经迷路后入路岩骨磨除范围的解剖学研究

目的 确定经迷路后入路中岩骨磨除范围的一种方便、实用、安全的方法。方法 观察20侧后半规管的位置,并测量其与乙状窦前缘、内耳门后下缘、岩骨表面的距离和乙状窦前缘、内耳门后下缘和外耳道后上棘的两两间距离,制出这些结构间的位置关系简图,并经过数学计算找到岩骨表面可以磨除的最前点。结果 内耳门后下缘、后半老人家管中点和外耳道后上棘基本处于同一水平面上,后半老人家向与乙状窦前缘、内耳门后下缘、岩骨表面的距离和乙状窦前缘到内耳门后下缘、乙状窦前缘到外耳道后上棘、骨耳孔后下缘到外耳道后上棘的距离分别为8.67mm、15.64mm、3.47mm、22.07mm、12.42mm、25.37mm。结论 内耳门下后缘水平内耳门下后缘后12.5mm或乙状窦前缘前10mm处和外耳道后上棘的连线可用来确定岩骨后部的磨除范围。     

岩骨胆脂瘤的诊断与治疗

目的 探讨岩骨胆脂瘤的诊断与治疗。方法 总结5例(5耳，其中2耳先天性，3耳后天性)岩骨胆脂瘤的临床表现，影像学结果及手术经验。结果 5耳均有重度聋或全聋，3耳面瘫，3耳脑膜炎；颞骨CT扫描呈低密度边缘光滑的膨胀性缺损，磁共振成像(magnetic resonance imaging，MRI)中Tl加权呈中等均一信号，T2加权呈高信号。增强扫描无强化。4(1耳先天性，3耳后天性)岩骨胆脂瘤耳采用迷路进路，1耳先天性岩骨胆脂瘤采用颅中窝-迷路联合进路手术。术后随访0．5～4年，无脑脊液漏，未见胆脂瘤复发，均获干耳。3耳面瘫患者，1例完全恢复，1例Ⅱ级恢复，1例Ⅲ级恢复。结论 颞骨CT扫描对临床诊断具有重要作用，MRI具有鉴别诊断价值。对于无实用听力患者，迷路进路是最实用和理想的手术进路。     

岩骨胆脂瘤的诊断与外科治疗

目的探讨岩骨胆脂瘤的病因和临床表现特点以及手术方式。方法对1986年12月～2003年4月收治的12例岩骨胆脂瘤患者(继发9例，原发3例)进行回顾性分析。结果原发岩骨胆脂瘤首发症状为面瘫及听力下降，鼓膜正常。继发岩骨胆脂瘤主要表现为耳流脓史，听力下降及面瘫，鼓膜通常有穿孔或不正常。慢性中耳炎病史及耳科手术史与继发性岩骨胆脂瘤的发生密切相关。颞骨CT可明确病变范围及与面神经的关系，能为确定手术方式提供直接的参考。继发及原发岩骨胆脂瘤的治疗原则相同：彻底清除胆脂瘤上皮。手术入路有4种：经迷路、中颅窝、迷路中颅窝联合入路、颅颈联合入路(迷路下)。1例继发胆脂瘤因反复复发而行4次手术外，其余11例随访4个月～15年无复发。吻合的3例面神经中，2例由House Brackmann分级V恢复到Ⅳ；减压及神经连续性完整的3例中2例由Ⅳ恢复到Ⅲ，1例无恢复。结论继发及原发胆脂瘤病因不相同，临床表现各具特点。手术进路的选择取决于病变部位、范围及听力状况，经迷路、中颅窝是主要入路。单纯中颅窝入路应采用术腔相对封闭的术式；其他人路应采取开放术腔式手术。     

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。     

经岩骨入路面神经的显微解剖学研究

目的为经岩骨入路保护面神经提供显微解剖学资料.方法手术显微镜下对10具(20侧)福尔马林固定的成人头颈部标本模拟经岩骨入路的手术操作,观测管段面神经的解剖及其与重要结构的关系.结果管段面神经分3段迷路段长(3.2±0.9)mm,上下方向管径(1.1±0.2)mm;鼓室段长(11.7±1.5)mm,水平方向管径(1.4±0.1)mm,两段成角71.0°±11.7°;垂直段长(13.9±1.8)mm,前后方向管径(1.6±0.2)mm,与水平段成角106.6°±7.7°.管段面神经的解剖标志①锥隆起是上膝部的标志,锥隆起与茎乳孔连线为垂直段的标志线;②面神经裂孔是膝状神经节的标志;③垂直段距离海伦嵴(15.0±1.3)mm.结论熟悉管段面神经的解剖特点和标志,有利于手术中保护面神经.     

