经鼻入路处理前颅底中线区病变的解剖学研究
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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。
Objectives:In order to clarify the anatomical relations of the dependency anatomical constructions in the way for operation of the transnasal approach,cadaveric heads were dissected and operated under microscope,especially for the observation and measurement of osteal mark,important vessels and nerves.We also got individual anatomical relations of Chinese by statistics and analysis to search a safe mark and boundary in the operational way of transnasal approach,so as to provide the important parameters of microdissection for the transnasal approach.
Methods:Our research assigned anterior nasal spine as our basal point,the line between anterior nasal spine and posterior nasal spine as our basal line.The nasal septum,turbinate, sphenoid,ethmoid,anterior ethmoidal artery,posterior ethmoidal artery,sphenopalatine artery and adjacent structures were dissected,observed,and measured under the operation microscope by use of 10 adult cranial bones and 10 preserved adult cadaveric heads.Then combinating the data measured,we simulated the operation on 3 preserved adult cadaveric heads.
Results:
1.Middle turbinate:when exploring from anterior nasal spine to the region of uncinate process and ethmoidal bulla,the data of uncinate process and ethmoidal bulla we measured conduce to the exactly localization of the constructions.To our observation,middle turbinate and lamella of middle turbinate can be marker grantly when ie was removed.Middle turbinate exist variations,2 sides of our samples was vesicular which were obviously overgrowth.But according to our observation,they could not couse the generally shift of nasal constructions. Middle turbinate and lamella of middle turbinate are the most fixed marker.
2.Typing of ethmoidal artery:there are 4 relationships between anterior ethmoidal artery, posterior ethmoidal artery and ophthalmic artery:"F" type 40%,while there are three subtype,which are "KⅠ" type 20%,"KⅡ" type 30%and "KⅢ" type 10%.The location of ethmoidal paragraph of anterior ethmoidal artery are different,30%of them located in ethmoid roof,50%located in the mucosae of ethmoid while the remaining 20%located in ethmiodal cells.The rate of posterior ethmoidal artery is 90%,50%of which seated in ethmoid roof,30%seated in the mucosae of ethmoid,10%seated in ethmiodal cells.The rate of middle ethmoidal artery is 10%,all of which seated anterior ethmoidal artery and between posterior ethmoidal artery,its orientation is grossly same to posterior ethmoidal artery.When we are entering anterior ethmoid with application of transnasal approach,we encounter anterior ethmoidal artery firstly,and then when we entered posterior ethmoid,we can find posterior ethmoidal artery which is principal in this area.The anatomical data of this area is very important which can help the positioning of anterior ethmoidal artery and posterior ethmoidal artery.There are decisive action to the run of transnasal approach for lesions of anterior skull base.
3.Branches of ethmoidal artery:there are 3～5 branches of anterior ethmoidal artery. The rate ofseptum branch is 100%,30%of which emerges 1 inferior branch,60%emerges 2 inferior branches,10%emerges three inferior branches.The rate of lateral branch is 90%, 25%of which emerges 2～3 inferior branches.The rate of nasal dorsum branch,dura branch and cribriform plate branch are 30%,55%and 25%.There are three main branches of posterior ethmoidal artery,including septum branch,lateral branch and cribriform plate branch when the rate of them are 90%,70%and 30%.The branches of anterior ethmoidal artery and posterior ethmoidal artery disposition to nasal cavity and anterior skull base extensively,and have closely related individual with sphenopalatine artery.When we are dealing with the artery of nasal septum and the area of aperture of sphenoidal sinus,bleeding often occur because for the injury of ethmoidal artery.So comprehension of their branches and distributing condition is important,which can help to the decreasing of bleeding.
4.Foramen sphenopalatinum:there is variation in foramen sphenopalatinum.According to our observation,45%is oval-shaped,35%is round while 20%is irregular.The type of foramen sphenopalatinum were 80%single foramen,20%diplopored.In the single foramen ones,45%of sphenopalatine artery divaricate before foramen sphenopalatinum while 35% divaricate after foramen sphenopalatinum.20%of the sphenopalatine artery threads from dominate hole and para hole sololy with sphenopalatine nerve.The main reason of bleeding in entering posterior ethmoid and sphenoid for transnasal approach is the injury of sphenopalatine artery and its branches.The anatomical significances of foramen sphenopalatinum is the precise locationship of sphenopalatine artery.With the combination of our data measured,we can get earlier site of sphenopalatine artery and its branches which can avoid bleeding greatly.
