中耳显微解剖标志与面神经定位

目的 观察中耳手术中面神经相关的显微解剖结构,并探讨其临床应用。方法 30具(60侧颞骨)中国人成年湿性头颅标本经乳突入路对颞骨进行显微解剖,重点观察面神经并根据其周围的固定解剖标志对其进行定位。 结果 面神经乳突段前缘和后缘至假想定位线的距离分别为（-0.11±0.36）mm和（-0.14±0.38）mm,鼓室段面神经下缘与假想定位线的距离为（0.31±0.12）mm,砧骨短脚末端至外半规管下缘的距离为（1.73±0.24）mm,外半规管至面神经锥段上缘的距离为（2.65±0.25）mm,砧骨短脚最末端至面神经锥段上缘的距离为（2.20±0.41）mm,镫骨头上缘至面神经水平段下缘的距离为（2.24±0.23）mm等。结论 外半规管、砧骨短突、鼓环、二腹肌嵴、前庭窗、匙突、卵圆窗、锥隆起和鼓索神经等是中耳显微手术的重要解剖标志,并与面神经关系极其密切和恒定。     

后鼓室颞骨切片与CT对照研究

目的：为后鼓室及耳科病变的影像诊断和手术治疗提供解剖学基础。方法：l5例成人头部标本，以眦耳线（cML）为基线，获得间隔为1．00mm，厚度为1．00mm的CT图像，扫描后的头部标本按原定位截取以耳颞区为中心的组织块并将其制成厚为1．00mm的连续横断薄层切片。标本切片与CT图像对照，对颞骨内砧骨窝、鼓索隆起、茎突隆起、面神经隐窝、鼓室窦、岬小桥、外耳道上棘等结构进行观察。结果：砧骨窝深度为1．49mm，至面神经锥曲的距离为5．67mm。后鼓室窦内侧壁至面神经水平部的距离为3．14mm。外耳道上棘至面神经垂直段、鼓索神经、鼓岬的距离分别为16．76mm、15．94mm和21．81mm。结论：耳颞区断面标本与CT图像进行对照研究，其结果对耳科疾病的影像诊断及手术治疗具有参考价值。     

面神经在颞骨内改道以延长其可利用长度的应用解剖

目的:探讨将面神经在颞骨内改道,以延长面神经颅外段(总干)可利用长度,解决颌面部外科手术中面神经总干长度不足问题。方法:在手术显微镜下,对20例(40侧)经福尔马林固定尸体头部标本进行解剖,观测面神经在颞骨内改道后颅外段延长的可利用长度。结果:①仅作乳突段向外耳道后壁及向颞骨浅面改道,可延长面神经总干长(7.1±0.3)mm。②鼓室段及乳突段联合向外耳道后壁及向颞骨浅面改道,可延长面神经总干长(13.4±0.6)mm,经统计学处理两者有显著性差异(P<0.05)。结论:将面神经鼓室段及乳突段联合向外耳道后壁及颞骨浅面改道,能有效延长面神经总干长度,是解决颌面部外科手术中面神经长度不足的有效方法。     

颞骨内面神经垂直段的显微解剖及其临床意义

目的：研究颞骨内面神经垂直段及其毗邻结构的显微解剖,为临床应用提供解剖学资料。方法：通过模拟临床经乳突入路的方法,分层解剖20个成人湿性头颅标本（40侧颞骨）,显露并观测颞骨内面神经垂直段及其毗邻结构。结果：面神经垂直段的长度为（17.39±1.78）mm、直径为（2.13±0.13）mm,面神经垂直段与水平段的夹角（向前）为（115.5±6.89）°,面神经垂直段近端至外半规管隆突距离为（2.86±0.31）mm,鼓索神经自面神经发出点至茎乳孔距离为（5.99±0.74）mm,面神经垂直段与鼓索神经的夹角（向上）为（38.6±1.99）°,锥隆起尖到面神经垂直段垂直距离为（2.05±0.65）mm,后半规管至面神经垂直段最短距离为（2.89±0.36）mm。有5%（2/40侧）的面神经垂直段的近端位于外半规管隆突外侧。结论：外半规管、鼓索神经、茎乳孔、锥隆起、后半规管是手术中确定面神经垂直段的重要标志。熟悉颞骨内面神经垂直段与其周围结构的毗邻关系,有利于面神经垂直段相关手术的顺利进行。     

