咽旁间隙的相关侧颅底应用解剖研究
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摘要
目的:从咽旁间隙肿瘤手术进路的角度观察测量侧颅底区骨性结构的有关解剖数据,为手术中准确定位颅底相关重要解剖结构,保全脑神经和重要血管提供较详实的依据;通过对尸头模拟经颈侧进路及经咽侧壁进路,明确手术进路中穿经的解剖结构以及重要血管神经的相互毗邻关系,加以保护,减少手术并发症。
方法:
1.在30具(60侧)成人颅骨上,对茎突根部、乳突、鼓乳裂最下点与咽旁间隙相关的侧颅底骨性标志的最短直线距离及与正中矢状面的前夹角等进行测量,并测量侧颅底区重要孔道直径。
2.研究观察咽旁间隙相关侧颅底区的范围及周围毗邻结构,测量咽旁间隙颅底区的长度和宽度。
3.在10具(20侧)成人湿性尸头(包含上颈部),应用颈侧进路及咽侧壁进路,对咽旁间隙及毗邻结构进行外科解剖研究,着重对茎突隔、后四组颅神经、颈内动脉等结构进行观测。
结果:
1.获得了茎突根部、乳突、鼓乳裂最下点分别与有关骨性结构的距离和角度数据,显示左侧与右侧比较有显著差异。
2.侧颅底区重要孔道测量(最大径)显示左侧与右侧比较有显著差异。
3.咽旁间隙颅底区测量:长度:左、右侧分别为33.11±2.95mm,34.88±2.36mm(P<0.01);宽度:左、右侧分别为17.31±2.22 mm,17.15±1.65 mm(P>0.05)。
4.乳突尖至下颌骨升支、乳突前缘至下颌骨升支、第一颈椎横突至下颌骨升支等的最短距离分别为22.94±3.08 mm,14. 50±3.57mm,20.34±9.03mm。
5.20侧标本中有30%副神经位于第一颈椎横突外侧走行,其余位其前面经过;有20%舌下神经弓形向前下走行时位于二腹肌后腹下缘下0.5~1.0cm。
结论:
1.乳突尖、鼓乳裂及茎突根部等骨性标志在手术中易于触摸、定位。对所选测量点间的距离及角度进行测量,可定位重要结构位置,明确手术进路的深度,估测其方位。
2.茎突根部是咽旁间隙的关键解剖标志,手术宜保护其后方的颈内动脉、颈内静脉、后组脑神经和其浅面的颈外动脉、面神经等重要结构。
3.以破裂孔内缘与茎突根部的连线作为咽旁前、后间隙在颅底区的分界线。蝶骨翼突内侧板、茎突、蝶骨大翼及颞骨岩部、破裂孔等作为茎突前间隙的标志;颈静脉孔及附近骨质、枕骨的外侧、枕骨髁等作为茎突后间隙的标志。以翼突内侧板根部至颈静脉窝外后缘的距离作为咽旁间隙颅底区的长度,蝶棘至颈静脉窝内后缘的距离作为其宽度。
4.第一颈椎横突在手术中易于触摸,可作为寻找、保护副神经的重要骨性标志;部分舌下神经弓形向前下走行时位于二腹肌后腹下缘下,在颈清扫术中注意避免伤及。
5.咽旁间隙的手术入路空间狭小,如何充分暴露术野是非常重要的。切除颌下腺、腮腺下极、茎突或乳突骨质,切断二腹肌、茎突肌肉组织、茎突下颌韧带,行下颌骨半脱位等,可获得充分的视野。
Objective
In order to orient and avoid damaging important neurovascular structures, from the aspect of operation on the parapharyngeal space (PPS), the anatomic information of the bony structures related to the lateral skull base was obtained. The cadaveric specimens were observed in detail by imitating operations through transcervical approach and transoral-pharyngeal approach.
Methods
1. The distance and angle among bony landmarks (the root of styloid process, the tip of mastoid process, tympanomastoid fissure, etc) in the lateral skull base in the PPS were determined by measurement of 30 (60 sides) dry adult skulls. So did it to the largest diameter of important foramina.
2. The range of the PPS in the cranium bottom district was studied and observed, and its length and width were measured.
3. On 10 (20 sides) adult cadaver heads, surgical anatomy were performed by transcervical and transoral-pharyngeal approach. The structures and their relationship in the PPS were carefully observed and recorded, especially in the styloid diaphragm, the last four groups of cranium nerves and the internal carotid artery, etc.
