耳科学

990941岩静脉的显微外科解剖及其临床意义/李光华…刀中国耳鼻咽喉颅底外科杂志一1 998,4(3)一138一140 目的:观测岩静脉的显微外科解剖特征,防止术中、术后出血等并发症。方法:通过20例(40侧)成人尸头解剖测量及60例临床手术的观测,并进行统计学处理。结果:总结了岩静脉的显微外科解剖特征、形态变异、走行、属支情况,测量了与手术有关的距离,提出了术中处理岩静脉的指征与最佳方法。结论:明确了岩静脉的解剖特点,术中能较早地处理好岩静脉,为顺利开展小脑脑桥角区手术创造良好条件。表2参2(秦斯)990942 Nd:YAG激光对耳廓软骨间积液的治…     

鼻鼻窦解剖变异与慢性鼻窦炎的关系

量化研究鼻鼻窦解剖变异与慢性鼻炎的发病的关系。用自行开发计算机图像分析系统定量分析９１例慢性鼻窦炎患者的冠状位鼻窦ＣＴ，观测指标包括：骨性解剖结构变异，筛漏钹突角度，筛泡等，测量相应结构的冠状位截面积，角度，长度。     

鼻科学

241 新生儿上颌窦的观测陆忠琪张奎启中华耳鼻咽喉科杂志19(3):164,1984 新生儿上颌窦的位置、形态和毗邻均与成人上颌窦不同,为向临床提供新生儿上颔窦的解剖数据和毗邻关系,作者观测了足月健康新生儿尸体25例(男18例,女7例)。叙述其解剖观测步骤及其测量仪器。结果:一、上颌窦     

面神经解剖在切除耳后鳃裂瘘管中的意义

目的 探讨面神经总干解剖在耳后鳃裂瘘管切除术中的意义。方法 12例耳后鳃裂瘘管患者术中常规解剖面神经总干，在明视面神经情况下将耳后瘘管及其周围的瘢痕组织一并切除。3例伴耳道软骨缺损，瘘管组织与耳道皮肤关系密切而切除部分耳道软骨和皮肤，耳道缺损用胸锁乳突肌瓣予以填塞封闭。结果 切口Ⅰ期愈合者11例，1例术腔积液并发感染，经清创换药后痊愈。其中1例术后有轻度面神经麻痹，术后10天完全恢复。3例行耳道软骨和皮肤部分切除者均无耳道狭窄和听力下降。本组中l例术后6月失访，11例患者随诊1年6月～2年均无复发。结论 面神经总干解剖有助于完整切除耳后鳃裂瘘管和防止面神经不可逆损伤。     

鼓室成形术中避免面神经损伤的体会

目的总结鼓室成形术中避免面神经损伤的经验与体会。方法将不同时期完成的鼓室成形术病例分为早期组和后期组，重点分析术中发现面神经解剖变异情况与术后面瘫发生率的关系。结果早期组患者86例，术中发现乳突段面神经裸露2例，术后发生完全性面瘫7例（8．1％）；后期组患者106例，术中发现乳突段和水平段面神经裸露者分别为4例和9例，术后发生不完全性面瘫2例（1．9％）。结论术者对面神经解剖及其变异情况的熟悉程度和耳显微手术操作经验，是避免术中发生面神经损伤的最大保证。     

腭咽成形术中保留悬雍垂的意义

目的 改进经典悬雍垂腭咽成形术（ＵＰＰＰ）手术方法，探讨术中保留悬雍垂的意义，提高ＵＰＰＰ手术疗效、减少术后并发症。方法 治疗睡眠呼吸暂停综合征患者３０例。①在主观症状改善的基础上，应用多导睡眠图分析及咽腔解剖参数测量等项指标，术后随访６个月以上，对术前术后所获资料进行统计学分析。②手术改进特点：力求维持咽腔正常生理解剖形态，完整保留悬雍垂，解剖切除腭帆间隙脂肪组织，扩大软腭成形范围，平均软腭切除     

腮腺良性肿瘤区域性切除术的临床探讨

腮腺良性肿瘤在临床上比较常见，传统的手术方法是进行肿瘤和腮腺浅叶切除术及面神经解剖术。1996-2006年间我科对31例腮腺良性肿瘤施行肿瘤及其周围腮腺组织切除术及部分面神经解剖术，取得了良好的临床疗效。现报告如下。     

