咽后壁瓣术后形态变化的临床研究

目的　研究上、下蒂型咽后壁瓣对腭咽闭合功能及患者发音的影响。方法　采用鼻咽纤维镜、头影测量及语音评价的方法 ,对咽后壁瓣的形态、腭咽闭合功能及语音清晰度进行对照定量分析。结果　上蒂型咽后壁瓣腭咽闭合不全率及矢状收缩不全率均小于下蒂型咽后壁瓣 ,两者的语音清晰度无明显区别。结论　上蒂型咽后壁瓣术式优于下蒂型咽后壁瓣术式 ,且患者术后均应进行系统的语音评估及治疗     

鼻咽镜、阻塞器在治疗腭咽闭合不全中的应用

目的应用鼻咽纤维镜、腭咽阻塞器治疗腭裂术后腭咽闭合不全。方法腭咽闭合不全患者通过鼻咽镜检查，根据腭咽孔大小、形状制作腭咽阻塞器。结果４５例腭咽闭合不全患者经戴阻塞器治疗后，１００％腭咽闭合不全得到改善，其中１５例（３３％）２年后摘掉阻塞器发音正常。结论联合应用鼻咽镜与腭咽阻塞器是保守治疗腭咽闭合不全的好方法     

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     

电子纤维鼻咽喉镜对腭咽环扎术疗效的评价

目的 应用电子纤维鼻咽喉镜观察腭咽环扎术后患者腭咽闭合功能，评价该手术的远期疗效。方法 选择腭咽环扎术后16年的腭裂患者23例，用电子纤维鼻咽喉镜观察患者在吞咽和发音时的咽侧壁、咽后壁、软腭的运动情况。结果 电子纤维鼻咽喉镜系统直接观察到发音时咽侧壁的运动及软腭的上、下、前、后运动，软腭与咽后壁的关系，软腭长度及在矢状面上提升的高度。结论 腭咽环扎术能有效地改善腭咽闭合功能；电子纤维鼻咽喉镜可直接观察到腭咽部的运动情况，是评价术后腭咽闭合功能的有效方法。     

腭裂术后腭咽闭合协调异常的训练治疗

腭裂术后腭咽闭合协调异常患者以闭合不全（ＶＰＩ）表现为主，仅靠主要判听或某一项检查骓以确诊，其治疗原则也不同。本文采用主客观检查方法对术后有ＶＰＩ表现者进行综合检查评价，并对其中确诊的１２例腭咽闭合协调异常患者进行针对性腭咽闭合协调功能训练，１－６个月后，所有患者腭咽闭合功能均达到说话时所需水平，配合发音技巧训练后，语音清晰度均提高到８０％以上，说明对腭裂术后有类似ＶＰＩ表现者应进行综合评价，对腭     

鼻咽纤维镜在腭裂术后语音效果随访中的应用

本文作者运用鼻咽纤维镜对本科所做的37例腭裂术后病人进行了随访。文童介绍了检查内容方法和结果,并对腭裂病人发音清晰度的有关因素进行了讨论。体会到鼻咽纤维镜在腭裂术后语音效果随访中十分有价值,其操作简便,无损伤,是一种既能直观检查病人腭咽部情况又能客观检测腭咽闭合功能的方法。     

腭帆提肌止点后上推移术与传统腭裂整复术的比较

目的 :研究腭裂功能性整复术 ,提出一种新术式———腭帆提肌止点后上推移术。方法 :在腭帆提肌及相关肌肉尸体解剖基础上 ,应用腭帆提肌止点后上推移腭裂整复术实施 2 0例 ,术后应用鼻咽镜、语音分析进行腭咽闭合功能及语音评价 ,与传统术式进行对照研究。结果 :2 0例手术术后均一期愈合。鼻咽镜检查示全部病例腭咽肌肉运动良好 ,发音时达到完全腭咽闭合 ,语音均得到改善。结论 :腭帆提肌止点后上推移术使软腭充分向后上提拉完成腭咽闭合 ,较好地解决了传统术式术后存在腭咽闭合功能不全的问题 ,是一种较好的腭裂功能性修复方法     

大龄腭裂患者治疗模式的初步研究

目的改进大龄腭裂患者的治疗模式,提高大龄腭裂患者术后的腭咽闭合率和语音清晰度。方法对37例年龄大于6岁（含6岁）的腭裂患者进行同期腭裂与腭咽肌瓣咽成形整复术,并对其术后10~15个月的效果进行了随访和语音评估。结果22例患者术后腭咽闭合完全,15例术后虽仍有腭咽闭合不全,但在鼻咽纤维镜下腭咽闭合度达85%以上;所有患者X线侧位咽腔造影显示软腭与咽后壁贴合;语音检测显示,高鼻音和鼻漏气程度显著下降,辅音清晰度提高。结论本研究中建立的大龄腭裂患者治疗模式可以显著提高腭裂患者术后的腭咽闭合率和语音清晰度,为改善其生存质量创造了条件。     

