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▼篩前動脈、篩后動脈（anterior and posterior ethmoidal artery）
▼在中顱底下方,，從外向內(nèi),，可見顳窩（Temporal fossa）內(nèi)有 顳肌（temporalis muscle）。 below the middle skull base laterally we see temporal fossa with temporalis muscle.
▼其內(nèi)側為顳下窩（infratemporal fossa）,，其向內(nèi)開口于翼腭窩（pterygopalatine fossa [t?r?ɡ??'p?le?ta?n]）,。 And then we come medially, we see infratemporal fossa that opens medially into pterygopalatine fossa.
▼翼腭窩（pterygopalatine fossa）
▼這是從側方所見的結構，可見如下三角： 床突三角（clinoidal triangle） And then looking at all of this from laterally, we see Clinoidal triangle,
▼動眼神經(jīng)三角（Oculomotor triangle）
▼滑車上三角(Supratrochlear triangle)
▼滑車下三角（帕金森三角）(infratrochlear triangle; Parkinson's triangle)
▼中顱窩前內(nèi)側三角（anteromedial triangle）
▼前外側三角(anterolateral triangle)
▼后外側三角（Glasscock's 三角）(posterolateral triangle)
▼后內(nèi)側三角（Kawase's 三角）(posteromedial triangles)
▼巖淺大神經(jīng)( Greater petrosal）
▼巖淺大神經(jīng),，其移行為 翼管神經(jīng)（vidian nerve）,，這是內(nèi)鏡下手術中非常重要的一個解剖標志。 Greater petrosal, and it is continuous with the vidian nerve. That's a very important landmark in endoscopic surgery.
▼巖淺小神經(jīng)（lesser petrosal） what nerve is this? This is lesser petrosal.
▼巖淺小神經(jīng)支配的神經(jīng)節(jié)是耳神經(jīng)節(jié)（Otic）,。其支配的腺體是腮腺（Parotid gland）,。 What ganglion does it innervate? Otic. And what gland does it innervate then? Parotid gland.But we always wanna have that vision from below to above, and above to below.
▼這是常用的前顱窩入路。 這里我們抬起了骨膜瓣（pericranial flap） Here's the common approach that we'll use to anterior fossa. We've elevated a pericranial flap,
▼顳肌（temporalis muscle）
▼對于該入路,，我們通常經(jīng)額竇做一個雙側額辦,，然后做一個額-鼻骨切除術 Commonly in approaching this area, we'll turn a bifrontal flap through the frontal sinus and then do a frontal-nasal osteotomy
▼從而同時顯露顱底上下方。 that will give us the area above and below the skull base.
▼因此該入路可局限化,，也可擴大化,，暴露范圍可從一側的眶外側壁到另一側 So these approaches can be limited or they can be very extended, extensive that go all the way from lateral orbital wall on one side to the opposite side,
▼顯露的范圍包括雙側眼眶（orbits）、前顱窩,、 and gives you access to both orbits,anterior fossa,
▼鼻腔（nasal cavity）
▼正如我們所說的“透視”解剖功力 And you always want to have that X-ray vision from above to below.
▼在前方,，可見額竇，其范圍可很大,。 And anteriorly we see frontal sinuses that can be very extensive.
▼后方是篩竇（ethmoid sinus） Behind that,ethmoid sinuses, and then
▼蝶竇（sphenoid sinus）
▼側方是眼眶,。這些區(qū)域都應該被術者暴露。 and laterally, the orbits. So that,we want to be able to deal with all of these areas.
▼從上方,，我們可很好地暴露眼眶,。從上方可輕易進入蝶竇，即為經(jīng)顱-經(jīng)蝶入路,。 From above, we have great access to orbit.You can fall into the sphenoid sinus from above and do a transcranial-transsphenoidal approach.
▼也可暴露海綿竇頂壁,，對于側壁的顯露不是該入路的優(yōu)勢,。 You have access to the roof of the cavernous sinus,not very good to the lateral wall.
▼我們需要具備貫視上下的“透視”解剖功力，將前顱窩下方的所有這些解剖結構了然于心,。 But you want to have the see-through-X-ray vision looking from above, and have a good perception of all of this anatomy below the anterior fossa.
▼現(xiàn)在來看看這一入路的實際操作,。掀起骨膜辦 So that, coming from above you can access much of this anatomy,pericranial flap.
