【摘要】： 目的:通過(guò)尸顱顯微解剖研究,觀察并測(cè)量經(jīng)鼻入路手術(shù)的骨性解剖標(biāo)志及重要血管、神經(jīng)的局部解剖,明確經(jīng)鼻入路前顱底手術(shù)通道上相關(guān)結(jié)構(gòu)的解剖關(guān)系,尋求安全、便捷的手術(shù)路標(biāo)和邊界,為臨床手術(shù)的成功開(kāi)展、預(yù)防和減少各種嚴(yán)重并發(fā)癥提供可靠的解剖學(xué)資料。 方法:本研究以前鼻棘作為測(cè)量的基點(diǎn),前鼻棘與后鼻棘連線作為測(cè)量的基線。采用10例(20側(cè))成人干性顱骨標(biāo)本和10例(20側(cè))經(jīng)5%福爾馬林常規(guī)防腐的成人尸顱標(biāo)本,在手術(shù)顯微鏡下對(duì)鼻中隔、鼻甲、蝶篩竇、篩前動(dòng)脈、篩后動(dòng)脈、蝶腭動(dòng)脈及其周?chē)Y(jié)構(gòu)進(jìn)行解剖、觀察和測(cè)量。結(jié)合所得數(shù)據(jù),在3例經(jīng)5%福爾馬林常規(guī)防腐的較為新鮮的成人尸顱標(biāo)本上摹擬手術(shù)入路,對(duì)手術(shù)徑路上各解剖標(biāo)志及重要結(jié)構(gòu)進(jìn)行進(jìn)一步的觀測(cè),獲取較為逼真的手術(shù)形態(tài)資料和經(jīng)驗(yàn)。 結(jié)果: 1.中鼻甲:自前鼻棘向鉤突、篩泡區(qū)域進(jìn)行探查,結(jié)合鉤突、篩泡的相關(guān)數(shù)據(jù)有助于術(shù)者對(duì)其進(jìn)行精確定位。中鼻甲是良好的術(shù)中定位標(biāo)志,當(dāng)必須采用經(jīng)中鼻甲入路而將中鼻甲部分切除時(shí),中鼻甲基板可作為解剖標(biāo)志。中鼻甲亦存在解剖變異,本組出現(xiàn)泡狀中鼻甲2側(cè),中鼻甲呈球形,其內(nèi)含3～5個(gè)氣房,較正常中鼻甲明顯肥大,鼻腔空間明顯減小。泡狀中鼻甲的出現(xiàn)不會(huì)引起鼻腔結(jié)構(gòu)的廣泛移位,故中鼻甲及其基板是經(jīng)鼻前顱底手術(shù)最為恒定的解剖標(biāo)志。 2.篩動(dòng)脈分型:眼動(dòng)脈與篩前動(dòng)脈、篩后動(dòng)脈分布呈“F”型者占40%,呈“K”型者又可分三種亞型,其中K-Ⅰ型占20%,K-Ⅱ型占30%,K-Ⅲ型占10%。篩前動(dòng)脈篩竇內(nèi)段30%走行于篩頂骨板內(nèi),50%走行于前組篩竇頂壁與篩竇粘膜之間,20%穿行于前組篩竇竇腔氣房?jī)?nèi)。篩后動(dòng)脈出現(xiàn)率90%,其中50%走行于篩頂骨板內(nèi),30%走行于后組篩竇頂壁與篩竇粘膜之間,10%走行于后組篩竇竇腔氣房?jī)?nèi)。篩中動(dòng)脈的出現(xiàn)率為10%,位于篩前、篩后動(dòng)脈之間,經(jīng)篩中孔進(jìn)入前組篩竇,穿行于前組篩竇竇腔氣房?jī)?nèi),向后內(nèi)側(cè)走行,其走行方向基本與篩后動(dòng)脈一致。篩前動(dòng)脈、篩后動(dòng)脈眶內(nèi)段及篩竇段的分布及其走行均存在變異。經(jīng)鼻前顱底手術(shù)在打開(kāi)篩泡后進(jìn)入前組篩竇進(jìn)行操作,此區(qū)域最主要的動(dòng)脈即為篩前動(dòng)脈,自前組篩竇向后方打開(kāi)中鼻甲基板后,進(jìn)入后組篩竇,此區(qū)域最主要的動(dòng)脈為篩后動(dòng)脈。了解篩前動(dòng)脈、篩后動(dòng)脈在此區(qū)域的分布及其變異情況,結(jié)合上述解剖數(shù)據(jù),有助于術(shù)中早期定位并對(duì)其作出處理,防止術(shù)中及術(shù)后鼻腔大出血并發(fā)癥的發(fā)生,對(duì)經(jīng)鼻入路前顱底手術(shù)的順利實(shí)施具有決定性意義。 3.