经岩骨入路手术中迷路保护的显微解剖学基础

目的 为经岩骨入路手术中保护迷路提供显微解剖学资料。方法 模拟幕上下联合经岩骨入路的手术操作,在手术显微镜下对１０具（２０侧）福尔马林固定的成人带颈头颅标本进行解剖,并观测骨迷路及其与重要结构间的解剖关系。结果 骨迷路为一块包绕膜迷路的质地致密、色泽亮丽的骨质,并构成乳突气房的内侧边界。磨削骨半规管透过菲薄的骨质显示暗蓝色的膜半规管即为“蓝线”。测量骨迷路与周围结构的距离有较大的个体差异,其中后半     

岩骨迷路后CT影像形态及其与梅尼埃病因初步探讨

10块防腐人体颞骨标本行横位及岩骨轴位CT扫描，岩骨轴位影像显示迷路后形态较横位影像佳，横位影像能如实反映迷路后形态。分析54名耳部正常者及20名梅尼埃病患者横位CT影像，岩骨迷路后有气房者则其对应之乳突多为高度气化型，其迷路后厚度也较大，但二者与前庭导水管（VA）的显示无确切的关系。两侧岩骨迷路后气化、厚度及VA形态基本对称。耳部正常组中迷路后有气房者占33．3％，迷路后厚度为10．93±2．41mm，VA显示者占63．0％。梅尼埃病组中则分别为13.8％，8.73±2.11mm及44.8％。CT检查的临床意义尚须进一步探讨。     

扩大迷路径路切除经枕下径路手术后复发的听神经瘤

目的：探讨听神经瘤经枕下径路手术后复发、后经扩大迷路径路再次切除肿瘤的方法及效果。方法：对5例复发的听神经瘤患者，采用扩大迷路径路手术，在经典迷路径路的基础上，通过充分切除岩骨骨质扩大手术视野，将复发的肿瘤组织完全切除。结果：5例听神经瘤直径为2．5～4．0cm，均全部切除，无死亡病例，未发生颅内感染及脑脊液漏；面神经功能与术前一致；术后CT和MRI复查均显示无肿瘤残存，小脑、脑干位置恢复正常。经0．5～2年7个月的随访，至今未见复发，患者已恢复正常生活和工作。结论：枕下径路手术容易残留内听道内的肿瘤，再次手术采用扩大迷路径路可直接暴露肿瘤并到达脑干，既可避免瘢痕粘连区，方便定位面神经，又能全部切除复发的肿瘤，且具有创伤小、面神经功能保存完好等优点。     

耳科学

981182颗骨岩部的应用解剖/李世亭…//解剖学杂志一1997,20(4、一313一317 在20个‘男10,女10)成人福尔马林固定的尸头标本上,对40例颗骨岩部的表面及内部结构进行了显微解剖研究。发现表面结构与内部结构间有恒定的空间位置关系,可以通过表面标志定位内部结构,并提出了颗骨岩部水平段颈内动脉和耳蜗定位新三角,对指导临床手术有重要价值。图4表6参言(原提要)981183咽鼓管吹张术应用解剖学标本制作法/刘文君…//中国临床解剖学杂志一j 997,15(4)一284981184内耳道x线摄影方法的体会/潘文林//南京医科大学学报(中文版)一1997,17(4)一395一396…     

面神经与岩骨胆脂瘤

岩骨胆脂瘤的诊断和处理是耳外科的一个疑难问题。现报道７例侵犯迷路、面神经管的破坏广泛的岩骨胆脂瘤，按临床表现、术中所见、Ｘ线表现及手术径路做回顾性分析。术前６例出现面瘫合并重度耳聋或全聋，皆有慢性中耳炎史，全部经颞骨外侧径路手术。对有慢性中耳炎的患者出现急性面瘫或渐进性面瘫，即使体检未发现胆脂瘤，应做Ｘ线检查以明确有无岩骨胆脂瘤。     

内耳的显微解剖及临床应用

目的了解内耳及相邻结构的显微解剖,为术中切除岩骨骨质提供解剖学参数.方法在显微镜下对15例成人尸头标本的内耳及相邻结构进行解剖学测量.结果乙状窦沟、内听道孔、颈静脉孔、耳蜗、岩嵴和后半规管最后点等可作为手术标志.后半规管最后点和内听道孔后缘到乙状窦沟距离为9.8mm及22.0mm,岩骨后面到面神经管垂直部距离9.1mm,岩嵴到颈静脉球窝顶距离15.1mm,岩嵴最后点到耳蜗距离为28.6mm.结论熟练掌握内耳及相邻结构的解剖,严格限制骨质切除范围,就能既得到满意的手术暴露,又不引起更多并发症.     

