【作者】 余得志；

【导师】 邱建新；

【作者基本信息】 安徽医科大学 ， 耳鼻咽喉科学， 2008， 硕士

【摘要】 目的:侧颅底肿瘤位置深在,毗邻重要的颅神经和动、静脉,传统的开颅手术和颌面进路手术,不但并发症和死亡率高,手术进路也常损坏面容。加之手术暴露困难,难以彻底切除病变,术后复发率高,因此侧颅底曾被认为是手术禁区。近年来随着医学影像学、耳显微医学、麻醉医学、重症监护医学的发展,侧颅底外科的诊疗技术也有了长足的发展。本研究通过对20具(40侧)黄种成人尸头侧颅底区域重要解剖标志进行观察与测量,得出相关实验结果,用于指导临床:侧颅底手术前设计最合理的手术路径;侧颅底手术中尽可能充分暴露手术野,避免损伤重要血管、神经,防止长时间和过度牵拉脑组织;同时也可增加内镜颅底手术的安全性及减少颅底导航技术的配准误差。方法:本组实验标本中男性12具,女性8具(性别、年龄由解剖教研室提供),按1—40的顺序进行编号。从外科手术的角度出发,按编号顺序对侧颅底区域进行解剖,行实验项目的观察与测量。解剖方法:尸头固定于解剖架上,颧根与顶骨最高点连线的中、上1/3处平行于眶-耳平面钢锯锯除颅骨,进行颅底内面观察与测量。切除下颌骨及其周围附着肌肉,进行颅底外面观察与测量。电钻行扩大乳突轮廓化上至中颅窝硬脑膜,暴露窦脑膜角,暴露上、外、后三组骨半规管;乙状窦全程显露至颈静脉球;自颅内段至颞骨外段全程显露面神经,行面神经改道及面神经的主动前移;颈部解剖颈内动脉至颈内动脉管外口,电钻磨除骨质显现岩骨段颈内动脉,颅内暴露颈内动脉至前床突段上部。结果:本研究结果包括三项内容:1、以骨性颈静脉孔静脉部、骨性颈静脉孔神经部、颧弓后根、茎突根部及星点为解剖基点,观察测量与侧颅底重要结构的解剖关系、解剖距离及解剖角度。2、测量迷路三角(窦脑膜角、颈静脉球、鼓窦入口),迷路后三角(窦脑膜角、颈静脉球、后半规管),乳突表面三角(星点、乳突尖、颧根)解剖面积。3、测量颞骨内面神经各段的长度;测量面神经垂直段改道及水平段、垂直段联合改道后延长的可利用面神经长度;行面神经长路径(从茎乳孔至膝状神经节)和短路径(从茎乳孔至外膝部)主动前移,在茎乳孔处面神经前移10mm的共同前提下,分别测量不同径路颈静脉球上缘、外膝部面神经前移的最大距离和角度。采用SPSS10.0统计软件计算各测量数据,计量资料以均数±标准差((?)±s)表示。结论:1.从外科手术的角度出发,以临床手术医师的视野,行成人侧颅底解剖学研究,能让研究结果更有征对性,进而能为临床提供更有力的参考。2.颈静脉球变异大,而骨性颈静脉孔静脉部变异小,本研究采用骨性颈静脉孔静脉部作为解剖基点测量其与体表骨性标志的距离,结果更准确,术者了解此结果可减小侧颅底术中损伤颈静脉球的可能性。以骨性颈静脉孔神经部为解剖基点所得到的解剖数据可为术中更好地保护后组颅神经提供参考。3.以茎突根部、颧弓根、星点为解剖基点所得到的解剖数据可降低临床侧颅底手术中损伤护重要血管、神经的风险;增加内镜颅底手术的安全性;减少颅底导航技术的配准误差。4.迷路三角、迷路后三角、乳突表面三角面积的测定为临床侧颅底手术方案的设计、手术径路的选择提供参考。5.颞骨内面神经改道可延长神经的可利用长度,减少面神经端端吻合时的张力。面神经主动前移可为术者提供更广阔的手术视野。茎乳孔处面神经前移应和神经周围的纤维鞘一同进行,防止损伤茎乳动脉。更多还原