篩動(dòng)脈分支:篩前動(dòng)脈的分支有3～5支,包括鼻中隔支、鼻外側(cè)支、鼻背支、硬腦膜支及篩板支。鼻中隔支出現(xiàn)率100%,分為1支者占30%,2支者占60%,3支者占10%。鼻外側(cè)支出現(xiàn)率90%,其中25%分為2～3支。鼻背支、硬腦膜支及篩板支的出現(xiàn)率分別為30%、55%和25%。篩后動(dòng)脈的分支主要有3支,包括鼻中隔支、鼻外側(cè)支及篩板支,其出現(xiàn)率分別為90%、70%和30%。篩前、篩后動(dòng)脈的分支廣泛分布于鼻腔及前顱底,與蝶腭動(dòng)脈及其分支存在廣泛吻合。經(jīng)鼻手術(shù)術(shù)中處理鼻中隔及探查鼻腔頂、蝶竇開(kāi)口等區(qū)域時(shí),可造成篩前動(dòng)脈、篩后動(dòng)脈及其分支的損傷而導(dǎo)致出血。了解篩前動(dòng)脈、篩后動(dòng)脈分支的分布及其與蝶腭動(dòng)脈分支的吻合情況,有助于術(shù)中避開(kāi)或者提前處理相關(guān)區(qū)域供血?jiǎng)用},減少術(shù)中出血。 4.蝶腭孔:蝶腭孔呈橢圓形者占45%,圓形者占35%,不規(guī)則形者占20%。其中單孔型者占80%,最為常見(jiàn),雙孔型者占20%。單孔型的蝶腭孔,蝶腭動(dòng)脈出孔前已分支者占45%,出孔后再分支者占35%。20%的蝶腭動(dòng)脈與蝶腭神經(jīng)分別從主、副孔穿出。蝶腭動(dòng)脈及其分支破裂出血,是經(jīng)鼻前顱底后部手術(shù),尤其是后組篩竇與蝶竇毗鄰區(qū)域手術(shù)時(shí),鼻腔出血的主要原因。蝶腭孔的解剖意義在于精確定位蝶腭動(dòng)脈及其分支,結(jié)合蝶腭孔相關(guān)解剖數(shù)據(jù),有助于術(shù)中早期尋找并處理蝶腭動(dòng)脈及其分支,防止術(shù)中鼻腔大出血的發(fā)生。 5.術(shù)式對(duì)比:經(jīng)中鼻道入路所提供的鼻腔術(shù)野寬度左側(cè)為(8.92±2.30)mm(5.3～13.2mm),右側(cè)為(9.72±1.79)mm(7.3～13.3mm)。經(jīng)隔旁入路術(shù)野寬度左側(cè)為(13.43±2.82)mm(8.6～17.8mm),右側(cè)為(13.14±3.18)mm(9.2～18.0mm)。中鼻甲切除術(shù)獲得的術(shù)野寬度左側(cè)為(18.33±3.12)mm(12.8～22.5mm),右側(cè)為(18.59±2.99)mm(12.9～22.1mm)。三種術(shù)式的術(shù)野寬度不斷增加的同時(shí),其損傷程度亦不斷增大,臨床手術(shù)應(yīng)根據(jù)病變的具體情況選擇合適的手術(shù)入路,避免不必要的手術(shù)創(chuàng)傷。 6.篩項(xiàng)與篩板關(guān)系:篩頂與篩板的高度差為(3.92±2.07)mm(1.1～9.7mm)。篩板與篩頂?shù)倪@種連接方式及其解剖關(guān)系的不對(duì)稱(chēng)性,導(dǎo)致這一區(qū)域成為經(jīng)鼻前顱底手術(shù)最易發(fā)生腦脊液漏的部位。故良好的前顱底重建是手術(shù)的關(guān)鍵。尤其是當(dāng)病變經(jīng)硬腦膜侵入顱內(nèi),或者為大腦額葉底部原發(fā)性病變,手術(shù)需打開(kāi)硬腦膜進(jìn)入顱內(nèi)進(jìn)行操作時(shí),病變處理完畢后需對(duì)硬腦膜進(jìn)行修復(fù)。 7.兩眶內(nèi)壁寬度:兩眶內(nèi)壁在雞冠中部水平的寬度為(22.31±3.08)mm(18.7～27.4mm),在篩前動(dòng)脈管水平的寬度為(23.00±2.93)mm(19.7～28.1mm),在篩后動(dòng)脈管水平的寬度為(26.25±2.88)mm(21.9～31.4mm),在視神經(jīng)管顱口內(nèi)側(cè)水平的寬度為(14.67±3.82)mm(9.8～22.1m)。