山东大学耳鼻喉眼学报 ›› 2019, Vol. 33 ›› Issue (5): 62-68.doi: 10.6040/j.issn.1673-3770.0.2019.177

• 论著 • 上一篇    下一篇

内镜下经外耳道耳蜗下径路切除岩尖病变的应用解剖学研究

卢飞燕,卢永田(),周俊伟,刘渊   

  1. 深圳大学附属第一医院 深圳市第二人民医院耳鼻咽喉头颈外科,广东 深圳 518035
  • 收稿日期:2019-04-08 修回日期:2019-06-01 出版日期:2019-09-20 发布日期:2019-10-15
  • 通讯作者: 卢永田 E-mail:luyongtian@263.net

Applied anatomy of endoscopic resection of the petrous apex through the transcanal infracochlear approach

Feiyan LU,Yongtian LU(),Junwei ZHOU,Yuan LIU   

  1. Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Shenzhen University,Shenzhen Second People′s Hospital, Shenzhen 518035, Guangdong, China
  • Received:2019-04-08 Revised:2019-06-01 Online:2019-09-20 Published:2019-10-15
  • Contact: Yongtian LU E-mail:luyongtian@263.net

摘要: 目的

探索内镜下经外耳道耳蜗下径路切除岩尖病变的手术入路,观察内镜下后下鼓室及圆窗周围重要的解剖标志,寻找定位耳蜗下通道的解剖标志,同时在高分辨颞骨CT三维重建下量化耳蜗下通道,为该手术入路提供国人恒定的解剖标志及影像学依据。

方法

1.应用10具(20侧)新鲜冰冻成人尸头,模拟内镜下经外耳道耳蜗下径路岩尖气房切除,寻找定位耳蜗下通道的解剖标志;术前在颞骨CT上分别测量耳蜗底转至颈内动脉与颈静脉球夹角之间的距离,以及耳蜗底转至颈静脉球之间的距离。2.回顾性阅读分析85例患者(170侧)颞骨高分辨CT,记录耳蜗下通道与岩尖气房在颞骨CT上的影像学特征,归类其分型情况。

结果

1.20侧冰鲜尸头以及170侧临床患者颞骨CT测量:耳蜗底转至颈内动脉与颈静脉球夹角之间的距离分别为(6.46±1.02)mm、(6.83±1.50)mm;耳蜗底转至颈静脉球之间的距离分别为(3.67±0.58)mm、(3.82±1.29)mm,其中,耳蜗底转至颈内动脉与颈静脉球夹角之间的距离:气化型岩尖分别为(6.79±0.60)mm、(7.19±1.44)mm,非气化型岩尖分别为(6.28±1.17)mm、(6.68±1.50)mm;耳蜗底转至颈静脉球的距离:气化型岩尖分别为(4.06±0.36)mm、(4.06±1.42)mm, 非气化型分别为(3.45±0.58)mm、(3.74±1.22)mm。2.耳蜗下通道与颞骨岩尖气房CT分型:A型气化型31.18%(53耳),B型板障型57.65%(98耳),C型硬化型11.18%(19耳)。

结论

高分辨颞骨CT可作为内镜下经外耳道耳蜗下径路岩尖病变切除的术前重要参考。从解剖学的角度,内镜下经外耳道耳蜗下径路切除岩尖病变是可行的,能够避免损伤内听道、耳蜗、迷路,保存听力,可作为临床治疗上岩尖后下部分较小病变的重要术式之一。

关键词: 内窥镜检查, 外耳道, 耳蜗下通道, 岩尖病变, 岬末脚, 柱骨, 解剖学

Abstract: Objective

To explore endoscopic transcanal infracochlear approach for resection of the petrous apex and observe structures of the middle ear. The study also aimed to identify anatomical landmarks for locating the infracochlear corridor as well as quantify the corridor under three-dimensional reconstruction of high-resolution CT(HRCT) of temporal bone. The purpose is to provide a constant anatomical landmark and imaging basis for surgical intervention.

Methods

1.Ten (20 sides) fresh frozen adult cadaver heads were used. Preoperative temporal bone CT was used to measure the vertical distance between the basal turn of the cochlea and angle between the internal carotid artery and jugular bulb, as well as the distance between the basal turn of the cochlea and jugular vein bulb. 2. Retrospective analysis of high-resolution CT(HRCT) of the temporal bone in 85 patients (170 sides) was performed to record and summarize the imaging characteristics between the infracochlear corridor and cells of the petrous apex.