5.Comparation in three operative routes:the laevus width of middle meatal approach is (8.924±2.30) mm(5.3～13.2mm),while dexter one is(9.72±1.79) mm(7.3～13.3mm). The laevus width of paraseptal approach is(13.43±2.82) mm(8.6～17.8mm),when dexter one is(13.14±3.18 ) mm(9.2～18.0mm ).The laevus width of middle turbinectomy approach is(18.33±3.12) mm(12.8～22.5mm),while dexter one is(18.594±2.99) mm(12.9～22.1mm).The width of three approaches increases gradually,but the damages to normal structures enlarge at the same time.We must select proper operation way according to the substantialconditions,considering to the damage of differdnt approaches.
6.Relationship between cribriform plate and ethmoid roof:the distance between cribriform plate and ethmoid roof is(3.924±2.07) mm(1.1～9.7mm).The conjunction way and skewness of them induce one consequence,that is the cerebrospinal fluid leakage of this area.So well reconstruction is very important,especially when we manipulate through dura mater.
7.Distance between inner wall of bilateral orbit:the distance of inner wall of bilateral orbit is different in different decks.The distance of in the deck of crista galli is(22.314±3.08 ) mm(18.7～27.4mm),(23.00±2.93)mm(19.7～28.1mm) in the deck of anterior ethmoidal artery,(26.254±2.88) mm(21.9～31.4mm) in the deck of posterior ethmoidal artery while (14.674±3.82) mm(9.8～22.1mm) in the deck of cranial opening of optic canal.When expanding to lateral areas in operation,we must keep our extent to correlate sinus to avoid damagement of lamina papgracea.We found that distance of bilateral orbit is different in different decks.It is increased from the deck of crista galli to the deck of posterior ethmoidal artery,while it is decreased to the deck of cranio-apertura of optic canal and the posterior one is the smallest.According to the charactor,the width of anterior part of anterior skull base is wider while posterior part is narrow,excess open to lateral can damage lamina papgracea.So the data measured help to avoid this complication.
8.Optic canal bulge and internal carotid artery bulge:the frequency of occurrence of optic canal bulge is 80%,20%of them located in the sphenoidal exclusively,35%of them located in the posterior ethmoid exclusively,25%of them located in the sphenoidal and posterior ethmoid at the same time.The frequency of occurrence of internal carotid artery bulge is 70%,25%of them only located in the sphenoidal while 30%of them located in the posterior ethmoid exclusively,15%of them located in the sphenoidal and posterior ethmoid at the same time.55%sample emerge optic canal bulge and internal carotid artery bulge in both side,35%sample emerge optic canal bulge or internal carotid artery bulge,10%sample is absence with foregoing construction.The relationship of optic canal bulge and internal carotid artery bulge with posterior ethmoid and sphenoid is reticular and unsymmetrical,this induce the injury of internal carotid artery and optic canal.Prehension of the relationship and variation combined with image data conduce to well recognization of this area.
Conclusions:
1.Transnasal approach for lesions of anterior skull base is a safe,utility and mini-invasive surgery operational-technique,but relative anatomical relationgship of nasal cavity,nasal sinuses and anterior skull base is complex.so master of their structure,especially contiguous zone anatomy is significant to the operation.
2.The field provid by middle meatal approach is limited,it is used for small ranged cerebrospinal fluid leakage or small process of anterior skull base.Paraseptal approach can enlarge operation field by fracting nasal septum and detaching it contralaterally.The field of middle turbinectomy approach can get broader field by excision of middle turbinate. Combining of the three aprroach can get larger field of vision.As the width increases,the damages enlarge at the same time.Combining with image data,and select proper approach is the best way to avoid unnecessary damage.
3.Anatomic landmark,including superior turbinate,middle turbinate(lamella of middle turbinate),uncinate process,ethmoidal bulla,lamina papgracea,anterior ethmoidal artery(canal),posterior ethmoidal artery(canal),optic canal bulge,internal carotid artery bulge, Sphenoethmoidal recess and aperture of sphenoidal sinus are important landmark of transnasal approach,the identification of them can help orientation and decreasing of complications.
4.The branch of ethmoidal artery and sphenopalatine artery shunt extensively in area of nasal cavity and anterior skull base.This area is the main reason of bleeding,find and deal with those artery early can avoid serious complications.
5.The emphasis of this operation lies in avoiding injury of lamina papgracea,optic nurve and internal carotid artery,keeping mid-line manipulations and determining the way of optic canal and internal carotid artery early can decrease the complication.
6.The occurrence of super sphenoid-ethmoid cell and side sphenoid-ethmoid cell make the relationship of them more complex,analyzing through image data is dangerous. Combining data of anatomy and image and landmarks is the best way of operation.