經(jīng)鼻前顱底手術(shù)向側(cè)方擴(kuò)展展開(kāi)操作時(shí),應(yīng)以相關(guān)鼻竇的邊界為界限,其范圍不可超過(guò)兩眶內(nèi)壁的寬度,否則會(huì)造成紙樣板損傷而致眶內(nèi)脂肪膨出及視神經(jīng)損傷等并發(fā)癥。經(jīng)解剖觀測(cè),兩眶內(nèi)壁在不同水平的寬度存在差異,其中雞冠中部至篩后動(dòng)脈管水平是逐漸增寬的,而自篩后動(dòng)脈管水平至視神經(jīng)管顱口內(nèi)側(cè)水平逐漸變窄,其中在視神經(jīng)管顱口內(nèi)側(cè)水平的寬度最窄。上述解剖特點(diǎn)導(dǎo)致經(jīng)鼻前顱底手術(shù)時(shí),前顱底前部術(shù)野相對(duì)較寬,前顱底中部術(shù)野最寬,而后部的術(shù)野最窄,向側(cè)方過(guò)度打開(kāi)易造成紙樣板及視神經(jīng)損傷。兩眶內(nèi)壁在不同水平寬度的測(cè)量結(jié)果有助于防止術(shù)中向側(cè)方過(guò)度打開(kāi)造成的并發(fā)癥。 8.視神經(jīng)管隆突與頸內(nèi)動(dòng)脈隆突:視神經(jīng)管隆突出現(xiàn)率80%,其中20%僅見(jiàn)于蝶竇內(nèi),35%僅見(jiàn)于后組篩竇內(nèi),同時(shí)見(jiàn)于篩竇和蝶竇內(nèi)者占25%。頸內(nèi)動(dòng)脈隆突出現(xiàn)率70%,其中25%僅見(jiàn)于蝶竇內(nèi),30%僅見(jiàn)于后組篩竇內(nèi),15%同時(shí)見(jiàn)于篩竇和蝶竇內(nèi)。雙側(cè)同時(shí)出現(xiàn)視神經(jīng)管隆突及頸內(nèi)動(dòng)脈隆突者占55%,35%僅出現(xiàn)視神經(jīng)管隆突或者頸內(nèi)動(dòng)脈隆突,視神經(jīng)管隆突與頸內(nèi)動(dòng)脈隆突均缺如者占10%。視神經(jīng)管隆突及頸內(nèi)動(dòng)脈隆突與后組篩竇和蝶竇的這種復(fù)雜解剖關(guān)系及其不對(duì)稱(chēng)性,是經(jīng)鼻前顱底手術(shù)損傷視神經(jīng)管及頸內(nèi)動(dòng)脈的根本原因,了解這種解剖關(guān)系及其變異,術(shù)前結(jié)合患者影像學(xué)資料,可良好判定此區(qū)域結(jié)構(gòu)的解剖關(guān)系,防止視神經(jīng)管及頸內(nèi)動(dòng)脈損傷導(dǎo)致的嚴(yán)重并發(fā)癥。 結(jié)論: 1.經(jīng)鼻前顱底手術(shù)是治療前顱底病變的一種比較安全、有效、微創(chuàng)的外科手術(shù)技術(shù),但相關(guān)鼻腔、鼻竇、前顱底解剖關(guān)系復(fù)雜,熟練掌握其解剖結(jié)構(gòu),特別是它們之間的毗鄰關(guān)系,對(duì)手術(shù)具有指導(dǎo)意義。 2.經(jīng)中鼻道入路所提供的術(shù)野有限,僅可用于治療小范圍的腦脊液漏或較小的前顱底病變。如病變顯露不足,可采用經(jīng)隔旁入路,通過(guò)將鼻中隔在與蝶嵴交界處折斷并推向?qū)?cè),并將同側(cè)中鼻甲向外側(cè)推移以擴(kuò)大術(shù)野。經(jīng)中鼻甲入路通過(guò)中鼻甲部分切除,可獲得的術(shù)野最寬。此外,將上述三種術(shù)式相結(jié)合,采用雙側(cè)進(jìn)路,可獲得更為寬闊的手術(shù)空間。但隨其顯露范圍的增加,手術(shù)對(duì)正常結(jié)構(gòu)的損傷程度亦逐步增大。術(shù)前應(yīng)結(jié)合患者影像資料,據(jù)前顱底病變范圍選擇最為適合的術(shù)式,不可盲目講求“擴(kuò)大”而造成不必要的手術(shù)創(chuàng)傷。 3.各解剖標(biāo)志物的數(shù)據(jù)對(duì)于術(shù)中定位有重要的意義。