% of type 2 and 43% of type 3. We found a pneumatization of the anterior clinoid process in 11% of the patients. The proportion of pneumatization of the anterior clinoid process in type 3 configurations is found out to be as high as 86%. Optic nerve dehiscence was seen with a proportion of 23% in cases of pneumatization of the anterior clinoid process. Pneumatization of the posterior nasal septum was detected in 15% of the 100 cases. When the optic nerves were evaluated in these cases, mostly the type 1 configuration with a proportion of 63% was observed. An extensively pneumatized sphenoid sinus was detected in 4% of the 100 cases. Five of the investigated 8 optic nerves of these 4 cases were found out to be type 3 (62.5%). No significant optic nerve variations were met in patients with pneumatization of the posterior nasal septum. Nevertheless while performing surgery, it is important to bear in mind that there may be significant optic nerve variations with pneumatization of the anterior clinoid process and extensively pneumatized sphenoid sinuses.     

16排多层螺旋CT对国人后筛的观测研究

目的：探讨多层螺旋CT扫描对国人后筛解剖特征的研究价值,为鼻内镜相关手术提供影像解剖依据。方法：对100例行椎动脉造影者进行头部螺旋CT横轴位扫描,通过多平面重组获得冠、矢状面图像,对后筛进行动态观测。结果：根据后筛与蝶窦的相邻关系,将后筛分为蝶前型后筛和蝶上型后筛;根据后筛与视神经管的毗邻位置关系分为管前型、半管相邻型和全管相邻型;根据后筛内视神经管突出程度,即筛窦气房占视神经管全程的比例,以10％和50％为界,将两者关系分为压迹型、半管型和管型。视神经结节发生率为20％。结论：多层螺旋CT扫描及多平面重建技术可对筛窦及毗邻作出更准确的判断。对临床手术治疗具有重要的指导意义。     

Danger areas of the posterior nasal base: anatomical, histological and endoscopic findings

In 52 cadaveric half-heads and endoscopic sphenoethmoidectomy was performed. Subsequently an anatomical preparation with registration of specific data like bulging of the optic canal, thickness of the bony wall covering the optic nerve and the internal carotid artery was achieved, followed by histological sections in specially selected cases. Thus the two key areas of major surgical hazard in the posterior rhinobasis could be clearly demonstrated: the immediate topographic relation of the optic canal and the internal carotid artery to the lateral wall of the sphenoid sinus and the cells of the posterior ethmoid, respectively. Onodi cells of varying degrees were found in 42% of all cases. The thickness of bony wall over the maximum bulging of the optic canal averaged 0.28 mm. Bony dehiscences could be demonstrated in 12% of the cases. The technique of data acquisition, the anatomical and histological findings as well as their clinical and surgical relevance are discussed.     

Danger areas of the posterior rhinobasis. An endoscopic and anatomical-surgical study.

In 52 cadaveric half-heads, an endoscopic sphenoethmoidectomy was performed. Then, an anatomical preparation with registration of specific data like bulging of the optic canal, thickness of the bony wall covering the optic nerve and the internal carotid artery was achieved, followed by histological sections in specially selected cases. Thus the two key areas of major surgical hazard in the posterior rhinobasis could be clearly demonstrated: the immediate topographic relation of the optic canal and the internal carotid artery to the lateral wall of the sphenoid sinus and the cells of the posterior ethmoid respectively. Onodi cells of varying degrees were found in 42% of all cases. The thickness of bony wall over the maximum bulging of the optic canal averaged 0.28 mm. Bony dehiscences could be demonstrated in 12% of the cases. The technique of data acquisition, the anatomical and histological findings as well as their clinical and surgical relevance are discussed.