▼顯露雙側眼眶?？梢?strong>內(nèi)眥韌帶(Medial canthal ligament),，如果切斷它,在做廣泛的經(jīng)眶壁入路時，我們須在關顱時重新縫合該韌帶,，以免眼球的外移,。 The orbits are freed up.Medial canthal ligament,that if you divide it, you...if you're dealing with extensive opening of the wall of the orbit,you want to re-approximate it at the end of the procedure or the globe can drift laterally.
▼這里已將內(nèi)眥韌帶切斷 And here we've divided the medial canthal ligament,
▼這是鼻淚管（nasolacrimal duct） [n?'s?le?kr?ml]
▼這個是穿行于眶內(nèi)側壁的篩前動脈，該動脈穿過篩板（cribriform plate） coming through the medial wall of the orbit is the anterior ethmoidal artery. It's going to run across the cribriform plate.
▼上述開顱可進一步擴大化,，進而形成經(jīng)顱-經(jīng)顱底入路,。 So, these openings can be very extensive and we'll turn this into a transcranial-transbasal procedure.
▼這是篩板處的硬膜。 the dura at the cribriform plate.
▼我們可切除篩板周圍的骨質(zhì) We can do an osteotomy around the cribriform plate.
▼這里我們經(jīng)額竇后方打開部分篩竇氣房（ethmoid air cells）,。 Here we're in back of frontal sinus into some of the ethmoid air cells.
▼現(xiàn)在我們切除了篩板周圍骨質(zhì),，但這一操作常需犧牲嗅覺。這是篩前動脈（下圖）,，該血管穿行于篩板,，并進入大腦鐮，可能成為鐮旁腦膜瘤的供血動脈,。 Here we've done the osteotomy around the cribriform plate, but that usually doesn't lead to preservation of olfaction.These are anterior ethmoidal.This artery running across the cribriform plate and eventually extending into the falx and possibly supplying falcine meningioma is an anterior ethmoidal artery.
▼我們可暴露蝶竇,、鼻腔（nasal cavity）、篩竇,。 We have access to the sphenoid, to the nasal cavity, to the ethmoids.
▼繼續(xù)向后解剖,，可進入蝶竇。走行于蝶竇下界的動脈,，是由側方的蝶腭動脈（sphenopalatine artery）發(fā)出的（下圖）,。它們是上頜動脈的分支，后者行經(jīng)顳下窩和翼腭窩,。因此,，蝶腭動脈恰位于鼻腔的外側壁。 And as we open backward, we're into sphenoid sinus. Now running along the lower margin of the sphenoid sinus are arteries that arise from laterally from what arteries? These are sphenopalatine arteries that are branches of the maxillary arteries that run through the infratemporal and pterygopalatine fossa.So these're just in the lateral wall of the nasal cavity here.
▼這一入路的外側界,，在前方是視神經(jīng),。沿著蝶竇底走行的是翼管神經(jīng)（Vidian nerves） The lateral limit of the exposure anteriorly,are the optic nerves. Now, what are these? What runs along the floor of sphenoid sinus? Vidian nerves
▼翼管神經(jīng) 前行至 翼腭神經(jīng)節(jié)（pterygopalatine ganglion），位于鼻腔的外側壁,。我經(jīng)歷了上千次經(jīng)蝶手術操作后才意識到,，走行于蝶竇底壁的翼管神經(jīng)常有骨質(zhì)覆蓋，但也有可能直接暴露于黏膜下，就如同該例,。在內(nèi)鏡下,，它們可作為重要標志,，引導我們向后至頸內(nèi)動脈巖骨段的末端。 Vidian nerves that come forward to the vidian...the ganglion here...the pterygopalatine ganglion in the fossa here in the lateral wall of the nasal cavity.I must have done a thousand transsphenoidal operations going to the sella before I realize that the vidian nerves running in the floor of sphenoid sinus often covered by bone in the floor but they may be exposed as in this case, directly under the mucosa.And in the endoscopic procedure they are great guides that lead us back to the terminal part of the petrous carotid artery.
▼現(xiàn)在我們打開了蝶竇,?？梢?span>翼管神經(jīng)引導我們至頸內(nèi)動脈巖骨段的末端，后者迂曲向上移行為海綿竇段,，后者是我們術野暴露范圍的外側界,。 And here we've opened sphenoid sinus.Here the vidian nerves that lead us back to the terminal part of the petrous carotid that blends upward into the cavernous carotid. And these arteries are in the lateral margin of the exposure.
▼接下來我們進一步打開斜坡（clivus），即經(jīng)顱-經(jīng)顱底入路,。 And here we've opened the clivus in this transcranial-transbasal exposure.
