鼻腔扩容术量化虚拟手术的气流动力学研究

目的　借助于计算流体力学数值模拟，分析鼻腔扩容术对上气道气流动力学的影响。方法　选取鼻科住院男性中度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者1例，主诉交替性鼻堵伴睡眠时打鼾4年余。接受高分辨率螺旋CT扫描并存储结果。借助于mimics 13.0软件进行虚拟手术，建立鼻腔扩容术不同的手术范围的手术模型并 进行计算流体力学数值模拟。结果　鼻中隔矫正术+双侧下鼻甲外移术虚拟手术后，鼻腔截面和咽腔截面的平均负压绝对值和平均气流速度降低，但鼻腔和咽腔的气流分布无明显改变；双侧中鼻道对称性虚拟开放后，气流速度和压力梯度变化趋于平缓、均匀，且咽腔最狭窄平面的平均负压值进一步降低。非对称性虚拟手术后，双侧鼻腔压力分布和最大气流速度分布不对称，咽腔最狭窄平面平均气流速度较原始模型无明显变化，平均负压绝对值甚至超过原始模型。结论　鼻腔扩容术一定程度上改善由于呼吸气流运动造成的咽腔塌陷趋势。双侧中鼻道对称性开放使鼻腔气流重新分布，进一步降低咽腔管腔内负压。非对称性手术导致双侧鼻腔压力和气流速度分布不对称，甚至可能升高咽腔负压绝对值，提示了鼻腔扩容术双侧对称性开放的必要性。     

鼻腔扩容术对上气道流场特征的影响

目的　通过分析鼻腔扩容术前后鼻腔和咽腔相关空气动力学指标的变化,探讨鼻腔扩容术对上气道流场特征变化影响,为研究鼻腔扩容术的临床意义,提供计算流体力学（computational fluid dynamics,CFD）的依据。方法　选取30例成年阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）患者进行鼻腔扩容术,随访至少3月,建立鼻腔扩容术前后上气道三维模型,应用CFD方法,数值模拟分析鼻腔扩容术前、后上气道空气动力学特征变化。结果　鼻腔扩容术后数值模拟鼻腔压力云图提示术后压力梯度变化趋于平缓,鼻腔速度云图提示上气道气流速度梯度变化较术前变小;鼻咽腔和腭咽腔云图同一截面的平均气流速度降低,分布相对于术前变得均匀对称;平均压力相对于术前显著降低。上气道流场特征值结果显示：鼻腔有效通气容积较术前显著增大（t =4.025,P <0.01）,鼻腔压力差较术前显著下降（t =-2.065,P <0.01）,上气道总阻力较术前下降（t =-2.659,P <0.01）,但有5例患者的上气道总阻力较术前增高。结论　鼻腔扩容术显著降低OSAHS患者的鼻腔总阻力,增大患者有效通气容积;降低患者咽腔气流速度,减小气流运动对咽壁产生的负压,降低咽腔塌陷性;鼻腔扩容术能降低OSAHS患者上气道总阻力,在于上游鼻腔通气程度的改善能否对下游咽腔产生有益的影响。上气道的CFD数值模拟分析可以评估鼻腔扩容术后上气道流场特征改变。     

阻塞性睡眠呼吸暂停综合征患者睡眠时咽腔观察

目的分析阻塞性睡眠呼吸暂停综合征（ｏｂｓｔｒｕｃｔｉｖｅｓｌｅｅｐａｐｎｅａｓｙｎｄｒｏｍｅ，ＯＳＡＳ）患者睡眠时咽腔阻塞特点及解剖原因，并与清醒时Ｍｕｌｅｒ检查比较。方法纤维喉镜检查４３例睡眠ＯＳＡＳ患者咽腔。结果①所有睡眠患者都有腭咽部阻塞，７９％病例合并口咽和／或下咽部阻塞。②咽阻塞涉及软腭或悬雍垂后坠、咽壁内陷、扁桃体或咽腭弓肥大、咽皱襞和咽侧索冗赘、舌根肥厚及后坠等诸多解剖异常。同一部位，个体间引起阻塞的解剖机制可不同。③睡眠时发现咽腔阻塞阳性率与Ｍｕｌｅｒ检查比较：腭咽部（１００％／９１％）、口咽部（５８％／４２％）、下咽部（５１％／２８％）。结论ＯＳＡＳ患者咽腔多部位阻塞很常见，解剖机制复杂多样，个体间常各异，对指导临床治疗及预后有重要意义。清醒时Ｍｕｌｅｒ检查较睡眠时观察阻塞部位少，尤其在腭咽以下部分，临床应用有局限性。     