远外侧经髁入路解剖标志的应用研究

目的对枕下远外侧经髁入路的解剖标志进行观测,以指导临床应用。方法模拟临床手术过程,在显微镜下对15例成年国人灌注头颅标本进行解剖观测。结果椎动脉从寰椎横突孔穿出后进入枕下三角内,走行在寰椎侧块的椎动脉沟内,被寰椎后弓的骨膜紧密包绕,覆盖丰富的椎静脉丛;颈静脉结节和枕髁阻碍了脑桥延髓腹侧的术野。结论游离椎动脉会增加出血和创伤的风险,一般情况下不予采用。颈静脉结节和枕髁的磨除有利于增大操作空间和视野,是否磨髁及其磨髁的多少应根据病变的性质和位置来决定,磨除颈静脉结节时勿损伤后组脑神经,术中均需行脑神经监测。     

改良Miccoli术中喉返神经的显露及损伤预防

目的：探讨甲状腺改良Miccoli术中解剖显露喉返神经的方法及预防喉返神经损伤的临床意义。方法：回顾性分析218例行甲状腺改良Miccoli术患者的资料，均在内镜直视下寻找喉返神经并进一步显露直至人喉处，行甲状腺次全切或腺叶全切除。结果：218例患者手术均获成功，无中转开放手术。术中均成功显露颈段喉返神经并保护之。术中、术后病理证实结节性甲状腺肿185例，甲状腺腺瘤8例，甲状腺乳头状微小癌25例。2例甲状腺乳头状微小癌及1例有鼻咽癌放疗史的患者，术后出现暂时性声嘶，3个月内声带活动恢复正常。结论：甲状腺改良Miccoli术中解剖显露喉返神经是该手术顺利进行的关键，是预防喉返神经损伤的有效方法。     

鼻内窥镜鼻窦手术中中鼻甲的处理方法和意义

中鼻甲在鼻腔生理功能方面发挥重要作用，又是鼻内窥镜鼻窦手术中极重要的解剖参考标志，所以强调术中保留中鼻甲。但中鼻甲自身解剖结构异常或存有病变，却可导致鼻腔鼻窦功能障碍，并有可能成为鼻窦炎的发源地。本文综合了１２１３例接受鼻内窥镜鼻窦手术的慢性鼻窦炎、鼻息肉患者中９７５例ＣＴ扫描和鼻内窥镜检查结果，并总结了鼻内窥镜鼻窦手术中和术后随访的体会，归纳提出中鼻甲与上颌骨额突（钩突附着缘）及鼻中镉的解剖结构     

听神经瘤显微手术中岩静脉的保护

目的探讨显微手术切除听神经瘤时岩静脉保护的方法和临床意义。方法显微手术治疗听神经瘤147例,术中先行肿瘤内减压,再逐步分离肿瘤周边结构。岩静脉143例保护良好;4例术中被切断行电凝处理。结果 143例患者术后未发生小脑出血性梗塞。4例电凝处理岩静脉,其中1例发生一过性广泛性小脑水肿,随访18个月能生活自理,但仍有走路步态不稳,3例出现小脑出血性梗塞并水肿,其中1例死亡;2例经后颅窝减压后恢复良好,其中1例随访3 3个月无明显神经功能障碍,1例随访1 2个月尚有走一字路不稳。结论在听神经瘤显微手术中应保护好岩静脉,一旦损伤需在手术后密切观察病情变化,做好再次后颅窝减压手术的准备。     

脑CTV评估听神经瘤与岩上窦关系的价值

目的探讨颅脑CT静脉成像（cerebral CT venography, CTV）术前评估听神经瘤与岩上窦、岩上静脉关系的价值。方法分析经病理证实的30例听神经瘤患者的术前CTV资料及临床资料,由2位放射科医生判定肿瘤的最大径、岩上窦引流类型,以及岩上静脉汇入岩上窦的节点与内听道后上壁的位置;进一步判断肿瘤与岩上窦的关系,分析岩上窦及岩上静脉保留情况及术后静脉并发症发生的情况,并对比肿瘤与岩上窦关系、岩上窦引流类型、岩上静脉汇入点的不同组别间肿瘤大小。结果按岩上窦引流类型分为3型：完整型、内侧型、外侧型;其中27例（90.0％）患者岩上窦为完整型;2例（6.7％）为外侧型;1例（3.3％）为内侧型。根据岩上静脉汇入岩上窦的节点与内听道后上壁的位置,分为内侧型、中间型、外侧型;11支(35.5％)岩上静脉汇入点为中间型;13支(41.9％)为内侧型;7支(22.6％)为外侧型,其中有1例患者发现两支岩上静脉,分别为内侧型、中间型。25例（83.3％）患者岩上窦走行于瘤体外侧,其中4例岩上窦受压;5例（16.7％）患者岩上窦走行于瘤体上方,岩上窦无受压。肿瘤最大径在不同肿瘤与岩上窦关系之间的差异具有统计学意义（P＜0.05）。手术均采用枕下乙状窦后入路,岩上窦、岩上静脉完整保留,术后无静脉性并发症的发生。结论脑CTV可术前评估听神经瘤与岩上窦关系,有助于减少术中对岩上窦、岩上静脉的损伤。     