▼切開硬膜后,，可見椎動脈（vertebral arteries） And then we've opened the dura. We see vertebrals,
▼基底動脈（basilar artery） [?b?s?l?r]
▼小腦前下動脈（AICA）
▼外展神經(jīng)（abducens nerve）[?b'dju:s?nz]
▼三叉神經(jīng)上頜支，行于眶底及上頜竇頂,。 that runs in the floor of the orbit and in the roof of the maxillary sinus? V2 here.
▼這里讓我們看看左側眼眶下的結構,，這是翼腭窩。 And here we're looking under the orbit in the lateral part of this exposure. Here's pterygopalatine fossa.
▼這是上頜竇（maxillary sinus）,。因此,，通過經(jīng)顱-經(jīng)顱底入路，上述部位都可暴露,。 And this is maxillary sinus.So in transcranial-transbasal approach, you can access all of these areas.
▼同時還可以實現(xiàn)如下的硬膜下暴露,，而不僅僅是上述的硬膜外暴露。 You have intradural access as well as extradural exposure
▼通過這一入路,，我們可顯露蝶鞍（sella）,。 You have access to sella in the transcranial-transbasal approaches.
▼進一步打開終板（Lamina Terminalis） Here we've opened the Lamina Terminalis,
▼可一直暴露至中腦導水管（aqueduct [??kw??d?kt]）。 and you're looking all the way back and to the aqueduct.
▼以上就是從上方入路對前顱底的顯露,。 So now, that's coming from above.
▼然而,，隨著現(xiàn)今內(nèi)鏡技術的發(fā)展,，我們還需了解從下方經(jīng)內(nèi)鏡暴露前顱底的入路,。通過內(nèi)鏡，我們從下方暴露的范圍從篩板(下圖）,， But today with the endoscopic approaches,we need to understand access from below and,using the endoscope from below we have access from cribiform plate,
▼甚至從額竇（下圖）， even to the frontal sinus
▼直至下方的樞椎齒狀突（odontoid [?'d?nt??d]）以及寰椎（atlas）的下界，都可由經(jīng)鼻入路實現(xiàn)。 all the way down to the odontoid and the lower margin of the C1 in these transnasal approaches.
▼因此,，我們需同時掌握上方入路和下方入路,。 So, you want to have the view from above, but you also want to develop that view from below upward.
▼我們來看一下顱底下方的結構,，鼻腔位于中線。 And if you Look at the area below the skull base, we have nasal cavity in the midline,
▼經(jīng)過鼻腔,，我們暴露的范圍可從篩板,，其位于直回（gyrus rectus）下方， that through the nasal cavity you have access from cribiform plate,here below gyrus rectus,
▼一直向后至蝶鞍,，向下至斜坡,。 all the way back to the sella,and down the clivus.
▼在側方有上頜竇。因此,，通過內(nèi)鏡技術,，在前方，我們可利用上頜竇和鼻腔,，暴露從一側到另一側的眶外側壁（lateral orbit）,。 But laterally you have the maxillary sinuses.And so if you look at this, think about the endoscopic possibilities from the front,using maxillary sinus and nasal cavity,you have access from lateral orbit all the way to contralateral lateral orbit.
▼這是顳肌（Temporalis Muscle） What muscle is that？Temporalis Muscle.
▼通過上頜竇的后壁,，我們可進入顳下窩 (infratemporal fossa),。 Coming through the back wall of the maxilla you have access to what fossa here? And then we go medially is infratemporal fossa.
▼進一步可顯露翼腭窩。通過上頜竇的后壁,，我們可進入翼腭窩,，其位于鼻腔的外側。 And then if we go into the pterygopalatine fossa, here, at the back...through the back wall of the maxillary sinus, we have access to pterygopalatine fossa in the lateral wall of the nasal cavity.
▼這里看到的是上頜動脈（infratemporal fossa）,，行于鼻中隔上,。內(nèi)鏡下手術的一個重要步驟就是利用帶有上頜動脈血管蒂的鼻中隔粘膜辦（septal flap）修補顱底切口。 And here we see the branches of maxillary artery coming onto the nasal septum. And,an important step forward in endoscopic surgery has been the septal flaps hinged on branches of the maxillary artery.
▼來看一下鼻中隔（septum）的血供來源,。此處的供血動脈是篩動脈（ethmoidal arteries） So that, above you have septum supplied by arteries here, these are branches of ethmoidal arteries.