7.The junction of cribriform plate and ethmoid roof is capital to cerebrospinal fluid leakage.Refering to the stump of ethmoidal artery,reconstruction of anterior skull base with mucosae and periosteum of nasal septum and inferior meatus can avoid the leakage.
8.The anterior extent of this approach should be anterior ethmoidal artery while the lateral one is the correlate nasal sinuses which can not exceed the distance of inner wall of bilateral orbit.The posterior extent should consider optic canal bulge and internal carotid artery bulge as the marker of operation to avoid injury to them.To our confirmation, transnasal approach can provie a windowing about 4.5cm2 to the midline of anterior skull base,which can be used for dealing with esthesioneuroblastoma,meningeoma, neurilemmoma,chordoma and cholesteatoma,strictly defining indication of operation.We must familiar with the indcation of this approach,the lesions extent out of relative sinus must be excluded immediately.
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。
Objectives:In order to clarify the anatomical relations of the dependency anatomical constructions in the way for operation of the transnasal approach,cadaveric heads were dissected and operated under microscope,especially for the observation and measurement of osteal mark,important vessels and nerves.We also got individual anatomical relations of Chinese by statistics and analysis to search a safe mark and boundary in the operational way of transnasal approach,so as to provide the important parameters of microdissection for the transnasal approach.
Methods:Our research assigned anterior nasal spine as our basal point,the line between anterior nasal spine and posterior nasal spine as our basal line.The nasal septum,turbinate, sphenoid,ethmoid,anterior ethmoidal artery,posterior ethmoidal artery,sphenopalatine artery and adjacent structures were dissected,observed,and measured under the operation microscope by use of 10 adult cranial bones and 10 preserved adult cadaveric heads.Then combinating the data measured,we simulated the operation on 3 preserved adult cadaveric heads.
Results:
1.Middle turbinate:when exploring from anterior nasal spine to the region of uncinate process and ethmoidal bulla,the data of uncinate process and ethmoidal bulla we measured conduce to the exactly localization of the constructions.To our observation,middle turbinate and lamella of middle turbinate can be marker grantly when ie was removed.Middle turbinate exist variations,2 sides of our samples was vesicular which were obviously overgrowth.But according to our observation,they could not couse the generally shift of nasal constructions. Middle turbinate and lamella of middle turbinate are the most fixed marker.
2.Typing of ethmoidal artery:there are 4 relationships between anterior ethmoidal artery, posterior ethmoidal artery and ophthalmic artery:"F" type 40%,while there are three subtype,which are "KⅠ" type 20%,"KⅡ" type 30%and "KⅢ" type 10%.The location of ethmoidal paragraph of anterior ethmoidal artery are different,30%of them located in ethmoid roof,50%located in the mucosae of ethmoid while the remaining 20%located in ethmiodal cells.The rate of posterior ethmoidal artery is 90%,50%of which seated in ethmoid roof,30%seated in the mucosae of ethmoid,10%seated in ethmiodal cells.The rate of middle ethmoidal artery is 10%,all of which seated anterior ethmoidal artery and between posterior ethmoidal artery,its orientation is grossly same to posterior ethmoidal artery.When we are entering anterior ethmoid with application of transnasal approach,we encounter anterior ethmoidal artery firstly,and then when we entered posterior ethmoid,we can find posterior ethmoidal artery which is principal in this area.The anatomical data of this area is very important which can help the positioning of anterior ethmoidal artery and posterior ethmoidal artery.There are decisive action to the run of transnasal approach for lesions of anterior skull base.
3.Branches of ethmoidal artery:there are 3～5 branches of anterior ethmoidal artery. The rate ofseptum branch is 100%,30%of which emerges 1 inferior branch,60%emerges 2 inferior branches,10%emerges three inferior branches.The rate of lateral branch is 90%, 25%of which emerges 2～3 inferior branches.The rate of nasal dorsum branch,dura branch and cribriform plate branch are 30%,55%and 25%.There are three main branches of posterior ethmoidal artery,including septum branch,lateral branch and cribriform plate branch when the rate of them are 90%,70%and 30%.The branches of anterior ethmoidal artery and posterior ethmoidal artery disposition to nasal cavity and anterior skull base extensively,and have closely related individual with sphenopalatine artery.When we are dealing with the artery of nasal septum and the area of aperture of sphenoidal sinus,bleeding often occur because for the injury of ethmoidal artery.So comprehension of their branches and distributing condition is important,which can help to the decreasing of bleeding.
