咽后壁瓣断蒂对腭咽闭合影响的探讨

目的 探讨咽后壁瓣成形术后腭咽闭合功能不全(velopharyngeal insufficiency,VPI)及其并发症阻塞性睡眠呼吸暂停低通气综合征(OSAHS)治疗中咽后壁瓣断蒂的作用.方法 1993至2008年于北京大学口腔医学院·口腔医院唇腭裂治疗中心接受咽后壁瓣断蒂术患者20例(不完全腭裂11例、完全性唇腭裂9例),20例断蒂术前均行鼻咽纤维镜、头颅定位侧位X线片检查及语音录音,对有OSAHS主述者行睡眠呼吸监测.全部患者术后48 h后进行语音评价.术中单纯断蒂14例,断蒂后重新改变咽成形术式6例.结果 ①14例成形术后语音改善不明显,仍存在过高鼻音,咽后壁瓣断蒂术后语音改善明显;②3例成形术后虽发音正常但出现呼吸道阻塞症状,断蒂术后呼吸睡眠状况改善,语音仍正常;③3例成形术后发音正常,因正颌手术的麻醉需要断蒂,断蒂后的语音无明显改变.结论 咽后壁瓣成形术后出现OSAHS或仍存在VPI,需手术断蒂或其他类型咽成形术治疗;断蒂的时间应在咽后壁瓣成形术半年后.     

同期咽后壁组织瓣转移修复后大龄腭裂患者语音改善效果的评价

目的探讨咽后壁瓣转移修复术对大龄腭裂患者语音效果的影响。方法选择2006年8月～2008年8月就诊于青岛大学医学院附属医院口腔颌面外科的大龄腭裂患者37例,20例采用两瓣法关闭裂隙并同期行咽后壁瓣转移修复术;17例单纯关闭裂隙。比较手术前后腭咽闭合不全率（RVPI）,单元音[i]三个共振峰频率,辅音[ka]、[pa]、[si]、[qi]冲直条和擦音乱纹及语音清晰度变化,并与健康儿童20例对照。结果所有患者均达到临床Ⅰ期愈合,两手术组术后RVPI均显著降低,语音也有不同程度改善,且关闭裂隙同期行咽后壁瓣转移修复术组明显优于单纯关闭裂隙组。结论大龄腭裂患者同期行腭裂修复术和咽后壁瓣转移修复术能显著改善患者的腭咽闭合功能,可作为大龄腭裂患者常规术式。     

华西改良腭咽肌瓣和Hogan咽后壁瓣术后腭咽功能及语音的对比研究

目的:通过对比研究华西改良腭咽肌瓣和Hogan咽后壁瓣2种术式在大龄腭裂患者术后腭咽功能和语音状况的变化,为临床大龄患者最佳术式的选择提供参考。方法:选择2009-01～2011-01行Hogan咽后壁瓣咽成形术(PF组,32例)和华西改良腭咽肌瓣咽成形术(P+SP组,49例)的患者,对其术后的腭咽闭合状况、共鸣、鼻漏气及辅音正确率、鼻呼吸通畅度进行分析对比统计。结果:PF组术后21例(62.50%)腭咽闭合完全;6例(18.75%)术后语音完全清晰。P+SP组术后VPC 30例(61.22%)腭咽闭合完全;13例(25.63%)语音完全清晰。PF组术后20例(62.5%)出现打鼾现象,P+SP组术后32例(65.31%)患者出现打鼾现象。PF和P+SP术式对术后腭咽闭合完全率、高鼻音、鼻漏气、辅音正确率以及呼吸的改变无差别。结论:2种术式都能显著提高患者的腭咽闭合率和语音清晰度。     

腭咽闭合功能不全语音清晰度评价

目的　研究腭咽闭合功能不全患者的语音清晰度。方法　 10 0例腭咽闭合功能不全患者 ,其中 15例为腭裂 ,2 1例为先天性腭咽闭合不全 ,5 6例为腭裂术后腭咽闭合不全 ,8例为咽成形术后腭咽闭合不全 ,对照组为 32名健康人。 3名语音专业人员共同评价汉语语音清晰度 ,并且分析语音障碍和语音清晰度的关系。结果　健康组的语音清晰度为 99 0 % ,腭咽闭合功能不全组为35 5 % ,其中未手术腭裂组为 19 9% ,先天性腭咽闭合不全为 32 8% ,腭裂术后腭咽闭合不全为4 0 3% ,咽成形术后腭咽闭合不全为 35 2 % ,统计分析显示健康组和病例组各类型之间差异有显著性 (P <0 0 1)。结论　①腭咽闭合功能不全异常语音的语音清晰度差 ,并伴过度鼻音 ;②腭咽闭合不全异常语音中 ,腭裂患者的语音清晰度最低 ,其余依次为先天性腭咽闭合不全、咽成形术后腭咽闭合不全和腭裂术后腭咽闭合不全     