上鼻甲、中鼻甲(基板)、鉤突、篩泡、紙樣板、篩前動(dòng)脈(管)、篩后動(dòng)脈(管)、視神經(jīng)管隆突、頸內(nèi)動(dòng)脈隆突、蝶篩隱窩及蝶竇開(kāi)口可作為經(jīng)鼻前顱底手術(shù)重要的解剖標(biāo)志,這些手術(shù)標(biāo)志物的確定,有助于重要解剖結(jié)構(gòu)定位,減少手術(shù)并發(fā)癥。 4.篩前動(dòng)脈的鼻中隔支、鼻外側(cè)支、鼻背支、硬腦膜支及篩板支,篩后動(dòng)脈的鼻中隔支、鼻外側(cè)支及篩板支,蝶腭動(dòng)脈的鼻后中隔支、鼻后外側(cè)支,相互之間存在廣泛吻合,分布于鼻腔、前顱底,是經(jīng)鼻入路前顱底手術(shù)術(shù)中出血及術(shù)后遲發(fā)性鼻腔出血的原因,早期找到并處理這些動(dòng)脈可避免出血導(dǎo)致的嚴(yán)重并發(fā)癥。 5.經(jīng)鼻前顱底手術(shù)重點(diǎn)在于避免紙樣板、視神經(jīng)及頸內(nèi)動(dòng)脈損傷,術(shù)中保持中線操作,早期確定視神經(jīng)管、頸內(nèi)動(dòng)脈的走行,可減少上述并發(fā)癥的發(fā)生機(jī)率。 6.蝶上篩房、蝶側(cè)篩房等解剖變異的出現(xiàn)使這一區(qū)域解剖關(guān)系變得更加復(fù)雜,僅憑借影像資料分析分辨術(shù)中結(jié)構(gòu)是十分危險(xiǎn)的,將解剖數(shù)據(jù)、術(shù)前影像學(xué)評(píng)估及手術(shù)標(biāo)志物相結(jié)合,可良好判定此區(qū)域結(jié)構(gòu)的解剖關(guān)系,進(jìn)行準(zhǔn)確的術(shù)中定位。 7.篩頂與篩板連接處是腦脊液漏發(fā)生的關(guān)鍵,病變處理完畢后,可采用鼻中隔與下鼻道黏骨膜瓣,以篩前動(dòng)脈管、篩后動(dòng)脈管的殘端作為標(biāo)志,進(jìn)行良好的前顱底重建。 8.經(jīng)鼻入路術(shù)中操作的前界不應(yīng)超過(guò)篩前動(dòng)脈水平,側(cè)方應(yīng)以相關(guān)的鼻竇為界,范圍不可超越兩眶內(nèi)壁水平寬度,后方操作可以視神經(jīng)管隆突和頸內(nèi)動(dòng)脈隆突為標(biāo)志,以避免對(duì)其造成損傷。經(jīng)鼻入路可在前顱底中線區(qū)附近提供一個(gè)大小約4.5cm~2的骨窗,用于處理前顱底中線區(qū)域的嗅神經(jīng)母細(xì)胞瘤、腦膜瘤、神經(jīng)鞘瘤、脊索瘤以及膽脂瘤等病變,但應(yīng)嚴(yán)格把握手術(shù)適應(yīng)證,病變范圍超過(guò)相關(guān)鼻竇邊界者應(yīng)予以排除。
[Abstract]:Objective: To observe and measure the anatomical marks of the osseous anatomy, the important vessels and the local anatomy of the nerve through the autopsy microanatomy of the nasal approach, and to clarify the anatomical relationship of the related structures on the anterior cranial base through the nasal approach, to seek safe and convenient surgical roadmap and boundary, to carry out the successful clinical operation, to prevent and reduce a variety of strictness. Heavy complications provide reliable anatomical data.
