超声引导下肉毒毒素环咽肌注射治疗延髓背外侧综合征所致吞咽障碍1例报道

目的 采用超声引导下肉毒毒素环咽肌注射治疗延髓背外侧综合征所致吞咽障碍。方法 回顾本院1例临床资料。结果 患者延髓背外侧梗死后,导致环咽肌失弛缓,经常规吞咽治疗和球囊扩张术后未见明显好转,予超声引导下肉毒毒素环咽肌注射,经藤岛一郎摄食-吞咽功能等级量表、Rosenbek渗漏-误吸量表评定和透视荧光吞咽检查分析,吞咽功能改善,治疗后1个月和3个月随访,吞咽功能正常。结论 超声引导下肉毒毒素注射治疗延髓背外侧综合征所致环咽肌失弛缓有一定的近期和远期效果。     

延髓背外侧综合征患者吞咽障碍的早期功能训练

目的：探讨延髓背外侧综合征患者的早期功能训练。方法：对57例延髓背外侧综合征致吞咽障碍患者随机分为实验组29例和对照组27例,用洼田氏饮水实验法为观察标准。结果：实验组吸入性肺炎发生率明显低于对照组（P〈0.01）,吞咽功能康复程度明显优于对照组（P〈0.01）。结论：对延髓背外侧综合征患者进行早期功能训练,使患者恢复了经口进食,减少了并发症,提高了患者的生活质量。     

球囊肌力训练法治疗重度格林-巴利综合征吞咽障碍1例

目的探讨球囊肌力训练法治疗重度格林-巴利综合征（GBS）所致吞咽障碍的可行性,客观评价其治疗效果。 方法重度GBS吞咽障碍患者1例,经电视透视检查(VFSS)评价,环咽肌完全不开放。将14号导尿管经鼻腔插入咽腔,不进入食管入口,向球囊内注入冰生理盐水,嘱患者做吞咽动作,同时在最大幅度喉上抬时尽可能保持5~10 s,逐渐改善吞咽肌群的力量。 结果经12次治疗后,VFSS显示：食物能较顺畅地穿过环咽肌处进入食管,吞咽肌力量明显增强,环咽肌开放正常,患者拔除胃管,经口安全进食。 结论球囊肌力训练法可以有效增强喉上抬肌群及咽部肌群的力量,其效果可能优于门德尔松手法和Shaker训练法,而且操作简单、安全可靠。     

球囊扩张术治疗吞咽功能障碍的疗效观察

目的探讨球囊扩张术在环咽肌失弛缓症所致吞咽障碍中的治疗作用。 方法共选取10例经吞咽X线荧光透视检查诊断为环咽肌失弛缓症的吞咽障碍患者。利用14号导尿管球囊，采用注水方式使球囊充盈以扩张环咽肌，同时辅以低频电刺激、口颜面吞咽器官运动训练及进食指导练习等。分别于治疗前、后进行吞咽功能评估。 结果上述患者经平均19.7次球囊扩张治疗后，其扩张球囊注水量由（2.65±0.91）ml增加至（8.20±0.92）ml，环咽肌开放功能显著提高，吞咽障碍明显改善，共显效7例，有效2例，这9例患者能完全经口自主进食糊状食物,无呛咳，吞咽造影复查显示在进食糊状食物时，其咽部期残留明显减少，环咽肌正常开放，误吸现象消失，仅余下1例患者只能达治疗性进食水平，吞咽造影复查显示其吞咽肌无力，环咽肌开放不全，仍存在误吸现象；比较治疗前、后患者饮水试验分级及吞咽障碍分级，发现治疗前、后差异均有统计学意义(P<0.01)。 结论球囊扩张术能显著改善环咽肌失弛缓导致的吞咽功能障碍，值得临床推广、应用。     

