环杓单位在环状软骨上喉部分切除术中的应用研究现状

环状软骨上喉部分切除术源于欧洲并广泛开展应用,其理论基础是环杓单位为喉功能解剖单位.环状软骨上喉部分切除术包括环状软骨上喉部分切除-环舌骨会厌吻合术（SCPL-CHEP）、环状软骨上喉部分切除-环舌骨吻合术（SCPL-CHP）和环状软骨上喉部分切除-气管环舌骨会厌吻合术（SCPL-TCHEP）3种术式.本文就环杓单位作为喉功能解剖单位在环状软骨上喉部分切除术中的应用加以论述。1 环杓单位解剖结构及生理作用Weinstein等Ⅲ提出环杓单位这一概念,强调其在喉功能保全性手术选择中起关键作用。环杓单位包括杓状软骨、环状软骨、完整的环杓关节、环杓后肌、环杓侧肌、喉返神经和喉上神经。其生理作用为使声带运动、声门内收和外展拉。     

选择性喉返神经吻合术治疗喉麻痹的实验研究

目的 研究不同神经源分别支配受损喉返神经内收及外展肌支的神经肌电表现。方法 将实验组犬左喉返神经完全切断，再将其外展肌支及内收肌支分别同期与同侧膈神经支及颈袢胸舌肌支吻合，吻合术后6个月分别用神经电图仪、光镜、电镜及直达喉镜等方法全面检测甲杓肌与环杓后肌神经肌电活动情况，所得数据用统计学方法进行分析。结果 吻合术后6个月，喉内收及外展肌均出现动作电位波，其甲杓肌潜伏期与术前比较无差异，甲杓肌神经传导速度已恢复正常，环杓后肌神经传导速度稍慢。结论 选择性喉返神经吻合术最大限度地从生理及解剖上避免了吻合术后喉内肌的联带运动问题，达到了预期目的。     

环杓关节在延期喉内肌神经再支配后的变化

目的：观察环杓关节在延期喉内肌神经再支配后的变化及对杓状软骨运动的影响。方法：在喉返神经切断后，将犬分为两组：实验组（６、８、１０、１２和１８个月后行延期神经再支配）和对照组（相同时间无神经再支配），观察其杓状软骨运动及环杓关节组织学变化。结果：１２个月以内行喉内肌神经再支配后环杓关节纤维化有不同程度的逆转，而１８个月行喉内肌神经再支配后环杓关节纤维化不可逆。结论：越早行喉内肌神经再支配对环杓关节     

人喉返神经分支的应用解剖研究

目的：了解喉返神经在喉内的分支及分布,为施行选择性喉返神经吻合术提供解剖学依据。方法：５０例正常人新鲜喉标本进行系统的显微神经解剖研究。结果：９５％喉返神经在距同侧环甲关节下方１．０－２．５ｃｍ处形成喉返神经喉外分叉点,根据分支情况可将分为三型。喉内肌除环甲状外,均由喉返神经前支支配,其中８８％的环杓后肌为喉返神经前支发出单支支配;１２％为双支支配,结论：在甲状软骨板后下部处开窗,可显露同侧喉返神     

有关喉上神经和杓间肌的解剖学研究

虽然目前已公认喉返神经分布于同侧除环甲肌以外之所有喉内肌肉,喉部粘膜感觉神经来自喉上神经之喉内支与喉返神经之分支。然而对喉上神经是否有一分支分布于杓间肌的内收肌始终存在着争论。作者首先回顾了过去有关喉部肌肉及粘膜感觉神经分布之各种意见,然后描述在6—25倍手术显微镜下对12例22侧新鲜尸检喉部标本进行的显微解剖和6例3—4个月胎儿喉组织切片的观察结果:(1)喉上神经仅有穿通支经过杓间肌分布于喉后部粘膜,并无分支终止于杓间肌。(2)喉上神经的最下支向下越过环杓后肌与喉返神经感觉支相吻合,形成Galeni攀。     