▼下方的鼻中隔的血供來自上頜動脈,，其蝶腭分支（sphenopalatine branch）供應鼻中隔下部的大部分血供,。利用這些粘膜辦有用于顱底的修補。 Below, here septum supplied by maxillary, sphenopalatine branch of maxillary artery that supply most of the the lower septum.You can turn flaps and mucosal flaps that help you closing, close up the skull base.
▼這些就是篩動脈（ethmoidal arteries）,，它們是眼動脈（ophthalmic artery）的分支,，走行于視神經(jīng)上方，并通過篩骨至大腦鐮（falx）,、篩板,，并向下行于鼻腔。 So here we see the ethmoidal arteries.that are branches of the ophthalmic artery that passes above the optic nerve and then through the ethmoids to the falx, cribiform plate,and turn downward in the nose.
▼這些是上頜動脈的分支,，其穿過蝶腭孔（sphenopalatine foramen）到達鼻中隔,。 And here we see these branches of the maxillary artery that come through the sphenopalatine foramen to this septum.
▼這里血供極為豐富。帶蒂粘膜辦可取自鼻甲（turbinate）,，或者鼻中隔（septum）,。 these arteries are fairly rich in supply. You can hinge a flap on a turbinate, or on the wall of the septum.
▼這里看到的就是鼻中隔粘膜辦（septal flap），由上頜動脈的分支供血,，可利用其修補前顱窩缺損,。 Here we see a septal flap started hinged on a branch of the maxillary artery.You can fill a large hole in the anterior fossa,
▼或者向下修補斜坡。 or fold it downward into the clivus.
▼這一技術推動了內(nèi)鏡技術在顱底外科的應用,。 So this has been one of the significant steps forwards in expanding these endoscopic approaches to the skull base.
▼接下來,，我們細細看一下每塊顱骨，并最終重塑出整個顱底,。下圖示篩骨（ethmoid bone）,，長有雞冠（crista galli）以附著大腦鐮（falx）。 We wanna just take a few minutes now and build a skull base.And, I was walking on the beach in Florida one day, and came on this skull.And someone said,this is a shark skull.Now what kind of shark do you think that is? What sort of shark has a skull that looks like that?Anyone wanna take a shot of that? For a cup of coffee, what is that? What do you think? Anyone live in a beach community? Well what kind of a shark has a crista galli that a falx attaches to?
▼中鼻甲（middle turbinate）亦附著于篩骨,。 Has a middle turbinate attached to it?
▼篩骨眶板構成眼眶的內(nèi)側壁,。 Has a plate here that faces the orbit?
▼篩骨還有內(nèi)含空氣的篩泡（ethmoid bulla） And then has some air filled bulla? Is that really a shark skull? What kind of bone is that? That's a human ethmoid bone.
▼接下來繼續(xù)構建我們的顱底，讓我們首先從位于中央的蝶骨開始,，其包括由蝶竇和蝶鞍組成的蝶骨體（下圖） So, now we'll build our skull base and we'll start at the center of the skull on the sphenoid bone, that has a body that contains the sphenoid sinus and sella,
▼蝶骨小翼（a lesser wing）
▼蝶骨大翼（a greater wing）
▼這是翼突（pterygoid process）。 And what do we call this? This is pterygoid process.
▼這區(qū)域的外側是 顳窩（temporal fossa）,，內(nèi)有顳肌附著,。 Now, out in this area,what fossa is this? What attaches here? Temporalis muscle.So this is temporal fossa.
▼這里是顳下嵴（infratemporal crest） And then there is a infratemporal crest.
▼顳下嵴內(nèi)側，位于蝶骨大翼下方是 顳下窩,。 And medial to it below the greater wing is infratemporal fossa
▼顳下窩內(nèi)側,、在翼突前方的是 翼腭窩（pterygopalatine fossa） And then it opens medially here in front of the pterygoid process and what fossa is in this area? Is pterygopalatine.
▼眶上裂（Superior orbital fissure）
▼翼管神經(jīng)（vidian nerve）行于蝶竇底，穿行于翼管（Vidian canal 下圖）,，進入翼腭窩 至 翼腭神經(jīng)節(jié)（pterygopalatine ganglion） [t?r?ɡ??'p?le?ta?n],。 What foramen is this? what comes through here,in the floor of sphenoid sinus?Vidian canal for vidian nerve that enters pterygopalatine ganglion in the fossa.