导尿管球囊扩张术对脑卒中后环咽肌失驰缓症的疗效及随访研究

目的探讨导尿管球囊扩张术在脑卒中后环咽肌失弛缓症所致吞咽障碍中的治疗作用及随访情况。方法共选取28例经电视透视下吞咽功能检查(VFSS)诊断为脑卒中后环咽肌失弛缓症的吞咽障碍患者,应用14号导尿管球囊,采用注水方式使球囊充盈以扩张环咽肌,同时辅以神经肌肉电刺激、常规吞咽康复训练。治疗终点为恢复经口进食或治疗已满6周。分别于治疗前、治疗终点时进行吞咽功能评估及吞咽造影检查,1年后随访。结果在导尿管球囊扩张治疗终点,28例患者中有22例恢复经口进食普通饮食,包括固体食物、流质物及水,24例可进食糊状食物,与治疗前比较有显著性差异(P<0.01)。吞咽造影中,治疗后咽通过时间缩短(P<0.05);VFSS吞咽障碍程度评分明显高于治疗前(P<0.01)。治疗终点时VFSS疗效评价显示总有效率达89.28%。1年后随访发现,23例(82.14%)患者均能从口进食普通食物;12例患者咽通过时间、吞咽障碍程度评分已接近正常。结论导尿管球囊扩张术能显著改善脑卒中后环咽肌失弛缓导致的吞咽功能障碍,且具有远期疗效。     

经口间歇胃管置管鼻饲法用于脑卒中后咽期吞咽障碍患者的效果观察

目的探讨经口间歇胃管置管鼻饲法对于改善脑卒中后患者咽期吞咽障碍的疗效。方法将入选的65例由脑卒中引起的咽期吞咽障碍患者分为观察组32例和对照组33例,观察组采用经口间歇胃管置管鼻饲法协同吞咽功能训练,对照组采用持续经鼻胃管置管鼻饲法协同吞咽功能训练,干预14 d后分别对患者的吞咽功能进行评估。结果观察组患者吞咽功能治愈率明显优于对照组,差异有统计学意义(P0.05)。结论经口间歇胃管置管鼻饲法对脑卒中引起的咽期吞咽障碍有效,值得进一步研究并在临床推广应用。     

导尿管球囊扩张术在脑卒中后环咽肌失弛缓所致吞咽障碍患者中的应用研究

目的 观察导尿管球囊扩张术对脑卒中后环咽肌失弛缓所致吞咽障碍的疗效。 方法 选取脑卒中后吞咽障碍患者32例,均经吞咽X线荧光透视检查（VFSS）确诊为环咽肌失弛缓,采用随机数字法分为研究组16例,对照组16例。对照组仅行吞咽功能训练及电刺激治疗,研究组在对照组治疗方案的基础上以普通导尿管为扩张工具,对其进行环咽肌扩张治疗。于治疗前和恢复经口进食或治疗达6周后（治疗后）评估2组患者的经口进食人数、吞咽障碍程度（VFSS评分）和临床吞咽功能。 结果 治疗后,研究组16例患者中恢复经口进食11例（68.75%）,对照组16例患者中恢复经口进食仅4例（25.0%）,2组比较,差异均有统计学意义（P<0.05）。治疗后,研究组患者的VFSS评分在口腔期、咽期、误吸以及总分与组内治疗前比较,差异均有统计学意义（P<0.05）,而对照组患者的VFSS评分仅口腔期和总分显著优于组内治疗前,差异均有统计学意义（P<0.05）。治疗后,研究组患者VFSS评分中的咽期、误吸程度、总分与对照组治疗后比较,差异均有统计学意义（P<0.05）。治疗后,研究组的临床吞咽功能评分与组内治疗前和对照组治疗后比较,差异均有统计学意义（P<0.05）。 结论 常规吞咽功能康复训练和电刺激联合环咽肌球囊扩张术可促进脑卒中后环咽肌失弛缓所致吞咽障碍患者及早经口进食,并改善其吞咽障碍程度,恢复其吞咽功能。     

脑卒中急性期吞咽障碍环咽肌功能的临床及影像学评定

目的：探讨脑卒中急性期吞咽障碍患者环咽肌功能障碍（CPD）的临床及影像学评定,旨在找到有效治疗CPD的依据和方法。方法：首次发病的急性脑卒中患者100例,均在入院24h进行临床吞咽功能评定,入院7d内完成吞咽造影录像检查（VFSS）,以确定患者的吞咽异常模式及客观判断环咽肌功能。结果：100例患者中存在吞咽障碍40例,能完成VFSS 30例,其中环咽肌功能正常24例;存在CPD 6例,其病变部位在脑干及小脑,临床上表现为中重度吞咽障碍,其中口咽期均受损2例,咽期障碍4例。6例中环咽肌打开不能1例,打开不全5例,同一患者可以存在多种吞咽异常模式,包括喉上抬不足、梨状窝较多钡剂残留、喉渗透及误吸。结论：脑卒中后CPD主要发生在脑干的损伤部位,表现为环咽肌打开困难,其发生的机制可能为环咽肌的皮质延髓通道发生退行性变,使之呈现去抑制的后果。CPD对患者生活影响很大,应及时给予相应的康复干预。     

