经鼻入路处理前颅底中线区病变的解剖学研究
发布时间：2018-08-08 12:55
【摘要】： 目的:通过尸颅显微解剖研究,观察并测量经鼻入路手术的骨性解剖标志及重要血管、神经的局部解剖,明确经鼻入路前颅底手术通道上相关结构的解剖关系,寻求安全、便捷的手术路标和边界,为临床手术的成功开展、预防和减少各种严重并发症提供可靠的解剖学资料。 方法:本研究以前鼻棘作为测量的基点,前鼻棘与后鼻棘连线作为测量的基线。采用10例(20侧)成人干性颅骨标本和10例(20侧)经5%福尔马林常规防腐的成人尸颅标本,在手术显微镜下对鼻中隔、鼻甲、蝶筛窦、筛前动脉、筛后动脉、蝶腭动脉及其周围结构进行解剖、观察和测量。结合所得数据,在3例经5%福尔马林常规防腐的较为新鲜的成人尸颅标本上摹拟手术入路,对手术径路上各解剖标志及重要结构进行进一步的观测,获取较为逼真的手术形态资料和经验。 结果: 1.中鼻甲:自前鼻棘向钩突、筛泡区域进行探查,结合钩突、筛泡的相关数据有助于术者对其进行精确定位。中鼻甲是良好的术中定位标志,当必须采用经中鼻甲入路而将中鼻甲部分切除时,中鼻甲基板可作为解剖标志。中鼻甲亦存在解剖变异,本组出现泡状中鼻甲2侧,中鼻甲呈球形,其内含3～5个气房,较正常中鼻甲明显肥大,鼻腔空间明显减小。泡状中鼻甲的出现不会引起鼻腔结构的广泛移位,故中鼻甲及其基板是经鼻前颅底手术最为恒定的解剖标志。 2.筛动脉分型:眼动脉与筛前动脉、筛后动脉分布呈“F”型者占40%,呈“K”型者又可分三种亚型,其中K-Ⅰ型占20%,K-Ⅱ型占30%,K-Ⅲ型占10%。筛前动脉筛窦内段30%走行于筛顶骨板内,50%走行于前组筛窦顶壁与筛窦粘膜之间,20%穿行于前组筛窦窦腔气房内。筛后动脉出现率90%,其中50%走行于筛顶骨板内,30%走行于后组筛窦顶壁与筛窦粘膜之间,10%走行于后组筛窦窦腔气房内。筛中动脉的出现率为10%,位于筛前、筛后动脉之间,经筛中孔进入前组筛窦,穿行于前组筛窦窦腔气房内,向后内侧走行,其走行方向基本与筛后动脉一致。筛前动脉、筛后动脉眶内段及筛窦段的分布及其走行均存在变异。经鼻前颅底手术在打开筛泡后进入前组筛窦进行操作,此区域最主要的动脉即为筛前动脉,自前组筛窦向后方打开中鼻甲基板后,进入后组筛窦,此区域最主要的动脉为筛后动脉。了解筛前动脉、筛后动脉在此区域的分布及其变异情况,结合上述解剖数据,有助于术中早期定位并对其作出处理,防止术中及术后鼻腔大出血并发症的发生,对经鼻入路前颅底手术的顺利实施具有决定性意义。 3.筛动脉分支:筛前动脉的分支有3～5支,包括鼻中隔支、鼻外侧支、鼻背支、硬脑膜支及筛板支。鼻中隔支出现率100%,分为1支者占30%,2支者占60%,3支者占10%。鼻外侧支出现率90%,其中25%分为2～3支。鼻背支、硬脑膜支及筛板支的出现率分别为30%、55%和25%。筛后动脉的分支主要有3支,包括鼻中隔支、鼻外侧支及筛板支,其出现率分别为90%、70%和30%。筛前、筛后动脉的分支广泛分布于鼻腔及前颅底,与蝶腭动脉及其分支存在广泛吻合。经鼻手术术中处理鼻中隔及探查鼻腔顶、蝶窦开口等区域时,可造成筛前动脉、筛后动脉及其分支的损伤而导致出血。了解筛前动脉、筛后动脉分支的分布及其与蝶腭动脉分支的吻合情况,有助于术中避开或者提前处理相关区域供血动脉,减少术中出血。 