Methods: the anterior nasal spines were used as the base point of the measurement, the anterior nasal spines and the posterior nasal spines were used as the baseline. 10 adult dry skull specimens (20 sides) and 10 adult cadaveric craniofacial specimens of 5% formalin were used in 5% formalin. The nasal septum, the turbinate, the anterior ethmoid artery, the posterior ethmoid artery, the sphenopalatine artery and the sphenopalatine artery were examined under the operative microscope. The surrounding structure was dissected, observed and measured. Combined with the obtained data, 3 cases of fresh adult cadaver cranial specimens of 5% formalin, which were routinely antiseptic, were simulated, and the anatomical signs and important structures of the surgical path were further observed.
Result:
1. middle turbinate: from the anterior nasal spines to the uncinate process, the area of the sieve bubble, combined with the uncinate process, the relevant data of the sieve bubble help the operator to locate it accurately. The middle turbinate is a good location marker. When the middle turbinate must be removed by the middle turbinate, the middle nasal methyl plate can be used as an anatomical sign. The middle turbinate is also dissected. In this group, there were 2 sides of the middle turbinate in the bubble, and the middle turbinate was spherical. It contained 3~5 air chambers, which was more hypertrophic than normal middle turbinate, and the space of the nasal cavity decreased obviously. The appearance of the middle turbinate in the bubble would not cause the wide displacement of the nasal cavity. Therefore, the middle turbinate and its basal plate were the most constant anatomical signs through the operation of the anterior nasal floor.
2. screen artery classification: the eye artery and the anterior ethmoidal artery, the posterior ethmoidal artery was "F" type 40%, and the "K" type could be divided into three subtypes, among which, the K- type I accounted for 20%, the K- II accounted for 30%, and the K- III type of the anterior ethmoid sinus of the 10%. anterior ethmoid sinus was in the sieved parietal plate, and 50% walked between the anterior ethmoid wall and the ethmoid sinus mucosa, and 20% of the anterior ethmoid sinus and the anterior ethmoid sinus mucosa, and 20% through the anterior sieves. The incidence of posterior ethmoidal artery was 90%, of which 50% were in the sieved parietal plate, 30% were between the posterior ethmoid sinus and the ethmoid sinus mucosa, and 10% in the posterior ethmoid sinus chamber. The incidence of the middle ethmoid artery was 10%, between the anterior ethmoid artery and the anterior ethmoid sinus through the mesoporous posterior ethmoidal sinus and through the anterior ethmoid sinus chamber. The anterior ethmoidal artery, the intraorbital segment of the posterior ethmoid artery and the sieved sinus were changed. The anterior ethmoidal artery was opened and the anterior ethmoid sinus was operated after opening the sieve bubble. The main artery in this area was the anterior ethmoid artery, which was opened from the anterior ethmoid sinus to the rear. The main artery of this area is the posterior ethmoidal artery after the base of the nasal concha. The distribution of the anterior ethmoidal artery and the posterior ethmoidal artery in this area and its variation, combined with the above anatomical data, can help to locate and deal with it early in the operation so as to prevent the complications of intraoperative and postoperative nasal bleeding, and the anterior cranium through the nasal passage. The smooth implementation of the bottom operation is of decisive significance.
The branch of the 3. sieved artery: the branches of the anterior ethmoid artery were 3~5 branches, including the nasal septum, lateral nasal branch, nasal dorsum, dura and sieve plate. The incidence of nasal septum was 100%, 1 were 30%, 2 were 60%, 3 of them accounted for 90% of the 10%. lateral branch, 25% of them were divided into 2~3. The incidence of the nasal dorsal branch, the dura branch and sieve plate branch was 30%, respectively. The branches of the posterior artery of 55% and 25%. were mainly 3 branches, including the nasal septum, the lateral branch of the nose and the sieve plate branch. The incidence of the artery was 90%, 70% and 30%.. The branches of the posterior ethmoidal artery were widely distributed in the nasal cavity and the anterior skull base. There were extensive anastomosis with the sphenopalatine artery and its branches. The distribution of the anterior ethmoidal artery, the distribution of the branch of the posterior ethmoidal artery and the anastomosis with the sphenopalatine artery are helpful for avoiding or treating the blood supply arteries in the related areas and reducing intraoperative bleeding during the operation.