神经肌肉电刺激对脑卒中后吞咽障碍的影响

目的探讨最适合神经肌肉电刺激治疗的脑卒中后吞咽障碍患者的类型及神经肌肉电刺激的作用方式。 方法60例经电视透视吞咽检查确诊的脑卒中后吞咽障碍患者分为治疗组和对照组,每组30例,疗程10 d,比较2组的误吸、喉上升、食物残留、进食量评分,将2组患者按电视透视吞咽检查评分标准分为轻、中、重3个亚组,比较各亚组间的疗效。 结果治疗前电视透视吞咽检查评分、误吸、喉上升、食物残留、进食量评分比较差异无统计学意义(P&rt;0.05);治疗第10天,治疗组误吸、喉上升的评分明显低于对照组,电视透视吞咽检查评分明显高于对照组(P<0.05),进食量、食物残留量评分2组差异无统计学意义（P&rt;0.05）。治疗第10天,治疗组中度吞咽障碍患者电视透视吞咽检查评分明显高于对照组(P=0.013),2组轻、重度吞咽障碍患者的电视透视吞咽检查评分比较差异无统计学意义(P&rt;0.05)。 结论神经肌肉电刺激疗效肯定,主要通过改善喉上升减弱、误吸程度起作用。中度吞咽障碍的患者最适合采用神经肌肉电刺激治疗,轻度患者无优势,重度患者具有疗效较好的趋势。     

脑损伤后吞咽障碍患者电视X线透视吞咽功能检查参数与吞咽预后的相关性研究

目的了解脑损伤后吞咽障碍患者的电视X线透视吞咽功能检查（VFSS）参数对于判断吞咽障碍预后的价值。 方法选取77例经VFSS诊断的脑损伤恢复期吞咽障碍患者均接受专业吞咽训练,主要包括饮食改变（如选择合适的形状、大小等）、调整进食姿势（如吞咽前误吸的患者可低头吞咽等）、行为治疗（如对于吞咽中误吸可进行声门上吞咽、环咽肌开放不全的患者进行门德尔松法）和口颜面肌肉的训练（每日1次,每次45min,共12周）。经3个月的吞咽训练后,再次进行VFSS检查,分别进食3ml液态钡食、10ml液态钡食、10ml半固体（酸奶）钡食、10cm3固体（1/4包钡蛋糕）钡食,确定能否完全经口进食。根据入组3个月后患者能否完全经口进食,将患者分为预后良好组（能完全经口进食,41例）和预后不良组（不能完全经口进食,36例）。分别采集患者VFSS参数,并记录3个月后各种食团吞咽时口腔传送时间、咽延迟时间、咽传送时间、舌骨上抬幅度、舌骨前移幅度,并对2组患者的VFSS参数及其与吞咽预后的相关性进行统计分析。 结果预后不良组患者吞咽3ml液体时的口腔传送时间、咽延迟时间、咽传送时间［（0.88±0.18）、（0.40±0.21）和（0.61±0.11）s］较预后良好组［（0.75±0.16）、（0.26±0.17）和（0.53±0.13）s］明显延长,其舌骨上抬幅度［（1.19±0.38）cm］较预后良好组［（1.54±0.53）cm］明显减小,且组间且差异有统计学意义（P<0.05）。预后不良组患者吞咽10ml半固体（酸奶）及10cm3固体（1/4包钡蛋糕）时的口腔传送时间、咽延迟时间均较预后良好组明显延长（P<0.05）;预后不良组患者吞咽10ml半固体（酸奶）时的咽传送时间及舌骨上抬幅度与预后良好组患者吞咽同类食团比较,差异亦有统计学意义（P<0.05）,但2组患者吞咽10cm3固体（1/4包钡蛋糕）时的咽传送时间及舌骨上抬幅度差异不明显（P>0.05）。经Logistic逐步回归分析统计显示,口腔传送时间（OR值=0.01,P＝0.048）、咽延迟时间（OR值=0.01,P＝0.040）、舌骨上抬幅度（OR值=20.26,P＝0.000）与吞咽障碍预后不良有关,即口腔传送时间越长,咽延迟时间越长,舌骨上抬幅度越小,则吞咽障碍预后越差。未发现舌骨前移幅度与吞咽障碍预后的相关关系。 结论VFSS参数对于分析中枢神经性吞咽障碍的预后有一定意义。     