【Abstract】 ObjectiveThe tumors of the lateral skull base often had deep localization .With vital structures such as cranial nerves , arteries and veins neighboring, traditional operations whether the occlusalf surface approach or the cranium approach, not only had damage to physiognomy, but also the complications and the death rate were high.With difficulties in exposure and dissection the tumor completely of the operation, the recurrence rate was also high. Thus, the operation in lateral skull base was once deemed to be restricted zone. In recent years, with developments in the subjects of medical imageology, anesthesia, critical care medicine and the micro-surgery of the ear, the diagnosis and treatments of the lateral skull base had also developed greatly. Our research was based on the observation and measurements of the important anatomical markers in the lateral skull base. With corresponding anatomical data arrived, we hope these results can provide anatomical guidance in the clinical surgeries: to expose operating field better; avoid the damage to important vessels、nerves and prevent excessive dragging ;design the best project of the re-establishment in the skull base when the tumors were dissected; in the endoscopic lateral skull base surgery, it can ensure the safety as well as decrease the possibility of the errors in the navigation and the localization.Methods20 heads with 40 sides of the lateral skull base of dead body with 10% formaldehyde soaked, which includs 12 male, 8 female.(the information of the gender and the age were provided by the anatomy department). Then these sides of the lateral skull base had a serial number from 1st to 40th.The cadaveric heads was fixed in the anatomical shelf . The calvaria was removed alone the plane parallel to the frankfort horizontal plane in the middle super point of the line between the root of zygomatic bone and the highest point of parietal bone.The structure in the skull base was observed and measured.Dissect the mandible and its affiliated muscles and the structure out the skull base was observed and measured. Skeletonize the mamillary process by electrodrill with its supra-boundary to cerebral dura mater of the middle cranial fossa, and expose sinus-menigeal angle, the lateral, anterior and posterior semicircular canals, the whole range from sigmoid sinus to bulbus venae jugularis , the omnidistance of the facial nerve from Intracalvarium to extratemporal segment. Dissect the carotid artery in the neck till the external aperture of the internal carotid artery was found. Drill the sclerotin with the diamond burr to expose the internal carotid artery’s os petrosum section, while of the Intracalvarium, internal carotid artery was exposed to the superior part of the anterior clinoid process.ResultsThis research includes three contents:①The asterion, and the vein and the nerve of the bony jugular foramen as well as the dorsal root of the zygomatic arch and the styloid process were set as the base of the anatomy, then observe the anatomical relationships, distances and the angles of the important structures in the lateral skull base.②Measure the areas of the labyrinthine triangle(sino-meninges angle, jugulotympanic body , aditus ad antrum tympanicum) , retrolabyrinthine triangle(sino-meninges angle, jugulotympanic body, posterior semicircular canal) and the triangle of the surface of mastoid process(asterion, mastoidle, Zygomatic root).③Measure the length of different segements of facial nerve in temporal bone; Measure the extended extracranial portion to provide anatomic data for repairing the facial nerve defect with extended facial nerve gotten by changing its course in temporal bone.Measure the distance and angles of the initiative anterior rerouting of the facial nerve, with it’s long-pathway(from foramen stylomastoideum to geniculate ganglion) and short-pathway(from foramen stylomastoideum to external genu).Analyze the metered parameters by the SPSS 10.0 statistics software and demonstrate the measurement data by the mean±root-mean square deviation ( (x|-)±s) .Conclusions1. This antomic investigation by imitating operations, with thoughts of the clinical surgery, may provide an advisable reference and guidance to the clinical operations .2. The jugulotympanic body had frequent variation, while the variation of the vein of the bony jugular foramen was uncommon. This research had set the bony part of the jugular foramen as basic point to measure the distances with bony markers, this may bring us more accurate results and decrease the possibility of the damage to the jugulotympanic body during the operation. And set the nerve part of the jugular foramen may provide the guidance and reference to protect the lower cranial nerves more effectively during the operation.3. The arrived anatomical data, which were set by the basic point of the styloid process and the zygomatic root, as well as the asterion, can not only decrease the risks of the damage to the nerve and vessels during the operation, but also ensure the safety of endoscopic surgery, decrease the mean fiducial registration errors in the image-guided navigation on the lateral skull base.4. The metered areas of labyrinthine triangle, retrolabyrinthine triangle and the triangle of the surface of mastoid process may provide guidance and reference to the reconstruction of the lateral skull base as well as the choice of the surgical approaches.5. The length of facial nerve stem can be extended in temporal bone by changing its course.It is applicable to repair the facial nerve defect in the lateral skull base surgery through extending the length of facial nerve; Extensive visual field of the operation was also provided by the initiative anterior rerouting of the facial nerve.Before anterior transposition is performed,the nerve has to be liberated in the parotid grand.A nontoothled forceps was used to hold the soft tissue surrounding the stylomastoid foramen,and anterior rerouting was carried out.更多还原