内镜下经口翼下颌皱襞内侧入路颈静脉孔区解剖学研究

doi:10.3969/j.issn.1672-6731.2023.07.005

摘要/Abstract

摘要：

目的: 探讨内镜下经口翼下颌皱襞内侧入路进入颈静脉孔区的解剖步骤，分析其临床施行之可行性。方法与结果: 于复旦大学附属眼耳鼻喉科医院鼻颅底肿瘤外科治疗技术创新单元解剖实验室以5具(10侧)尸头标本作为研究对象，模拟经口翼下颌皱襞内侧入路进入颈静脉孔区及其相邻结构的解剖步骤，观察并描述重要解剖标志。(1)颈静脉孔区解剖步骤：首先通过翼下颌皱襞内侧切口切开软腭黏膜、咽上缩肌进入咽旁前间隙，剔除间隙内脂肪组织，显露茎突咽筋膜和茎突肌群，切除茎突咽筋膜后进入咽旁后间隙，进一步显露颈内动脉并进入颈静脉孔区。(2)颈静脉孔及其毗邻解剖结构：颈静脉孔上界为颈静脉球窝，前方为颈内动脉，前外侧为茎突前外侧，后方为头外侧直肌、寰椎横突，内侧为舌下神经和枕髁内侧，外侧为乳突、二腹肌和面神经。结论: 经口翼下颌皱襞内侧入路进入颈静脉孔区视野良好，显露范围广泛，路径更短。

关键词: 颈静脉孔, 咽旁间隙, 内窥镜检查, 尸体解剖

Abstract:

Objective: To investigate the endoscopic transoral-medial pterygomandibular fold approach anatomic procedures for jugular foramen, and to analyze the clinical feasibility of this approach. Methods and Results: In the anatomical laboratory of the Surgical Treatment Technology Innovation Unit of Nasal Skull Base Tumor in Eye & ENT Hospital of Fudan University, a total of 5 specimens of necroheads (10 sides) were taken as research objects to simulate the anatomical steps of entering the jugular foramina and its adjacent structures through the oral pterygomandibular fold medial approach, and observe and describe important anatomical markers. 1) Anatomical procedures of the jugular foramen: firstly, the soft palate mucosa and suprapharyngeal retractive muscle were cut through the medial incision of pterygomandibular fold to enter anterior parapharyngeal space, the adipose tissue in the space was removed, and the stylopharyngeal fascia and stylopharyngeal muscle group were exposed. After the stylopharyngeal fascia was removed, the internal carotid artery (ICA) was further exposed and the jugular foramen was exposed. 2) The jugular foramen and its adjacent anatomical structures: the upper boundary of the jugular foramen was jugular bulbous fossa, the anterior was ICA, the anterolateral lateral was styloid process, the posterolateral boundary was the lateral rectus of head and transverse process of atlas, the medial boundary was the hypoglossal nerve and medial of occipital condyle, and the lateral boundary was the mastoid, digastric and facial nerves. Conclusions: Endoscopic transoral-medial pterygomandibular fold approach for jugular foramen has better visual field, wider exposure range and shorter path.

Key words: Jugular foramina, Parapharyngeal space, Endoscopy, Autopsy

李静, 张焕康, 刘全, 顾晔, 薛凯, 孙希才, 余洪猛. 内镜下经口翼下颌皱襞内侧入路颈静脉孔区解剖学研究[J]. 中国现代神经疾病杂志, 2023, 23(7): 591-598.

Jing LI, Huan-kang ZHANG, Quan LIU, Ye GU, Kai XUE, Xi-cai SUN, Hong-meng YU. Endoscopic transoral - medial pterygomandibular fold approach anatomic study for jugular foramen[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2023, 23(7): 591-598.

https://journal11.magtechjournal.com/cjcnn/CN/Y2023/V23/I7/591

图/表 4

图 1 颈静脉孔区骨性结构所见 1a 正面观 1b，1c 右侧面观

Figure 1 View of bone structures in the jugular foramen. Front view (Panel 1a). Right lateral view (Panel 1b).