4. sphenopalatine foramen: 45% of the sphenopalatine hole oval, 35% for circular, 80% in 20%., and the most common in the irregular form. The double pore type is the sphenopalatine hole of 20%. single pass, 45% of the sphenopalatine artery before the foramen, and the sphenopalatine artery and sphenopalatine artery of 35%.20% after the foramen, and the sphenopalatine artery and the sphenopalatine artery, respectively. It is the main reason for the bleeding of the nasal cavity when the posterior nasal anterior skull base surgery, especially the posterior group of the ethmoid sinus and the sphenoidal sinus, is the main reason. The anatomical significance of the sphenopalatine foramen is to locate the sphenopalatine artery and its branches accurately, and combine the sphenopalatine foramen with the anatomical data, which helps to find and deal with the sphenopalatine artery and its branches in the early stage. Prevention of intraoperative hemorrhage of the nasal cavity.
5. comparison: the left side of the nasal cavity was (8.92 + 2.30) mm (5.3 ~ 13.2mm) and the right was (9.72 + 1.79) mm (7.3 ~ 13.3mm) on the right side. The left side of the parasal approach was (13.43 + 2.82) mm (8.6 to 17.8mm), and the right was (13.14 + 3.18) mm (9.2 to 18.0mm). The left side of the middle turbinectomy was (18.33). 3.12) mm (12.8 ~ 22.5MM), the right is (18.59 + 2.99) mm (12.9 ~ 22.1mm). Three kinds of surgical field widths are constantly increasing and the degree of injury is increasing. The clinical operation should choose the appropriate surgical approach according to the specific condition of the disease, and avoid unnecessary surgical trauma.
The relationship between 6. sieves and sieve plates: the height difference between the screen top and the sieve plate is (3.92 + 2.07) mm (1.1 ~ 9.7mm). The connection mode of the sieve plate and the top of the sieve and the asymmetry of the anatomical relationship cause the region to be the most likely location of the cerebrospinal fluid leakage in the anterior cranial base operation. The dura mater invades the skull, or is the primary lesion of the frontal lobe of the brain. The operation needs to open the dura and enter the intracranial operation. The dura needs to be repaired after the treatment is completed.
7. the width of the inner wall of the orbit: the width of the inner wall of the two orbit was (22.31 + 3.08) mm (18.7 ~ 27.4mm), the width of the anterior ethmoid artery tube was (23 + 2.93) mm (19.7 to 28.1mm), the width of the posterior ethmoidal artery tube was (26.25 + 2.88) mm (21.9 ~ 31.4mm), and the width of the medial level of the optic canal was (14.67 + 3.08) mm. 2.1m). The boundary of the paranasal sinus should be bounded by the boundary of the paranasal sinus through the anterior nasal skull base operation. The range should not exceed the width of the two orbital inner wall. Otherwise, there will be complications in the orbital fat swelling and optic nerve injury caused by the damage of the paper template. The two orbital walls are different in different levels of the width of the inner wall of the orbit. The level of the arterial canal in the middle of the crown was gradually widened, but the level of the posterior canal was narrower and narrower in the medial level of the optic canal, and the narrowest width at the medial level of the optic canal. The above anatomical features led to the wider anterior cranial base operation in the anterior skull base and the broadest field in the middle anterior skull base. The narrowest area of the operation is the narrowest area of the operation, and excessive opening to the side may cause damage to the paper template and optic nerve. Two the measurement results of the different horizontal width of the inner wall of the orbit help to prevent the complications caused by excessive opening of the intraoperative side.