阻塞性睡眠呼吸暂停综合征患者睡眠时咽腔观察

目的 分析阻塞性睡眠呼吸暂停综合征（ｏｂｓｔｒｕｃｔｉｖｅ ｓｌｅｅｐ ａｐｎｅａ ｓｙｎｄｒｏｍｅ,ＯＳＡＳ）,患者睡眠时咽腔阻塞特点及解剖原因,并与清醒时Ｍｕｌｌｅｒｘ检查比较。方法 纤维喉镜检查４３例睡眠ＯＳＡＳ患者咽腔。结果 ①所有睡眠患者都有腭咽部阻塞,７９％病例合并口咽和／或下咽部阻塞。②咽阻塞涉及软腭或悬雍垂后坠、咽壁内陷、扁桃体或咽腭弓肥大、咽皱襞和咽侧索冗赘、舌根肥厚及后坠等诸多     

同期鼻腔扩容术联合改良悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停低通气综合征

目的探讨鼻腔扩容术同期联合改良悬雍垂腭咽成形术（Han—uvulopalatopharyngoplasty,H．UPPP）治疗阻塞性睡眠呼吸暂停低通气综合征（obstructivesleepapneahypopneasyndrome,OSAHS）的疗效。方法多道睡眠图（polysomnography,PSG）监测及临床检查确诊的OSAHS且阻塞平面为鼻腔及腭咽腔患者132例,同期行鼻腔扩容术和H．UPPP,术后6个月～1年复查PSG监测,观察联合手术治疗的效果。结果成功随访108例患者,有效率为83．33％（90／108）,术后患者夜间平均动脉血氧饱和度、血氧饱和度低于90％的时间占总睡眠时间的百分比、最低动脉血氧饱和度、Epworth嗜睡量表4个指标均较术前有明显改善（P〈0．01）;术后发生2例鼻腔出血,1例扁桃体窝出血,7例鼻腔粘连,未发生其他并发症。结论对存在鼻腔及腭咽腔平面狭窄的OSAHS患者,同期行鼻腔扩容联合H-UPPP,安全有效,可以作为此类患者的首选手术治疗方式。     

腭咽功能不全言语障碍的诊断(英文)

腭咽功能不全(Velopharyngcal insufficiency,YPI)言语障碍是指腭咽口不能完全关闭引起的一种称为腭裂言语状况.Warred指出腭咽关闭不全仅仅遗留10～20mm~2的缺口即可影响正常言语产生.腭咽功能不全的原因可以是腭咽口结构异常(包括腭裂、深鼻咽腔、短软腭等),也可以是神经功能障碍和学习发音方法不当.只有依据口腔检查、言语功能评价、X线影像和鼻内窥镜观察腭咽口所获得的信息进行综合评价,才能正确选择最佳而恰当的矫治方法,包括外科手术、赝体修复和行为治疗,口腔检查评价:要正确识别软、硬腭解剖学结构和运动形式,正常言语时软腭的中1/3与咽后壁接触,腭帆下1/3包括悬雍垂由下向上覆盖并形成一向前倾斜的角度以关闭腭咽口,口腔检查还可识别扁桃体肥大、软腭痿管、软腭上举不对称(发ah时)、软腭粘膜下裂隙等,言语评价:目的是为了决定(1)腭咽功能不全是持续性还是间歇性;(2)在言语障碍中VPI作用所占的比例.评价包括测量口腔和鼻腔共鸣、发口腔辅音时并漏气情况、言语连贯程度和言语可懂度.具体方法有:①纸条振动试验,即令病人发10个双音节单词,包含20个非鼻腔爆破音,检查者持一小纸条置于患者鼻孔下方,观察并评价鼻腔漏气振动纸条的单词数,记录其分数在0/10～10/10之间;②过度鼻音试验,令患者发10个口     

关于Passavant隆起的意义及其形成的研究

发声时为了闭锁鼻咽腔,即隔开口腔与鼻腔,可采取三种方式:(1)软腭向后上方提举;(2)两侧咽壁向正中方向靠拢;(3)咽后壁向前方隆起。众所周知,软腭运动中起主要作用的乃腭帆提肌,它是关闭鼻咽腔的主力,而咽侧、咽后壁的运动到底在关闭鼻咽腔运动中有何意义,目前尚有不明     

咽腔扩大成形术治疗阻塞性睡眠呼吸暂停综合征(附49例报告)