鼻咽癌放疗术后吞咽障碍患者的吞咽造影影像学研究

目的 观察鼻咽癌放疗术后患者吞咽障碍的吞咽造影表现及不同性状食物对其吞咽功能的影响。 方法 选取20例鼻咽癌放疗后吞咽障碍患者进行吞咽造影检查,患者进食3种不同粘稠度的对比剂,观察其吞咽功能情况并分析不同性状对比剂对其吞咽功能的影响。观察指标包括口腔运送时间、口腔残留量、咽部残留量、渗漏误吸分级、环咽肌开放率。 结果 患者进食3种食物的各项观察指标比较,差异均有统计学意义（P<0.05）。两两比较中,患者进食稀流质与糊状食物比较,各项观察指标的差异均有统计学意义（P<0.05）,进食浓流质与糊状食物的各项观察指标比较,差异均有统计学意义（P<0.05）,患者进食稀流质与浓流质比较,口腔运送时间、口腔残留量和咽部残留量的差异有统计学意义（P<0.05）。 结论 鼻咽癌放疗后吞咽障碍患者的吞咽功能严重程度不一,不同食物性状对其吞咽功能的影响也不同,吞咽造影检查可以客观评价患者的吞咽功能,并为选择食物提供客观依据。     

Motions of the posterior pharyngeal wall in human swallowing: a quantitative videofluorographic study

OBJECTIVE: To quantify segmental motions of the posterior pharyngeal wall during swallowing. DESIGN: Prospective study. SETTING: Hospital radiology suite. PARTICIPANTS: Six healthy adult volunteers. INTERVENTIONS: Videofluorography of the pharynx in posteroanterior and lateral projections during water swallows by 6 able-bodied adults. Radiopaque suction markers, inserted through the nose, were attached by suction to the midline of the posterior pharyngeal wall of the upper and lower oropharynx, pharyngoesophageal segment (PES), or cervical esophagus. MAIN OUTCOME MEASURES: Displacement of the larynx, hyoid bone, and markers. RESULTS: Marker pathways were ovoid in the oropharynx but linear in the PES and esophagus. Marker displacement was greatest in the vertical dimension, intermediate in posteroanterior dimension, and smallest in mediolateral dimension. Vertical displacement was greater for the PES marker than for larynx, hyoid bone, or oropharynx markers (p < .001), so that the pharynx shortened significantly during each swallow. Marker displacement was unaffected by bolus volume. CONCLUSIONS: The pharyngeal wall shortened during swallowing. The mechanism for PES elevation may differ from that of laryngeal elevation. Shortening of the pharynx may be produced by contraction of the pharyngeal suspensory muscles and traction on the larynx by suprahyoid muscles.     

吞咽造影量化分析的信度研究

目的采用自主开发的吞咽造影数字化采集与分析系统进行吞咽造影时间学参数和运动学参数的量化分析,确定该分析方法的信度。 方法选取吞咽功能障碍患者18例,接受标准吞咽造影检查,分别选择质地为3ml、5ml由600kg/m3硫酸钡混悬液调制的稀流质、浓流质、糊状食团,每位受试者共进行6次吞咽。由两名分析者分别对所采集的吞咽造影视频进行间隔时间为4周的2次分析,分析参数包括口腔运送时间、软腭上抬时间、舌骨位移时间、喉关闭时间、环咽肌开放时间、舌骨向前位移、舌骨向上位移、环咽肌开放幅度及咽腔收缩率。 结果不同参数之间信度存在差异,除两名分析者测得的舌骨向前位移（HAM）及向上位移（HSM）的内测信度为0.41～0.60,信度欠佳,以及间测信度为0.61～0.80,信度中等外,其余参数信度均较好。 结论自主开发的吞咽造影数字化采集与分析系统信度比较理想,该软件可用于临床吞咽造影量化分析。     