Results
1. The distance and angle data about styloid process, mastoid process and tympano-mastoid fissure were obtained. It showed that there were remarkable differences in the left side and the right side.
2. The measurements of foramina in the lateral skull base showed that there were remarkable differences in the left side and the right side.
3. The district of the PPS in cranium bottom was measured. Its length was 33.11±2.95mm (left), 34.88±2.36mm (right), P<0.01. Its width was 17.31±2.22 mm(left),17.15±1.65 mm (right), P>0.05.
4. The shortest distance between mandible and the tip , anterior border of mastoid process and the transverse process of the first cervical vertebra were respectively 22.94±3.08 mm,14. 50±3.57mm,20.34±9.03mm.
5. In 20 side samples, there were 30% of the accessory nerves lying in the transverse process of the first cervical vertebra outside, others passing forward. There were 20% of the hypoglossal nerves below the posterior belly of digastrics muscle in 0.5~1.0cm.
Conclusion
1. The root of styloid process, the tip of mastoid process and the tympanomastoid fissure can be easily detected. The measurement of the distance and angle among reference points can help to orient the important structure, estimate its depth.
2. The root of styloid process is a key dissection sign in the PPS. Behind it, there are internal carotid artery, internal jugular vein, cranial nerves, external carotid artery and facial nerve. They must be protected during operation.
3. The roof of PPS in the lateral skull base is divided into prestyloid and retrostyloid compartments by the line between the inner margin of lacerated foramen and the root of styloid process. The bony landmarks of prestyloid compartment are medial lamina of pterygoid process, styloid process, great wing of sphenoid bone, petrous pyramid and lacerated foramen. The sign of retrostyloid compartment are jugular foramen and its bone around, the lateral of occipital, occipital condyle. The anterioposterior length of the PPS is from the root of medial pterygoid plate to the lateral-posterior margin of the jugular foramen. The mediolateral width is between the spine of the sphenoid bone and the posterior-medial margin of the jugular foramen.
4. The transverse process of the first cervical vertebra can be easily detected on operation, it is an important bony landmarks in which we can look for and protect the accessory nerves. The hypoglossal nerves below the posterior belly of digastrics muscle must be protected on neck dissection.
5. The operation space on the PPS is narrow and small; it is very important how to fully expose the PPS. This can be obtained by removing submaxillary salivary gland, the inferior of parotid, styloid process, mastoid process or by abscising digastric muscle, muscle tissue in styloid process, stylomylohyoid ligament, or by subluxating mandible.
方法:
1.在30具(60侧)成人颅骨上,对茎突根部、乳突、鼓乳裂最下点与咽旁间隙相关的侧颅底骨性标志的最短直线距离及与正中矢状面的前夹角等进行测量,并测量侧颅底区重要孔道直径。
2.研究观察咽旁间隙相关侧颅底区的范围及周围毗邻结构,测量咽旁间隙颅底区的长度和宽度。
3.在10具(20侧)成人湿性尸头(包含上颈部),应用颈侧进路及咽侧壁进路,对咽旁间隙及毗邻结构进行外科解剖研究,着重对茎突隔、后四组颅神经、颈内动脉等结构进行观测。
结果:
1.获得了茎突根部、乳突、鼓乳裂最下点分别与有关骨性结构的距离和角度数据,显示左侧与右侧比较有显著差异。
2.侧颅底区重要孔道测量(最大径)显示左侧与右侧比较有显著差异。
3.咽旁间隙颅底区测量:长度:左、右侧分别为33.11±2.95mm,34.88±2.36mm(P<0.01);宽度:左、右侧分别为17.31±2.22 mm,17.15±1.65 mm(P>0.05)。
4.乳突尖至下颌骨升支、乳突前缘至下颌骨升支、第一颈椎横突至下颌骨升支等的最短距离分别为22.94±3.08 mm,14. 50±3.57mm,20.34±9.03mm。
5.20侧标本中有30%副神经位于第一颈椎横突外侧走行,其余位其前面经过;有20%舌下神经弓形向前下走行时位于二腹肌后腹下缘下0.5~1.0cm。
结论:
1.乳突尖、鼓乳裂及茎突根部等骨性标志在手术中易于触摸、定位。对所选测量点间的距离及角度进行测量,可定位重要结构位置,明确手术进路的深度,估测其方位。
2.茎突根部是咽旁间隙的关键解剖标志,手术宜保护其后方的颈内动脉、颈内静脉、后组脑神经和其浅面的颈外动脉、面神经等重要结构。
3.以破裂孔内缘与茎突根部的连线作为咽旁前、后间隙在颅底区的分界线。蝶骨翼突内侧板、茎突、蝶骨大翼及颞骨岩部、破裂孔等作为茎突前间隙的标志;颈静脉孔及附近骨质、枕骨的外侧、枕骨髁等作为茎突后间隙的标志。以翼突内侧板根部至颈静脉窝外后缘的距离作为咽旁间隙颅底区的长度,蝶棘至颈静脉窝内后缘的距离作为其宽度。
4.第一颈椎横突在手术中易于触摸,可作为寻找、保护副神经的重要骨性标志;部分舌下神经弓形向前下走行时位于二腹肌后腹下缘下,在颈清扫术中注意避免伤及。
5.咽旁间隙的手术入路空间狭小,如何充分暴露术野是非常重要的。切除颌下腺、腮腺下极、茎突或乳突骨质,切断二腹肌、茎突肌肉组织、茎突下颌韧带,行下颌骨半脱位等,可获得充分的视野。
Objective
In order to orient and avoid damaging important neurovascular structures, from the aspect of operation on the parapharyngeal space (PPS), the anatomic information of the bony structures related to the lateral skull base was obtained. The cadaveric specimens were observed in detail by imitating operations through transcervical approach and transoral-pharyngeal approach.