目的：为了治疗阻塞性睡眠呼吸暂停综合征（ＯＳＡＳ），将腭咽成形术加以改良，共行４９例手术。方法：摘除扁桃体，将腭舌弓大部分切除，保留腭咽弓，并将腭咽弓上端向外上４５°剪开，将其向外牵拉缝合；软腭前面较后面多切除约０．６ｃｍ，将后面粘膜向前上牵拉缝合，以扩大咽腔。对舌扁桃体肥大者，彻底切除三角皱襞，将舌根两侧分别向前外牵拉缝合，固定到前创缘。结果：术后咽横截面积由术前的１０３．９４±１５．４１ｍｍ２增加到３５６．２１±１６．４６ｍｍ２。呼吸暂停消失者３２例、减轻１５例，总有效率为９５．９％。结论：改良的腭咽成形术较传统的手术效果为好，尤其对舌扁桃体肥大者也有效。但其适应证仍不包括因各种鼻疾、颌部畸形等所致阻塞性睡眠呼吸暂停综合征。     

扁桃体带蒂移植咽后壁治疗腭咽闭合不全

腭咽闭合不全多见于鼻咽腔过度宽大和软腭麻痹患者。吞咽和发音时,由于软腭不能与咽后壁相触而关闭鼻咽,引起食物鼻腔返流和开放性鼻音。 作者以改良Misra法为1例患者用其一侧扁桃体带蒂埋植于同侧咽后壁,缩小腭咽腔,以恢复腭咽功能,获得成功,报告如下。     

鼻腔扩容术对上气道流场改变的数值模拟

目的　通过比较不同程度阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）患者实施鼻腔扩容术,分析术前后的 鼻腔和咽腔流场等上气道流场特征的变化,评价鼻腔扩容术的临床意义。方法　选择轻、中、重度OSAHS患者各1例,进行鼻腔扩容术手术治疗。3个月后随访复查,提取患者术前、术后上气道高分辨率CT扫描数据,建立手术前后的鼻腔咽腔三维模型,运用计算流体力学方法,给出合理的边界条件,进行数值模拟计算,分析比较三者鼻腔扩容术前后上气道流场的改变。结果　数值模拟分析发现：轻、中度病例OSAHS患者术后鼻腔通气容积增加,鼻腔压力明显减小,且分布相对均匀,咽腔气流速度减低,咽腔负压降低,上气道总阻力降低。重度OSAHS患者手术前后鼻腔通气有所改善,但术前、术后咽腔气流速度差异明显,咽腔负 压升高,上气道总阻力增大。结论　计算流体力学数值模拟分析可以评估鼻腔扩容术后上气道流场特征改变,为选择合适的鼻腔扩容手术适应证提供依据,为个性化鼻腔扩容术提供研究方法。     

Intraoral pressure, nasal pressure and airflow rate in cleft palate speech

We have suggested that compensatory behaviors associated with cleft palate may be strategies developed for the purpose of satisfying the requirements of a speech regulating system. The purpose of the present study was to test this hypothesis in subjects demonstrating various degrees of velopharyngeal inadequancy. The pressure-flow technique was used to assess aerodynamic responses to a loss of velar resistance in 74 subjects compared to a control group of 137 subjects with adequate velopharyngeal closure. The results of this study demonstrate that as degree of inadequacy increased, airflow rate also increased. Although intraoral pressure fell as inadequacy increased, many subjects were able to maintain pressures above 3.0 cm H2O by increasing airflow rate. Nasal pressure increased in proportion to the decrease in intraoral pressure while combined nasal plus oral pressure remained constant across groups. These findings suggest that a loss of resistance at the velar port is compensated by an increase in resistance at the nasal port. Airflow rate appears to be adjusted to total upper airway resistance. These findings support our contention that the speech system is constrained to meet aerodynamic requirements.     

The speech regulating system: temporal and aerodynamic responses to velopharyngeal inadequacy

Temporal and respiratory responses to a loss of velar resistance were measured in 107 subjects demonstrating varying degrees of velopharyngeal inadequacy. The subject data were compared to data generated by a mechanical model representing a passive system. The pressure-flow technique was used to estimate velopharyngeal orifice size and measure respiratory and temporal characteristics of aerodynamic events associated with the production of the nasal-plosive blend /mp/ in the word "hamper". Subjects were categorized as having adequate closure (less than 0.05 cm2), adequate/borderline closure (0.05-0.09 cm2), borderline/inadequate closure (0.10-0.19 cm2) and inadequate closure (greater than or equal to 0.20 cm2). The data revealed that intraoral pressure fell 10-fold in the model as velopharyngeal orifice area changed from adequate closure to inadequate. The subject data demonstrated only a 1.4-fold drop in pressure. Airflow data indicated that there was a 10-fold increase in respiratory volume in the subject data corresponding to the change from adequacy to inadequacy. When respiratory and temporal responses were assessed together, the findings revealed that airflow and temporal changes minimized the fall of pressure as velar resistance declined across groups.     