改良咽后壁瓣咽腔成形术的围手术期护理

目的 总结改良咽后壁瓣咽腔成形术治疗腭咽闭合不全的护理经验.方法 术前检测腭咽闭合不全患者汉语语音清晰度,完善各项术前检查;术后重点加强观察生命体征,加强对切口渗血的观察与护理,确保呼吸道通畅,减少鼻腔分泌物,保持创口清洁,注意营养支持,加强术前术后患者的健康教育.结果 78例患者中77例术后恢复良好, 1例因出院后家庭护理不当造成咽后壁瓣脱落.结论 做好改良咽后壁瓣咽腔成形术的围手术期护理,可帮助患者顺利完成手术治疗,减轻其术后痛苦,减少并发症的发生.     

腭咽环扎术后腭咽闭合功能的评价

为评价腭咽环扎术后腭咽闭合功能,本文对腭咽环扎术后的289例病人进行了信函随访,并对随机抽样复查的20例患者进行了全面的语音检查。采用了鼻咽部敷钡剂后,颅底位和咽腔侧位电视透视、拍片以及EYBH—81型腭咽闭合功能检测仪等综合性检查,并以咽后壁瓣手术及兰氏手术后的患者作为对照。据观察腭咽环扎术能使软腭充分延长,鼻咽腔全面缩小,并且软腭和鼻咽腔活动良好,有利于患者语音功能的改善。其语音效果优于兰氏手术。与咽后壁瓣手术相比,其优点是手术安全、并发症少、效果稳定。     

咽后壁瓣的形态及位置对腭裂术后语音效果的影响

本文采用回顾性调查,通过对41名腭裂咽后壁瓣手术后的患者的头颅侧位X线片测量及语音清晰度的测定,进行咽后壁辦的形态位置以及施行手术年龄与语音效果的相关性研究。实验结果:(1)施咽后壁瓣手术的15岁以下年龄组术后语音清晰度明显高于15岁以上年龄组。(2)咽后瓣的长短,软腭发音时的动度与术后语音效果无显著性相关关系;而咽后壁瓣在咽后壁上的位置及咽后壁瓣附着在软腭上的位置与术后语音效果有一定的相关倾向,蒂的位置越近第一颈椎水平,瓣附着在软腭的位置越近中下1/3处,语音效果越有好的倾向。(3)术后的语音效果与术前及术后咽侧壁的运动状态可能有密切关系,咽侧壁运动好,语音效果相应较好。     

颞肌瓣修复上颌骨及腭部缺损的语音功能评价

目的　分析颞肌瓣即刻修复上颌骨及腭部术后缺损患者的语音功能恢复情况。方法　通过对 19例应用颞肌瓣修复上颌骨及腭部缺损的患者进行腭咽闭合功能、头颅腭咽侧位X线片测量和语音清晰度测定 ,分析评价颞肌瓣即刻修复上颌骨及软腭部术后缺损患者的语音功能恢复情况。结果　 19例患者中 ,有 15例 (78.0 0 % )为完全腭咽闭合 ,3例 (15 80 % )为边缘性腭咽闭合 ,1例 (5 2 6 % )为腭咽闭合不全 ,平均语音清晰度为 94 3% ,接近正常人语音清晰水平。结论　颞肌瓣修复上颌骨及腭部缺损能够较好地重建口腔发音结构 ,维持腭部功能 ,较好地恢复术后语音功能     

