经乳突岩骨乙状窦前入路的显微解剖与临床研究

发布时间：2018-06-24 04:06

本文选题：乳突岩骨乙状窦手术入路 + 解剖　；参考：《蚌埠医学院》2012年硕士论文

【摘要】：目的：（1）通过尸体解剖与断层影像(CT)对经乳突岩骨乙状窦前入路相关的解剖结构进行显微断层研究，测量并观察它们之间的相互关系，明确经乳突岩骨乙状窦前显微手术入路中颅骨的特征性标记点。（2）将尸体解剖及断层影像（CT）研究获得的结果应用于临床，以期提高经乳突岩骨乙状窦前入路外科治疗水平。方法：（一）解剖研究：（1）应用15具（30侧）10%福尔马林充分固定的汉族成人尸颅湿标本，无法确切判定年龄和性别。所有标本均在动脉系统中灌注混有红色染料的乳胶，静脉系统灌注混有蓝色染料的乳胶。完全模拟经乳突岩骨乙状窦前显微手术入路，，并且对与经乳突岩骨乙状窦前手术相关的解剖结构进行详尽的观察、测量、统计和拍照。（2）应用15具（30侧）汉族完整成人颅骨干标本，无法确切判定年龄和性别。水平锯开颅盖，暴露颞骨岩部，保留外耳道后上棘、横-乙状窦沟，观察并测量外耳道后上棘、横-乙状窦沟转角下缘与颞骨岩部相关骨性结构之间距离。（二）断层影像研究：应用日本东芝Asteion多排螺旋CT，自外眦与外耳道上缘的连线（OM线）作为水平扫描的基线，厚度2.0mm。对40例（男22例，女18例）住院病人进行颅脑CT扫描。在CT片上对颞骨、外耳道后上棘及各解剖结构进行观察测量。（三）临床研究：将通过尸体解剖及断层影像（CT）研究获得的手术入路标记应用于临床，从2010年4月-2012年2月，共11例患者采用该手术入路，对以上手术病例进行总结分析。结果：（一）解剖研究：1.以外耳道后上棘为颅骨标记点，测量其与以下解剖结构之间的距离：（1）横-乙状窦转角前缘：左侧(13.54±2.82)mm；右侧(13.89±2.66)mm；（2）弓状隆起：左侧(12.10±1.14)mm；右侧(12.21±1.16)mm；（3）面神经垂直段：左侧(7.25±1.06)mm；右侧(7.19±1.09)mm；（4）后半规管最后部：左侧(17.80±1.20)mm；右侧(18.84±1.33)mm；（5）内耳门后缘：左侧(31.23±1.10)mm；右侧(30.96±1.23)mm；（6）前庭水管外口：左侧(19.77±1.68)mm；右侧(19.35±1.42)mm；（7）三叉神经压迹：左侧(47.25±3.01）mm；右侧（47.47±3.29）mm；（8）岩尖：左侧(49.24±2.74）mm；右侧(49.03±2.75)mm。2.以横-乙状窦转角前缘为标记点，测量其与以下解剖结构之间的距离：（1）弓状隆起：左侧(8.16±2.56)mm；右侧(8.34±2.59)mm；（2）面神经垂直段：左侧(9.14±1.68)mm；右侧(9.27±1.76)mm；（3）后半规管最后部：左侧(14.25±1.95)mm；右侧(14.96±1.87)mm；（4）内耳门后缘：左侧(36.56±2.41)mm；右侧(36.45±2.38)mm；（5）前庭水管外口：左侧(11.62±0.86)mm；右侧(11.45±1.12)mm；（6）三叉神经压迹：左侧(59.26±1.98)mm；右侧(59.58±1.73)mm；（7）岩尖：左侧(59.55±2.58)mm；右侧(60.74±2.57)mm。3.（1）后半规管最后部至内耳门后缘距离：左侧(10.62±1.72)mm；右侧(10.77±1.71)mm；（2）前庭水管后口与后半规管最后部距离：左侧(1.66±0.55)mm；右侧(1.71±0.56)mm；（3）小脑被牵离岩骨面的最大距离：左侧(13.84±1.01)mm；右侧(13.91±1.03)mm。（二）断层影像研究：40例断层影像研究测量结果与解剖研究测量结果基本一致。（三）临床研究：11例患者病变基本达到显微镜下全切除，1例患者术前有面瘫术后面瘫加重，经过住院期间的治疗该病人的面瘫得以缓解，可能与术中对面神经直接刺激以及脑水肿有关。术后新增1例周围性面瘫者，经2周治疗出院时仍有轻度瘫痪。所有患者术后均无颅内感染。结论：（1）经乳突岩骨乙状窦前手术入路是处理岩斜区病变较理想的手术入路；（2）研究和熟悉手术入路中的解剖结构，明确各重要解剖结构与标记点的关系，对指导手术操作是十分必要的。（3）由于个体的解剖结构存在差异，单纯的依靠解剖研究测量数据来判断手术中的结构，或单凭影像资料来指导手术都是不妥的，易导致手术失误，从而带来严重甚至致命性的后果。将解剖研究数据与断层影像研究结合起来，能更有利的定位，提高手术疗效和减少并发症。（4）临床证实经乳突岩骨乙状窦前手术入路在处理岩斜区病变具有巨大优越性，基本达到显微镜下全切除。