Nasal nitric oxide in children: a novel measurement technique and normal values

OBJECTIVES: To develop and standardize a technique for measuring nasal nitric oxide (NO) output in children and to determine normal values in this population. STUDY DESIGN: Prospective study evaluating a new technique for measuring nasal nitric oxide in a cohort of normal patients and a cohort of patients with nasal disease. METHODS: Nasal NO was measured using an aspiration technique, aspirating room air through the nasal cavities by means of a Teflon nozzle placed in one nasal vestibule while maintaining velopharyngeal closure using a party "blow-out" toyRESULTS Nasal NO measurements were performed in 45 children (mean age, 11.0 y; age range, 3.2-17.6 y) There were 20 girls and 25 boys. All children were able to perform the maneuvers necessary for measurement of nasal NO output. Among the subgroup of normal healthy children (30), there was considerable variation in NO output between subjects, with a mean NO output of 481 nL/min and an SD of 283 nL/min. CONCLUSIONS: Nasal NO can be readily measured in children using the presented technique. There is considerable variability in the values for nasal NO output in normal children.     

Effects of size of the nasal airway on nasal airflow rate

The controversy concerning the effects of nasal airway impairment on facial growth has stimulated renewed interest in upper airway respiratory function. We assessed the relationship between nasal airway patency and nasal airflow rate, using the pressure-flow technique to estimate nasal cross-sectional size and nasal airflow rate in 30 normal and 82 nasally impaired adults. Groups were categorized according to otolaryngologic examination results and pressure-flow measurements. The results clearly demonstrate that size of the airway influences airflow rate when the smallest nasal cross-sectional area is under 0.4 cm2. The data suggest that the nose becomes flow-limiting when it is less than 0.18 cm2. These data support our contention that nasal airway impairment in adults occurs when the airway is less than 0.4 cm2 in size.     

Variations in velar position over time: a nasal videoendoscopic study

Changes in velar position during production of nonnasal speech in two adults were measured using field-by-field videoendoscopic tracking procedures. The data suggested that the changes in velar position were coordinated with syllable production. Peak velar displacement occurred during maximum oral closure for oral consonant production and was followed by lowering of velar position during vowel production. This pattern of velar movement was not altered by changes in speaking rate or by jaw fixation. The timing of peak velar elevation relative to peak intraoral air pressure and peak jaw elevation was also examined. Timing of peak velar displacement was statistically associated with timing of peak intraoral air pressure in one subject. The data are discussed with regard to the potential value of studying variations in velar position during nonnasal speech in patients with marginal velopharyngeal incompetence.     

Aerodynamic influences on nasal nitric oxide output measurements.

Nitric oxide (NO) concentration in aspirated nasal air is flow-dependent. Nasal NO outputs calculated from steady-state plateaux at flows < 1 l/min are substantially smaller than those at flows > 2 l/min. This study aimed to determine the differences in NO output as calculated from the NO concentration plateaux in aspirated nasal air, resulting from different aspiration flows. Nasal NO was determined by chemiluminescent analysis of air obtained from the nasal passages in series during velopharyngeal closure in 8 healthy adults (flows: 0.2-3.7 l/min) and 5 with symptomatic allergic rhinitis (flows: 0.2-3.7 l/min). Mean NO output in the healthy subjects was stable at approximately 315 nl/l/min at flows of 0.2-0.7 l/min, and increased to a second steady output level of approximately 400 nl/l/min (+28%, p < 0.0001) at more physiological flow rates of 2.7 l/min and higher. The symptomatic subjects had substantially higher NO output at all flows (p < 0.001) (709.3 nl/min at 3.7 l/min) than the non-allergic subjects. The flow dependency of the nasal NO output may be explained by failure at low flows for the air stream to penetrate the peripheral parts of the complex nasal passages, and by the presence of a laminar flow regime in which a marginal lamina would tend to insulate the main stream from the mucosa. Thus, previously reported NO outputs obtained at low flows may underestimate nasal NO output compared to output at higher and more physiological transnasal airflow rates, thus affecting interpretation of results.     

Effects of age, body mass index, and gender on nasal airflow rate and pressures.

