本文選題：乳突巖骨乙狀竇手術(shù)入路 + 解剖��； 參考：《蚌埠醫(yī)學(xué)院》2012年碩士論文

【摘要】：目的：（1）通過尸體解剖與斷層影像(CT)對經(jīng)乳突巖骨乙狀竇前入路相關(guān)的解剖結(jié)構(gòu)進行顯微斷層研究，測量并觀察它們之間的相互關(guān)系，明確經(jīng)乳突巖骨乙狀竇前顯微手術(shù)入路中顱骨的特征性標記點。（2）將尸體解剖及斷層影像（CT）研究獲得的結(jié)果應(yīng)用于臨床，以期提高經(jīng)乳突巖骨乙狀竇前入路外科治療水平。 方法：（一）解剖研究：（1）應(yīng)用15具（30側(cè)）10%福爾馬林充分固定的漢族成人尸顱濕標本，無法確切判定年齡和性別。所有標本均在動脈系統(tǒng)中灌注混有紅色染料的乳膠，靜脈系統(tǒng)灌注混有藍色染料的乳膠。完全模擬經(jīng)乳突巖骨乙狀竇前顯微手術(shù)入路，，并且對與經(jīng)乳突巖骨乙狀竇前手術(shù)相關(guān)的解剖結(jié)構(gòu)進行詳盡的觀察、測量、統(tǒng)計和拍照。 （2）應(yīng)用15具（30側(cè)）漢族完整成人顱骨干標本，無法確切判定年齡和性別。水平鋸開顱蓋，暴露顳骨巖部，保留外耳道后上棘、橫-乙狀竇溝，觀察并測量外耳道后上棘、橫-乙狀竇溝轉(zhuǎn)角下緣與顳骨巖部相關(guān)骨性結(jié)構(gòu)之間距離。 （二）斷層影像研究：應(yīng)用日本東芝Asteion多排螺旋CT，自外眥與外耳道上緣的連線（OM線）作為水平掃描的基線，厚度2.0mm。對40例（男22例，女18例）住院病人進行顱腦CT掃描。在CT片上對顳骨、外耳道后上棘及各解剖結(jié)構(gòu)進行觀察測量。 （三）臨床研究：將通過尸體解剖及斷層影像（CT）研究獲得的手術(shù)入路標記應(yīng)用于臨床，從2010年4月-2012年2月，共11例患者采用該手術(shù)入路，對以上手術(shù)病例進行總結(jié)分析。 結(jié)果：（一）解剖研究：1.以外耳道后上棘為顱骨標記點，測量其與以下解剖結(jié)構(gòu)之間的距離：（1）橫-乙狀竇轉(zhuǎn)角前緣：左側(cè)(13.54±2.82)mm；右側(cè)(13.89±2.66)mm；（2）弓狀隆起：左側(cè)(12.10±1.14)mm；右側(cè)(12.21±1.16)mm；（3）面神經(jīng)垂直段：左側(cè)(7.25±1.06)mm；右側(cè)(7.19±1.09)mm；（4）后半規(guī)管最后部：左側(cè)(17.80±1.20)mm；右側(cè)(18.84±1.33)mm；（5）內(nèi)耳門后緣：左側(cè)(31.23±1.10)mm；右側(cè)(30.96±1.23)mm；（6）前庭水管外口：左側(cè)(19.77±1.68)mm；右側(cè)(19.35±1.42)mm；（7）三叉神經(jīng)壓跡：左側(cè)(47.25±3.01）mm；右側(cè)（47.47±3.29）mm；（8）巖尖：左側(cè)(49.24±2.74）mm；右側(cè)(49.03±2.75)mm。2.