成人侧颅底临床解剖学研究

目的:通过对侧颅底重要解剖标志的观察与测量.为临床侧颅底手术的定位、导航提供解剖学依据.方法:20具40侧10%甲醛浸泡的成人尸头(黄种人)和20例临床手术患者进行侧颅底指引标志的观察与测量.尸头标本按1～40的顺序进行编号;20侧临床手术患者按1～20的顺序进行编号.结果:通过测量得出侧项底相关定位标志的解剖数据:颈静脉孔静脉部、神经部与颅底重要指引标志的距离;迷路三角、迷路后三角及乳突表面三角的面积;侧颅底手术中面神经主动移位的最大距离.结论:耳科与颅底外科的手术几乎均在深埋于颅(颞)骨的狭窄空间内操作,周围布满了重要的血管和神经,术者了解侧颅底重要标志的定位测量数据有利于手术中安全扩大手术视野,有效避免术中损伤重要血管、神经,最大限度地保留面神经功能,最终提高患者的生存质量.     

Surgery of snoring

Habitual, loud snoring is common in the adult population, and may be the only symptom of the more serious Obstructive Sleep Apnoea syndrome. We report here our results of uvulo-palato-pharyngo-plasty (UPPP), with or without nasal surgery, for snoring. Quantitative grading of the severity of the snoring shows that all patients were cured of symptomatic snoring, but that snoring was not altogether abolished in all patients.     

Frequency analysis of snoring sounds during simulated and nocturnal snoring

Despite several ways of investigation, such as clinical examination, drug-induced sleep endoscopy and pressure measurement of the upper airway, it is still difficult to locate the site of snoring exactly. Frequency analysis of snoring sounds is described as a promising diagnostic tool. The aim of the study was to examine simulated snoring under conditions awake, record the produced snoring sounds and compare those sounds with nocturnal snoring. A total of 50 snoring male patients were examined clinically by flexible nasal endoscopy and simulated snoring under conditions awake, and the simulated snoring sounds were recorded. Additionally, nocturnal snoring sounds were recorded during nighttime polysomnography. Snoring events were analyzed by fast-fourier-transformation and the intensity peaks 1–5 were evaluated. Rhythmic and non-rhythmic snoring events were distinguished depending on present obstructive apneas. Clinical and polysomnographical data were correlated with the results of the frequency analysis of the snoring sounds. Simulated snoring sounds revealed a low frequency of 200 Hz in intensity peaks 1 and 2 with an increase up to 3,000 Hz in peaks 3–5. Similar frequency patterns were detected in rhythmic nocturnal snoring. Non-rhythmic snoring events revealed frequency patterns between 2,000 and 3,000 Hz in all five intensity peaks. Simulated snoring resembles rhythmic nocturnal snoring with low-frequency intensity peaks, whereas non-rhythmic snoring revealed high frequencies. The examination during simulated snoring and frequency analysis of snoring sounds might contribute in locating the pathogenesis of snoring.     

Objective evaluation of tongue base snoring after the use of an oral appliance: a prospective case series

Summary: Oral appliances have become increasingly popular for treatment of obstructive sleep apnoea especially for patients who are not able to tolerate continuous positive airway pressure devices. For simple snoring, oral appliances have become one of the treatments of choice despite a relative lack of scientific evidence of their efficiency. Objectives: This study was designed to objectively evaluate the clinical effectiveness of oral appliance in the treatment of simple snoring. Design: Prospective case series. Participants: Fifteen patients with confirmed simple tongue base snoring had pre‐ and post‐oral appliance objective assessment of their snoring loudness and duration at home. Main outcome measures: The Snore Index was calculated as the number of snores per hour slept. Patients bed partners were asked to rate the snoring severity on a Spouse Dissatisfaction Scale. Results: Overall there was no significant difference in the Snore Index in the pre‐ and post‐oral appliance recordings. Subjectively, there was a statistically significant decrease in the Spouse Dissatisfaction Scale following the use of oral appliance. Conclusion: Tongue base snorers had no significant reduction in their snoring with the oral appliances. There is a subjective benefit which may be due to the placebo effect.     

Surgery for snoring

Snoring is a common obnoxious disturbance in human society. Although considered a mere nuisance by most, it can have significant social and medical effects. Snoring has caused marriage breakdown and murder. It can lead to hypertension, heart failure, and the obstructive sleep apnea syndrome. Since Ikematsu developed palatopharyngoplasty (PPP) in 1952 and Fujlta introduced it to North America in 1981, numerous reports have alluded to its efficacy in the management of snoring. From June 1986 to February 1988, 110 PPP operations were performed at The Wellesley Hospital, University of Toronto. Of these, 58 patients responded to review and questionnaire. Elimination or improvement of their snoring was reported by 75.9% of patients. Complications encountered are discussed. We conclude that palatopharyngoplasty (PPP) is a safe and effective technique in the treatment of problematic snoring.     