▼這是圓孔（foramen rotundum [r??'t?nd?m] 下圖），其內(nèi)走行的是進入翼腭窩的三叉神經(jīng)上頜支,。 And this is foramen rotundum through which 2nd division passes to enter pterygopalatine fossa.
▼因此,，在這一區(qū)域,，我們可見蝶竇、蝶鞍,，鼻腔側壁,、翼腭窩。 So that if we look here, just at this area, we see sphenoid sinus,sella,and in the lateral wall of the nasal cavity,we have what fossa? (pterygopalatine fossa)
▼進入翼腭窩的是 翼管神經(jīng),，其加入 翼腭神經(jīng)節(jié),。 And entering the pterygopalatine fossa here is what nerve? Vidian nerve that enters the ganglion.
▼這里，稍外上方的是圓孔,，其內(nèi)穿行有三叉神經(jīng)上頜支,，并進入翼腭窩。 And here,a little bit superior and lateral is foramen rotundum through which 2nd division passes to enter the pterygopalatine fossa.
▼那么,，連于此處的是哪塊顱骨,？什么位于蝶骨的前方？ So now, what bone is going to fit in this area? What backs up to the front of the sphenoid?
▼篩骨（Ethmoid bone）
▼這是篩板（cribriform plate） that has cribriform plate,
▼眶板（orbital plate 下圖）,，此處的篩骨紙板（lamina papyracea ['l?m?n?]）,，構成眼眶菲薄的內(nèi)側壁，可輕易地通過它進入眼眶,，這常在內(nèi)鏡下經(jīng)篩骨入路中用到,。 and orbital plate,This lamina papyracea here,that thin medial wall of the orbit, it's easy to get through it and get into the orbit when you're doing some of the endoscopic procedures through the ethmoid.
▼這是篩骨垂直板（perpendicular plate [?p?:p?n?d?kj?l?(r)] 下圖），其構成鼻中隔的上部,。 Here we see perpendicular plate of the ethmoid that formsthe upper part of the nasal septum.
▼從上方看篩骨,，這是篩板（下圖）。篩竇氣房開口于前顱窩嗎,？在篩板的外側,，額骨構成了篩竇氣房的頂。 Now we're looking at ethmoids from above,cribriform plate. Do the ethmoid air cells open into the anterior fossa? What roofs the ethmoid air cells lateral to the cribiform plate? Is it actually open here under the dura? No.
▼這是下面觀,。額骨構成篩竇氣房的頂壁,，位于篩切跡（ethmoidal notch 下圖）的外側，篩切跡正是篩板的位置,。 The frontal bone roofs the ethmoid air cells lateral to this ethmoidal notch where the cribriform plate sits. This is the view from below.
▼這是上面觀,。篩板正位于此處。 Here is the view from above. And the cribiform plate fits in this area.
▼篩竇氣房頂壁由額骨篩切跡外側的額骨構成,。 And the ethmoid air cells are roofed by the frontal bone lateral to this ethmoidal notch.
▼我們繼續(xù)構建顱底,。我們將額骨和蝶骨拼接，再放上篩骨,。 So, we'll continue building the skull base. And,we put frontal bone with sphenoid.We add in an ethmoid.
▼額骨構成眼眶上緣,。上頜骨、上頜骨額突構成眶內(nèi)側緣以及眶底。鼻骨在內(nèi)側,。淚骨在后方,。 The frontal bone forms the upper part of the orbital rim.What bone forms the medial part of the orbital rim and fits right here? What bone? I heard lacrimal bone.Any other possibilties? What about nasal bone? what bone is this that attaches to the frontal bone here? Maxilla.The frontal process of the maxilla forms the medial part of the orbital rim as well as the lower part.The nasal bones are medial.The lacrimal bone is posteriorly.
▼上頜骨 And this maxillary bone
▼上頜骨有一巨大空腔（上頜竇），經(jīng)過此上頜竇 打開上頜骨,。 maxillary bone has a large cavity in it,a large sinus through which if you open the maxilla,
▼向后方打開上頜竇后壁,，即可進入翼腭窩（下圖）。這是眶上裂（下圖）,，圓孔在上頜骨后方開口于翼腭窩,。翼管在稍內(nèi)側。 if you go directly backwards,and open the back wall, you can enter pterygopalatine fossa.And here we see superior orbital fissure and foramen rotundum opening behind the maxilla into pterygopalatine fossa.The vidian canal is a little medial.