以橫-乙狀竇轉(zhuǎn)角前緣為標記點，測量其與以下解剖結(jié)構(gòu)之間的距離：（1）弓狀隆起：左側(cè)(8.16±2.56)mm；右側(cè)(8.34±2.59)mm；（2）面神經(jīng)垂直段：左側(cè)(9.14±1.68)mm；右側(cè)(9.27±1.76)mm；（3）后半規(guī)管最后部：左側(cè)(14.25±1.95)mm；右側(cè)(14.96±1.87)mm；（4）內(nèi)耳門后緣：左側(cè)(36.56±2.41)mm；右側(cè)(36.45±2.38)mm；（5）前庭水管外口：左側(cè)(11.62±0.86)mm；右側(cè)(11.45±1.12)mm；（6）三叉神經(jīng)壓跡：左側(cè)(59.26±1.98)mm；右側(cè)(59.58±1.73)mm；（7）巖尖：左側(cè)(59.55±2.58)mm；右側(cè)(60.74±2.57)mm。3.（1）后半規(guī)管最后部至內(nèi)耳門后緣距離：左側(cè)(10.62±1.72)mm；右側(cè)(10.77±1.71)mm；（2）前庭水管后口與后半規(guī)管最后部距離：左側(cè)(1.66±0.55)mm；右側(cè)(1.71±0.56)mm；（3）小腦被牽離巖骨面的最大距離：左側(cè)(13.84±1.01)mm；右側(cè)(13.91±1.03)mm。 （二）斷層影像研究：40例斷層影像研究測量結(jié)果與解剖研究測量結(jié)果基本一致。 （三）臨床研究：11例患者病變基本達到顯微鏡下全切除，1例患者術(shù)前有面癱術(shù)后面癱加重，經(jīng)過住院期間的治療該病人的面癱得以緩解，可能與術(shù)中對面神經(jīng)直接刺激以及腦水腫有關(guān)。術(shù)后新增1例周圍性面癱者，經(jīng)2周治療出院時仍有輕度癱瘓。所有患者術(shù)后均無顱內(nèi)感染。 結(jié)論：（1）經(jīng)乳突巖骨乙狀竇前手術(shù)入路是處理巖斜區(qū)病變較理想的手術(shù)入路；（2）研究和熟悉手術(shù)入路中的解剖結(jié)構(gòu)，明確各重要解剖結(jié)構(gòu)與標記點的關(guān)系，對指導(dǎo)手術(shù)操作是十分必要的。（3）由于個體的解剖結(jié)構(gòu)存在差異，單純的依靠解剖研究測量數(shù)據(jù)來判斷手術(shù)中的結(jié)構(gòu)，或單憑影像資料來指導(dǎo)手術(shù)都是不妥的，易導(dǎo)致手術(shù)失誤，從而帶來嚴重甚至致命性的后果。將解剖研究數(shù)據(jù)與斷層影像研究結(jié)合起來，能更有利的定位，提高手術(shù)療效和減少并發(fā)癥。（4）臨床證實經(jīng)乳突巖骨乙狀竇前手術(shù)入路在處理巖斜區(qū)病變具有巨大優(yōu)越性，基本達到顯微鏡下全切除。
[Abstract]:Objective : ( 1 ) To study the anatomy of the anterior approach of ethmoid sinus by autopsy and tomography ( CT ) , to measure and observe the correlation between them and to identify the characteristic marking points of the skull in the transmastoid approach . ( 2 ) The results of autopsy and tomography ( CT ) were applied to the clinic in order to improve the level of surgical treatment of the transmastoid bone sigmoid sinus .

