鼻内镜下鼻中隔正中进路行额窦底壁切除的可行性研究

目的:探讨鼻内镜下额窦底壁鼻中隔正中进路的可行性。方法:①对60例经甲醛固定的成人尸头进行CT扫描,并进行三维CT重建。②取30例尸头紧贴一侧鼻中隔沿矢状线锯开,对重要解剖标志进行相关解剖学观测。③结合CT和解剖学数据,在30例尸头上,进行鼻内镜下鼻中隔正中入路额窦模拟手术。记录模拟手术时间、手术步骤、手术过程中手术标记的寻找、鼻内镜度数的视野影响、视野中额窦各壁的可视度、手术器械的影响、鼻中隔以及嗅丝的损伤程度等等。结果:①额窦底后缘均在中鼻甲根部的前端,中鼻甲根部均附着于筛顶与筛板交界处。②中鼻甲垂直部与水平部交接点与鼻中隔相对应的点称为M点,M点到鼻骨的水平距离为(20.07±6.21)mm,M点到第一对嗅丝距离为(24.38±7.68)mm,第一对嗅丝到额窦底后缘距离为(9.57±2.73)mm,中鼻甲根部附着缘到额窦底后缘距离为(5.38±1.23)mm,额窦底壁前后径为(7.62±2.45)mm,额窦底壁左右径为(9.41±3.37)mm,额窦间隔上下径为(16.97±3.23)mm,额窦间隔前后径为(12.34±2.23)mm。③结合CT和解剖学测量,在鼻内镜下完成鼻中隔正中入路的额窦手术,模拟手术平均时间为1h45min。鼻内镜0°镜下的视野可以观察到部分额窦内侧壁、后壁和顶壁,30°镜下完成鼻中隔切除,0°镜下暴露额窦底壁并将其切除,70°镜下3例不能观测到额窦外侧壁,30例均能观测到部分额窦顶壁、内侧壁、前壁以及后壁,鼻中隔损伤范围约为2.23cm×2.59cm,嗅丝未见损伤。结论:鼻内镜下鼻中隔正中径路容易寻找额窦,以此进路进行额窦底壁切除是可行的。

Endoscopic feasibility study and nasal septum median path of frontal sinus surgery

Objective:To discuss the feasibility of endoscopic frontal sinus surgery in the nasal septum median path.Method:①Sixty adult cadaveric heads fixed with formalin were CT scanned,and were three dimensional reconstruction.②Thirty adult cadaveric heads were sawn along the sagittal line close to the side of the nasal septum,then the important anatomic marks were observed and measured.③Combined with CT and anatomical data,thirty adult cadaveric heads were operated in different degree,and the damage of nasal septum and fila olfactoria were detected in the same time.Result:①The roots of middle nasal concha were simulated in the endoscopic frontal sinus surgery.The operation time,operative procedures,markers foundation,endoscopic back of posterior border of frontal sinus foundation and attached to the sympheses with cribriform plate and the top of ethmoidal sinus were recorded.②The intersection point formed by the level of middle nasal concha and the vertical of middle nasal concha corresponded with the nasal septum was called the M point.The distance from the M point to the horizon of the nasal bone was(20.07±6.21)mm,the distance from the M point to the first fila olfactoria was(24.38±7.68)mm,the distance from the first fila olfactoria to the posterior edge of frontal sinus was(9.57±2.73)mm,the distance from the root of the middle nasal concha to posterior edge of frontal sinus was(5.38±1.23)mm,the anteroposterior diameter of frontal sinus fundus was(7.62±2.45)mm,the transverse diameter of frontal sinus fundus was(9.41±3.37)mm,the seesaw diameter of frontal sinus partition was(16.97±3.23)mm,the anteroposterior diameter of frontal sinus partition was(12.34±2.23)mm.③The operation time through the nasal septum path was 105 minutes which combined with CT and anatomical measurements.0 degrees endoscopy could be used to observe the frontal part of the lateral,posterior and top wall,while nasal septum remove should be finished with 30 degree endoscopy.The bottom of frontal sinus can be exposed and removed with 0 degree endoscopy.3 cases of cadaveric frontal sinus lateral wall can not be observed with 70 degree endoscopy.30 cases of cadaveric frontal sinus,some of the top and the lateral wall,anterior and posterior wall could be observed with 70 degree endoscopy,nasal septum damage range was about 2.23 cm×2.59 cm,and no fila olfactoria damage was found.Conclusion:Endoscopic frontal sinus surgery in the nasal septum median path is a good way to find frontal sinus.