▼打開上頜竇外側壁,，則進入顳下窩,。繼續(xù)向外側，甚至可進入顳窩,。也可打開上頜竇內(nèi)側壁而進入鼻腔,。 If you open the lateral wall,you enter this fossa which is infratemporal fossa.And you can even open laterally and get into temporal fossa.You can also open the medial wall of the sinus and access the nasal cavity.
▼因此，我們?nèi)舸蜷_上頜竇后壁,， So that if we look at back wall of maxillary sinus and open it,
▼在上頜竇后方即可見翼腭窩（下圖） well, directly behind it we have pterygopalatine fossa,
▼三叉神經(jīng)上頜支（下圖） and V2,，
▼可見翼管神經(jīng)末端、翼腭神經(jīng)節(jié)（下圖）,。 the terminal end of vidian nerve, pterygopalatine ganglion.
▼打開上頜竇外側壁,，則可進入顳下窩（下圖） If we open the lateral wall of the maxillary sinus,then we have access then to infratemporal fossa
▼可見翼肌（ pterygoid muscles）、翼狀靜脈叢（pterygoid venous plexus）,、 with pterygoid muscles, pterygoid venous plexus,
▼上頜動脈分支（下圖） branches of maxillary artery,
▼以及卵圓孔（ovale [??'ve?l]）下方的三叉神經(jīng)下頜支的各分支,。 plus branches of V3 below ovale.
▼內(nèi)鏡下，通過經(jīng)鼻入路,，暴露范圍可上至蝶骨平臺,，下至齒狀突。 But endoscopically we can access from planum all the way down to the odontoid using transnasal approaches.
▼如果進一步針對鼻腔外側壁操作,，磨除三叉神經(jīng)上頜支與下頜支之間的骨質(zhì) And if we work off in the lateral wall of the nasal cavity,and drill out this bone between V2 and V3,
▼我們可沿著翼管神經(jīng),，向后暴露頸內(nèi)動脈巖骨段，打開海綿竇前內(nèi)側壁,。這些即為經(jīng)鼻入路的暴露范圍,。 we can follow the vidian nerve backwards here on the petrous carotid. We can access anteromedial wall of cavernous sinus.So these are some of the possibilities.
▼這里（下圖）是鼻腔、篩竇后壁,。打開上頜竇即可顯露翼腭窩。三叉神經(jīng)上頜支自圓孔穿出,。 Here we see nasal cavity,back wall of ethmoids.And here we are looking through the back wall of the maxillary sinus at pterygopalatine.And this is V2 at rotundum [r??'t?nd?m]
▼這是翼腭神經(jīng)節(jié),。 And here is the pterygopalatine ganglion.
▼觀察右側，可見翼管的前端（下圖）。循著翼管神經(jīng)向后,，沿著蝶竇側壁,，可至頸內(nèi)動脈巖骨段末端。 On one side that's the anterior end of vidian canal.And we can follow that nerve back in the lateral wall of the sphenoid sinus to the terminal petrous carotid
▼從左側觀察,，這是眼眶,、上頜竇外側壁。 here we're looking from lateral,orbit,lateral wall of maxillary sinus.
▼下圖示上頜竇已經(jīng)打開,。若打開其后壁,，則可暴露三叉神經(jīng)上頜支，其位于翼腭窩內(nèi),。 We've opened the sinus. If you open the back wall we can access V2,，in pterygopalatine fossa.
▼若向稍外側進一步暴露則可顯露三叉神經(jīng)下頜支，其位于顳下窩內(nèi),。 If we open it more lateral, we can access V3 and trigeminal nerve here in infratemporal fossa.
▼從左側觀察下外側,。這是蝶骨的顳下嵴。 So,here's just a view inferolateral.And here is infratemporal crest on sphenoid bone.
▼這是顳窩,。顳窩與眶下裂相溝通,。 what fossa is this? Temporal fossa.And you see the temporal fossa opens into inferior orbital fissure.
▼顳下嵴內(nèi)側為顳下窩，位于蝶骨大翼的下方,。其向上與眶下裂溝通,。 Then medial to the infratemporal crest is infratemporal fossa here,below the greater wing of the sphenoid.It opens above through the inferior orbital fissure.
▼下圖示翼腭窩，其位于上頜骨后壁與翼突之間,。其向上也開口于眶下裂,。 And then here is pterygopalatine fossa between the back wall of the maxilla and the pterygoid process.And it opens upward into inferior orbital fissure.
▼再從下方看右側?？梢?span>上頜竇后壁,、顳下窩，三叉神經(jīng)下頜支進入顳下窩,。 So this is just a view from below now.We are looking at back of maxillary sinus from below,infratemporal fossa,V3 branches entering infratemporal fossa.