4.Foramen sphenopalatinum:there is variation in foramen sphenopalatinum.According to our observation,45%is oval-shaped,35%is round while 20%is irregular.The type of foramen sphenopalatinum were 80%single foramen,20%diplopored.In the single foramen ones,45%of sphenopalatine artery divaricate before foramen sphenopalatinum while 35% divaricate after foramen sphenopalatinum.20%of the sphenopalatine artery threads from dominate hole and para hole sololy with sphenopalatine nerve.The main reason of bleeding in entering posterior ethmoid and sphenoid for transnasal approach is the injury of sphenopalatine artery and its branches.The anatomical significances of foramen sphenopalatinum is the precise locationship of sphenopalatine artery.With the combination of our data measured,we can get earlier site of sphenopalatine artery and its branches which can avoid bleeding greatly.
5.Comparation in three operative routes:the laevus width of middle meatal approach is (8.924±2.30) mm(5.3～13.2mm),while dexter one is(9.72±1.79) mm(7.3～13.3mm). The laevus width of paraseptal approach is(13.43±2.82) mm(8.6～17.8mm),when dexter one is(13.14±3.18 ) mm(9.2～18.0mm ).The laevus width of middle turbinectomy approach is(18.33±3.12) mm(12.8～22.5mm),while dexter one is(18.594±2.99) mm(12.9～22.1mm).The width of three approaches increases gradually,but the damages to normal structures enlarge at the same time.We must select proper operation way according to the substantialconditions,considering to the damage of differdnt approaches.
6.Relationship between cribriform plate and ethmoid roof:the distance between cribriform plate and ethmoid roof is(3.924±2.07) mm(1.1～9.7mm).The conjunction way and skewness of them induce one consequence,that is the cerebrospinal fluid leakage of this area.So well reconstruction is very important,especially when we manipulate through dura mater.
7.Distance between inner wall of bilateral orbit:the distance of inner wall of bilateral orbit is different in different decks.The distance of in the deck of crista galli is(22.314±3.08 ) mm(18.7～27.4mm),(23.00±2.93)mm(19.7～28.1mm) in the deck of anterior ethmoidal artery,(26.254±2.88) mm(21.9～31.4mm) in the deck of posterior ethmoidal artery while (14.674±3.82) mm(9.8～22.1mm) in the deck of cranial opening of optic canal.When expanding to lateral areas in operation,we must keep our extent to correlate sinus to avoid damagement of lamina papgracea.We found that distance of bilateral orbit is different in different decks.It is increased from the deck of crista galli to the deck of posterior ethmoidal artery,while it is decreased to the deck of cranio-apertura of optic canal and the posterior one is the smallest.According to the charactor,the width of anterior part of anterior skull base is wider while posterior part is narrow,excess open to lateral can damage lamina papgracea.So the data measured help to avoid this complication.
8.Optic canal bulge and internal carotid artery bulge:the frequency of occurrence of optic canal bulge is 80%,20%of them located in the sphenoidal exclusively,35%of them located in the posterior ethmoid exclusively,25%of them located in the sphenoidal and posterior ethmoid at the same time.The frequency of occurrence of internal carotid artery bulge is 70%,25%of them only located in the sphenoidal while 30%of them located in the posterior ethmoid exclusively,15%of them located in the sphenoidal and posterior ethmoid at the same time.55%sample emerge optic canal bulge and internal carotid artery bulge in both side,35%sample emerge optic canal bulge or internal carotid artery bulge,10%sample is absence with foregoing construction.The relationship of optic canal bulge and internal carotid artery bulge with posterior ethmoid and sphenoid is reticular and unsymmetrical,this induce the injury of internal carotid artery and optic canal.Prehension of the relationship and variation combined with image data conduce to well recognization of this area.
Conclusions:
1.Transnasal approach for lesions of anterior skull base is a safe,utility and mini-invasive surgery operational-technique,but relative anatomical relationgship of nasal cavity,nasal sinuses and anterior skull base is complex.so master of their structure,especially contiguous zone anatomy is significant to the operation.
2.The field provid by middle meatal approach is limited,it is used for small ranged cerebrospinal fluid leakage or small process of anterior skull base.Paraseptal approach can enlarge operation field by fracting nasal septum and detaching it contralaterally.The field of middle turbinectomy approach can get broader field by excision of middle turbinate. Combining of the three aprroach can get larger field of vision.As the width increases,the damages enlarge at the same time.Combining with image data,and select proper approach is the best way to avoid unnecessary damage.
3.Anatomic landmark,including superior turbinate,middle turbinate(lamella of middle turbinate),uncinate process,ethmoidal bulla,lamina papgracea,anterior ethmoidal artery(canal),posterior ethmoidal artery(canal),optic canal bulge,internal carotid artery bulge, Sphenoethmoidal recess and aperture of sphenoidal sinus are important landmark of transnasal approach,the identification of them can help orientation and decreasing of complications.
