内镜下咽旁间隙肿瘤手术入路解剖研究

Anatomical study of surgical approaches for parapharyngeal space tumors under endoscope

目的研究内镜下咽旁间隙(PPS)肿瘤手术入路及各入路的解剖标志。方法采用8例(16侧)新鲜灌注的尸头标本,在高清内镜下模拟PPS肿瘤切除手术。由浅入深进行经颈入路、经口腔前庭入路手术,研究相应的解剖标志。结果经颈入路可以定位颈动脉、各组脑神经,以及与固定骨性结构的关系,内镜下可快速顺利抵达PPS,对术中颈动脉的保护具有巨大优势。经口腔前庭-颞下窝入路,在微创条件下充分暴露了颞下窝的解剖结构,可定位下颌神经、下牙槽神经、上颌动脉和翼外肌等解剖标志点,分离舌神经、脑膜中动脉、颈动脉,为内镜下切除颞下窝、上咽旁间隙(UPPS)肿瘤提供了微创手术的解剖学参考。经口咽进入茎突前、后间隙,可确定颈内动脉及其与各后组脑神经(Ⅸ~Ⅻ)的解剖关系,为内镜或机器人辅助下经咽入路PPS肿瘤切除术提供了解剖学基础。结论内镜下经颈、经口腔前庭、经口咽入路,可明确判定咽旁间隙内血管、神经等的毗邻关系及解剖标志,为临床内镜下PPS肿瘤的切除提供了解剖学依据。

Objective To investigate the surgical approaches for the parapharyngeal space(PPS)tumor under endoscopy,the anatomical landmarks and the feasibility of each approach.Methods Eight fresh cadaveric specimens(16 sides)with vascular silicone injection were prepared for endoscopic transcervical,transvestibular and transoralpharynx anatomy research.Results With endoscope,the carotid artery,the cranial nerves,and the relationships with the fixed bone structures could be positioned through the cervical approach.The PPS could be reached quickly and smoothly under the endoscope,which would have great advantages in the control of the carotid artery during the operation.Detailed endoscopic anatomy of the infratemporal fossa(ITF)was clearly observed with minimal invasiveness.The fundamental roles of mandibular nerve,inferior alveolar nerve,maxillary artery and lateral pterygoid muscles in targeting ITF were confirmed,which could provide anantomical reference for resection of ITF and upper parapharyngeal space(UPPS)tumors under endoscopy.The roles of internal carotid artery,cranial nerves(Ⅸ~Ⅻ)in the endoscopic transoralpharynx approach were critical.Conclusions Transcervical,transvestibular and transoralpharynx approaches provide clear and feasible working corridors and better visualization for resection of PPS lesions,which will help otolaryngologists identify the critical anatomic landmarks in clinical practices.