Anatomy and physiology of feeding and swallowing: normal and abnormal

Eating and swallowing are complex behaviors involving volitional and reflexive activities of more than 30 nerves and muscles. They have two crucial biologic features: food passage from the oral cavity to stomach and airway protection. The swallowing process is commonly divided into oral, pharyngeal, and esophageal stages, according to the location of the bolus. The movement of the food in the oral cavity and to the oropharynx differs depending on the type of food (eating solid food versus drinking liquid). Dysphagia can result from a wide variety of functional or structural deficits of the oral cavity, pharynx, larynx, or esophagus. The goal of dysphagia rehabilitation is to identify and treat abnormalities of feeding and swallowing while maintaining safe and efficient alimentation and hydration.     

Swallowing disorders in persons with cerebrovascular accident

Thirty-eight CVA patients with swallowing disorders were studied videofluorographically (VFG) to determine: (1) the nature of their swallowing disorders, (2) the relationship between the site of the cerebrovascular accident and the nature of the swallowing disorder(s) exhibited and (3) the frequency and etiology of any aspiration present. The 38 CVA patients exhibited a variety of physiologic disturbances in swallowing, usually occurring in combination rather than as isolated disorders. A delayed swallowing reflex was the most frequent disorder seen in all patient groups. Reduced pharyngeal peristalsis was the next most frequent disorder, followed by reduced tongue control. Only brainstem CVA patients exhibited reduced laryngeal closure. Two patients (no right CVAs) experienced cricopharyngeal dysfunction. Few differences in nature of swallowing disorders were seen according to lesion location. Approximately one third of the patients aspirated, most frequently because of delayed triggering of the swallowing reflex. All aspiration occurred because of disorders in the pharyngeal stage of the swallow, emphasizing the importance of VFG evaluation of dysphagia in CVA patients.     

Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction

OBJECTIVE: To evaluate the therapeutic effectiveness of botulinum toxin type A (BTX-A) in poststroke patients with cricopharyngeal muscle dysfunction. DESIGN: Before-after trial. SETTING: University hospital. PARTICIPANTS: Eight poststroke patients. INTERVENTION: BTX-A injection into the cricopharyngeal muscle under endoscope guidance for poststroke cricopharyngeal muscle dysfunction. MAIN OUTCOME MEASURES: Clinical symptom score, disability rating scale for swallowing impairment, videofluoroscopic swallowing study, and upper esophageal sphincter (UES) manometry. RESULTS: Clinical symptom score, disability rating scale for swallowing impairment, residue in piriform sinus, and UES pressure were all significantly improved at 2 weeks after BTX-A injection compared with evaluations before injection (P<.05). The effects on the clinical symptom score and disability rating scale for swallowing impairment continued to be significantly improved to 12 weeks after injection (P<.05). However, the residue in piriform sinus and the UES pressure at 12 weeks postinjection were reduced compared with before-injection evaluations; these results were not significant. The pharyngeal transit time was not changed after injection. There were no side effects observed in the patients studied. CONCLUSIONS: The results of the present study suggest that BTX-A injection may be an effective and safe treatment in patients with poststroke cricopharyngeal muscle dysfunction.     

表面肌电图在环咽肌失弛缓患者吞咽障碍评定中的应用

目的 观察舌骨下肌群和颏下肌群表面肌电图(sEMG)在缺血性脑卒中后环咽肌失弛缓患者吞咽评定中的应用价值。方法 2015年1月至2019年12月,本院缺血性脑卒中后咽期吞咽障碍患者48例,根据透视荧光吞咽检查(VFSS)结果,存在环咽肌功能异常者为观察组,无环咽肌功能异常者为对照组,各24例,同期选取健康志愿者24例为健康组。行sEMG检测,记录三组在静息,空吞咽,吞咽水、浓流质、糊状食物等不同模式下,舌骨下和颏下肌群的均方根值(RMS),观察RMS与VFSS的相关性。结果 各组各肌群RMS均随吞咽难度提高而显著升高(F > 77.652, P< 0.001)。相同吞咽模式下,观察组各肌群RMS最高,其次为对照组和健康组(F > 42.505, P< 0.001)。各肌群RMS与VFSS评分呈正相关(r > 0.548, P <0.05)。结论 检测缺血性脑卒中后环咽肌失弛缓患者咽期颏下及舌骨下肌群sEMG,可初步揭示吞咽肌收缩力,为临床筛查和评估吞咽功能提供帮助。     

Successful treatment of long-standing post-stroke dysphagia with botulinum toxin and rehabilitation.