4.蝶腭孔:蝶腭孔呈椭圆形者占45%,圆形者占35%,不规则形者占20%。其中单孔型者占80%,最为常见,双孔型者占20%。单孔型的蝶腭孔,蝶腭动脉出孔前已分支者占45%,出孔后再分支者占35%。20%的蝶腭动脉与蝶腭神经分别从主、副孔穿出。蝶腭动脉及其分支破裂出血,是经鼻前颅底后部手术,尤其是后组筛窦与蝶窦毗邻区域手术时,鼻腔出血的主要原因。蝶腭孔的解剖意义在于精确定位蝶腭动脉及其分支,结合蝶腭孔相关解剖数据,有助于术中早期寻找并处理蝶腭动脉及其分支,防止术中鼻腔大出血的发生。 5.术式对比:经中鼻道入路所提供的鼻腔术野宽度左侧为(8.92±2.30)mm(5.3～13.2mm),右侧为(9.72±1.79)mm(7.3～13.3mm)。经隔旁入路术野宽度左侧为(13.43±2.82)mm(8.6～17.8mm),右侧为(13.14±3.18)mm(9.2～18.0mm)。中鼻甲切除术获得的术野宽度左侧为(18.33±3.12)mm(12.8～22.5mm),右侧为(18.59±2.99)mm(12.9～22.1mm)。三种术式的术野宽度不断增加的同时,其损伤程度亦不断增大,临床手术应根据病变的具体情况选择合适的手术入路,避免不必要的手术创伤。 6.筛项与筛板关系:筛顶与筛板的高度差为(3.92±2.07)mm(1.1～9.7mm)。筛板与筛顶的这种连接方式及其解剖关系的不对称性,导致这一区域成为经鼻前颅底手术最易发生脑脊液漏的部位。故良好的前颅底重建是手术的关键。尤其是当病变经硬脑膜侵入颅内,或者为大脑额叶底部原发性病变,手术需打开硬脑膜进入颅内进行操作时,病变处理完毕后需对硬脑膜进行修复。 7.两眶内壁宽度:两眶内壁在鸡冠中部水平的宽度为(22.31±3.08)mm(18.7～27.4mm),在筛前动脉管水平的宽度为(23.00±2.93)mm(19.7～28.1mm),在筛后动脉管水平的宽度为(26.25±2.88)mm(21.9～31.4mm),在视神经管颅口内侧水平的宽度为(14.67±3.82)mm(9.8～22.1m)。经鼻前颅底手术向侧方扩展展开操作时,应以相关鼻窦的边界为界限,其范围不可超过两眶内壁的宽度,否则会造成纸样板损伤而致眶内脂肪膨出及视神经损伤等并发症。经解剖观测,两眶内壁在不同水平的宽度存在差异,其中鸡冠中部至筛后动脉管水平是逐渐增宽的,而自筛后动脉管水平至视神经管颅口内侧水平逐渐变窄,其中在视神经管颅口内侧水平的宽度最窄。上述解剖特点导致经鼻前颅底手术时,前颅底前部术野相对较宽,前颅底中部术野最宽,而后部的术野最窄,向侧方过度打开易造成纸样板及视神经损伤。两眶内壁在不同水平宽度的测量结果有助于防止术中向侧方过度打开造成的并发症。 8.视神经管隆突与颈内动脉隆突:视神经管隆突出现率80%,其中20%仅见于蝶窦内,35%仅见于后组筛窦内,同时见于筛窦和蝶窦内者占25%。颈内动脉隆突出现率70%,其中25%仅见于蝶窦内,30%仅见于后组筛窦内,15%同时见于筛窦和蝶窦内。双侧同时出现视神经管隆突及颈内动脉隆突者占55%,35%仅出现视神经管隆突或者颈内动脉隆突,视神经管隆突与颈内动脉隆突均缺如者占10%。