Hogan法治疗大龄腭咽闭合不全患者的临床疗效分析

目的 探讨使用Hogan法咽后壁组织瓣转移术治疗大龄腭咽闭合不全（VPI）患者的临床疗效。方法收集33例腭裂术后VPI患者，年龄10～35岁，平均年龄20.4岁。所有患者均行Hogan法咽后壁组织瓣转移术治疗腭咽闭合不全。采用汉语语音清晰度测定法评估患者语音情况，鼻咽纤维镜（NPF）评估腭咽闭合程度，并进行分级。平均随访时间13.3个月。结果 33例患者术后创口均达到Ⅰ期愈合。术后语音清晰度明显提高，鼻漏气及高鼻音减少，与术前相比差异有统计学意义（P<0.05）。NPF检查示，术后腭咽闭合功能明显改善，30例（91%）患者腭咽闭合率达到Ⅰ级，3例（9%）患者达到Ⅱ级。结论 Hogan法咽后壁组织瓣转移术可显著改善大龄VPI患者的腭咽闭合状况，减少鼻漏气和高鼻音。     

视觉模拟评分法评价腭裂术后无声状态下腭咽闭合状态的研究

目的 分析视觉模拟评分法(visual analog scale,VAS)评价腭裂术后腭咽闭合状态的可靠性,为非直观检测腭咽闭合功能声学仪器间接评价腭咽闭合功能提供参考.方法 应用鼻咽纤维镜对唇腭裂修复术后82例患者进行11个语音样本的腭咽闭合状态检查,由3名有多年治疗唇腭裂临床经验的专家在无声状态下对腭咽闭合状态进行分级定性及视觉模拟量表评价,对选取语音样本VAS值与分级定性评价进行Spearman相关分析,对选取语音样本中10个非鼻辅音语音样本按照腭咽闭合程度分级定性评价分类,计算定性评价不同类型腭咽闭合的VAS值范围.结果 定性评价不同类型腭咽闭合状态VAS值明显不同,重度腭咽闭合不全VAS值最小(28.4137),完全性腭咽闭合VAS值最大(96.0568),而且正常值范围相互交叉范围较大,通过VAS值界定腭咽闭合状态有效性＞70％.结论 腭咽闭合程度VAS评价能够正确反映腭咽闭合定性评价的结果,VAS值对腭咽闭合形态是可靠的,提出VAS值评价腭咽闭合状态的标准进一步细化了腭咽闭合功能的定性评价.     

The effect of nasopharyngoscopic biofeedback in patients with cleft palate and velopharyngeal dysfunction.

OBJECTIVE: To evaluate the immediate, long-term, and carry-over effects of nasopharyngoscopic biofeedback therapy in patients with cleft palate who exhibit velopharyngeal dysfunction (VPD). DESIGN: Pre- versus posttreatment and follow-up comparisons. SETTING: Cleft palate center of the Heidelberg University Hospital, Heidelberg, Germany. SUBJECTS: Eleven patients with VPD who had received conventional speech therapy without showing significant improvement. INTERVENTIONS: A four-stage feedback procedure. The patients watched and evaluated their velopharyngeal (VP) valving during speech by an endoscopic image displayed on a video monitor. Two feedback sessions took place for every target sound. MAIN OUTCOME MEASURES: Mean occurrence of VP closure during speech sound production on different linguistic levels. Patients' self-perception was assessed by a questionnaire and speech diary. RESULTS: Significant improvement and stability of VP closure was noted. Mean occurrence of VP closure was 5% before therapy, 91% after two biofeedback sessions, and 86% in the follow-up after 6 months. Velopharyngeal dysfunction associated with compensatory articulation proved to be equally well trained as VPD on sounds with good articulatory placement. No significant difference was observed in the degree of improvement between phoneme-specific VPD and generalized VPD. The transfer to the level of words and sentences was successful and showed significant stability. The stability of VP closure for vowels was less than the stability for fricatives and stop sounds. Patients gained improved auditory and kinesthetic self-perception of their articulation. CONCLUSIONS: Nasopharyngoscopic biofeedback therapy proves to be a quick and effective method to change VPD. It shows stable results and carry-over effects.     