[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 卤 2.82 ) mm ;
Right side ( 13.89 卤 2.66 ) mm ;
( 2 ) arcuate bulge : left side ( 12.10 卤 1.14 ) mm ;
Right side ( 12.21 卤 1.16 ) mm ;
( 3 ) Facial nerve vertical segment : left side ( 7.25 卤 1.06 ) mm ;
Right side ( 7.19 卤 1.09 ) mm ;
( 4 ) The last part of the posterior semicircular canal : the left side ( 17.80 卤 1.20 ) mm ;
Right side ( 18.84 卤 1.33 ) mm ;
Right side ( 8.34 卤 2.59 ) mm ;
Right side ( 30.96 卤 1.23 ) mm ;
( 6 ) Outer mouth of vestibular aqueduct : left side ( 19.77 卤 1.68 ) mm ;
Right side ( 19.35 卤 1.42 ) mm ;
( 7 ) trigeminal nerve pressure : left side ( 47.25 卤 3.01 ) mm ;
Right side ( 47.47 卤 3.29 ) mm ;
( 8 ) Rock tip : left side ( 49.24 卤 2.74 ) mm ;
Right side ( 49.03 卤 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 卤 2.56 ) mm ;
( 5 ) Rear edge of inner ear : left side ( 31.23 卤 1.10 ) mm ;
( 2 ) The vertical segment of facial nerve : left side ( 9.14 卤 1.68 ) mm ;
Right side ( 9.27 卤 1.76 ) mm ;
( 3 ) The last part of the posterior semicircular canal : the left side ( 14.25 卤 1.95 ) mm ;
Right side ( 14.96 卤 1.87 ) mm ;
( 4 ) Rear edge of inner ear : left side ( 36.56 卤 2.41 ) mm ;
Right side ( 36.45 卤 2.38 ) mm ;
( 5 ) Outer mouth of vestibular aqueduct : left ( 11.62 卤 0.86 ) mm ;
Right side ( 11.45 卤 1.12 ) mm ;
( 6 ) trigeminal nerve pressure : left side ( 59.26 卤 1.98 ) mm ;
Right side ( 59.58 卤 1.73 ) mm ;
( 7 ) Rock tip : left side ( 59.55 卤 2.58 ) mm ;
Left side ( 60.74 卤 2.57 ) mm . 3 . ( 1 ) Distance from the last part of semicircular canal to the rear edge of inner ear : left side ( 10.62 卤 1.72 ) mm ;
Right side ( 10.77 卤 1.71 ) mm ;
( 2 ) The last part of the posterior semicircular canal of the vestibular aqueduct : the left side ( 1 . 66 卤 0.55 ) mm ;
Right side ( 1.71 卤 0.56 ) mm ;
( 3 ) The maximum distance from the cerebellum to the bone surface : left side ( 13.84 卤 1.01 ) mm ;
Right side ( 13.91 卤 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 .
【学位授予单位】：蚌埠医学院
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R322

【参考文献】