▼這是翼腭窩,。三叉神經(jīng)上頜支出自圓孔。 Here is pterygopalatine fossa.V2 atrotundum.
▼翼管神經(jīng)進入翼腭窩,。 And what nerve is this? Vidian that enters pterygopalatine fossa.
▼從下方看右側蝶鞍,，翼管神經(jīng)行于蝶竇底。巖淺大神經(jīng)沿著頸內(nèi)動脈巖骨段移行為翼管神經(jīng)進入翼腭窩,。 So that, if you look at the sella from below,here we have vidian nerve running along the floor of the sphenoid sinus.And,greater petrosal nerve on petrous carotid becoming vidian nerve entering pterygopalatine fossa.
▼三叉神經(jīng)上頜支也進入翼腭窩,。 And then 2nd division entering pterygopalatine fossa.
▼經(jīng)蝶暴露至蝶竇側壁，磨除蝶竇側方的骨質(zhì),，即在圓孔和卵圓孔之間磨除一小塊骨質(zhì),，即可獲得前內(nèi)側視野至海綿竇內(nèi)側。 上述內(nèi)容是內(nèi)鏡下經(jīng)鼻入路的解剖學基礎。 And if you're in the lateral wall of the transsphenoidal exposure,and you drill off this bone in the lateral wing of the sphenoid sinus,between rotundum and ovale,just taking that little bit of bone, gives you anteromedial access to the medial part of cavernous sinus.So this is some of the anatomic basis of the endoscopic approaches.
▼我們繼續(xù)加上顴骨（zygomatic bone） [?za?g?'m?t?k] Well we add in the zygomatic bone.
▼這是完整的眼眶骨性結構,，但我們暫時不展開討論,。 We complete this orbit and I won't talk a lot about this but we need to move on.
▼這是腭骨（Palatine bone ['p?l?ta?n]）。這在內(nèi)鏡下入路中非常重要,。 now what bone is this? This is an important bone in the endoscopic approaches.This is what bone?Palatine bone.
▼腭骨有一塊垂直板（perpendicular plate）和一塊水平板（horizontal plate）,。 It has a perpendicular and a horizontal plate.
▼兩塊腭骨連接構成硬腭的后部。垂直板構成了翼腭窩的內(nèi)側壁,。 The plates fit together,like this to complete the posterior part of the hard palate.The perpendicular part forms the medial wall of the pterygopalatine fossa.
▼中鼻甲后部附著于上方,，位于蝶腭孔下方鼻腔側壁。 下方為下鼻甲后部的附著處,。 And what attaches here below the sphenopalatine foramen that is in the lateral wall of the nasal cavity? That's the attachment of the posterior part of the middle turbinate. Here's the attachment of the posterior part of the inferior turbinate.
▼這是腭骨的眶突（orbital process）,，其參與構成眶底的一小部分。 And here there's a orbital process of the palatine bone that forms a small part of the floor of the orbit.
▼這是腭骨的蝶突（sphenoid process）,，在蝶竇下方與蝶骨下部相連,。 This part, the sphenoid process joins the lower part of the sphenoid bone below the sinus.
▼這是蝶腭孔（sphenopalatine foramen 下圖），上頜動脈的分支經(jīng)由該孔進入鼻腔側壁,，供血于鼻甲和鼻中隔,。該孔位于中鼻甲附著處后部的上方。 And here's the sphenopalatine foramen through which the branches of the maxillary artery pass in the lateral wall of the nasal cavity to supply the turbinates and the nasal septum. And that foramen is just above the posterior attachment of the middle turbinate.
▼這就是腭骨,，構成翼腭窩的內(nèi)側壁,。 So here we see palatine bone forming medial wall of pterygopalatine foramen.
▼這根前行的神經(jīng)是三叉神經(jīng)上頜支。 走行自顳下窩及翼腭窩的上頜動脈分支繼續(xù)進入鼻腔并供血,。 This is what nerve passing forward? V2. And coming from infratemporal and pterygopalatine fossa is a branch of the maxillary artery then it supplies the nasal cavity.
▼這些顱骨拼接起來后,，這是上頜骨、構成翼腭窩內(nèi)側壁的腭骨,，以及后方的蝶骨,。 So the bones fit together something like this,maxilla, medial wall of pterygopalatine fossa formed by palatine bone,and then back posteriorly, sphenoid bone.