OBJECTIVES: The purpose of this study was to evaluate the variation of airflow rate and oral-nasal pressure with age, body mass index (BMI), and gender (i.e., to evaluate whether the effects of age, BMI, and gender on airflow rate and pressures are convergent with their effects on nasal cross-sectional area and resistance). STUDY DESIGN: A cross-sectional study of 332 subjects (214 female and 118 male subjects) aged 16 to 82 years. METHODS: The aerodynamic measurements of nasal airflow rate and nasal and oral pressures were performed by posterior rhinomanometry. Age, gender, weight, and height were recorded for each subject, and the BMI was calculated. The effects of age, BMI, and gender on airflow rate and nasal and oral pressures were estimated by ANOVA. RESULTS: Nasal airflow rate and oral and nasal pressures increased with increasing BMI. In addition, the mean values of airflow rate and pressures were significantly higher in male than in female subjects. Increasing age was related to increased oral pressure, but was not associated with airflow rate or nasal pressure. CONCLUSIONS: This study suggests that, on the contrary to the findings in children and adolescents, BMI and gender should be taken into consideration when measuring the patency of upper airway in adults.     

Velopharyngeal port status during classical singing.

PURPOSE: This investigation was undertaken to examine the status of the velopharyngeal (VP) port during classical singing. METHOD: Using aeromechanical instrumentation, nasal airflow (mL/s), oral pressure (cm H2O), and VP orifice area estimates (cm2) were studied in 10 classically trained sopranos during singing and speaking. Each participant sang and spoke 3 nonsense words-/hampa/, /himpi/, and /humpu/-at 3 loudness levels (loud vs. comfortable vs. soft) and 3 pitches (high vs. comfortable vs. low), using a within-subject experimental design including all possible combinations. RESULTS: In general, nasal airflow, oral pressure, and VP area estimates were significantly greater for singing as compared to speech, and nasal airflow was observed during non-nasal sounds in all participants. Anticipatory nasal airflow was observed in 9 of 10 participants for singing and speaking and was significantly greater during the first vowel in /hampa/ versus /himpi/ and /humpu/. The effect of vowel height on nasal airflow was also significantly influenced by loudness and pitch. CONCLUSIONS: The results from this investigation indicate that at least some trained singers experience regular VP opening during classical singing. Vowel height seems to influence this effect. Future research should consider the effects of voice type, gender, experience level, performance ability, and singing style on VP valving in singers.     

Perceptual and respiratory responses to added nasal airway resistance loads in older adults

The purpose of the present study was to assess breathing behavior under various nasal resistance load conditions and, in particular, to determine whether respiratory responses to added nasal resistance loads occur before the threshold perception of an added load. The participants were 40 older adults who ranged in age from 59 to 82 years. Nasal airflow and resistance were measured with the pressure-flow technique, which was modified to create calibrated resistance loads. Statistical analyses revealed a significant decrease in airflow rate and volume during load conditions both before perceptual detection and at detection of increased resistance in comparison to a “no load” condition. No differences in respiratory behaviors were found between the load condition just before perceptual detection of an increased resistance load and the load condition at detection. The present findings suggest that physiologic responses to changes in the airway environment apparently occur even before there is perceptual recognition that the environment has changed.     

Laryngeal factors in voiceless consonant production in men, women, and 5-year-olds.

Voicing control in stop consonants has often been measured by means of voice onset time (VOT) and discussed in terms of interarticulator timing. However, control of voicing also involves details of laryngeal setting and management of sub- and supraglottal pressure levels, and many of these factors are known to undergo developmental change. Mechanical and aerodynamic conditions at the glottis may therefore vary considerably in normal populations as functions of age and/or sex. The current study collected oral airflow, intraoral pressure, and acoustic signals from normal English-speaking adults and children producing stop consonants and /h/ embedded in a short carrier utterance. Measures were made of stop VOTs, /h/ voicing and flow characteristics, and subglottal pressure during /p/ closures. Clear age and gender effects were observed for /h/: Fully voiced /h/ was most common in men, and /h/ voicing and flow data showed the highest variability among the 5-year-olds. For individual participants, distributional measures of VOT in /p t/ were correlated with distributional measures of voicing in /h/. The data indicate that one cannot assume comparable laryngeal conditions across speaker groups. This, in turn, implies that VOT acquisition in children cannot be interpreted purely in terms of developing interarticulator timing control, but must also reflect growing mastery over voicing itself. Further, differences in laryngeal structure and aerodynamic quantities may require men and women to adopt somewhat different strategies for achieving distinctive consonantal voicing contrasts.