The use of videonasopharyngoscopy for biofeedback therapy in adults after pharyngeal flap surgery

Nasopharyngoscopy with videorecording was used as a visual feedback therapy tool to establish and promote consistent closure of the velopharyngeal ports during connected speech after pharyngeal flap surgery. Of the three adults in this report, two achieved consistent closure during connected discourse and have been discharged from therapy; the third demonstrated improved velopharyngeal closure but elected not to continue therapy. These outcomes demonstrate that nasopharyngoscopy biofeedback therapy is useful in helping the motivated adult to achieve better velopharyngeal closure during connected speech after pharyngeal flap surgery or revision. This type of therapy may also prove beneficial with children.     

Comparison between multiview videofluoroscopy and nasendoscopy of velopharyngeal movements.

The videofluoroscopic and nasopharyngoscopic observations of velopharyngeal movements during speech were compared in 80 subjects with hypernasal speech. An endviewing flexible fiberoptic endoscope was used for nasopharyngoscopic examination. This failed to demonstrate movements of the lateral pharyngeal walls that were videofluoroscopically documented in one third of the patients. In the cases of disagreement, the angle of view was impaired because of the presence of adenoid tissue. The misinterpretation at nasopharyngoscopy was explained by an unfavorable observation position of the flexible scope and failure to pass it further into the pharynx. Conclusions are satisfactory that videofluoroscopy is an indispensable procedure for assessing velopharyngeal function.     

Speech outcome after closure of oronasal fistulas with bone grafts.

PURPOSE: The purpose of this prospective study was to evaluate the outcome of speech after complete closure of oronasal fistulas with bone grafts and to determine the possible relationship between outcome of speech and the size and location of the oronasal fistulas. PATIENTS AND METHODS: Ten unilateral cleft lip and palate patients with postoperative oronasal fistulas, ranging in age from 7 to 14 years, underwent secondary alveolar cleft repair and closure of the oronasal fistulas with an iliac bone graft. All patients underwent videofluoroscopic evaluation of the velopharyngeal valve, audiologic assessment, and speech evaluation (resonance, nasal emission, articulation, intelligibility, and nasalance) preoperatively. The examinations were repeated 3 months postoperatively. RESULTS: Six patients had preoperative velopharyngeal competency (60%). Of the 4 patients with slight to mild velopharyngeal incompetency preoperatively, 2 developed velopharyngeal competency postoperatively. All patients had satisfactory audiologic function preoperatively. Every patient also was intelligible before and after surgery. Eight patients (80%) showed nasal emission before surgery and 7 of these patients improved postoperatively (P <.01). Nine patients had articulation errors before surgery, with no significant improvement postoperatively. Nasalance was significantly improved in selected sequences. All patients had variable levels of nasality preoperatively; 8 showed a significant decrease of nasality postoperatively (P <.002). The results were not related to location or size of the oronasal fistulas. CONCLUSION: A significant improvement in speech is noticeable after closure of oronasal fistulas. Early oronasal fistula closure might prevent permanent speech distortions acquired by the cleft palate patients at an early age.     

腭裂咽成形术后患者语音治疗疗效评价

目的:对腭咽成形术后存在语音障碍的患者进行语音治疗,通过治疗前后语音清晰度比较,评价该方法的疗效。方法:咽成形术后患者82例,年龄4~31岁。采用汉语语音清晰度测试表对患者进行治疗前后语音清晰度检测,根据代偿性发音特点进行系统化语音训练:①腭咽闭合功能锻炼;②音素→音节→词组→短句→短文、会话。训练时按发音部位由前→后,按发音方法由易→难、送气音→不送气音、塞音→擦音→塞擦音。训练周期1.5~12个月,平均3.83个月。结果:以腭咽闭合不全型为特点的代偿性语音患者共71例;其中声门塞音患者语音清晰度由治疗前的46.27%提高到治疗后的97.16%;咽摩擦音患者由治疗前的57.19%提高到治疗后的97.72%。以腭咽闭合良好型为特点的代偿性语音共11例,腭化、侧化音患者语音清晰度由治疗前的71.10%提高到治疗后的98.55%;3组经t检验,P均<0.001,具有极显著性差异。结论:对咽成形术后腭咽闭合不全型的代偿性发音,首先加强腭咽闭合功能,再建立正确的发音部位和方法;对咽成形术后腭咽闭合良好型的代偿性发音,可直接建立正确的发音部位和方法。     

Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern.This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed.There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea.Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.     

