耳鼻咽喉头颈外科学：鼻应用解剖及生理学症状学

1、鼻应用解剖及生理学症状学,耳鼻咽喉头颈外科学,解剖相沟通 生理相关联 病理相影响 检查有共性 治疗相辅佐,鼻应用解剖,外鼻：面部正中间 后方为鼻腔 鼻腔：前鼻腔固有鼻腔 鼻窦：上颌窦筛窦额窦蝶窦,外 鼻,骨 软骨 皮肤,外鼻,外鼻标志,外鼻骨性支架,额骨的鼻突（部） 鼻骨 上颌骨额突 腭突,Nasal Bone,vary in size considerably fused and form bridge of nose the point of junction with the frontal bone is the nasion articulates with 2 cranial an

2、d 2 facial bones,Nasal bone fracture,the most common facial fracture type . etiology : assault , motor vehicle collision , falls , sports , occupations . may cause deformity of the nose , swelling, skin laceration, epistaxis, cerebrospinal rhinorrhea. treatment: closed reduction and open reduction .

3、,Trauma,Nasal bone fracture is diagnosed by palpation, not x-ray. If other facial fractures are suspected, the most useful study is a thin-cut (1-3 mm) axial CT of the face with coronal reconstructions Nasal fracture is quite common during birthgreenstick type simple treat adult fracturesmash both t

4、o one side - frontal blow depress bone -various other injures -facial fracture inferior orbital rim or zygoma,Trauma,External nose lacerated compound fracture may exist Usually simple nasal fracture Cartilage of septum injure but not nasal bone Both Cartilage of septum and nasal bone Occasionally th

5、e tip of nose injure independently,The intercanthal line demarcates the transition point between thicker nasal bone superiorly and thinner bone inferiorly. Most nasal fractures will occur below this level,Examples of nasal fracture patterns,Trauma,Treatment is not difficult Aim of ruduction are to o

6、btain a satisfactory airway and to restore the original appearance of the nose Lateral type of fracture smash inward and other outward simple thumb press back on the convex side Depressed fracturereduction under local or general anesthesia an elevator or a hemostat cover with a thin rubber tubing is

7、 used to pry up the nasal bone,Closed nasal reduction.,After marking the distance of the intercanthal line on the elevator with a thumb, the tip of the instrument is used to reduce the medialized fragment. The opposite thumb may simultaneously reduce a contralateral outfractured nasal bone,Closed se

8、ptal reduction using Asch forceps.,A, Deviated nose prior to septoplasty. B, The significant correction of the deviated nose with septoplasty alone,Trauma,Comom errors Set nasal fracture many years previously a new trauma X-ray reneal no fracture but actually there is little pracal value clinic judg

9、ement is much more important An easy-to-reduce fracture too seriously or a severe fracture too lightly Wait too long to reduce the fracture within 1 week,梨状孔和隔背软骨,外鼻软骨支架,外鼻皮肤,薄：鼻根鼻梁及其侧面皮下组织疏松皱纹 厚：鼻尖鼻翼鼻前庭软骨膜紧密炎症疼痛剧烈 鼻尖鼻翼皮肤含有较多汗腺及皮脂腺，粉刺座疮疖肿及酒渣鼻好发部位,外鼻神经,外鼻动脉,外鼻由鼻背动脉筛前动脉额动脉面动脉上唇动脉眶下动脉的分支,外鼻静脉,Dangerous

10、 triangle of the face,From corners of the mouth to nasion of the nose It is possible (although very rare) for retrograde infections from the nasal area to spread to the brain,外鼻淋巴,鼻腔,鼻腔冠状观,鼻腔分区,鼻前庭,前鼻孔和固有鼻腔之间位于鼻腔最前起于鼻缘止于鼻内孔或鼻阈 鼻翼软骨内侧面 鼻阈有调节呼吸功能 鼻前庭被覆皮肤丰富皮脂腺汗腺疖肿好发,固有鼻腔,鼻腔内侧面,为鼻中隔有骨和软骨组成,鼻中隔,鼻中隔偏曲,鼻腔外