正常喉诱发电位特点的研究

目的 分析正常喉肌诱发电位特点,得出其参数正常参考值范围,以利于喉神经功能的评估.方法 检测36例健康受试者72侧喉诱发电位反应,刺激相应喉返神经、喉上神经内、外支及迷走神经,检测诱发肌电反应潜伏期、时程、波幅(电位).结果 甲杓肌喉返神经诱发肌电潜伏期正常参考值(-x±2s,以下同)为(1.13～2.25)ms,迷走神经诱发肌电潜伏期(2.57～5.85)ms,迷走神经与喉返神经潜伏期相比差异有统计学意义(P＜0.01);其中右侧迷走神经诱发肌电潜伏期(2.01～4.53)ms,左侧迷走神经(3.70～6.98)ms,双侧比较差异有统计学意义(P＜0.01),左侧明显较右侧长.诱发肌电时程和波幅各神经亦略有差异,时程差异较小,波幅值变化较大.刺激喉上神经(外支)在环甲肌可直接引出诱发电位,其波形和潜伏期与喉返神经诱发电位大致相同,刺激喉上神经(内支)在甲杓肌、环杓侧肌和环杓后肌可引出反射性感觉诱发电位前波R1和迟发波R2.结论 喉各支配神经诱发电位特点各不相同;神经诱发电位的潜伏期相对时程和波幅来说,是更重要的评估参数.     

喉肌电图对自发性或甲状腺切除术后喉固定的诊断

作者报道20例喉固定(喉返神经麻痹)患者的喉肌电图检查结果,5例甲状腺切除术后喉固定,15例自发性喉固定。局麻下用RaciaMS7型肌电记录仪及双极电极记录,针极经皮穿刺插入环甲肌,经皮和环甲膜穿刺插入声带肌(甲杓肌),经鼻纤维镜插入环杓后肌或侧肌,或在无箭毒中毒的神经安定药作用下经直接喉镜插入环杓后肌,以保存声带自主活动。20例喉固定患者肌电定位诊断结果有6种表现:①喉肌电正常,环杓关节强直或脱位;②     

犬喉返神经损伤后环杓关节组织病理学特性初步研究

目的 通过对动物模型喉返神经损伤后环杓关节组织病理学特点研究,探讨喉返神经损伤后环杓关节结构及功能的变化特点.方法 喉返神经不同损伤(全切、半切、结扎及挫灭)模型及正常对照犬共16只(32侧半喉,其中8侧为正常对照),于损伤后1个月、3个月、6个月、12个月进行环杓关节组织病理研究.结果 喉返神经损伤后,环杓关节可呈现出不同程度的纤维蛋白渗出(12/24)、关节面纤维膜破裂(9/24)、纤维增生(7/24)、关节软骨退行性变(3/24)等表现.损伤后1个月主要是纤维蛋白渗出及关节面纤维膜的破裂;损伤后3个月主要表现为关节面纤维膜的破裂;损伤后6个月各种组织病理改变均出现,开始出现关节腔纤维增生及关节软骨的退行性变;损伤后12个月以纤维增生出现比例最高,但纤维化所占面积未超过关节面50.0%.仅全切组及结扎组出现环杓关节纤维增生及杓状软骨的退行性变,全切组及结扎组纤维化比率与正常对照组差异有统计学意义(t值分别为6.23及3.65,P值均<0.01);全切组环杓关节平均软骨细胞核数与正常对照组间差异有统计学意义(t=2.78,P<0.05).半切组和挫灭组的表现基本一致,病理变化程度轻.纤维增生(7侧次)与关节软骨退行性改变(3侧次)只在9侧声带麻痹加重及未恢复组出现(其中1侧标本存在两种病变),预后不良.结论 环杓关节病理变化程度与神经损伤程度一致,全切组及结扎组出现的病理变化较重,且在喉返神经损伤后6个月已有表现.     