上颌前徙术后腭咽闭合功能的临床观察

目的　临床观察评价上颌前徙术后腭咽闭合功能变化。方法　对 7例上颌发育不全患者及 3例唇腭裂继发上颌发育不全患者行LeFortI型截骨术前移上颌骨 ,术前术后行鼻咽纤维镜及发“i”音时的头颅侧位片检查 ,结合术前术后语音的评价 ,对上颌前徙术后腭咽闭合及发音的改变进行观察分析。结果　经统计学分析 ,软腭动度、腭咽闭合程度、语音清晰度等指标术前术后比较差异均无显著性。结论　患者术前腭咽闭合功能良好时 ,上颌前徙术后腭咽闭合功能无明显变化     

鼻咽纤维镜生物反馈治疗在腭裂术后语音治疗中的应用

目的了解鼻咽纤维镜生物反馈治疗在腭裂术后语音治疗中的作用。方法采用鼻咽纤维镜在直视监控下让患者按规定语音材料在治疗师指导下进行发音练习,通过视一听反馈调节机制使患者自行调节腭咽部肌肉等结构功能以形成完全、持续的腭咽闭合,同时配合常规语音训练改善发音技能。结果共有8例患者接受治疗。其中5例患者腭咽闭合恢复正常,2例咽后壁瓣术后患者一侧孔闭合,另一侧孔仍为闭合不全状态,1例患者训练2次后中途退出治疗。结论鼻咽纤维镜能使病人在视一听反馈状态下在较短时间内改善腭咽闭合功能,但主要适用于具有腭咽闭合潜能的患者,如边缘性腭咽闭合或腭咽闭合不连续等腭咽闭合协调异常等患者。     

咽后壁瓣术后蒂端局部组织血管重建的实验研究

目的　探讨上、下蒂型咽后壁瓣术后蒂端咽后壁组织血管重建的一般规律。方法　将 1 0条杂种犬随机分为 2组 ,每组 5条 ,分别作上、下蒂型咽后壁瓣手术 ,并分别于术后即刻、3、7、30、90d处死 ,另 1条犬作正常对照 ,直接处死 ,用血管造影X线片研究咽后壁血管重建情况。结果　正常犬咽后壁的主干血管呈横行或斜行于咽缩肌筋膜下 ,通过肌肉穿支在同侧和对侧间相互吻合成网。上蒂型咽后壁瓣术后蒂端咽后壁组织血管重建主要发生在瓣蒂上方的咽后壁组织内 ,血管呈横向走行 ,自瓣蒂上方分支进入瓣内 ,构成瓣的纵行血管网 ,供瓣区没有血管进入瓣内。下蒂型咽后壁瓣术后蒂端咽后壁组织血管重建主要发生在瓣蒂下方的咽后壁组织内 ,其正中血管逐步纵行化 ,自瓣蒂下方进入瓣内 ,构成瓣蒂端的纵行血管网。结论　上、下蒂型咽后壁瓣术后蒂端咽后壁组织内血管分别呈横行和纵行改建     

咽后瓣术后组织超微结构变化实验研究

目的 :观察咽后瓣术后组织超微结构变化 ,探讨咽后瓣术后组织瓣萎缩的原因。方法 :以 10只成年健康杂种狗为实验对象 ,随机分为两组 ,分别模拟上、下蒂型咽后瓣手术 ,于术后 3 0 ,90d处死 ,以术后当天为各自正常对照组 ,采用超薄切片透射电镜观察。结果 :上、下蒂型咽后瓣术后当天瓣内组织无炎症及水肿 ,肌纤维排列规则 ,肌丝排列紧密、规则 ,Z线及肌节清晰 ,肌膜完整 ,肌原纤维整齐 ,横纹清晰 ;术后 3 0d时肌原纤维出现断裂、溶解 ,排列紊乱 ,Z线弯曲或断裂 ,肌原纤维之间有大量的空泡出现 ;术后 90d时上蒂型咽后瓣内可见肌纤维再生 ,下蒂型咽后瓣组织变化与 3 0d时基本类似。结论 :上蒂型咽后瓣显示较好的远期效果。     