图 2 经口翼下颌皱襞内侧入路进入咽旁前间隙所见茎突前间隙解剖结构 2a 软腭解剖标志由中线向外依次为悬雍垂、腭咽弓、腭舌弓、翼下颌皱襞 2b 切开间隙内黏膜，显露咽上缩肌 2c 切开咽上缩肌，显露咽旁间隙外侧翼内肌以及间隙内脂肪组织 2d 剔除咽旁前间隙内脂肪组织，可见其上方外侧为腭帆张肌、上方内侧为腭帆提肌、内侧为咽上缩肌，茎突咽筋膜位于茎突肌群及咽上缩肌之间的三角区 2e 颈动脉鞘与头长肌之间可见咽后淋巴结，舌神经位于翼内肌前下缘自颞下窝穿行进入舌体 2f 茎突肌群外侧、翼内肌内后方可见茎突隔膜增厚形成茎突下颌韧带，茎突下颌韧带覆有茎突舌骨肌和部分颈外动脉分支

Figure 2 Anatomy of anterior styloid space through transoral - medial pterygomandibular fold approach into the anterior parapharyngeal space The anatomical marks of the soft palate were uvula, palatopharyngeal arch, palatoglossus arch and pterygomandibular fold from the center line outward (Panel 2a). The internal mucosa was incised to reveal the suprapharyngeal retractor (Panel 2b). The suprapharyngeal retractor muscle was incised to reveal the internal muscle of lateral parapharyngeal space and the adipose tissue within the space (Panel 2c). After removing the adipose tissue in the anterior parapharyngeal space, it could be seen the upper outside of the parapharyngeal space was the tensor veli palatine muscle, and the upper medial side was the levator veli palatine muscle, the inner side was the superior pharyngeal constrictor muscle, the stylopharyngeal fascia was located in the triangular area between the styloid process muscle group and the superior pharyngeal constrictor muscle (Panel 2d). The posterior pharyngeal lymph nodes could be seen between the carotid sheath and the longus capitis. The lingual nerve was located in the anterior inferior limb of the medial pterygoid muscle and passes through the inferior temporal fossa into the tongue body (Panel 2e). The styloid septum thickened to form the styloid mandibular ligament, which was covered by the styloid hyoid muscle and some branches of the external carotid artery (Panel 2f).

图 3 经口翼下颌皱襞内侧入路进入咽旁前间隙所见茎突后间隙解剖结构 3a 切除茎突咽筋膜和茎突隔膜，显露颈内动脉、颈内静脉及后组脑神经 3b 向外侧拨开颈内动脉，可见头外侧直肌和C1神经位于颈内静脉后方，后组脑神经及咽升动脉脑膜支位于其内侧 3c 向内侧拨开颈内动脉，可显露位于头外侧直肌表面的后组脑神经和C1神经 3d 岩骨下方、颈内动脉内前方有咽颅底筋膜附着 3e 于茎突肌群和腮腺之间切除茎突隔膜、茎突下颌韧带，逐一显露颈外动脉主干以及穿行于腮腺内部的下颌后静脉；颈外动脉分支枕动脉向内后方走行，穿行于二腹肌后腹与头外侧直肌之间，耳后动脉发出茎乳动脉进入茎乳孔营养面神经

Figure 3 Anatomy of the posterior styloid space through transoral- medial pterygomandibular fold into the anterior parapharyngeal space The stylopharyngeal fascia and stylopharyngeal septum were excised to reveal the ICA, internal jugular vein and posterior cranial nerve (Panel 3a). Pulling the ICA outside to see the rectus capitis lateralis, the C1 nerve, the medial posterior cranial nerve and the meningeal branch of the ascending pharyngeal artery behind the internal jugular vein (Panel 3b). The ICA was pushed aside, the posterior cranial nerve and the C1 nerve located on the surface of the lateral rectus capitalis muscle (Panel 3c). Under the petrous bone, the pharyngobasilar fascia attached to the inside and front of the ICA (Panel 3d). The styloid septum and the styloid mandibular ligament were removed between the styloid muscle group and the parotid gland, and the main ECA and the posterior mandibular vein running through the parotid gland were exposed one by one. The ECA branches and the occipital artery run inward and backward between the posterior abdomen of the digastric muscle and the lateral rectus of the head. The posterior auricular artery sent out the stylomastoid artery into the stylomastoid foramen to feed the facial nerve (Panel 3e).

图 4 经口翼下颌皱襞内侧入路进入咽旁间隙所见颈静脉孔区及其周围解剖结构 4a 显露咽旁后间隙，切除头长肌，可见咽升动脉脑膜支以及舌下神经出舌下神经管，并穿越寰枕侧韧带后下行 4b，4c 切除头前直肌，以提供进入整个斜坡的通道，包括髁上沟、枕骨大孔前缘、寰椎侧块和寰枕关节囊 4d 切除咽颅底筋膜、寰枕侧韧带、寰枕关节囊，显露岩尖 4e 于颈内动脉与茎突肌群之间，依次显露副神经、颈内静脉，以及颈内动脉和茎突肌群深面内侧的头外侧直肌、外侧的二腹肌，枕动脉于头外侧直肌与二腹肌后腹之间由外侧向内侧走行，并可见副神经越过头外侧直肌表面向外侧走行 4f 磨除颈静脉结节及枕髁骨质，显露颈静脉结节和舌下神经管，并进一步显露岩斜裂中岩斜下静脉，岩斜下静脉汇入岩部静脉汇 4g 完全显露颈静脉孔神经部，以及岩下窦，岩下窦与岩斜下静脉为脑膜内外的镜像结构，共同汇入岩部静脉汇，并在舌咽神经与迷走神经之间汇入颈内静脉 4h 磨除颈内静脉后方的部分枕骨颈静脉突以及附着其上的部分头外侧直肌，可见乙状窦汇入颈静脉球 4i 于寰椎横突孔和头外侧直肌内侧，可见椎动脉硬膜外段，向上向后穿入脑膜