喉的开闭机制

喉的开放或闭合取决於喉内肌、喉外肌的运动。喉的开或闭受两个机制的影响:(1)环甲肌收缩和喉内肌的收缩可开放和闭合声带;(2)附着於喉软骨的肌肉收缩,可伸展和开放或缩短和压迫喉内的软组织皱褶。作者为研究这些机制,复习了文献及解剖,并作了实验研究。实验结果:环杓后肌可使杓状软骨倾斜,并使声突向侧方移位而打开声带,降低气道阻力。当环甲肌与环杓后肌协同活动时,可使声带向侧方移动而增大喉的前后径使喉开至最大。     

保留杓状软骨喉次全切除喉功能重建的体会

目的　探讨应用保留杓状软骨的喉次全切除喉功能重建术治疗T3 喉癌 (声门及声门上型 )的拔管率和 3、5年生存率。方法　对 2 0例T3 级喉癌 ,其中声门型 3例 (T3 N0 M0 )、声门上型 17例(T3 N1 M0 5例 ,T3 N0 M0 12例 ) ,根据病变范围行保留单侧或双侧杓状软骨喉次全切除及功能重建术 ,并设计环咽吻合术式。结果　 3、5年生存率分别为 16/ 17(94 1% )和 11/ 12 (91 8% )。全部患者均恢复了吞咽和发音功能 ,拔管率为 95 0 %。结论　保留杓状软骨喉次全切除及功能重建术是治疗T3 喉癌的一种很好术式。手术的关键是不能损伤杓状软骨及喉返神经 ,设计好环咽吻合方案。     

A Decrease in Maxillary Sinus Pressure,as Seen in Upper Airway Allergy or Infection,Results in an Increase in Upper Airway Nitric Oxide Levels

The paranasal sinuses are connected to the nasal cavity via small osties. Ostial occlusion, caused by mucosal swelling, will result in a slowly increasing negative pressure inside the sinus cavity. In parallel, the oxygen content in the sinus will decrease, resulting in the development of relative hypoxia. Hypoxia is a powerful inducer of nitric oxide (NO) synthase, and inducible NO synthase has been shown to be present in considerable amounts in the upper airways, including the sinuses. The present study was designed to investigate whether a reduction in sinus pressure would affect upper airway NO production. Thirteen healthy volunteers were investigated. A pressure chamber was used to lower the ambient pressure to-4.9 kPa. NO was sampled from one nostril or via a drainage tube inserted into the maxillary sinus before, during and after the hypobaric exposure. When the pressure was decreased, NO levels increased from 256 &#45 15 to 316 &#45 19 ppb ( n =13, p <0.001). The NO levels remained elevated (282 &#45 21 ppb; p <0.05) when measurements were repeated 20 min after leaving the chamber. The nasal airway resistance (V2 tot ) also increased as a result of the chamber session (from 16 &#45 2° before to 21 &#45 3° after; p <0.05). An increase in NO levels was also found when the experiments were repeated with NO sampled directly from the maxillary sinus (225 &#45 6 before and 265 &#45 9 ppb after; n =6, p <0.001). For control purposes the nasal analyses were repeated again, this time under hyperbaric conditions (+4.9 kPa). This resulted in a slight decrease in the NO levels (from 273 &#45 22 to 241 &#45 17 ppb; n =10, p <0.001), but there was no change in the nasal airway resistance. We conclude that a reduction in sinus pressure, as seen in upper airway allergy or infection, may result in an increase in upper airway NO production.     

One‐stop neck lump clinic: phase 2 of audit. How are we doing?

One‐stop neck lump clinic: phase 2 of audit. How are we doing? Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one‐stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.     

A case of cortical deafness and anarthria

The nasal epithelium protects the underlying tissue from damage. Epithelial cell growth is controlled by epidermal growth factor (EGF) and is possibly affected by toxic proteins, e.g. eosinophil cationic protein (ECP). The aims of this study were to examine nasal fluid epithelial cell counts and their relations to EGF, eosinophils and ECP in 23 patients with seasonal allergic rhinitis and 20 healthy controls. Nasal fluid epithelial cell counts were lower in patients than in controls. EGF levels did not differ between patients and controls, and correlated with epithelial cell counts in controls but not in patients. Eosinophils and ECP were higher in patients than in controls, but did not correlate with epithelial cell counts. The role of growth factors, such as EGF, in regulating epithelial cells merits further study.     