犬咽后壁瓣术后并发症及瓣外观变化的初步研究

目的 研究咽后壁瓣术后不同时期瓣外观形态的改变及对呼吸道阻塞等并发症的影响。方法 将10只健康杂种犬随机分为两组，每组5只，分别作上、下蒂因后壁瓣手术，观察其临床症状。每组再随机分为5亚组，分别于术后即刻、3、7、30、90天处死，将瓣取下后观察其外观形态的变化。结果 上蒂型咽后壁术后早期瘀血水肿，上呼吸道阻塞，鼾声明显，以术后2－3天时最严重，以后逐渐改善，2周后可消失，远期瓣体未见明显萎缩。下蒂型咽后壁瓣术后早期轻度水肿，上呼吸道阻塞不明显，瓣尖至瓣中部黏膜血坏死，逐渐为口腔黏膜取代，远期瓣体未见明显萎缩。结论 上蒂型咽后壁瓣术后早期瓣瘀血水肿，下蒂型咽后壁瓣术后早期瓣尖缺血坏死，上、下蒂型咽后壁瓣远期都无明显萎缩。     

犬咽后壁瓣微血管构筑的组织学研究

目的:研究上、下蒂型咽后壁瓣术后不同时期、不同部位血管重建情况。方法:将10只杂种犬随机分为两组,每组5只,分别作上、下蒂型咽后壁瓣手术,并分别于术后即刻及术后3、7、30、90d处死,采用血管造影、常规HE切片,光镜观察及计算机图象分析等方法,比较术后不同时期、不同部位的平均血管数量和横截面积的变化。另1只犬直接处死,血管造影,取对应部位作正常对照。结果:上蒂型咽后壁瓣术后即刻无血管显影,但其血管重建较快;术后不同部位血管重建同步,分布均匀,其平均横截面积、血管数量逐渐增加,30d后和对照组相近(P>0.05)。下蒂型咽后壁瓣术后即刻蒂部有少量血管显影;术后不同部位血管重建不同步,分布不均匀,术后血管重建首先发生在瓣蒂区和瓣尖肌肉层,其平均横截面积、血管数量逐渐增加,30d时和对照组相近(P>0.05)。术后早期瓣中部和瓣尖粘膜下无血管显影,其血管重建较慢,瓣中部一直血管稀少,90d时才和对照组相近。结论:上、下蒂型咽后壁瓣术后均能建立和术前相近、分布均匀的血管网。     

Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art.

Surgical management of velopharyngeal insufficiency by attachment of posterior pharyngeal flap or construction of sphincter pharyngoplasty is reviewed. Posterior pharyngeal flap surgery is well established, with a long history dating back to the 19th century. Flaps have been based superiorly, inferiorly, or laterally. There have been reports of airway obstruction and obstructive sleep apnea associated with posterior pharyngeal flap surgery. The concept of surgical creation of a dynamic sphincter pharyngoplasty to provide velopharyngeal closure was first introduced by Hynes in 1950. Hynes and others have proposed several subsequent anatomic modifications. Airway dysfunction has also been reported following sphincter pharyngoplasty, but may not be as frequent or severe as with posterior pharyngeal flap. While several studies have compared posterior pharyngeal flap and sphincter pharyngoplasty in terms of speech outcome or complications, there is not, as yet, a consensus regarding the specific choice of one versus the other for surgical management of velopharyngeal insufficiency.     

咽后瓣术后组织形态变化的实验观察

目的　研究咽后瓣术后愈合动态的组织形态变化。方法　 10只成年健康杂种狗为实验对象 ,随机分为 2组 ,分别模拟上、下蒂型咽后瓣手术 ,于术后 0、3、7、30、90d处死 ,采用常规石蜡切片、光镜观察及计算机图像分析相结合的方法 ,比较术后不同时期瓣愈合的动态组织形态变化。结果　 (1)上、下蒂型咽后瓣术后当天瓣内组织无炎症及水肿 ,肌纤维排列规则 ;术后 3d时瓣组织水肿 ,大量炎症细胞浸润 ,肌纤维粗大 ;术后 7d水肿消退 ,少量炎症细胞浸润 ,肌纤维大小与当天时类似 ;术后 30d时瓣内结缔组织增多 ,未见炎症细胞 ,肌纤维变细 ,成为菱角形 ;术后 90d时瓣内组织变化与 30d时基本类似。 (2 )形态计量分析 (与当天比较 ) ,术后 3d时 ,肌纤维平均截面积及直径显著增加 (P <0 .0 1) ;术后 7d时无显著增加 (P <0 .0 5 ) ;术后 30d及 90d肌纤维平均截面积及直径显著减少(P <0 .0 1) ;两者比较 ,无显著差异 (P >0 .0 5 ) ;上、下蒂型咽后瓣术后同期互相比较差异无显著性 (P <0 .0 5 )。结论　上、下蒂型咽后瓣术后组织学变化类似 ,术后 30d肌纤维萎缩明显 ,90d呈稳定的萎缩状态。     

The case for the inferiorly based posterior pharyngeal flap.