Methods : ( 1 ) The anatomical study was as follows : ( 1 ) There were 15 ( 30 sides ) 10 % formalin - fixed Han adult corpse wet specimen unable to determine the age and sex . All the specimens were perfused with red dye latex in the arterial system , and the latex of blue dye was poured into the venous system .

( 2 ) There were 15 ( 30 sides ) Han nationality complete adult skull dry specimen , unable to determine the age and sex . Horizontal saw skull cover , exposed temporal bone part , left external auditory canal posterior superior iliac spine , transverse - sigmoid sinus sulcus , observed and measured the distance between the inferior margin of external auditory canal and the related bony structure of temporal bone part .

( 2 ) The study of fault imaging : Using the spiral CT of Toshiba , Japan , the line ( OM line ) from the upper edge of the external and external ear canal was used as the baseline of horizontal scanning , and the thickness was 2.0 mm . 40 cases ( 22 males and 18 females ) were hospitalized for cranial CT scan .

( 3 ) Clinical study : The surgical approach mark obtained through the autopsy and tomography ( CT ) study was applied to the clinic . From April 2010 to February 2012 , 11 patients received the surgical approach , and the above procedure cases were summarized and analyzed .

Results : ( 1 ) The anatomical study was as follows : 1 . The distance between them and the following anatomical structures : ( 1 ) the anterior margin of transverse - sigmoid sinus : the left side ( 13.54 鹵 2.82 ) mm ;
Right side ( 13.89 鹵 2.66 ) mm ;
( 2 ) arcuate bulge : left side ( 12.10 鹵 1.14 ) mm ;
Right side ( 12.21 鹵 1.16 ) mm ;
( 3 ) Facial nerve vertical segment : left side ( 7.25 鹵 1.06 ) mm ;
Right side ( 7.19 鹵 1.09 ) mm ;
( 4 ) The last part of the posterior semicircular canal : the left side ( 17.80 鹵 1.20 ) mm ;
Right side ( 18.84 鹵 1.33 ) mm ;
Right side ( 8.34 鹵 2.59 ) mm ;
Right side ( 30.96 鹵 1.23 ) mm ;
( 6 ) Outer mouth of vestibular aqueduct : left side ( 19.77 鹵 1.68 ) mm ;
Right side ( 19.35 鹵 1.42 ) mm ;
( 7 ) trigeminal nerve pressure : left side ( 47.25 鹵 3.01 ) mm ;
Right side ( 47.47 鹵 3.29 ) mm ;
( 8 ) Rock tip : left side ( 49.24 鹵 2.74 ) mm ;
Right side ( 49.03 鹵 2.75 ) mm . 2 . The distance between it and the following anatomical structures was measured by the leading edge of transverse - sigmoid sinus : ( 1 ) arcuate bulge : left side ( 8.16 鹵 2.56 ) mm ;
( 5 ) Rear edge of inner ear : left side ( 31.23 鹵 1.10 ) mm ;
( 2 ) The vertical segment of facial nerve : left side ( 9.14 鹵 1.68 ) mm ;
Right side ( 9.27 鹵 1.76 ) mm ;
( 3 ) The last part of the posterior semicircular canal : the left side ( 14.25 鹵 1.95 ) mm ;
Right side ( 14.96 鹵 1.87 ) mm ;
( 4 ) Rear edge of inner ear : left side ( 36.56 鹵 2.41 ) mm ;
Right side ( 36.45 鹵 2.38 ) mm ;
( 5 ) Outer mouth of vestibular aqueduct : left ( 11.62 鹵 0.86 ) mm ;
Right side ( 11.45 鹵 1.12 ) mm ;
( 6 ) trigeminal nerve pressure : left side ( 59.26 鹵 1.98 ) mm ;
Right side ( 59.58 鹵 1.73 ) mm ;
( 7 ) Rock tip : left side ( 59.55 鹵 2.58 ) mm ;
Left side ( 60.74 鹵 2.57 ) mm . 3 . ( 1 ) Distance from the last part of semicircular canal to the rear edge of inner ear : left side ( 10.62 鹵 1.72 ) mm ;
Right side ( 10.77 鹵 1.71 ) mm ;
( 2 ) The last part of the posterior semicircular canal of the vestibular aqueduct : the left side ( 1 . 66 鹵 0.55 ) mm ;
Right side ( 1.71 鹵 0.56 ) mm ;
( 3 ) The maximum distance from the cerebellum to the bone surface : left side ( 13.84 鹵 1.01 ) mm ;
Right side ( 13.91 鹵 1.03 ) mm .

( 2 ) Fault image research : 40 cases of fault image research are basically consistent with the results of anatomical study .

( 3 ) Clinical study : In 11 cases , the lesions were completely removed under the microscope , 1 patient had facial paralysis after operation , and the facial paralysis was relieved during hospitalization , which could be related to the direct stimulation of facial nerve and cerebral edema during hospitalization . One case of peripheral facial paralysis was added after operation , and there was slight paralysis after 2 weeks of treatment . All patients had no intracranial infection after operation .

Conclusion : ( 1 ) The transmastoid approach is the ideal approach to treat the pathological changes of the oblique area of the rock .
( 2 ) It is very necessary to study and acquaint with the anatomical structure in the surgical approach and to clarify the relationship between important anatomical structures and marking points . ( 3 ) Because of the difference of the anatomy structure of the individual , it is necessary to rely on the anatomical study measurement data to judge the structure in the operation , or to guide the operation by using the image data .
【學(xué)位授予單位】：蚌埠醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R322

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