4.The branch of ethmoidal artery and sphenopalatine artery shunt extensively in area of nasal cavity and anterior skull base.This area is the main reason of bleeding,find and deal with those artery early can avoid serious complications.
5.The emphasis of this operation lies in avoiding injury of lamina papgracea,optic nurve and internal carotid artery,keeping mid-line manipulations and determining the way of optic canal and internal carotid artery early can decrease the complication.
6.The occurrence of super sphenoid-ethmoid cell and side sphenoid-ethmoid cell make the relationship of them more complex,analyzing through image data is dangerous. Combining data of anatomy and image and landmarks is the best way of operation.
7.The junction of cribriform plate and ethmoid roof is capital to cerebrospinal fluid leakage.Refering to the stump of ethmoidal artery,reconstruction of anterior skull base with mucosae and periosteum of nasal septum and inferior meatus can avoid the leakage.
8.The anterior extent of this approach should be anterior ethmoidal artery while the lateral one is the correlate nasal sinuses which can not exceed the distance of inner wall of bilateral orbit.The posterior extent should consider optic canal bulge and internal carotid artery bulge as the marker of operation to avoid injury to them.To our confirmation, transnasal approach can provie a windowing about 4.5cm2 to the midline of anterior skull base,which can be used for dealing with esthesioneuroblastoma,meningeoma, neurilemmoma,chordoma and cholesteatoma,strictly defining indication of operation.We must familiar with the indcation of this approach,the lesions extent out of relative sinus must be excluded immediately.
引文
[1].Griffith HB,Veerapen R.A direct transnasal approach to sphenoid sinus[J].J Neurosurg,1987,66(2):140-142.
[2].王守森,章翔 主编.鞍区的显微解剖与手术[M].北京:人民军医出版社,2005,320-331.
[3].Mosher HP.Symposium on the ethmoid:the surgical anatomy of the ethmoidal labyrinth [J].Trans Am Acad Ophthamol Otolaryngol,1929,34:376-410.
[4].Casiano RR,Numa WA,Falquez AM.Endoscopic resection of esthesio-neuroblastoma[J].Am J Rhinol,2001,15(4):271-279.
[5].许庚,李源,谢民强,等.经鼻内镜颅底进路手术的探索[J].中华耳鼻咽喉科杂志,2002,(37)6:443-446.
[6].Jho HD,Ha HG.Endoscopic endonasal skull base surgery:part 1-The midline anterior fossa skull base[J].Minim Invasive Neurosurg,2004,47(1):1-8.
[7].Thomas RF,Monacci WT,Mair EA.Endoscopic image-guided transethmoid pituitary surgery [J].Otolaryngul Head Neck Surg,2002,127(5):409-416.
[8].Casler JD,Doolittle AM,Mair EA.Endoscopic surgery of the anterior skull base[J].Laryngoscope,2005,115(1):16-24.
[9].曹荣萍,吴皓,黄琦,等.鼻内镜下经鼻前颅底手术的探讨[J].临床耳鼻咽喉科杂志,2006,(20)23:1057-1059.
[10].Irish JC,Gullane PJ,Gentili F,et al.Tumor of the skull base:outcome and survival analysis of 77 cases[J].Head Neck,1994,16:3-10.
[11].王荣光,许庚,郭宝煌 主编.鼻内窥镜手术图解[M].北京:解放军出版社,1998,12-16.
[12].韩德民,周兵 主译.功能鼻重建外科学[M].北京:人民卫生出版社,2006,19-20.
[13].Ohnishi T.High risk areas in endoscopic sinus surgery and prevention of complications [J].Laryngoscope,1993,103:1181-1185.
[14].许庚,李源 主编.内窥镜鼻窦外科学[M].广州:暨南大学出版社,1994,34.
[15].韩德民,周兵 主编.鼻内窥镜外科学[M].北京:人民卫生出版社,2001,8.
[16].廖建春,李健,陆书昌,等.鼻外筛-蝶窦进路视神经管减压术的应用解剖研究[J].临床耳鼻咽喉科杂志,1994,(8)4:221-222.
[17].范静平,章松勤,廖建春,等.内窥镜视神经管减压术应用解剖[J].中国临床解剖学杂志,1996,(14)2:92-94.
[18].李健,吕光宇,陆书昌,等.后筛窦及其毗邻结构的解剖学研究[J].中华耳鼻咽喉科杂志,1991,26(3):138-141.
[19].Lawson W.The intranasal ethmoidectomy:evolution and an assessment of the procedure [J].Laryngoscope,1994,104:1-49.
[20].朱世杰,赵恒珂,曹焕军,等.蝶上筛房与蝶侧筛房的应用解剖观察[J].解剖与临床,1997,(2)1:5-7.