A simple objective evaluation and grading for facial paralysis outcomes

Matrix metalloproteinase (MMP)-2 and -9 degrade type IV collagen, which is one of the major components of the basement membrane in normal tissue and expressed in the surroundings of the cancer nest in squamous cell carinoma. The degeneration of type IV collagen is an essential step in the metastasis to lymph nodes and distant organs. In this study, we examined MMP-2 and -9 levels of cancer tissue and serum obtained from patients with head and neck squamous cell carcinoma (HNSCC) in order to evaluate the relationship between the clinicopathologic features and MMPs. We examined the production of MMP-2 and -9 in cancer tissue homogenates of 73 patients who had HNSCC and the serum MMP levels of 16 patients with HNSCC and 8 healthy volunteers. We also studied the localization of MMP-2 in the carcinoma using an immunohistochemical approach. The concentrations of MMP-2 and -9 in the tissue homogenates and serum were measured by means of a sandwich enzyme immunoassay using a monoclonal antibody. Immunohistochemical analyses were performed with monoclonal antibody to MMP-2. The concentration of MMP-2 in the tumor tissue homogenates was unrelated to tumor size, but that in patients with lymph node metastases was significantly higher than in those without lymph node metastases. The concentration of MMP-9 was unrelated to lymph node metastasis and tumor size. The levels of both MMP-2 and -9 in serum were unrelated to lymph node metastasis. Immunohistochemistry indicated that MMP-2 was mainly expressed in cancer cells. Because MMP-2 degrades type IV collagen, the level of MMP-2 in carcinomas may be a useful indicator of the degree of invasion and metastasis.     

Bilateral versus unilateral cochlear implantation in young children

Objectives

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

Material and methods

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

Results

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p < 0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

Conclusions

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.     

Autoimmunity in Sudden Sensorineural Hearing Loss: Possible Role of Anti-endothelial Cell Autoantibodies

In order to verify whether anti-endothelial cell autoantibodies (AECAs) can be used as serological markers of inner ear vasculitis in sudden sensorineural hearing loss (SSHL), 32 patients affected by idiopathic SSHL were investigated. All patients underwent a routine general physical examination and extensive audiovestibular, microbiological and immunological investigations. Fourteen normal subjects without a history of HL, autoimmune or metabolic disease served as controls. Detection of AECAs was performed using an indirect immunofluorescence technique. AECA-positive patients were treated with methylprednisone, while AECA-negative patients were treated with a combined regimen of steroids, plasma expander and aspirin. The average hearing recovery for 5 frequencies (0.25-4 kHz) was analyzed in each subject 1 month after treatment and every 3 months thereafter; median follow-up was 12 months (range 9-18 months). A total of 15/32 patients (46.8%; 11/19 females, 4/13 males) were AECA-positive and thus differed significantly from the normal population in whom only 2/14 tested cases were positive ( p =0.03). Severe hearing loss was associated with being AECA-positive in 8/11 cases. During follow-up, 25/32 patients improved their hearing and 17 of these patients were AECA-negative. The seven cases without hearing improvement were all AECA-positive. In patients with SSHL, immune-mediated vascular damage may have a pathogenetic role and AECAs may represent a serological marker of vasculitis even if they are not inner ear-specific and even if they represent an epi-phenomenon rather than the only cause of SSHL.     

Correction of the Glosso-Larynx and Resultant Positional Changes of the Hyoid Bone and Cranium

In ankyloglossia with deviation of the epiglottis and larynx (ADEL) the tongue is located forward and as a result the epiglottis is elevated and leans towards the mouth. The larynx is also raised and curves ventrally. Various symptoms have been observed as a result of this condition. Correction of the glosso-larynx (CGL) is the operation performed to treat ADEL. The CGL procedure and the results obtained with it are reported in this paper. In addition, we studied the following six parameters using head and neck X-rays before and after CGL (the changes in these parameters as a result of CGL are shown in parentheses): ( i ) the shortest vertical length between the hyoid bone and mandible (+10.3 mm); ( ii ) the vertical length between the hyoid bone and the tangent line of C2-4 (+4.6 mm); ( iii ) the shortest length between the hyoid bone and the chin (+2.9 mm); ( iv ) the angle between the hyoid bone and the tangent line of C2-4 (+3.3°); ( v ) the length of H-M, where H is the intersection of a tangent line of C2-4 and a vertical line from the hyoid bone and M is the intersection of a tangent line of C2-4 and the mandible (+7.4 mm); and ( vi ) the width of the narrowest part of the hypopharynx (+3.0 mm). The changes in all the measured parameters after CGL were significantly different ( p <0.05).     