The superiorly based and inferiorly based posterior pharyngeal flaps are compared. Reasons for choosing one or the other in specific cases are given. The complications with each are enumerated. The results obtained in speech comparing the two flaps in two retrospective series and one prospective series of cases failed to show a significant difference between them. Therefore, with little difference in the results and some good reasons for preferring one or the other under certain conditions, it would seem logical to select the one best suited for the particular problem.     

Results of speech improvement following simultaneous push-back together with velopharyngeal flap surgery in cleft palate patients

ObjectiveVelopharyngeal insufficiency (VPI) can be caused by a variety of disorders. The most common cause of VPI is the association with cleft palate. The aim of this study was to evaluate the effectiveness of different surgical techniques for cleft palate patients with VPI: 1) velopharyngoplasty with an inferiorly based posterior pharyngeal flap (VPP posterior, Schönborn–Rosenthal), and 2) combination of VPP posterior and push-back operation (Dorrance).Patients and methods41 subjects (26 females, 15 males) with VPI were analysed. Hypernasality was judged subjectively and nasalance data were assessed objectively using the NasalView^® system preoperative and 6 months postoperative.ResultsSubjective analysis showed improved speech results regarding hypernasality for all OP-techniques with good results for VPP posterior and VPP posterior combined with push-back with success rates of 94.4% and 87.7%, respectively. Objective analysis showed a statistically significant reduction of nasalance for both VPP posterior and VPP posterior combined with push-back (p < 0.01). However, there were no statistically significant differences concerning measured nasalance values postoperatively between the VPP posterior and VPP posterior combined with push-back.ConclusionBased on our findings, both VPP posterior and VPP posterior combined with push-back showed good results in correction of hypernasality in cleft patients with velopharyngeal insufficiency.     

Comparison of Hogan pharyngeal flap and sphincter pharyngoplasty in postoperative velopharyngeal function

The purpose of this study was to compare speech and breathing after sphincter pharyngoplasty and the Hogan pharyngeal flap in the management of cleft-related velopharyngeal insufficiency (VPI). We reviewed 78 patients with VPI who had either the Hogan flap (n = 30) or sphincter pharyngoplasty (n = 48) between 2009 and 2011. Velopharyngeal function, nasal patency, and speech were compared. In the Hogan flap group, 25 patients had achieved velopharyngeal competence and nine had normal speech. In the sphincter pharyngoplasty group, 29 patients achieved velopharyngeal competence and 20 normal speech. The Hogan flap group had a higher rate of velopharyngeal competence (n = 25) than the sphincter pharyngoplasty group (p = 0.033), but there was no significant difference in intelligibility of speech. Eighteen patients in the Hogan flap group and 33 in the sphincter pharyngoplasty group reported symptoms of snoring, with no significant difference in nasal ventilation. Our results suggest that a posterior pharyngeal flap is a more effective technique for managing VPI after repair of cleft palate than sphincter pharyngoplasty, and causes no more postoperative complications in nasal breathing.     

Revisional surgery following the superiorly based posterior pharyngeal wall flap. Historical perspectives and current considerations

The aim of this study was to describe the surgical and functional complications following superiorly based posterior pharyngeal wall (SBPP) flap surgery. Records of 130 patients with velopharyngeal insufficiency (VPI) who had undergone SBPP flap surgery as a secondary procedure to reduce nasal resonance in speech were reviewed. Complications were defined as the incidence of revisional surgery required to obtain a more satisfactory result. 20 patients (15%) required revisional surgery. In 4 patients (3%) early revisional surgery was indicated to treat surgical complications (1 postoperative bleeding, 3 flap dehiscences). In 16 patients (12%) late revisional surgery was indicated to achieve a better functional result with regard to nasal resonance in speech. The low incidence of surgical complications indicates that SBPP flap surgery is a safe procedure. After SBPP flap surgery, a satisfactory functional result with respect to nasal resonance was obtained in 88% of patients. This result was improved after revisional surgery. The hypothesis that the patients of an experienced surgeon have fewer complications and better functional results than those of a less experienced one was tested. The individual skill of the surgeon rather than their experience led to a better functional result.