[21].廖建春,胡国汉,卢亦成,等.后筛窦气化发育对蝶鞍区手术的影响[J].中国解剖与临床,2001,(6)3:129-132.
[22].贡振扬,王延生,朱春生.鼻中隔及下鼻道黏骨膜瓣修复前颅底缺损的解剖学研究[J].中国耳鼻咽喉颅底外科杂志,2004,(10)4:204-206.
[1]WEISS M H.Transnasal transsphenoidal approach[M].Apuzzo MLJ:Surgery of the third ventricle.Baltimore:Williams&Wilkins,1987,476-494.
[2]GRIFFITH H B,VEERAPEN R.A direct transnasal approach to the sphenoid sinus.Technical note[J].J Neurosurg.1987,66(1):140-142.
[3]DE DIVITIIS E,CAPPABIANCA P,CAVALLO L M.Endoscopic transsphenoidal approach:adaptability of the procedure to different sellar lesions[J].Ueurosurgery,2002,51(3):699-705.
[4]JHO H D.Endoscopic transsphenoidal surgery[J].J Neurooncol,2001,54(2):187-195.
[5]DUSICK J R,ESPOSITO F,KELLY D F,et al.The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors[J].J Neurosurg,2005,102(5):832-841.
[6]JHO H D,ALFIERI A.Endoscopic endonasal pituitary surgery:evolution of surgical technique and equipment in 150 operations[J].Minim Invasive Neurosurg,2001,44(1):1-12.
[7]JHO H D,HA H G.Endoscopic endonasal skull base surgery:part 1-The midline anterior fossa skull base[J].Minim Invasive Neurosurg,2004,47(1):1-8.
[8]THOMAS R F,MONACCI W T,MAIR E A.Endoscopic image- guided transethmoid pituitary surgery[J].Otolaryngol Head Neck Surg,2002,127(5):409-416.
[9]CASLER J D,DOOLITTLE A M,MAIR E A.Endoscopic surgery of the anterior skull base [J].Laryngoscope,2005,115(1):16-24.
[10]CATAPANO D,SLOFFER C A,FRANK G,et al.Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach:anatomical study[J].J Neurosurg,2006,104(3):419-425.
[11]鲁晓杰,王清,季卫阳,等.神经内镜下经鼻蝶窦入路鞍区肿瘤的手术治疗[J].中华神经外科杂志,2007,23(3):175-178.
[12]COULDWELL W T,WEISS M H,RABB C,et al.Variations on the standard transsphenoidal approach to the sellar region,with emphasis on the extended approaches and parasellar approaches:surgical experience in 105 cases[J].Neurosurgery,2004,55(3):539-547.
[13]LAUFER I,ANAND V K,SCHWARTZ T H.Endoscopic,endonasal extended transsphenoidal,transplanum transtuberculum approach for resection of suprasellar lesions[J].J Neurosurg,2007,106(3):400-406.
[14]DE DIVITIIS E,CAVALLO L M,CAPPABIANCA P,et al.Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors:Part 2[J].Neurosurgery.2007,60(1):46-58.
[15]MAIRA G,ANILE C,ALBANESE A,et al.The role of transsphenoidal surgery in the treatment of craniopharyngiomas[J].J Neurosurg,2004,100(3):445-451.
[16]COOK S W,SMITH Z,KELLY D F.Endonasal transsphenoidal removal of tuberculum sellae meningiomas.Technical note[J].Neurosurgery,2004,55(1):239-244;discussion 244-246.
[17]ALFIERI A,JHO H D.Endoscopic endonasal approaches to the cavernous sinus:surgical approaches[J].Neurosurgery,2001,49(2):354-360.
[18]JHO H D,HA H G.Endoscopic endonasal skull base surgery:Part 2-The cavernous sinus [J].Minim Invasive Neurosurg,2004,47(1):9-15.
[19]张庆丰,刘海生,杨占泉.鼻内镜下扩大的经鼻腔蝶窦入路治疗鞍周病变的解剖研究和临床应用[J].临床耳鼻咽喉科杂志,2005,19(11):481-483.
[20]张荣伟,杨辉,袁绍纪,等.扩大经蝶入路显微手术治疗海绵窦侵袭性垂体瘤[J].中国微侵袭神经外科杂志,2006,11(6):269-270.
[21]JHO H D,HA H G.Endoscopic endonasal skull base surgery:Part 3-The clivus and posterior fossa[J].Minim Invasive Neurosurg.2004,47(1):16-23.
[22]宋明,宗绪毅,王新生,等.经鼻入路显露斜坡区的内镜解剖研究[J].中华神经外科杂志,2007,23(3):179-181.