Figure 4 Anatomy of the jugular foramen and adjacent anatomy through transoral- medial pterygomandibular fold approach After exposing the posterior parapharyngeal space, the longus capitis muscle was excised, and the ascending pharyngeal artery meningeal branch and the hypoglossal nerve emerged from the hypoglossal neural tube and passed through the atlanto - occipital ligament to descend posteriorly (Panel 4a). The anterior rectus capitis was resected to provide and access to the supracondylar groove, lateral mass of the atlas, and capsule of the atlanto - occipital joint (Panel 4b, 4c). Resecting the pharyngobasilar fascia, lateral atlanto - occipital ligament, exposing the petrous apex (Panel 4d). Between the ICA and the styloid muscles, the accessory nerve, the internal jugular vein, and the deep medial rectus capitis lateralis, and the digastric muscle laterally, the occipital artery runs from the inside to the outside between the the lateral rectus capitis and posterior belly of digastric muscles. And the accessory nerve crosses the surface of the lateral rectus capitis and runs to the outside (Panel 4e). Grinding away the bone of the jugular tubercle and occipital condyle, exposing the jugular tubercle and the hypoglossal canal, and further exposing the inferior petroclival vein in the petroclival fissure, which flows into the petrous vein confluence (Panel 4f). The inferior petrosal sinus and inferior petrooblique vein were mirror structures inside and outside the meninges, and they were merged into the petrosal venous confluence, and into the internal jugular vein between the glossopharyngeal nerve and the vagus nerve (Panel 4g). Grinding away part of the jugular process and part of the lateral rectus capitis attached to it, the sigmoid sinus can be seen to merge into the jugular bulb (Panel 4h). In the medial side of the transverse process foramen and the lateral rectus muscle, the epidural VA can be seen, and was upward and then penetrating the meninges (Panel 4i).