▼接下來，這塊難看的骨頭是下鼻甲（inferior turbinate）,。獨立成為一塊顱骨,。 Now what is this terrible looking bone? Is that a fish? That's inferior turbinate, which is its own bone.
▼現(xiàn)在我們從上方觀察蝶骨，可見蝶骨平臺（planum ['ple?n?m]）,，兩側的視神經(jīng)管之間的是視交叉溝（chiasmatic sulcus）,。 And we look at sphenoid bone now from above,we see the planum, and then between the optic canals is the chiasmatic sulcus.
▼視交叉溝有一前緣和一后緣，視神經(jīng)管位于外側,。 the chiasmatic sulcus that has an anterior limbus and a posterior limbus with the optic canals laterally.
▼鞍結節(jié)（tuberculum [tj?'b?:kj?l?m]）,，位于視交叉溝的后緣。實際上幾乎位于蝶鞍的前壁,。 And is the tuberculum on the anterior limbus or the posterior limbus of the chiasmatic sulcus? Well it's on that posterior limbus,actually down almost in the anterior wall of the sella.
▼因此,，鞍結節(jié)腦膜瘤起源于此,，而非蝶骨平臺的后界，常位于前緣下方,，沿著后緣生長。在處理鞍結節(jié)腦膜瘤蒂部時,，需要從蝶骨平臺周圍,，一直向下至蝶鞍的前壁。 So that tuberculum meningiomas arise here,not at the back edge of the planumbut actually around the corner below the anterior limbus along this posterior limbus.And if you are going to devascularize a tuberculum meningioma, well, you need to get around the corner from the planum almost down in the anterior wall of the sella.
▼這個突起是什么,？這是中床突（middle clinoid） And what is this prominence? That's a middle clinoid
▼中床突,，有時可骨化，向前連于前床突,。形成一個位于海綿竇頂環(huán)繞頸內(nèi)動脈的骨環(huán),。 middle clinoid that can sometimes ossify over to the anterior clinoid and complete a bony ring around the carotid at the roof of the cavernous sinus.
▼側方可見卵圓孔（foramen ovale），其位于顳下窩頂部,。 Laterally we are looking at foramen ovale in the roof of the infratemporal fossa.
▼再來看鼻腔,，鼻中隔上部是篩骨（ethmoid），下部為犁骨（vomer ['v??m?]）,。而前部為鼻中隔軟骨（naso-septal cartilage）,。 So nasal septum is formed above by ethmoid,below by vomer,and anteriorly there is naso-septal cartilage.
▼向鼻腔內(nèi)部觀察，這是蝶竇開口 As you look back into the nasal cavity,what foramen is this.This is sphenoid ostium.
▼這是蝶腭孔（sphenopalatine foramen）,，位于腭骨蝶突和眶突之間,，其內(nèi)有上頜動脈穿行入鼻腔。 This is sphenopalatine foramen between the sphenoid and orbital process of the palatine bone,and this is where the maxillary artery comes into the nasal cavity.
▼從側方觀察,，鼻中隔上部由篩骨垂直板構成,，下部為犁骨，前方為鼻中隔軟骨,。 So, nasal septum is formed above by perpendicular plate of ethmoid,below by vomer,anteriorly by naso-septal cartilage.
▼這是犁骨,。 Here we see a vomer.
▼從上頜骨向后觀察，這是犁骨,、垂直板,。 We look now across the maxillary bone.We see the vomer,the perpendicular plate.
▼從后方看蝶骨，這是翼管開口,，位于蝶竇后界,，并走行于蝶竇底。 And looking at the sphenoid bone from posteriorly,what is this opening? This is the opening for the vidian canal at the back edge of the sphenoid,and it runs along the floor of the sphenoid.
▼現(xiàn)在我們要加入枕骨（occipital bone）,，再把顳骨（temporal bone）加上去,，這是顱底的上面觀。 Here we...now we'll fit in...what bone fits here on the back of the sphenoid? An occipital bone.We add in the temporal bones.We see skull base here from above,
▼下面觀,。 from below.
▼最后,，我們是否還遺漏了什么顱底的骨頭,？我們遺漏了三塊。 錘骨（malleus ['m?l??s]）,、砧骨（incus ['??k?s]）,、鐙骨（stapes ['ste?pi:z]）。 Now have we missed any bones in the skull base? We miss three. Malleus,incus,stapes.
▼以上,，就是今天介紹的顱底上下面,。 So we've looked at the skull base above and below.
希望對大家有所幫助。 未完待續(xù)... 推薦閱讀 1 2 |
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