11、侧壁,复杂和鼻窦密切联系 由上颌骨泪骨下鼻甲骨筛骨腭骨垂直板及蝶骨构成 三个阶梯状排列骨性组织:上鼻甲中鼻甲下鼻甲,Spheno-Ethmoidal Recess - Above Sup. Concha Superior Meatus - Below Sup. Concha Middle Meatus - Below Mid. Concha Inferior Meatus - Below Inf. Concha,Inferior meatus 1) opening of nasolarimal duct 2) maxillary sinus acupuncture Middle meatus

12、1) opening of frontal sinus and anterior ethmoid 2)ostiomeatal complex(OMC) : obstruction cause sinusitis Superior meatus: opening of posterior ethmoid,Ostiomeatal Complex(OMC),Agger nasi, nasofrontal recess , infundibulum, uncinate process ,ethmoidal bulla and the anterior group of ethmoidal air ce

13、lls. Anterior ethmoid, frontal and maxillary sinuses drain Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it Important landmark in FESS,窦口鼻道复合体,中鼻甲中鼻道及其附近区域，其解剖异常和病理改变与鼻窦炎关系密切 内镜鼻窦手术的基础,Landmarks in FESS,1) uncinate process: a curved lamina project

14、s downward and backward 2) ethmoidal bulla: rounded elevation below middle concha , formed by projection of middle ethmoidal air cells 3) hiatus semilunaris : C shaped slit between uncinate process and bulla,鼻腔黏膜,嗅区黏膜：鼻腔顶中部，下至中隔上部和鼻腔外侧壁上部 呼吸部黏膜：前1/3自前向后为鳞状上皮移行上皮假复层上皮后2/3为假复层纤毛上皮,鼻腔顶壁,顶壁,鼻腔底壁,底壁,前后鼻孔

15、,前后鼻孔,鼻腔血管,Internal carotid a.,Opthalmic a.,Anterior ethmoidal a.,Posterior ethmoidal a.,Internal carotid artery,Superior orbital fissure,Posterior ethmoidal foramen,Posterior entmoidal sinus, sphenoid sinus,Cribiform plate,Lateral branch,Septal branch,Posterosuperior of lateral nasal wall and septu

16、m,Anterior entmoidal sinus, frontal sinus, dura,Anterior ethmoidal foramen,Nasociliary nerve,Lateral branch,Septal branch,Anterosuperior of lateral nasal wall and septum,External carotid artery,External carotid a.,Internal maxillary a.,Facial a.,Superior labial a.,Septal branch,Anterior nasal septum

17、, vestibule,Descending palatine a.,Sphenopalatine a.,Pterygopalatine fossa,Sphenopalatine foramen,Posterior lateral nasal branch,Septal branch,Lateral wall of nasal canal, Middle, inferior turbinate & Meatus, ethmoid & maxillary sinus,Sphenoid bone,Lower septum, anterior septum (Littles area),Lesser

18、 palatine,Greater palatine,Greater palatine canal,Anterior nasal septum,Lateral wall,Medial wall,Little area,Blood supply Anterior ethmoidal artery Septal branch of the sphenopalatine artery Greater palatine Branch from superior labial a (facial artery) These vessels anastomose in the region about 1

19、.5cm behind the anterior mucocutaneous junction,鼻腔血管,鼻腔淋巴,淋巴回流,鼻窦,鼻窦头颅骨的含气空腔 上颌窦 筛窦 额窦 蝶窦,鼻窦,Development of Sinuses,Ethmoid are present at birth and developed at 3 years of age Maxillary are present at birth and developed by 3 years of age Sphenoid are present at 3 years of age and developed by 12 y

20、ear of age Frontal are present at 8 years of age and developed by 12 years of age,Drainage,Frontal : nasofrontal duct into the ethmoid infundibulum of the middle meatus Anterior ethmoid : middle meatus Posterior ethmoid : superior meatus Sphenoid : sphenoethmoid recess,上颌窦,上颌窦,The Maxillary Sinus,-

21、Largest, occupies entire body of maxilla - Roof : floor of Orbit -Floor : alveolar process of maxilla and hard palate - Medial: nasal lateral wall -Anterior: canine fossa -Posterior: infratemporal space, pterygomaxillary fossa,The Maxillary Sinus,MS: maxillary sinus, MT: middle turbinate MO: maxilla