参考文献 20

1	Snyderman CH , Pant H , Carrau RL , Prevedello D , Gardner P , Kassam AB . What are the limits of endoscopic sinus surgery: the expanded endonasal approach to the skull base. ? Keio J Med, 2009, 58: 152- 160. doi: 10.2302/kjm.58.152
2	Komune N , Komune S , Matsushima K , Rhoton AL . Comparison of lateral microsurgical preauricular and anterior endoscopic approaches to the jugular foramen. J Laryngol Otol, 2015, 129(Suppl): S12- S20.
3	Bejjani GK , Sullivan B , Salas-Lopez E , Abello J , Wright DC , Jurjus A , Sekhar LN . Surgical anatomy of the infratemporal fossa: the styloid diaphragm revisited. Neurosurgery, 1998, 43: 842- 852. doi: 10.1097/00006123-199810000-00072
4	Liu J , Pinheiro-Neto CD , Yang D , Wang E , Gardner PA , Hirsch BE , Snyderman CH , Fernandez-Miranda JC . Comparison of endoscopic endonasal approach and lateral microsurgical infratemporal fossa approach to the jugular foramen: an anatomical study. J Neurol Surg B Skull Base, 2021, 83(Suppl 2): e474- e483.
5	Lee DL , McCoul ED , Anand VK , Schwartz TH . Endoscopic endonasal access to the jugular foramen: defining the surgical approach. J Neurol Surg B Skull Base, 2012, 73: 342- 351. doi: 10.1055/s-0032-1322796
6	Sun X , Yan B , Truong HQ , Borghei-Razavi H , Snyderman CH , Fernandez-Miranda JC . A comparative analysis of endoscopic-assisted transoral and transnasal approaches to parapharyngeal space: a cadaveric study. J Neurol Surg B Skull Base, 2018, 79: 229- 240. doi: 10.1055/s-0037-1606551
7	Sun XC , Xue K , Liu Q , Zhang HK , Liu Q , Jiang XW , Zhao KQ , Gu Y , Song XL , Yu HM . Endoscopic transoral retropharyngeal lymphadenectomy. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2022, 36: 81- 86. URL
	孙希才, 薛凯, 刘强, 张焕康, 刘全, 蒋晓文, 赵可庆, 顾晔, 宋小乐, 余洪猛. 内镜经口入路咽后淋巴结切除术. 临床耳鼻咽喉头颈外科杂志, 2022, 36: 81- 86. URL
8	Fisch U . Infratemporal fossa approach to tumours of the temporal bone and base of the skull. J Laryngol Otol, 1978, 92: 949- 967. doi: 10.1017/S0022215100086382
9	Willson TJ , Fernandez-Miranda JC , Ferrareze Nunes C , Lieber S , Wang EW . Anatomic considerations for sinonasal and ventral skull base malignancy. Otolaryngolog Clin North Am, 2017, 50: 245- 255. doi: 10.1016/j.otc.2016.12.003
10	Vaz-Guimaraes Filho F , Wang EW , Snyderman CH , Gardner PA , Fernandez-Miranda JC . Endoscopic endonasal "far-medial" transclival approach: surgical anatomy and technique. Oper Tech Otolaryngol Head Neck Surg, 2013, 24: 222- 228. doi: 10.1016/j.otot.2013.09.003
11	Vaz-Guimaraes F , Nakassa ACI , Gardner PA , Wang EW , Snyderman CH , Fernandez-Miranda JC . Endoscopic endonasal approach to the ventral jugular foramen: anatomical basis, technical considerations, and clinical series. Oper Neurosurg(Hagerstown), 2017, 13: 482- 491. doi: 10.1093/ons/opx014
12	Maza G , Omar AMM , Subramaniam S , Otto BA , Prevedello DM , Carrau RL . Modified endoscopic endonasal approach with a minimally invasive transoral approach-an adjunct to infrapetrous approaches. Laryngoscope, 2019, 129: 339- 343. doi: 10.1002/lary.27469
13	Ozer E , Durmus K , Carrau RL , de Lara D , Ditzel Filho LF , Prevedello DM , Otto BA , Old MO . Applications of transoral, transcervical, transnasal, and transpalatal corridors for robotic surgery of the skull base. Laryngoscope, 2013, 123: 2176- 2179. doi: 10.1002/lary.24034
14	Hoff SR , Edwards M , S B , Bailey CM , Koltai PJ . The transpalatal approach to repair of congenital basal skull base cephaloceles. J Neurol Surg B Skull Base, 2014, 75: 96- 103. doi: 10.1055/s-0033-1358374
15	Soriano RM , Rindler RS , Helman SN , Pradilla G , Solares CA . Endoscopic transoral nasopharyngectomy. Head Neck, 2021, 43: 278- 287. doi: 10.1002/hed.26483
16	Li L , London NR Jr , Gao Y , Carrau RL , Chen X . Endoscopic transoral approach for resection of retrostyloid parapharyngeal space tumors: retrospective analysis of 16 patients. Head Neck, 2020, 42: 3531- 3537. doi: 10.1002/hed.26415
17	Liu J , Liu Q , Wang H , Sun XC , Yu HM . Anatomical signs and adjacent relationship of parapharyngeal space through endoscopic transoral approach. Ju Jie Shou Shu Xue Za Zhi, 2022, 31: 297- 283. URL
	刘娟, 刘全, 王欢, 孙希才, 余洪猛. 内镜下经口入路咽旁间隙的解剖标志及毗邻关系. 局解手术学杂志, 2022, 31: 297- 283. URL
18	Basma J , Michael LM 2nd , Sorenson JM . Deconstruction of the surgical approach to the jugular foramen region: anatomical study. J Neurol Surg B Skull Base, 2019, 80: 518- 526. doi: 10.1055/s-0038-1676512
19	Zhang HK , Zhang M , Jiang XW , Xue K , Sun XC , Liu Q , Gu Y , Li WP , Song XL , Yu HM . The application of submental flap in the nasopharyngectomy for nasopharyngeal carcinoma. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2022, 36: 506- 509. URL
	张焕康, 张明, 蒋晓文, 薛凯, 孙希才, 刘全, 顾晔, 李万鹏, 宋小乐, 余洪猛. 颏下瓣在鼻咽癌手术修复中的应用. 临床耳鼻咽喉头颈外科杂志, 2022, 36: 506- 509. URL
20	Liu Q , Sun XC , Wang H , Zhang HK , Yu HM , Wang DH . Anatomy of transposition of the temporalis muscle flap for skull base reconstruction. Jie Pou Xue Bao, 2020, 51: 659- 663. URL
	刘全, 孙希才, 王欢, 张焕康, 余洪猛, 王德辉. 颞肌瓣鼻颅底区转位的解剖. 解剖学报, 2020, 51: 659- 663. URL

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