舌下神经-面神经直接侧端吻合的应用解剖学研究

目的:为舌下神经-面神经直接侧端吻合提供解剖学依据。方法:①在21例防腐固定的成人头颈部标本上,测量面神经干及其颞骨内乳突段、鼓室段长度;面神经干分叉处至舌下神经颈部的最短距离。②3例新鲜标本取舌下神经及面神经干行组织学检测,测定其神经束数目和横切面积。③2例标本摹拟术式设计。结果:舌下神经干在寰椎水平为单束形式,横切面积为(8.5±0.3)mm2;面神经干在出茎乳孔处为单束形式,横切面积为(5.1±0.2)mm2;面神经干的长度为(15.7±2.0)mm,颞骨内面神经乳突段的长度为(14.6±1.5)mm、鼓室段的长度为(9.6±1.2)mm;面神经干分叉处至舌下神经颈部的最短距离为(17.2±2.3)mm。结论:舌下神经-面神经直接侧端吻合治疗面瘫具有可行性。     

听小骨的动脉供应

对20例足月新生儿,经颈总动脉注射含墨汁的乳胶液,显示听小骨的动脉。在解剖显微镜下观察到锤骨和砧骨具有滋养动脉和粘膜动脉,而镫骨只由粘膜动脉供应。鼓室前动脉是锤骨和砧骨的主要动脉来源,经岩鼓裂进入鼓室,分为五支——锤骨动脉、砧骨动脉、上支、后支和鼓索支。锤骨动脉为滋养动脉,经锤骨颈部的滋养孔入骨,砧骨动脉经长脚基部的滋养孔入骨。上支和后支为粘膜动脉,供应锤骨头、砧骨体和短脚。锤骨柄由分布于鼓膜上的耳深动脉和茎乳动脉的分支供应。砧骨长脚的粘膜动脉由砧骨动脉的分支、沿鼓索分布的动脉以及来自镫骨方面的动脉供应。镫骨的动脉一是来自面神经管内的动脉,一是来自鼓室岬血管丛。来自后者的有:镫骨头动脉、镫骨后脚动脉和镫骨前脚动脉,前两种动脉过去未曾被提到。面神经管内有茎乳动脉和岩浅动脉,前者发出镫骨肌腱动脉,后者发出残存的镫骨动脉及后脚动脉。关于砧镫关节及砧骨长脚下部的血供,来自镫骨方面的动脉多于砧骨方面的动脉。综上所述,由第一鳃弓软骨发生的锤骨头、砧骨体和短脚主要由鼓室前动脉分布,由第二鳃弓软骨发生的听小骨的其余部分主要由茎乳动脉供应。     

后鼓室手术入路的应用解剖学研究

目的　为后鼓室入路手术提供解剖学依据。方法　利用成人 6 0侧颞骨标本 ,用牙科钻磨开乳突腔 ,打开外耳道外侧壁和鼓室盾板 ,充分暴露后鼓室入路手术中有关的解剖结构。以外耳道上棘、面神经管锥曲为测量标志 ,在手术显微镜下 ,对在手术中遇到的解剖结构之间的距离进行了测量。结果　外耳道上棘至砧骨窝、锥隆起、鼓索隆起、面神经管锥曲、外侧半规管、后半规管、前庭窗、蜗窗、匙突、乙状窦垂直部前缘中点、窦膜角的距离分别是 17 19、18 0 2、15 2 2、14 4 9、15 39、17 35、19 5 8、2 0 0 9、2 0 32、15 6 8、18 76mm。面神经管锥曲至鼓索隆起、水平半规管、后半规管的距离分别是 3 33、1 5 3、2 15mm。结论　外耳道上棘、面神经管锥曲是后鼓室入路的重要手术标志 ,鼓索隆起向内 3mm是手术入路的安全区 ,面神经减压术时应避免损伤水平半规管及后半规管等结构     

