内镜下改良翼突入路下颌神经解剖及颞下窝血管神经关系研究

Modified transpterygoid approach to access V3 and exploration of neurovascular correlation in infratemporal fossa

目的通过整体外移翼外板及翼外肌的改良翼突入路暴露下颌神经,并探索颞下窝内神经、肌肉及血管间的关系。方法采用6个动静脉双灌注的标本(共12侧),内镜下切除鼻腔外侧壁及上颌窦后外壁,磨除翼突根部的翼内板与翼外板之间的骨质连接,分离翼外板及翼外肌下头,整体外移翼外板及翼外肌,显露下颌神经,并分析颞下窝血管神经之间的解剖关系。结果通过整体外移翼外板及翼外肌,在12侧标本中均可显露下颌神经后干、下牙槽神经和舌神经。在9侧(75%),上颌动脉的主干经颞肌与翼外肌之间进入颞下窝浅部;在3侧(25%),上颌动脉经翼外肌上下两头之间穿出后进入颞下窝浅部。颞深神经是翼外肌上下头之间分界的一个恒定标志。结论整体外移翼外板及翼外肌能直接暴露下颌神经,且有利于避免翼深静脉丛及上颌动脉的出血。

OBJECTIVE The infratemporal fossa,containing complicated neurovascular relationships,is anatomically complex.Furthermore,bleeding from the pterygoid plexus brings challenges to surgery.The goals of this study are to explore the detailed anatomical relationships among V3,pterygoid muscles,and branches of the internal maxillary artery and to introduce a lateral pterygoid plate displacement approach to access V3.METHODS Six perfused cadaveric specimens(12 sides)were dissected via an endonasal approach to the infratemporal fossa modified by releasing the lateral pterygoid plate and muscle,which were displaced laterally all together.The anatomic relationships among the V3,pterygoid muscles,and internal maxillary artery were explored.RESULTS Through an endonasal lateral pterygoid displacement approach,the posterior trunk of V3 may be accessed while sparing the fascia covering the lateral pterygoid muscle.In 9/12 sides(75%),the proximal internal maxillary artery ran between the temporalis and the lateral pterygoid muscles;in 3/12 sides(25%),the internal maxillary artery pierced the lateral pterygoid muscle.The deep temporal nerve was a consistent landmark to separate the superior and inferior heads of lateral pterygoid muscle.CONCLUSION Displacement of the lateral pterygoid plate and muscle provided direct exposure of V3 avoiding direct dissection of the masticator space.This may be helpful preventing intraoperative bleeding from the deep pterygoid plexus as well as avoiding injury to the internal maxillary artery.