Methods
1. The distance and angle among bony landmarks (the root of styloid process, the tip of mastoid process, tympanomastoid fissure, etc) in the lateral skull base in the PPS were determined by measurement of 30 (60 sides) dry adult skulls. So did it to the largest diameter of important foramina.
2. The range of the PPS in the cranium bottom district was studied and observed, and its length and width were measured.
3. On 10 (20 sides) adult cadaver heads, surgical anatomy were performed by transcervical and transoral-pharyngeal approach. The structures and their relationship in the PPS were carefully observed and recorded, especially in the styloid diaphragm, the last four groups of cranium nerves and the internal carotid artery, etc.
Results
1. The distance and angle data about styloid process, mastoid process and tympano-mastoid fissure were obtained. It showed that there were remarkable differences in the left side and the right side.
2. The measurements of foramina in the lateral skull base showed that there were remarkable differences in the left side and the right side.
3. The district of the PPS in cranium bottom was measured. Its length was 33.11±2.95mm (left), 34.88±2.36mm (right), P<0.01. Its width was 17.31±2.22 mm(left),17.15±1.65 mm (right), P>0.05.
4. The shortest distance between mandible and the tip , anterior border of mastoid process and the transverse process of the first cervical vertebra were respectively 22.94±3.08 mm,14. 50±3.57mm,20.34±9.03mm.
5. In 20 side samples, there were 30% of the accessory nerves lying in the transverse process of the first cervical vertebra outside, others passing forward. There were 20% of the hypoglossal nerves below the posterior belly of digastrics muscle in 0.5~1.0cm.
Conclusion
1. The root of styloid process, the tip of mastoid process and the tympanomastoid fissure can be easily detected. The measurement of the distance and angle among reference points can help to orient the important structure, estimate its depth.
2. The root of styloid process is a key dissection sign in the PPS. Behind it, there are internal carotid artery, internal jugular vein, cranial nerves, external carotid artery and facial nerve. They must be protected during operation.
3. The roof of PPS in the lateral skull base is divided into prestyloid and retrostyloid compartments by the line between the inner margin of lacerated foramen and the root of styloid process. The bony landmarks of prestyloid compartment are medial lamina of pterygoid process, styloid process, great wing of sphenoid bone, petrous pyramid and lacerated foramen. The sign of retrostyloid compartment are jugular foramen and its bone around, the lateral of occipital, occipital condyle. The anterioposterior length of the PPS is from the root of medial pterygoid plate to the lateral-posterior margin of the jugular foramen. The mediolateral width is between the spine of the sphenoid bone and the posterior-medial margin of the jugular foramen.
4. The transverse process of the first cervical vertebra can be easily detected on operation, it is an important bony landmarks in which we can look for and protect the accessory nerves. The hypoglossal nerves below the posterior belly of digastrics muscle must be protected on neck dissection.
5. The operation space on the PPS is narrow and small; it is very important how to fully expose the PPS. This can be obtained by removing submaxillary salivary gland, the inferior of parotid, styloid process, mastoid process or by abscising digastric muscle, muscle tissue in styloid process, stylomylohyoid ligament, or by subluxating mandible.
引文
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