幼儿人工耳蜗植入点定位的应用解剖学

目的 为幼儿人工耳蜗植入术提供解剖学依据.方法 取1～5周岁因故死亡儿童头颅14具,在28例标本上,模拟经乳突后鼓室入路手术.切除乳突,保留外耳道后壁,显露砧骨窝,去除面神经和鼓索神经之间的骨质进入后鼓室,在手术显微镜下(×6)观察并测量与耳蜗植入点相关的解剖学数据.结果 圆窗位于圆窗龛前缘上部.锥隆起、镫骨肌腱、砧镫关节、镫骨底板、圆窗龛、鼓岬、外侧半规管突等解剖标志清晰且恒定.镫骨后弓相当于鼓阶的前界.鼓阶位于前庭阶后下的位置.圆窗龛前缘中点到鼓阶下壁、鼓阶后壁、基底膜、锥隆起、外侧半规管突、镫骨底板下缘中点、匙突的距离分别为(1.49±0.42)mm、(0.90±0.31)mm、(1.49±0.41)mm、(3.28±0.55)mm、(7.41±0.9)mm、(3.09±0.53)mm、(4.83±0.65)mm.结论 幼儿人工耳蜗植入点应选择在圆窗龛前游离缘中点向前0.90～1.49mm、向下1.49mm以内的位置;在圆窗龛显示困难的病例,植入点应定位于距镫骨底板下缘中点下方约3mm处.     

听小骨空间结构相关形态学研究

目的　探讨听小骨在鼓室内相对空间位置结构,为听小骨的空间定位提供数据,为听骨链重建术提供相关解剖学依据。 方法　10%福尔马林固定的完整成年男性头颅20个(40例),解剖并测量锤骨柄长轴、锤骨头颈长轴、砧骨长突、镫骨长轴分别与水平面、矢状面夹角,锤骨柄与锤骨头颈长轴夹角、锤砧关节夹角及砧骨与镫骨间夹角。 结果　锤骨柄长轴与水平面、矢状面夹角分别为（44.89±11.66）°、（41.92±11.68）°,锤骨头颈长轴与水平面、矢状面夹角分别为（41.94±11.14）°、（39.48±10.11）°,砧骨长突与水平面、矢状面夹角分别为（43.50±11.27）°、（35.84±12.39）°,镫骨长轴分别与水平面、矢状面夹角为（25.93±10.39）°、（58.19±8.19）°,锤骨柄与锤骨头颈长轴夹角 (140.93±10.43)°、锤砧关节夹角(96.19±　13.82)°、砧骨与镫骨间夹角(104.27±9.22)°。 结论　听骨链在鼓室内的空间排列呈斜体“N”型。     

面神经隐窝进路的相关解剖研究

目的：对面神经隐窝进路涉及解剖区域的相关显微解剖和影像学解剖的研究进展进行综述。方法：选用近几年关键词为“面神经”、“颞骨”及“后鼓室”的文章进行分析和总结。结果：其解剖结构复杂精细,涉及面神经乳突段、鼓索神经、砧骨窝之间的解剖区域。一些重要解剖结构的位置相对恒定,如锥隆起、圆窗龛、圆窗、前庭窗、镫骨、砧骨短脚、匙突、面神经鼓室段、水平半规管凸、后半规管凸等,可以作为手术的参考标记。结论：面神经隐窝进路在现代耳显微外科中有重要地位,熟悉其解剖关系,可以指导临床手术,避免损伤。     

Connections between postparotid terminal branches of the facial nerve: An immunohistochemistry study