鼾症患者模拟打鼾与药物诱导睡眠内镜下鼾声来源部位的对比研究

目的 对单纯打鼾(SS)及轻度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的患者,通过鼻咽纤维喉镜观察清醒状态下模拟打鼾及药物诱导睡眠下打鼾时的鼾声来源,研究这两种检查方法判断鼾声来源部位的一致性及模拟打鼾判断鼾声来源的可靠度。 方法 经多导睡眠监测(PSG)诊断为单纯打鼾患者及轻度OSAHS患者共40例,依次进行清醒状态下模拟打鼾及药物诱导睡眠,通过纤维鼻咽喉镜观察患者仰卧位打鼾时咽部组织的振动情况。 结果 在模拟打鼾及药物诱导睡眠两种状态下咽部组织的振动情况有所不同。统计学McNemar检验结果显示,两种方法对软腭振动及会厌/舌根振动判断的差异无统计学意义(P=0.774, 0.077),对咽侧壁振动判断的差异有统计学意义(P=0.002)。两种检查对软腭及会厌/舌根振动的检出率差异无统计学意义(P=0.770,0.110), 药物诱导睡眠对咽侧壁振动的检出率远高于模拟打鼾(P=0.005)。 结论 与药物诱导睡眠内镜检查相比,模拟打鼾能较好地判断软腭振动,其次为舌根/会厌,对咽侧壁振动则较难判断。     

舌动脉及舌下神经与舌根的解剖关系

目的 通过舌重要神经血管局部解剖学特点的研究,探讨舌等离子射频消融术进针的安全范围.方法 对8例(16侧)成人尸体舌的局部解剖测量,了解舌动脉及舌下神经在舌内的走行,并进行相对定位.结果 舌动脉及舌下神经的主干在舌盲孔周围距舌表面的垂直距离不随其走行而改变,约为20 mm;但其水平位距中线距离差异有统计学意义(P<0.01),越靠近舌前部距离越小.舌动脉水平位距中线距离与舌宽的比值于舌盲孔后10mm、舌盲孔及舌盲孔前10mm分别为0.269±0.012、0.262±0.003及0.233±0.009,舌下神经水平位距中线距离与舌宽的比值在以上3个断面分别为0.262±0.010、O.202±0.014及0.193±0.010,即舌动脉及舌下神经主干在舌根部走行于舌中线与舌外缘连线的内1/3与外1/3之间,靠近舌外缘侧1/3处.结论 舌根等离子射频消融的相对安全范围:舌表面下垂直深度不超过20mm,水平方向为舌中线与舌外缘连线的内1/3和外1/3,舌中线与舌外缘连线的外1/3处是最危险的部位.     

The annoyance of snoring

Is the annoyance of snoring a reliable tool for the measurement of snoring or does it depend more on the sensitivity of the listener? During an automatized hearing experiment, 550 representative snoring sequences, recorded during polysomnography, were randomly presented to ten examiners for the evaluation of their annoyance (0–100). The mean annoyance score for each snoring sound and the covariance parameters for rater and snoring sounds (restricted maximum likelihood method) were calculated. The average annoyance rating of all snoring sequences was 63.9 ± 23.0, the most acceptable snoring sequence rating was 49.2 ± 28.0, the most annoying rating was 77.7 ± 16.4. The covariance parameters were estimated as 28.7% for the rater and 22.3% for the snoring sound. Our results show that the listeners’ noise sensitivity is at least equally relevant for the snoring annoyance as the snoring sound itself.     

Danger areas of the posterior nasal base: anatomical, histological and endoscopic findings

In 52 cadaveric half-heads and endoscopic sphenoethmoidectomy was performed. Subsequently an anatomical preparation with registration of specific data like bulging of the optic canal, thickness of the bony wall covering the optic nerve and the internal carotid artery was achieved, followed by histological sections in specially selected cases. Thus the two key areas of major surgical hazard in the posterior rhinobasis could be clearly demonstrated: the immediate topographic relation of the optic canal and the internal carotid artery to the lateral wall of the sphenoid sinus and the cells of the posterior ethmoid, respectively. Onodi cells of varying degrees were found in 42% of all cases. The thickness of bony wall over the maximum bulging of the optic canal averaged 0.28 mm. Bony dehiscences could be demonstrated in 12% of the cases. The technique of data acquisition, the anatomical and histological findings as well as their clinical and surgical relevance are discussed.     