[23]FRANK G,SCIARRETTA V,CALBUCCI F,et al.The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas[J].Neurosurgery,2006,59(1 Suppl 1):ONS50-57.
[24]张秋航,孔锋,严波,等.内镜经鼻斜坡肿瘤的外科治疗[J].中华耳鼻咽喉头颈外科杂志,2007,42(1):7-10.
[22]SADE B,MOHR G,FRENKIEL S.Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery:use of post-operative lumbar drain and sellar reconstruction without fat packing[J].Acta Neurochir(Wien),2006,148(1):13-18;discussion 18-19.
[26]BUDROVICH R,SAETTI R.Microscopic and endoscopic ligature of the sphenopalatine artery [J].Laryngoscope,1992,102:1391-1394.
[2].王守森,章翔 主编.鞍区的显微解剖与手术[M].北京:人民军医出版社,2005,320-331.
[3].Mosher HP.Symposium on the ethmoid:the surgical anatomy of the ethmoidal labyrinth [J].Trans Am Acad Ophthamol Otolaryngol,1929,34:376-410.
[4].Casiano RR,Numa WA,Falquez AM.Endoscopic resection of esthesio-neuroblastoma[J].Am J Rhinol,2001,15(4):271-279.
[5].许庚,李源,谢民强,等.经鼻内镜颅底进路手术的探索[J].中华耳鼻咽喉科杂志,2002,(37)6:443-446.
[6].Jho HD,Ha HG.Endoscopic endonasal skull base surgery:part 1-The midline anterior fossa skull base[J].Minim Invasive Neurosurg,2004,47(1):1-8.
[7].Thomas RF,Monacci WT,Mair EA.Endoscopic image-guided transethmoid pituitary surgery [J].Otolaryngul Head Neck Surg,2002,127(5):409-416.
[8].Casler JD,Doolittle AM,Mair EA.Endoscopic surgery of the anterior skull base[J].Laryngoscope,2005,115(1):16-24.
[9].曹荣萍,吴皓,黄琦,等.鼻内镜下经鼻前颅底手术的探讨[J].临床耳鼻咽喉科杂志,2006,(20)23:1057-1059.
[10].Irish JC,Gullane PJ,Gentili F,et al.Tumor of the skull base:outcome and survival analysis of 77 cases[J].Head Neck,1994,16:3-10.
[11].王荣光,许庚,郭宝煌 主编.鼻内窥镜手术图解[M].北京:解放军出版社,1998,12-16.
[12].韩德民,周兵 主译.功能鼻重建外科学[M].北京:人民卫生出版社,2006,19-20.
[13].Ohnishi T.High risk areas in endoscopic sinus surgery and prevention of complications [J].Laryngoscope,1993,103:1181-1185.
[14].许庚,李源 主编.内窥镜鼻窦外科学[M].广州:暨南大学出版社,1994,34.
[15].韩德民,周兵 主编.鼻内窥镜外科学[M].北京:人民卫生出版社,2001,8.
[16].廖建春,李健,陆书昌,等.鼻外筛-蝶窦进路视神经管减压术的应用解剖研究[J].临床耳鼻咽喉科杂志,1994,(8)4:221-222.
[17].范静平,章松勤,廖建春,等.内窥镜视神经管减压术应用解剖[J].中国临床解剖学杂志,1996,(14)2:92-94.
[18].李健,吕光宇,陆书昌,等.后筛窦及其毗邻结构的解剖学研究[J].中华耳鼻咽喉科杂志,1991,26(3):138-141.
[19].Lawson W.The intranasal ethmoidectomy:evolution and an assessment of the procedure [J].Laryngoscope,1994,104:1-49.
[20].朱世杰,赵恒珂,曹焕军,等.蝶上筛房与蝶侧筛房的应用解剖观察[J].解剖与临床,1997,(2)1:5-7.
[21].廖建春,胡国汉,卢亦成,等.后筛窦气化发育对蝶鞍区手术的影响[J].中国解剖与临床,2001,(6)3:129-132.
[22].贡振扬,王延生,朱春生.鼻中隔及下鼻道黏骨膜瓣修复前颅底缺损的解剖学研究[J].中国耳鼻咽喉颅底外科杂志,2004,(10)4:204-206.
[1]WEISS M H.Transnasal transsphenoidal approach[M].Apuzzo MLJ:Surgery of the third ventricle.Baltimore:Williams&Wilkins,1987,476-494.
[2]GRIFFITH H B,VEERAPEN R.A direct transnasal approach to the sphenoid sinus.Technical note[J].J Neurosurg.1987,66(1):140-142.