It has been assumed that connections between the postparotid terminal branches of the facial nerve are purely motor. However, the nature of their fibers remains unexplored. The aim of this study is to determine whether these connections comprise motor fibers exclusively. In total 17 connections between terminal facial nerve branches were obtained from 13 different facial nerves. Choline acetyltransferase antibody (ChAT) was used to stain the fibers in the connections and determine whether or not all of them were motor. All connections contained ChAT positive and negative fibers. The average number of fibers overall was 287 (84–587) and the average proportion of positive fibers was 63% (37.7%–91.5%). In 29% of the nerves, >75% of the fibers were ChAT+ (strongly positive); in 52.94%, 50%–75% were ChAT+ (intermediately positive); and in 17.65%, <50% were ChAT+ (weakly positive). Fibers traveling inside the postparotid terminal cranial nerve VII branch connections are not exclusively motor.     

The role of gold weight implants in the management of paralytic lagophthalmos

Background/aimThe study aims to evaluate the usage of gold weight implants and monitor complaints and comfort of patients.Materials and methodsA hundred and ninety-one implantations performed between January 2009 and January 2019 were analyzed. Seventy-eight patients included in this study The average age of the patients was 51.3 ± 14.5 years. Forty-five (57.7%) of them were male and 33 (42.3%) female. Patient satisfaction was measured with a questionnaire containing the most common complaints related to gold weight in the literature through telephone surveys.ResultsThe average follow-up time was 74.5 months. Ninety-three-point-five percent of subjects had operational causes, among which the most widespread was acoustic neuroma (44.9%). The average time between facial paralysis and implantation was 141.1 days. Implantation was performed 26.6 days on average after acoustic neuroma surgery and 3.2 days on average after temporal zone malignancy surgery. Thirty-eight patients had their implants removed over either complication (n = 14) or recovery (n = 24). Recovery was the fastest after facial nerve decompression (mean= 4.75 ± 3.6 (2–10) months) and the slowest after 7–12 cranial nerve transfer (mean= 18.3 ± 8.2 (3–31) months). Twenty-six-point-nine percent (n = 21) of patients had complications, of which the most common was extrusion (n = 10). The overall satisfaction rate was 88.5% with the highest in visual acuity and the lowest in continuous requirement for artificial tear. ConclusionThe gold weight implantation is an effective, reversible, and easy procedure significantly reducing complaints regarding paralytic lagophthalmos. Early implementation may be beneficial for ocular complications. A dynamic facial reanimation could terminate need of implant.     

面神经损伤的针刺效应与面神经核胆碱乙酰转移酶的关系

目的:揭示针刺促进损伤面神经再生修复的机制。方法:大耳白兔分为假手术组、模型组、西药组、传统针刺组、电针刺激组,每组又分为术后4个时间点,应用神经卡压法造成面神经损伤模型,观察各组家兔面神经核中胆碱乙酰转移酶(ChAT)的变化。结果:术后细胞核核仁偏位,术后2、3、4周时模型组胞体肿胀,截面积均明显大于假手术组、西药组、传统针刺组、电针刺激组,尼氏体明显减少,随治疗时间延长,西药组、传统针刺组、电针刺激组均有不同程度的尼氏体增多,其中电针刺激组增多较明显。电针刺激组ChAT于各时间点均明显好于其他对照组,西药组、传统针刺组、电针刺激组均有随治疗时间延长ChAT表达增多的趋势,且有显著性差异。结论:穴位针刺可提高家兔面神经核中ChAT的表达,并对损伤面神经修复有促进作用。     

去细胞异体神经的形态结构及移植后的组织相容性

目的:为面神经缺损寻找一种理想的异体神经移植物。方法:取Wistar大鼠胫神经,经Triton X-100和脱氧胆酸钠溶液进行化学去细胞处理。将处理后的神经行组织学染色和免疫组织化学染色;并行异体移植修复面神经缺损,观察其组织相容性。结果:去细胞神经为一中空的神经基质管,其中的细胞和髓鞘成分被有效清除,神经基底膜被保留;异体移植后无明显炎症反应,无排斥和吸收反应,能引导宿主轴突和Schwann细胞增殖。结论:去细胞异体神经移植物具有良好的仿生性和组织相容性,可能用于修复面神经缺损。     