22、ry sinus ostium *:hiatus semilunaris,Coronal image,The Maxillary Sinus,MS: maxillary sinus, NLD: nasolacrimal duct, IT: inferior turbinate,Axial image,筛窦,筛骨前面观,筛骨上面观,The Ethmoid Sinuses,a) Orbit-papyraceous lamina b) Lamina cribrosa- horizontal ethmoidal bonec) Nasal septumd) Superior conchae) Middl

23、e concha f) Inferior conchag) Ethmoid cellaeh) Maxillary sinus i) Hard palate,The Ethmoid Sinuses,CG: crista galli MT: middle turbinate IT: inferior turbinate,Coronal image,arrowhead showing lateral attachment of basal lamellae to lamina papyracea marked by the arrow,The Ethmoid Sinuses,AE: anterior

24、 ethmoid PE: posterior ethmoid NS: nasal septum SpS: sphenoid sinus,Axial image,The Ethmoid Sinuses,AE :anterior ethmoid PE: posterior ethmoid sinuses. FS: frontal sinus AG: agger nasi cell SpS: sphenoid sinus MT: middle turbinate,Sagittal image,arrow showing vertical attachment of basal lamellae to

25、 anterior skull base separating AE and PE sinuses.,The Ethmoid Sinuses,Arrowhead demonstrating anterior ethmoid drainage to hiatus semilunaris and middle meatus. Arrow showing posterior ethmoid drainage to sphenoethmoidal recess and superior meatus.,Sagittal image,额窦,额窦,The Frontal Sinus,Axial image

26、,Coronal image,The Frontal Sinus,* : shows frontal sinus ostium arrow: pointing to the superior compartment of the FSDP. FS: frontal sinus AG: agger nasi PE: posterior ethmoid SpS: sphenoid sinus MT: middle turbinate IT: inferior turbinate,Sagittal image,蝶窦,蝶窦的位置及开口,The Sphenoid Sinus,* : sinus osti

27、um SER: sphenoethmoidal recess PE: posterior ethmoid sinus,Sagittal image,The Sphenoid Sinus,FR: foramen rotundum VC: vidian canal OC: optic canal AC: anterior clinoid PtP: pterygoid plate,Coronal image,Endoscopic view of the right sphenoid ostium,The sphenoid ostium (arrow) can be found at SER and

28、provides an important landmark for the level of the sphenoid sinus. SER : sphenoethomoid recess,landmarks on the posterior wall of the sphenoid sinus,The asterisk indicates the tuberculum sellae C = clivus ICA = internal carotid artery OCR = opticocarotid recess ON = optic nerve S = sella SP = sphen

29、oid planum.,鼻窦血管,鼻窦血管,鼻窦血管,鼻窦血管,鼻窦神经,鼻窦淋巴,鼻颅相关解剖学,鼻颅底：筛板 额窦后壁 筛窦顶 蝶窦的上后侧壁与颅相连 鼻前颅底 前部：额窦的后壁 薄 黏膜与硬脑膜仅 有极薄的骨板 静脉相通 中央部：鼻腔顶的筛板和筛窦顶部 筛静 脉流入眼静脉入海绵窦 筛顶 与筛板的连接关系（高台型 倾 斜型 平台型 混合型,鼻颅相关解剖学,鼻中颅底 蝶窦区域 碟鞍 颈内动脉 海绵窦 视神经 管 视交叉及III IV V VI颅神经 蝶窦顶壁 蝶窦侧壁 鼻侧颅底（鼻与翼腭窝） 上颌骨与翼突间 前为上颌骨后为翼突 和蝶骨大翼顶为蝶骨体 内侧壁为腭骨,鼻眼相关解剖学,鼻窦与视神经管 后组筛窦和蝶窦关系密切 鼻窦与眶内侧壁 上颌骨额突 额骨 鼻突 泪骨 筛骨纸样板 蝶骨 鼻腔和泪囊 泪囊长12-15mm 宽4-7mm 内侧壁与鼻腔： 鼻腔黏膜 上颌骨额突和泪骨 泪囊向下鼻泪管 长约15-20mm开口于下鼻 道顶端,外鼻生理,人种或种族有