[3]DE DIVITIIS E,CAPPABIANCA P,CAVALLO L M.Endoscopic transsphenoidal approach:adaptability of the procedure to different sellar lesions[J].Ueurosurgery,2002,51(3):699-705.
[4]JHO H D.Endoscopic transsphenoidal surgery[J].J Neurooncol,2001,54(2):187-195.
[5]DUSICK J R,ESPOSITO F,KELLY D F,et al.The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors[J].J Neurosurg,2005,102(5):832-841.
[6]JHO H D,ALFIERI A.Endoscopic endonasal pituitary surgery:evolution of surgical technique and equipment in 150 operations[J].Minim Invasive Neurosurg,2001,44(1):1-12.
[7]JHO H D,HA H G.Endoscopic endonasal skull base surgery:part 1-The midline anterior fossa skull base[J].Minim Invasive Neurosurg,2004,47(1):1-8.
[8]THOMAS R F,MONACCI W T,MAIR E A.Endoscopic image- guided transethmoid pituitary surgery[J].Otolaryngol Head Neck Surg,2002,127(5):409-416.
[9]CASLER J D,DOOLITTLE A M,MAIR E A.Endoscopic surgery of the anterior skull base [J].Laryngoscope,2005,115(1):16-24.
[10]CATAPANO D,SLOFFER C A,FRANK G,et al.Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach:anatomical study[J].J Neurosurg,2006,104(3):419-425.
[11]鲁晓杰,王清,季卫阳,等.神经内镜下经鼻蝶窦入路鞍区肿瘤的手术治疗[J].中华神经外科杂志,2007,23(3):175-178.
[12]COULDWELL W T,WEISS M H,RABB C,et al.Variations on the standard transsphenoidal approach to the sellar region,with emphasis on the extended approaches and parasellar approaches:surgical experience in 105 cases[J].Neurosurgery,2004,55(3):539-547.
[13]LAUFER I,ANAND V K,SCHWARTZ T H.Endoscopic,endonasal extended transsphenoidal,transplanum transtuberculum approach for resection of suprasellar lesions[J].J Neurosurg,2007,106(3):400-406.
[14]DE DIVITIIS E,CAVALLO L M,CAPPABIANCA P,et al.Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors:Part 2[J].Neurosurgery.2007,60(1):46-58.
[15]MAIRA G,ANILE C,ALBANESE A,et al.The role of transsphenoidal surgery in the treatment of craniopharyngiomas[J].J Neurosurg,2004,100(3):445-451.
[16]COOK S W,SMITH Z,KELLY D F.Endonasal transsphenoidal removal of tuberculum sellae meningiomas.Technical note[J].Neurosurgery,2004,55(1):239-244;discussion 244-246.
[17]ALFIERI A,JHO H D.Endoscopic endonasal approaches to the cavernous sinus:surgical approaches[J].Neurosurgery,2001,49(2):354-360.
[18]JHO H D,HA H G.Endoscopic endonasal skull base surgery:Part 2-The cavernous sinus [J].Minim Invasive Neurosurg,2004,47(1):9-15.
[19]张庆丰,刘海生,杨占泉.鼻内镜下扩大的经鼻腔蝶窦入路治疗鞍周病变的解剖研究和临床应用[J].临床耳鼻咽喉科杂志,2005,19(11):481-483.
[20]张荣伟,杨辉,袁绍纪,等.扩大经蝶入路显微手术治疗海绵窦侵袭性垂体瘤[J].中国微侵袭神经外科杂志,2006,11(6):269-270.
[21]JHO H D,HA H G.Endoscopic endonasal skull base surgery:Part 3-The clivus and posterior fossa[J].Minim Invasive Neurosurg.2004,47(1):16-23.
[22]宋明,宗绪毅,王新生,等.经鼻入路显露斜坡区的内镜解剖研究[J].中华神经外科杂志,2007,23(3):179-181.
[23]FRANK G,SCIARRETTA V,CALBUCCI F,et al.The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas[J].Neurosurgery,2006,59(1 Suppl 1):ONS50-57.
[24]张秋航,孔锋,严波,等.内镜经鼻斜坡肿瘤的外科治疗[J].中华耳鼻咽喉头颈外科杂志,2007,42(1):7-10.
[22]SADE B,MOHR G,FRENKIEL S.Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery:use of post-operative lumbar drain and sellar reconstruction without fat packing[J].Acta Neurochir(Wien),2006,148(1):13-18;discussion 18-19.
[26]BUDROVICH R,SAETTI R.Microscopic and endoscopic ligature of the sphenopalatine artery [J].Laryngoscope,1992,102:1391-1394.