Cricopharyngeal myotomy is the most common treatment used to restore normal swallowing in patients with persistent (>6 months) cricopharyngeal muscle dysfunction post-stroke. We describe 2 patients whose dysphagia was due to cricopharyngeal muscle over-activity and who significantly improved after a percutaneous botulinum toxin injection in the cricopharyngeal muscle in combination with a rehabilitation treatment (dietary modifications, postural techniques, airflow protection manoeuvres). Swallowing was assessed clinically and by fibreoptic endoscopic evaluation of swallowing and videofluoroscopy; the degree of dysphagia was scored using the penetration-aspiration scale. Two months after the botulinum toxin injection the patients, who were previously fed via percutaneous endoscopic gastrostomy, returned to independent oral feeding and at 6, 12 and 24 months follow-up, both were still able to maintain an adequate oral intake with no signs of aspiration (by videofluoroscopy) or clinical complications. No further botulinum toxin injections or rehabilitation treatments were required. Our findings strongly suggest that even long-standing dysphagia can improve dramatically in selected patients. To the best of our knowledge, there are no other reports with such a long follow-up.     

实时电刺激并球囊扩张治疗脑干卒中致环咽肌失弛缓的疗效观察

目的观察吞咽时实时神经肌肉电刺激（NMES）联合球囊扩张治疗脑干卒中致环咽肌失弛缓的疗效。 方法采用随机数字表法将30例脑干卒中致环咽肌失弛缓患者分为实验组和对照组,每组15例。实验组患者给予吞咽时实时NMES+球囊扩张治疗,对照组患者给予常规NMES+球囊扩张治疗。 结果经治疗后,两组共有26例患者恢复正常经口进食,视频吞咽造影检查(VFSS)显示患者吞咽食物时环咽肌正常开放,食物能顺利通过环咽肌,误吸消失。两组患者吞咽功能改善情况组间差异无统计学意义（P>0.05）,但两组恢复正常进食患者其平均治疗次数（Z=2.423,P=0.0201）、平均治疗天数（Z=2.116,P=0.0352）、平均治疗费用（Z=2.296,P=0.0263）组间差异均具有统计学意义（P<0.05）,且上述指标均以实验组患者相对较优。 结论吞咽时实时NMES+球囊扩张及常规NMES+球囊扩张治疗对脑干卒中致环咽肌失弛缓均具有较好疗效,并且吞咽时实时NMES+球囊扩张治疗能进一步缩短疗程、降低治疗费用。     

磁共振动态扫描在鼻咽癌患者放疗后无自觉症状吞咽功能评价中的应用

目的探讨磁共振Fast GRE+Asset序列动态扫描在鼻咽癌（NPC）患者放疗后无自觉症状吞咽功能评价的初步应用。方法对80例放疗后NPC患者训练其掌握吞咽要领,在GE 3.0T磁共振系统上选用fast GRE序列,并结合Asset技术（加速因子均为2.0ph）,对咽部进行吞咽过程的单层矢状位动态快速扫描,分别连续采集60幅图像,并自动生成动态电影图像,采用双盲法对所获得的全部图像分别进行目测评价。结果80例患者全部成功完成检查,咽部形态显示清晰,会厌、软腭、舌部、肌肉清晰显示率分别为92.5%、98.75%、93.75%、95%。动态电影图像能清楚显示整个吞咽过程,完整展示吞咽动作过程中会厌、软腭、舌部,以及参与吞咽过程有关肌肉的变化过程。结论用fast GRE+Asset序列做吞咽动态矢状位磁共振成像,可以较好地评价NPC患者放疗后的吞咽功能。