中颅窝进路内听道毗邻结构的解剖学研究

目的 :针对中颅窝手术进路 ,以面神经裂孔为标记 ,对内听道的毗邻结构进行测量 ,为临床手术操作提供应用解剖学基础。方法 :采用甲醛固定的头颅标本 2 4具 (4 8侧 ) ,分别暴露棘孔、岩浅大神经、岩浅小神经、面神经裂孔和弓状隆起 ,并对其相互之间的位置关系进行测量。结果 :8.3%面神经迷路段和膝状神经节骨管型缺如 ,面神经裂孔到膝神经节的距离变异较大。结论 :该研究提供的测量数值 ,对临床进行中颅窝手术进路的内听道定位有较大的参考价值。     

Haemorrhagic venous infarction following the posterior petrosal approach for acoustic neurinoma surgery: a report of two cases

The authors report two surgical cases with acoustic neurinoma in which haemorrhagic infarction occurred via a compromise in cerebral deep venous outflow. In both cases, surgery was performed via the posterior petrosal approach, and the neurinomas were completely removed. In the first case, the haemorrhagic infarction was considered to have resulted from transection of the tentorial sinus, the presence of which had not been predictable by preoperative angiography. In the second case, the haemorrhagic infarction was caused by a coagulation of the petrosal vein, which was firmly adherent to a tumour. With the posterior petrosal approach, meticulous care is necessary to preserve the deep anastomotic veins into and around the cerebellar tentorium. Thereby, catastrophic morbidity related to compromised deep cerebral venous outflow can be avoided.     

Jugular foramen schwannoma: analysis on its origin and location.

OBJECTIVE: To examine the microsurgical anatomy of the jugular foramen and correlate anatomical findings to clinical manifestations of jugular foramen schwannomas concerning tumor origin and location. STUDY DESIGN: Anatomical analysis of jugular foramen was performed by dissection of 25 cadavers (50 sides). By retrospective review of 9 cases of jugular foramen schwannomas surgically treated, the origin and location of tumor were studied. SETTING: Tertiary referral center. MAIN OUTCOME MEASURES: The anatomical characteristics of jugular foramen, lower cranial nerves, and inferior petrosal sinus were correlated with the origin and growth pattern of jugular foramen schwannomas. RESULTS: The superior and inferior ganglions of the glossopharyngeal nerve and the superior ganglion of the vagus nerve were located within the jugular foramen. The superior ganglions of the glossopharyngeal and vagus nerves were located superiorly, whereas the inferior ganglion of the glossopharyngeal nerve was found inferiorly in relation to the inferior petrosal sinus orifice. In our series of 9 cases of jugular foramen schwannoma, the most common nerve of origin was the vagus nerve, followed by the glossopharyngeal nerve. CONCLUSION: The reason for the predilection of the jugular foramen schwannoma for the glossopharyngeal and vagus nerves may be associated with the presence of their ganglions within the jugular foramen. Also, the inferior petrosal sinus may act as a barrier to tumor growth, and the location of the ganglion of tumor origination within the jugular foramen in relation to the inferior petrosal sinus may be correlated to the predominant direction of tumor extension.     

Anatomical study of jugular foramen in the neck

IntroductionThe anatomical complexity of the jugular foramen makes surgical procedures in this region delicate and difficult. Due to the advances in surgical techniques, approaches to the jugular foramen became more frequent, requiring improvement of the knowledge of this region anatomy.ObjectiveTo study the anatomy of the jugular foramen, internal jugular vein and glossopharyngeal, vagus and accessory nerves, and to identify the anatomical relationships among these structures in the jugular foramen region and lateral-pharyngeal space.MethodsA total of 60 sides of 30 non-embalmed cadavers were examined few hours after death. The diameters of the jugular foramen and its anatomical relationships were analyzed.ResultsThe diameters of the jugular foramen and internal jugular vein were greater on the right side in most studied specimens. The inferior petrosal sinus ended in the internal jugular vein up to 40 mm below the jugular foramen; in 5% of cases. The glossopharyngeal nerve exhibited an intimate anatomical relationship with the styloglossus muscle after exiting the skull, and the vagal nerve had a similar relationship with the hypoglossal nerve. The accessory nerve passed around the internal jugular vein via its anterior wall in 71.7% of cadavers.ConclusionAnatomical variations were found in the dimensions of the jugular foramen and the internal jugular vein, which were larger in size on the right side of most studied bodies; variations also occurred in the trajectory and anatomical relationships of the nerves. The petrosal sinus can join the internal jugular vein below the foramen.     