8. optic canal protuberance and internal carotid artery protuberance: 80% of the optic canal protuberance, 20% only in the sphenoidal sinus, 35% only in the posterior ethmoid sinus, and at the same time in the ethmoid and sphenoidal sinus, 70% of the 25%. internal carotid artery protuberance, 25% only in the sphenoidal sinus, 30% in the posterior ethmoid sinus and 15% at the same time in the ethmoid sinus and sphenoidal sinus. When the optic canal protuberance and internal carotid artery protuberance occurred in 55%, 35% of the optic canal protuberance or internal carotid artery protuberance, the optic canal protuberance and the internal carotid artery protuberance were absent, the complex anatomical relationship between the 10%. optic canal protuberance and the internal carotid artery protuberance and the posterior group of ethmoid sinus and the sphenoid sinus and its asymmetry, it was the anterior skull base. The anatomical relationship and variation of the optic canal and internal carotid artery were damaged by surgery, and the anatomical relationship of the regional structure could be judged well and the serious complications caused by the optic canal and internal carotid artery were prevented before operation.
Conclusion:
1. the anterior cranial base surgery is a safe, effective and minimally invasive surgical technique for the anterior cranial base lesions, but the anatomical relationship of the related nasal cavity, the sinus and the anterior skull base is complicated, and the anatomical structure is mastered, especially the adjacent relationship between them, which has the guiding significance for the operation.
2. the surgical field provided by the middle nasal passage is limited and can only be used to treat a small range of cerebrospinal fluid leakage or smaller anterior cranial base lesions. If the lesions are not exposed, the transseptal approach can be used to break the nasal septum at the junction of the sphenoid ridge to the opposite side, and to expand the field to the lateral turbinate to the lateral. Through the middle turbinate approach pass through Partial resection of the middle turbinate can obtain the most wide operation field. In addition, the above three methods are combined and bilateral approach is used to obtain wider operation space. However, with the increase of the exposure range, the damage degree of the operation on the normal structure is also increased gradually. The operative method should not blindly focus on "expansion" and cause unnecessary surgical trauma.
3. the data of the anatomic markers are important for intraoperative location. The upper turbinate, the middle turbinate (basal plate), the uncinate process, the sieve bubble, the paper template, the anterior ethmoidal artery (tube), the posterior ethmoidal artery (tube), the optic canal protuberance, the internal carotid artery protuberance, the sphenoid fossa and the sphenoid sinus openings can be used as an important anatomical sign for the anterior cranial base operation. These surgical markers indeed are true. It is helpful to locate important anatomical structures and reduce operative complications.
4. the nasal septum of the anterior ethmoid artery, the lateral branch of the nose, the dorsal branch of the nose, the dural branch and the sieve plate branch, the nasal septum of the posterior ethmoidal artery, the lateral branch of the nose and the sieve plate, the posterior nasal septum of the sphenopalatine artery and the posterolateral branch of the nose, which were distributed in the nasal cavity and the anterior skull base. Early diagnosis and treatment of these arteries can avoid serious complications caused by bleeding.
5. the focus of the anterior cranial base of the nose is to avoid paper template, optic nerve and internal carotid artery injury, maintain midline operation during the operation, early determine the optic canal and the internal carotid artery, which can reduce the incidence of the complications.
6. the anatomic variations such as the screen room of the butterfly and the sieves of the butterfly side make the anatomical relationship more complicated in this area. It is very dangerous to distinguish the structure in the operation by image data analysis only. The anatomical data of the area, the preoperative imaging evaluation and the surgical markers can be combined to determine the anatomical relationship of the region well, and make the accurate location of the operation.
The key to the occurrence of cerebrospinal fluid leakage is the junction of the 7. sieves and the sieve plate. After the treatment is completed, the nasal septum and the inferior nasal canal mucus flap can be used to screen the anterior artery tube and the remnant end of the posterior artery tube as a sign to make a good reconstruction of the anterior skull base.
8. the anterior boundary of the operation should not exceed the level of the anterior ethmoid artery, and the side should be bounded by the paranasal sinus. The range should not exceed the horizontal width of the inner wall of the two orbit. The posterior operation can be marked as a sign of the nerve canal protuberance and the internal carotid artery protuberance to avoid the damage. The bone window of about 4.5cm~2 is used to deal with the olfactory neuroblastoma, meningioma, neurilemmoma, chordoma and cholesteatoma in the midline of the anterior skull base, but the surgical indications should be strictly controlled, and the extent of the lesion beyond the boundary of the paranasal sinus should be excluded.
【學(xué)位授予單位】：福建中醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2008
【分類(lèi)號(hào)】：R323.1

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