Results

1. CT measurements of temporal bones of 20 sides in the frozen cadavers and 170 sides in patients showed that vertical distance between the basal turn of the cochlea and angle between the internal carotid artery and jugular bulb were (6.46 ±1.02) mm and (6.83 ±1.50) mm, respectively, and that between the basal turn of the cochlea and jugular bulb were (3.67±0.58) mm and (3.82±1.29) mm, respectively. Among them, the vertical distance between the pneumatized petrous apices were (6.79 ± 0.60) mm and (7.19 ± 1.44) mm, and that between the non-pneumatized apices were (6.28 ± 1.17) mm and (6.68 ± 1.50) mm, respectively. The distances from the basal turn of the cochlea to the jugular bulb with respect to the pneumatized petrous apices were (4.06 ± 0.36) mm and (4.06 ± 1.42) mm, respectively; and that of the non-pneumatized portions were (3.45 ± 0.58) mm and (3.74 ± 1.22) mm, respectively. 2. Results of CT classification of the infracochlear corridor and petrous apex of the temporal bone were as follows: Type A, pneumatized type 31.18% (53 ears); Type B, marrow type 57.65% (98 ears), and Type C, sclerosed type 11.18% (19 ears).

Conclusion

High-resolution CT (HRCT) may be considered an important pre-operative reference tool for endoscopic transcanal infracochlear approach for resection of the petrous apex. From an anatomical point of view, endoscopic resection of lesions in the petrous apex is feasible using the transcanal infracochlear approach as it can avoid damage to the internal auditory canal, cochlea, and labyrinth, and preserve hearing. The technique can be considered one of the important surgical methods for treatment of minor lesions in the posterior and inferior aspects of the upper petrous apex.

Key words: Endoscopy, Transcanal, Infracochlear approach, Petrous apex, Finiculus, Fustis, Anatomy

中图分类号: 

  • R764.1

图1

高分辨CT(层厚1 mm)三维重建后耳蜗下通道的影像学测量。a,水平位(横轴位),定位耳蜗底转;b,冠状位,可见内听道下方的耳蜗下通道及岩尖气房(黄色箭头区域为耳蜗下通道);c,三维重建后显示耳蜗底转、颈内动脉、颈静脉球之间的关系;d,量化耳蜗下通道,可见气化型岩尖气房。"

图2

耳蜗下通道及颞骨岩尖气房CT上 A、B、C分型示意图。pr,鼓岬;su,岬下脚;fu,柱骨;f,岬末脚。"

图3

后鼓室及圆窗周围结构解剖(0°内镜)。蓝色箭头为耳蜗下通道,通往岩尖。a,内镜下中耳鼓室图;b,内镜下后下鼓室图;c,圆窗周围结构图;d,圆窗周围结构图。ma,锤骨; in,砧骨; et,咽鼓管鼓室口;cp,匙突;ct,鼓索神经;pe,锥隆起;p,岬小桥;su,岬下脚;pr,鼓岬;rw,圆窗;te,圆窗龛;st,鼓室窦;fu,柱骨;f,岬末脚;sty,茎突复合体;pts,后鼓室窦;ss,下鼓室窦;ap,前柱;pp,后柱;t,耳蜗下通道;ac,后下鼓室。"

图4

0°内镜下显露耳蜗下通道。其中蓝色三角形区域为耳蜗下通向岩尖的气房,气化型。ma,锤骨; in,砧骨; et,咽鼓管鼓室口;p,岬小桥;su,岬下脚;pr,鼓岬;rw,圆窗;st,鼓室窦;f,岬末脚;fu,柱骨;ICA,颈内动脉;jb,颈静脉球。"

图5

0°内镜下经外耳道耳蜗下径路术式,其中,蓝色箭头区域为耳蜗下通道,通往岩尖, 三角形区域为耳蜗下通向岩尖的气房,气化型。ma,锤骨; in,砧骨;et,咽鼓管鼓室口;ct,鼓索神经;pr,鼓岬;su,岬下脚;rw,圆窗; fu,柱骨;f,岬末脚;t,耳蜗下通道;ICA,颈内动脉;jb,颈静脉球。"

表1

10具(20侧)冰鲜标本和85例(170侧)临床患者颞骨CT上测量耳蜗底转至颈内动脉及颈静脉球夹角、颈静脉球之间距离(mm, x ˉ ± s )"

研究对象

测量

指标

最小值(min) 最大值(max) 距离(mm) t F P
10具标本颞骨CT a 4.3 7.8 6.46±1.02 10.654 0.514 <0.001
b 2.6 4.5 3.67±0.58
85例患者颞骨CT a 3.2 11.1 6.83±1.50 19.776 2.964 <0.001
b 1.3 8.1 3.82±1.29

表2

10具(20侧)冰鲜标本和85例(170侧)临床患者中气化型岩尖与非气化型岩尖在耳蜗底转至颈内动脉及颈静脉球夹角、颈静脉球之间的距离(mm, x ˉ ± s )"

研究对象 测量指标 气化型岩尖 非气化型岩尖 t F P
10具标本颞骨CT a 6.79±0.60 6.28±1.17 1.050 0.616 0.15
b 4.06±0.36 3.45±0.58 2.495 2.003 0.01
85例患者颞骨CT a 7.19±1.44 6.68±1.50 2.093 0.025 0.019
b 4.06±1.42 3.74±1.22 1.534 3.109 0.06
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