视神经管隆突及颈内动脉隆突与后组筛窦和蝶窦的这种复杂解剖关系及其不对称性,是经鼻前颅底手术损伤视神经管及颈内动脉的根本原因,了解这种解剖关系及其变异,术前结合患者影像学资料,可良好判定此区域结构的解剖关系,防止视神经管及颈内动脉损伤导致的严重并发症。 结论: 1.经鼻前颅底手术是治疗前颅底病变的一种比较安全、有效、微创的外科手术技术,但相关鼻腔、鼻窦、前颅底解剖关系复杂,熟练掌握其解剖结构,特别是它们之间的毗邻关系,对手术具有指导意义。 2.经中鼻道入路所提供的术野有限,仅可用于治疗小范围的脑脊液漏或较小的前颅底病变。如病变显露不足,可采用经隔旁入路,通过将鼻中隔在与蝶嵴交界处折断并推向对侧,并将同侧中鼻甲向外侧推移以扩大术野。经中鼻甲入路通过中鼻甲部分切除,可获得的术野最宽。此外,将上述三种术式相结合,采用双侧进路,可获得更为宽阔的手术空间。但随其显露范围的增加,手术对正常结构的损伤程度亦逐步增大。术前应结合患者影像资料,据前颅底病变范围选择最为适合的术式,不可盲目讲求“扩大”而造成不必要的手术创伤。 3.各解剖标志物的数据对于术中定位有重要的意义。上鼻甲、中鼻甲(基板)、钩突、筛泡、纸样板、筛前动脉(管)、筛后动脉(管)、视神经管隆突、颈内动脉隆突、蝶筛隐窝及蝶窦开口可作为经鼻前颅底手术重要的解剖标志,这些手术标志物的确定,有助于重要解剖结构定位,减少手术并发症。 4.筛前动脉的鼻中隔支、鼻外侧支、鼻背支、硬脑膜支及筛板支,筛后动脉的鼻中隔支、鼻外侧支及筛板支,蝶腭动脉的鼻后中隔支、鼻后外侧支,相互之间存在广泛吻合,分布于鼻腔、前颅底,是经鼻入路前颅底手术术中出血及术后迟发性鼻腔出血的原因,早期找到并处理这些动脉可避免出血导致的严重并发症。 5.经鼻前颅底手术重点在于避免纸样板、视神经及颈内动脉损伤,术中保持中线操作,早期确定视神经管、颈内动脉的走行,可减少上述并发症的发生机率。 6.蝶上筛房、蝶侧筛房等解剖变异的出现使这一区域解剖关系变得更加复杂,仅凭借影像资料分析分辨术中结构是十分危险的,将解剖数据、术前影像学评估及手术标志物相结合,可良好判定此区域结构的解剖关系,进行准确的术中定位。 7.筛顶与筛板连接处是脑脊液漏发生的关键,病变处理完毕后,可采用鼻中隔与下鼻道黏骨膜瓣,以筛前动脉管、筛后动脉管的残端作为标志,进行良好的前颅底重建。 8.经鼻入路术中操作的前界不应超过筛前动脉水平,侧方应以相关的鼻窦为界,范围不可超越两眶内壁水平宽度,后方操作可以视神经管隆突和颈内动脉隆突为标志,以避免对其造成损伤。经鼻入路可在前颅底中线区附近提供一个大小约4.5cm~2的骨窗,用于处理前颅底中线区域的嗅神经母细胞瘤、脑膜瘤、神经鞘瘤、脊索瘤以及胆脂瘤等病变,但应严格把握手术适应证,病变范围超过相关鼻窦边界者应予以排除。
[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.
【学位授予单位】：福建中医学院
【学位级别】：硕士
【学位授予年份】：2008
【分类号】：R323.1
本文编号：2171843
[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.
【学位授予单位】：福建中医学院
【学位级别】：硕士
【学位授予年份】：2008
【分类号】：R323.1
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