耳大神经移植治疗面神经麻痹的应用解剖学研究

用22具成年尸体的44侧耳大神经进行了解剖观察和测量.耳大神经的平均长度为4.12cm,有2～4个分支.耳大神经的体表投影相当于胸锁乳突肌后缘中点稍下方至耳垂的连线,主干在颈外静脉后方约0.7cm.结果表明:耳大神经是用于神经移植治疗面神经麻痹较理想的神经移植物,耳大神经的体表投影、颈外静脉及下颌角是术中寻找的可靠标志.     

Anatomical study of the masseteric and obturator nerves: Application to face transplant and reanimation procedures

The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 μm, and stained following a standard immunohistochemical procedure using anti‐choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end‐to‐end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612–617, 2019. © 2019 Wiley Periodicals, Inc.     

The nerve supply of zygomaticus major: Variability and distinguishing zygomatic from buccal facial nerve branches

The zygomaticus major (ZM) is important for the human smile. There are conflicting data about whether the zygomatic or buccal branches of the facial nerve are responsible for its motor innervation. The literature provides no precise distinction of the transition zone between these two branch systems. In this study, a definition to distinguish the facial nerve branches at the level of the body of the zygoma is proposed. In the light of this definition, we conducted an anatomical study to determine how the source of innervation of the ZM was distributed. A total of 96 fresh‐frozen cadaveric facial halves were dissected under loupe magnification. A hemiparotidectomy was followed by antegrade microsurgical dissection. Any branch topographically lying superficial to the zygoma or touching it was classed as zygomatic, and any neighboring inferior branch was considered buccal. The arborization of the facial nerve was diffuse in all cases. In 64 out of 96 specimens (67%, 95% CI: 56% to 76%), zygomatic branches innervated the ZM. Buccal branches innervated ZM in the other 32 facial halves (33%, 95% CI: 24% to 44%). There were no differences in respect of sex or facial side. All facial halves displayed additional branches, which crossed the muscle on its inner surface without supplying it. In 31 specimens, a nerve branch ran superficial to ZM in its cranial third. According to our classification, the zygomaticus major is innervated by zygomatic branches in 67% of cases and by buccal branches in 33%. Clin. Anat. 31:560–565, 2018. © 2018 Wiley Periodicals, Inc.     

Microsurgical anatomy of the facial nerve trunk

Dissection and manipulation of the facial nerve (FN) trunk between its exit from the cranial base through the stylomastoid foramen (SMF) and its bifurcation is a critical step in various otologic, plastic and neurosurgical procedures. This study demonstrates the anatomical relationships and variability of the FN trunk with emphasis on some important morphometric data, particularly with relevance to hypoglossal-facial nerve anastomosis (HFA). Bilateral microsurgical dissection was performed on twenty-three human cadavers fixed with formalin. The whole trunk of the FN was exposed, its diameter at the SMF and its length were measured, its branches were observed and the site of its bifurcation was determined. Anastomotic connections with other nerves and blood supply of the trunk were studied. The FN invariably emerged from the cranial base through the SMF. Its diameter upon its emergence from the foramen was 2.66 +/- 0.55 mm. Two branches consistently originated from the trunk: the posterior auricular nerve and the nerve to the digastric muscle. Less consistent were the communicating branch with the glossopharyngeal nerve and the nerve to the stylohyoid muscle. The bifurcation of the FN occurred before its penetration into the parotid gland in 15% of cases and within the gland in 85%. The length of the FN trunk was 16.44 +/- 3.2 mm. Anastomoses between the FN and other nerves were observed in one-third of the dissections. The blood supply to the FN trunk was provided by the stylomastoid artery that was identified in 91% of cases. Understanding the microsurgical anatomy of the FN trunk is essential for performing any surgical procedure in the relevant region. Surgical implications of this study are presented with emphasis on HFA surgery.