High-resolution computed tomography of posterior tympanum

A complex set of sinuses, eminences and ridges lies in the posterior border of the tympanic cavity (posterior tympanum). The facial nerve canal is located between the facial sinus and the sinus tympani. The posterior limit is the posterior semicircular canal. The posterior tympanum is often the site of residual collection of granulation tissue or cholesteatoma, and is not directly visualized by the usual surgical approaches. Thus preoperative knowledge of cholesteatoma in these area is of obvious importance. It has been accepted that high-resolution computed tomography (HRCT) has the significant advantage to provide specific information of the middle ear. Contribution of the HRCT for diagnosis of posterior tympanum was examined by three temporal bone specimens and one hundred subjects with normal middle ear. In the experiments using the temporal bone specimens, each structure in the posterior tympanum was labeled by a fine needle. HRCTs were subsequently obtained to confirm the labeled structure. In one hundred subjects, it was examined whether each structure was also confirmed by the routine HRCT. Results are as follows: (1) Axial HRCT sections provided essential informations for the preoperative evaluation of the posterior tympanum. (2) Such bony structures as the pyramidal eminence and the pyramidal ridge were the most prominent structures on the posterior wall. (3) Laterally close to the pyramidal eminence lies one sinus which was marked by the needle placed in the facial sinus proper or in the lateral tympanic sinus; It is the facial sinus in a wide sense.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of safe surgical treatment of peritonsillar abscess using computed tomography

With the development of new antimicrobial agents, the incidence of peritonsillar abscess (PTA) is on the decline. PTA is still often encountered in general practice, however, where it requires immediate diagnosis and treatment. Because the internal carotid artery runs medially to the medial parapharyngeal space, damage to nearby vascular or other structures is a surgical risk of PTA. We used contrast computed tomography (CT) from PTA patients to investigate the anatomical relationship between the abscess and parapharyngeal space, and to determine safe surgical sites. We observed 31 patients with PTA--19 men and 12 women--between February 1997 and April 1999, all examined by contrast CT and undergoing drainage or incision. The average age was 30.7 years (range: 12-54 years). The abscess was on the right side in 20 cases and on the left side in 11. We determined the sites of the abscess and carotid artery, internal jugular vein, and surrounding soft tissue density area including nerves in the parapharyngeal space based on the angle and distance from recognizable anatomical structures in CT scans. The anterior margin of the parapharyngeal space was 29 +/- 5 mm posterior from the upper posterior alveolar margin. The medial margin of that space was at 15 +/- 2 degrees laterally from the midline of the incisors, and 24 +/- 4 mm laterally from the midline sagittal plane. The internal carotid artery was located medially to the parapharyngeal space, running on the sagittal plane containing the upper posterior alveolar margin. The distance from the anterior margin of the parapharyngeal space to the posterior wall of the PTA was 9 +/- 4 mm, and the distance to the anterior wall of the abscess (including the pharyngeal mucosa) was 31 +/- 5 cm. The relationship between the upper posterior alveolar margin and midline sagittal plane was useful for determining the site of the parapharyngeal space. Because the internal carotid artery is located on the same sagittal plane as the upper posterior alveolar margin, when conducting drainage or incision of PTA, we should advance sagittaLly from the point of incision to a depth of no more than 20 mm. If the tip of the instrument is kept medial to the sagittal plane of the upper posterior alveolar margin, effective treatment should be achievable without the risk of vascular damage.     

Neoglottic formation from posterior pharyngeal wall conserved in surgery for hypopharyngeal cancer

