鼻内镜下鼻后神经丛解剖研究

Endoscopic anatomy of the posterior nasal nerve plexus

摘要:

目的 探讨鼻内镜下鼻后神经丛(PNNP)的构成及分布特点，为后续行鼻内镜下高选择性PNNP切断术提供解剖学参考。方法 利用5具(10侧)冰鲜尸头灌注标本，经内镜下中鼻道入路，解剖蝶腭孔周围区域内结构;利用5具人体标本解剖前接受的鼻窦CT扫描结果，经影像学工具测量相应结构间距离。利用内镜系统采集解剖图像，影像测量软件获取影像学数据，并由资深放射科医师盲法测量。在解剖过程中，寻找蝶腭孔周围区域重要解剖标志及各结构间的毗邻关系。去除腭骨蝶突及蝶骨鞘突骨质，开放骨性腭鞘管，暴露PNNP咽支，在腭鞘管前口外侧探查定位翼管神经。结果 PNNP出蝶腭孔后均存在3个主要分支与蝶腭动脉分支血管伴行，前下方有与蝶腭鼻后外侧支伴行的鼻腔外侧壁支，后上方有与上鼻甲动脉伴行的上鼻甲支，后内侧有与鼻后中隔动脉伴行的鼻中隔支，蝶腭神经节在翼腭窝内即发出咽支，未穿出蝶腭孔，通过腭鞘管进入鼻咽部，且翼管前口均位于腭鞘管前口的外侧。腭鞘管前口外侧壁至翼管前口内侧壁间距，内镜下测量值(5.90±1.12)mm，影像学测量值(6.30±1.06)mm。结论 通过解剖定位腭鞘管，开放骨性腭鞘管，暴露其中的PNNP咽支，探讨腭鞘管前口与翼管前口之间的位置关系及术中规避翼管神经及蝶腭神经节的安全操作范围，为变应性鼻炎精准手术治疗提供解剖依据。

关键词:鼻内镜;鼻后神经丛解剖;高选择性鼻后神经丛切断术

Abstract:

Objective To investigate the composition and distribution of the posterior nasal nerve plexus (PNNP) under nasal endoscope so as to provide an anatomical reference for nasal endoscopic surgery of highly selective posterior nasal neurectomy. Methods The structures around the sphenopalatine foramen were dissected via endoscopic middle meatus approach in 5 frozen cadaveric heads (10 sides). Based on the CT imaging results of nasal sinuses of the 5 heads before gross anatomy, the distances between the corresponding structures were measured by imaging tools. The anatomical images were collected by Tiansong endoscopic system, and the imaging data were obtained by image measurement software. In the process of dissection, the important anatomical landmarks of the region around the sphenopalatine foramen and the adjacent relationships among the structures were ascertained. The sphenoid process of palatine bone and vaginal process of sphenoid bone were removed to open the bony palatovaginal canal. Then, the pharyngeal branch of PNNP was exposed, and the vidian nerve was explored and located lateral to anterior orifice of the palatovaginal canal. Results After emerged from the sphenopalatine foramen, three branches of PNNP accompanied with corresponding branches of sphenopalatine artery could be clearly recognized under endoscope. They were lateral wall branch anteroinferiorly, superior turbinate branch posterosuperiorly, and posteromedial septum branch posteromedially. Sphenopalatine ganglion sended out pharyngeal branch in pterygopalatine fossa and entered the nasopharynx through the palatovaginal canal without penetrating sphenopalatine foramen. Moreover, the anterior opening of the vidian canal was constantly located outside the anterior opening of the palatovaginal canal. The distance between the lateral wall of the anterior opening of the palatovaginal canal and the medial wall of the anterior opening of the vidian canal was (5.90±1.12) mm by endoscope and (6.30±1.06) mm by imaging. Conclusion Exposure of the pharyngeal branch of PNNP via positioning and opening bony palatovaginal canal and discussion on the positional relationship between anterior openings of palatovaginal canal and vidian canal as well as safe operating range to protect vidian nerve and sphenopalatine ganglion may provide anatomical references for precise surgical treatment of allergic rhinitis.

Key words:Endoscope;Anatomy of the posterior nasal nerve plexus;Highly selective posterior nasal neurectomy