颈静脉孔的显微外科解剖研究

目的研究颈静脉孔的硬脑膜结构和孔内神经、血管结构的行程及形态特征。方法显微镜下模拟枕下极外侧入路、颈-乳突入路和Fisch颞下窝入路的手术操作，研究10例福尔马林及乳胶灌注头颈标本颈静脉孔的显微解剖特征。结果在颈静脉孔的颅内开口，舌咽神经与迷走、副神经间被纤维或骨性结构隔开。在颈静脉孔内，脑神经行于颈静脉球上方的内侧，舌咽神经位于最前方，所有神经束均可用显微外科技术分开，副神经的脑根同脊髓根一起进入颈静脉孔后又加入迷走神经。颈静脉球及临近颈内静脉接受来自乙状窦、岩下窦、椎静脉丛、舌下神经管静脉丛、髁导静脉及岩斜下静脉的静脉回流。结论颈静脉孔的颅内开口可分为岩部、颈内部(或神经部)和乙状窦部．颈静脉孔内脑神经的不同神经纤维束在整个行程中彼此独立，副神经仅由脊髓根构成。     

内窥镜下桥小脑角手术

目的 探讨内窥镜在桥小脑角手术中的适应症、技术方法。方法 气管插管全身麻醉,通过录像监视器观察,内窥镜经乙状窦后进路进入桥小脑角,首先看到面、听神经和内听道,内窥镜向上可看到三叉神经、外展神经、岩静脉,向下可看到颈静脉孔和舌咽、迷走神经、然后根据下同的手术要求进行神经根减压、梳理及选择性切断术。结果 面神经根梳理术3例;三叉神经根减压术1例;感觉根选择性切断术9例;前庭神经切断术3例。结论 内窥镜扩大了桥小脑角区的手术视野,可以观察到手术显微镜下不易观察到的部位,减少了手术创伤,增加了手术的安全性。     

Patency and flow of the internal jugular vein after functional neck dissection

OBJECTIVES: To assess the patency and flow of the internal jugular vein after functional neck dissection. STUDY DESIGN: Prospective study of 54 internal jugular veins in 29 oncologic patients undergoing functional neck dissection between September 1994 and February 1997. METHODS: Patency, presence of thrombosis, characteristics of the vein wall, compressibility, area of the vein both in rest and during Valsalva maneuver, expiratory flow speed, Valsalva flow speed, jugular flow in each side, and total jugular flow were assessed in all veins before and after dissection. All patients were evaluated before and after the procedure by means of duplex Doppler ultrasonography. RESULTS: In no case was there thrombosis before or after the operation. Although total jugular flow decreases during the early postoperative period, it recovers to normal parameters within 3 months after surgery. CONCLUSIONS: According to these results, the patency of the internal jugular vein remains unaltered after functional neck dissection. Ultrasonographically there is no thrombosis after this procedure.     

Combined petrosal approaches in the management of temporal bone meningiomas.

OBJECTIVES: To evaluate the indications and outcomes of the combined petrosal approaches in the surgical management of temporal bone meningiomas. STUDY DESIGN: Retrospective chart review. SETTING: University teaching hospital. PATIENTS: Adults with temporal bone meningiomas. INTERVENTION(S): Meningioma removal using a combined petrosal approach. MAIN OUTCOME MEASURE(S): Cranial nerve outcomes, complications, completeness of resection, and recurrence rates. RESULTS: Forty-nine patients underwent surgical excision of a temporal bone meningioma between 1996 and 2004 at our institution. Nineteen of these patients required a combined petrosal approach for excision. The most common presenting complaints were balance disturbance, 11 (58%); hearing loss, 10 (53%); headache, 10 (53%); and tinnitus, 9 (47%). The most common tumor origin was of the petrous ridge (14; 74%). Average tumor size was 3.1 cm. Complete resection was possible in 17 (89%) patients. Upper cranial nerve (III-VI) function was improved in two (11%) patients and worsened in three (16%) patients. Lower cranial nerve (IX-XII) function improved in one (5%) patient and was worsened in one (5%) patient. Postoperative facial nerve function was Grades I to II in 16 (84%) patients and Grades III to IV in 1 (5%) patient at last follow-up. Hearing data were available in 14 patients. Of those patients, 11 (85%) had serviceable hearing after surgery. The most common surgical complication was a cerebrospinal fluid leak, with three (16%) incidences. There were no reported incidents of stroke, death, or meningitis in the cohort. CONCLUSION: The use of the combined petrosal approach for temporal bone meningioma resection results in favorable outcomes for the patient. The incidence of complications is acceptably low, and cure rates are high.