OBJECTIVE: To describe a new treatment modality of hypopharyngeal cancer consisting of total laryngectomy plus partial pharyngectomy (TLPP) conserving the posterior wall of the pharynx vertically for voice restoration. METHODS: Review of hospital charts, TLPP was undertaken in 15 of 54 patients. Surgical modalities of reconstruction subsequent to TLPP were indicated on the basis of the width of posterior pharyngeal wall conserved during surgery. Posterior pharyngeal walls of width 3 cm or larger were sutured in primary closure. If the width of posterior wall was less than 3 cm, a free forearm flap or free jejunal flap was patched to the wall. Tracheo-esophageal shunt with a voice prosthesis was performed 3 weeks after surgery. RESULTS: The Kaplan-Meier method indicated no difference in survival rate between patients with TLPP (46.4%) and the remaining patients (47.4%). Nine of 15 patients with TLPP (two patients with primary closure, three with free forearm flap, and four with free jejunal flap) were examined for voice restoration and fluoroscopy of the neopharynx. Eight of the nine patients, in whom more than 2 cm of the posterior pharyngeal wall had been conserved, demonstrated a good speech rating, maximum phonation time and neoglottic formation by the posterior pharyngeal wall. CONCLUSION: The combination of conservation of the posterior pharyngeal wall, patch graft and a voice prosthesis is a useful method that offers sufficient quality of phonation without deterioration of survival rate for patients with hypopharyngeal cancer.     

后鼓室解剖结构测量观察及临床意义

目的通过研究后鼓室有关解剖结构,及对后鼓室入路手术的径路进行观察、测量,为中耳相关手术入路提供理论参考依据。方法取成人30个干性颅骨的60侧颞骨,用耳科钻完成乳突腔气房“轮廓化",充分暴露后鼓室的各相关结构,在手术显微镜下进行解剖学观察,并对有关结构之间的距离进行测量。结果颞骨标本解剖观察结果,锥隆起至鼓索隆起的距离（3.22±0.41）mm、锥隆起至面神经管直线距离（3.59±0.48）mm、鼓索后小管的长度（9.44±1.65）mm;面神经管锥曲至鼓索隆起间的距离（3.34±0.42）mm、面神经锥曲至水平半规管距离（1.54±0.25）mm、面神经锥曲至后半规管距离（2.15±0.29）mm。面神经垂直段从外向内观察大部分呈后凸弧形下行,但有2例（3.33%）呈直线型垂直下行。面神经镫骨肌支全部从面神经管前壁穿出,鼓索神经自面神经管外发起9例（15%）,自面神经管下1/3处分出49例（81.67%）,自1/3处分出2例（3.33%）。结论经后鼓室进路手术开放面神经隐窝时,鼓索隆起至面神经管锥曲和至锥隆起的距离可作为开放面神经隐窝的宽度,面神经管与锥隆起可作为手术中互为寻找的依据。术中处理面神经隐窝病变时勿随意磨低锥隆起及鼓索隆起,以免损伤面神经镫骨肌支及鼓索神经。     

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.     

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...     

Bilateral pulsating pharynx with abnormal internal carotid artery

A five years old female, presented with long standing snoring & recurrent tonsillitis. Examination showed pulsating soft palate & posterior pharyngeal wall. Magnetic resonance angiography (MRA) of the carotids revealed abnormal course of the right internal carotid artery (ICA) with its proximal segment coursing medially and reaching the midline of the retropharyngeal space. The right ICA kinked 2.3 cm medially. It was 3.1 mm posterior to the right palatine tonsil & 3.5 mm away from posterior part of the adenoid. The dilemma of undergoing adenotonsillectomy was considered to be of a high risk & the patient was kept on conservative management only.     

The bacterial flora of the nasopharynx, with special reference to middle ear pathogens. A quantitative study in twenty children

Quantification of middle ear pathogens (S. pneumoniae, H. influenzae and B. catarrhalis) and potential pathogens (S. aureus and coagulase-negative staphylococci) adhering to the posterior wall of the nasopharynx was performed in 20 patients of whom 5 were suffering from secretory otitis media (SOM), 5 from recurrent attacks of acute otitis media (rAOM), 5 from attacks of upper respiratory infection (URI) and 5 from blocked nose (BN). While the patients were under general anesthesia a glass cylinder (diameter 1.3 cm) was pressed against the posterior wall of the nasopharynx and swabs were taken from the mucosa delineated by the glass tube. Quantification of the bacteria was performed using blood and chocolate agar plates. Total bacterial counts ranged between 2.6 x 10(4)CFU/cm2 and 4.0 x 10(8)CFU/cm2. In the rAOM group, 4 out of 5 children had bacterial counts in the nasopharynx which constituted of 95% pathogens. Coagulase-negative staphylococci never exceeded 1.9 x 10(5)CFU/cm2.     

The retroconchal space of the lateral nasal wall.

The retroconchal space is defined in this article as the posterior part of the lateral wall of the nasal fossa. Considerable variations in the size and shape of this retroconchal space exist, these in turn depending on the variations of the middle and inferior conchae. The retroconchal space can be defined in plain radiographs or in nasopharyngograms. This would be of help in pinpointing the site of a neoplasm.