Carcinoma of the Nasopharynx: Analysis of Treatment Results in 91 Patients

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan -Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% ( n ¾ 3) for Stage I; 100% ( n ¾ 2) for Stage IIA; 90.9% ( n ¾ 11) for Stage IIB; 78.8% ( n ¾ 25) for Stage III; 53.0% ( n ¾ 29) for Stage IVA; 37.5% ( n ¾ 16) for Stage IVB; and 20.0% ( n ¾ 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% ( n ¾ 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% ( n ¾ 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% ( n ¾ 19). These results showed a statistically significant difference ( p ¾ 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit.     

Treatment Effects in Patients with Squamous Cell Carcinoma of the Oral Cavity

A total of 221 patients (155 males, 66 females; stage I, n ¾ 55; stage II, n ¾ 58; stage III, n ¾ 57; stage IV, n ¾ 51) with squamous cell carcinoma of the oral cavity were studied. Tumor localization was as follows: cancer of the tongue, n ¾ 161; cancer of the oral floor, n =28; cancer of the hard palate, n ¾ 12; cancer of the buccal mucosa, n ¾ 11; and cancer of the gingiva, n ¾ 9. In order to compare the effect of different treatments, three major treatment groups were defined, namely a surgery group, a radiotherapy group and a combination treatment group. Five-year cumulative survival rates showed significant differences between stage classifications (stage I=91%, stage II=73%, stage III=63%, stage IV=47%; p <0.01) but not between tumor sites. The 5-year cumulative survival rate was highest for oral floor cancer (80%). In the early-cancer group, the 5-year cumulative survival rate for the surgery group (92%) was significantly higher ( p <0.05) than those for both the radiation (69%) and combination (71%) groups. In the advanced-cancer group, the 5-year cumulative survival rate for the surgery group (74%) was significantly higher ( p <0.05) than those for both the radiation (37%) and combination (51%) groups. No significant difference in regional control rates was observed between the treatment groups. Five-year regional control rates were 86% for cervical untreated patients with T1N0 tumors and 60% for cervical untreated patients with T2N0 tumors. Fourteen N0 cases were treated with neck dissection. Cervical metastasis was found pathologically in 2/14 (14%) of these cases. The 5-year survival rate for patients with cervical recurrences after primary tumor resection was 70% ( n ¾ 15). In contrast, the 5-year survival rate for patients with both primary tumor resection and neck dissection was 74% ( n ¾ 14) but no significant difference was observed between these 2 groups.rate .     

Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis

Objective

To systematically evaluate the diagnosis of eosinophilic esophagitis (EE).

Methods

A retrospective review of 657 patients seen at the EE center of a tertiary care children's hospital between 1994 and 2007 was performed. Charts were reviewed for the 144 patients who were also seen by the otolaryngology service.

Results

One hundred forty-four patients received 193 otolaryngology-related diagnoses. Eustachian tube dysfunction (27.5%) and sleep disordered breathing (24.9%) were the most common, followed by dysphagia (13.0%), rhinosinusitis/nasal congestion (9.3%) and airway stenosis (5.2%). Seventy-nine patients (54.9%) had a pre-existing diagnosis of EE at the time of their otolaryngology consultation. Twenty-one patients (14.6%) were referred to the gastroenterology service for evaluation for EE. Forty-four patients (30.5%) remained undiagnosed. Twenty-five of these patients presented with dysphagia, 16 of whom were not previously diagnosed with EE; only 4 of these 16 patients were referred for evaluation for EE. In one case, a child with moderate sized tonsils underwent adenotonsillectomy for dysphagia and failure to thrive; this patient was diagnosed with EE 1 month post-operatively.

Conclusions

Twenty percent of patients with EE may require care by an otolaryngologist for a myriad of complaints. Even experienced pediatric otolaryngologists may not recognize this condition. Otolaryngologists should consider EE in patients presenting with dysphagia. A careful gastroenterology review of symptoms may also allow otolaryngologists to identify EE in patients with allergy mediated nasal complaints, or laryngeal/airway disorders.