Surgical treatment of borderline velopharyngeal insufficiency using homologous cartilage implantation with videonasopharyngoscopic monitoring

Borderline cases of velopharyngeal insufficiency were treated with homologous cartilage implants. The selection of patients and technique for this procedure are described. Videonasopharyngoscopy was used to identify a specific location on the posterior pharyngeal wall for the implant. A small cube of homologous cartilage was implanted in the selected site in order to achieve adequate closure. The preliminary nasopharyngoscopic and speech evaluation results in 10 patients, who were followed every 3 months for at least 1 year, are reported. Hypernasality and audible nasal emission were eliminated. The displacement and reabsorption of the implants that occurred was minimal and did not affect velopharyngeal closure. Homologous cartilage, which is inexpensive and easy to obtain, appears to be a good option for implantation in the posterior pharyngeal wall in borderline cases of velopharyngeal insufficiency.     

自体脂肪颗粒注射移植治疗腭咽闭合不全的可行性

目的探讨咽后壁自体脂肪颗粒注射移植在5～7岁腭裂患儿术后腭咽闭合不全治疗中应用的可行性。方法先天性腭裂术后腭咽闭合不全的5～7岁患儿7例,采用腹部抽吸自体脂肪颗粒注射于咽后壁,平均注射量为5.7 mL。分别在术前、术后1周及术后3个月行鼻咽纤维镜检查,对其最大腭咽闭合程度进行等级评价,进行吹水泡试验,对比手术前后的语音评估结果。结果 7例患者术前、术后1周及术后3个月鼻咽纤维镜评估腭咽闭合程度均有改善。术前吹水泡试验时间为(4.71±1.38)s,术后1周及3个月分别为(16.29±3.90)s和(11.14±5.30)s;术前与术后1周(t=9.704,P<0.01)及3个月(t=4.052,P<0.01)比较,术后吹水泡试验时间均有明显延长,差异均具有统计学意义。而术后3个月与术后1周相比时间缩短,其结果差异具有统计学意义(t=4.076,P<0.01)。手术前后语音评估结果与前两种检测方法结果一致。结论自体脂肪颗粒注射移植具有操作可逆、局部创伤小及术后护理简单等优势,能有效增大腭咽闭合最大面积。但其适应证选择需慎重,对于腹壁脂肪层过薄、咽腔过于宽大、腭帆提肌功能未能重建者并不适用。     

Visual training for velopharyngeal closure in cleft palate patients; a fibrescopic procedure (preliminary report)

Velopharyngeal closure in various tasks was examined in 59 cleft palate patients with persistent velopharyngeal incompetence using nasopharyngeal fibrescopic (NPF) examination. The degree of velopharyngeal closure was analyzed according to the categories reported previously by Yamaoka (1973) and Matsuya et al. (1979). The NPF self-training system was developed and applied to those patients so as to investigate a longitudinal effect of the NPF in velopharyngeal closure mechanism. The training was performed every two weeks for nearly one year. The results indicated that the patient who showed complete velopharyngeal closure during blowing and/or several productions of speech samples could attain a much better improvement in all speech samples after one year of self-training. On the other hand, the patients who did not show complete velopharyngeal closure during all tasks, failed to improve the velopharyngeal closing mechanism. The ability to close the velopharynx during swallowing was seen in all patients examined. However, it appeared to have nothing to do with the prognosis of velopharyngeal closure. The data suggested that the NPF self-training system provided a strong neuro-muscular signal for velopharyngeal movement. Besides, it was considered that the NPF was a useful tool for activation of velopharyngeal activity by way of visual feed-back control.     

The effect of timing of surgery for velopharyngeal dysfunction on speech

The timing of surgery for velopharyngeal dysfunction has been based on assumptions about the relation between age, speech development, and velopharyngeal dysfunction. Cleft palate teams often counsel parents to have an intervention for velopharyngeal dysfunction performed earlier rather than later, believing that earlier interventions result in more rapid or better normalization of speech. The objective of this retrospective chart review study is to determine whether the age at surgical intervention for velopharyngeal dysfunction has an effect on the subsequent length of speech therapy. Of 174 patients included in the study database, 36 had velopharyngeal dysfunction for which further velopharyngeal management was required. Of the 36 patients who received surgical velopharyngeal dysfunction management, 27 had verifiable speech therapy records. These 27 patients represent the study population. The outcome measure was the total length of subsequent speech therapy until speech normalization. The data suggest that there is no relation between the age at velopharyngeal dysfunction surgical management and the amount of speech therapy needed to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management. In conclusion, 1) the age at surgical velopharyngeal dysfunction management (pharyngeal flap or sphincter pharyngoplasty) does not have an effect on subsequent normalization of speech as measured by the duration of speech therapy necessary to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management, and 2) the age at surgical velopharyngeal dysfunction management does not affect the likelihood of subsequent surgical velopharyngeal dysfunction management procedures.