Radiocephalometric findings and duration of snoring in habitual snoring and obstructive apnea syndrome

In 11 patients with chronic snoring and 12 subjects with obstructive apnoea syndrome the percentage of snoring duration above a preset sound pressure level during one night's sleep was correlated with the radiocephalometric data. Cephalometric distances PAS, PM-Pg, MP-H and angles SNA and SNB representing measures for posterior airway space, size of soft palate, relative position of hyoid bone and relative position of maxilla and mandibula were evaluated. Each patient showed pathological deviations from normal values in at least one of the cephalometric parameters. A significant correlation between snoring duration and a single cephalometric distance could not be found. However, an index combining pathological deviations from all three cephalometric distances showed a highly significant correlation with snoring duration (p less than 0.01 - Fig. 11), as did deviations from normal values of angle SNB (p less than 0.03 - Fig. 10). Our findings indicate that snoring and obstructive apnoea syndrome are not only caused by neurologic dysregulation, and that in addition specific craniofacial anomalies are prerequisites for the development of the disease. For the first time it is demonstrated that these anomalies exist in chronic snorers as well as in apnoeic patients. Our findings support Lugaresi's hypothesis that heavy snoring and obstructive apnoea syndrome are based on the same defect and differ in severity only.     

Uvulopalatopharyngoplasty — surgery for snoring

Snoring is a social problem and is considered to be a warning sign, in relation to the upper airway structural and physiological anatomy. The complications and sequelae of snoring can be life threatening also. Therefore it becomes important to treat snoring in the first instance. Surgical treatment of snoring is the standard protocol (UPPP) Uvulopalatopharyngoplasty, was started by Fujita a and this technique has now been found to be very effective. 8 cases of snoring with no evidence of sleep apnta were operated in the department with a standard modified technique. The technique und the results are discussed here.     

Diagnosis and therapy of primary snoring

Snoring, excessive daytime sleepiness and nocturnal apnoea are among the leading symptoms of the obstructive sleep apnoea syndrome (OSAS). Primary snoring without upper airway obstruction is a more common and normal phenomenon in sleep and has to be distinguished from OSAS. Patients with primary snoring are often suffering and complain of great distress and social embarrassment and therefore request professional help. Therefore, the otorhinolaryngologist has to be aware of the different treatment options that are possible and sensible. Apart from behavioral changes and general measures (weight loss, reduction of alcohol consumption, sleep position training), there are different conservative and surgical treatment options. In this article, the pathophysiology, diagnosis and treatment of primary snoring will be discussed.     

Diagnostic work-up of socially unacceptable snoring

In the diagnostic work-up of socially unacceptable snoring (SUS) with or without a history suggestive of obstructive sleep apnoea syndrome (OSAS), information on the severity of the pathology as well as on local and general causative factors is needed. In part I of this study, we reported on the findings recorded in 380 patients by means of sleep registration. In this part, our emphasis is on analysis of the local contributing factors. In 340 of the 380 patients sleep endoscopy was performed to establish the level(s) of obstruction as accurately as possible. Sleep endoscopy was performed following artificial induction of sleep with midazolam and consisted in endoscopy and flexible nasopharyngoscopy and laryngoscopy. Although obstruction at the oropharyngeal level was often present, obstructions at lower levels or at multiple levels were also frequently found. In many cases sleep endoscopy showed obstruction at different level(s) than had been suspected on the grounds of ear nose and throat (ENT) investigation only. An obstruction at only one level was recorded in 35% of the patients (119), while 65% of patients (221) had multiple-level obstruction. The level(s) of obstruction could be well established by sleep endoscopy. We conclude that a diagnostic work-up involving a combination of sleep registration, sleep endoscopy, and analysis of general factors is worthwhile. Combining the results of these tests makes it possible to give individually tailored advice on treatment.     

Comparison of methods for assessing snoring

Objective measurements of several sound level indices were made on 32 subjects referred because of snoring and who subsequently underwent uvulopalatopharyngoplasty (UPPP). The measurements were repeated approximately 6 months post-UPPP. The indices were compared with the subjective assessment of snoring by both the subject and his/her bed partner. Correlations between objective and subjective assessments were generally weak and were strongest when the supine posture only was considered. The index which correlated best with subjective assessment was the level which 1% of the sound level samples exceeded.     

Diagnostic work-up of socially unacceptable snoring

Should all patients with socially unacceptable snoring (SUS) undergo polysomnography, or is history-taking sufficient to identify the presence of obstructive sleep apnoea syndrome (OSAS)? Three hundred and eighty consecutive patients with SUS who underwent sleep registration were evaluated retrospectively to determine the predictive value of a history of apnoea or excessive daytime somnolence (hypersomnia). Of the patients analysed, 54% had OSAS, defined as an apnoea / hypopnoea index (AHI) of >15. This is higher than previously reported in the literature (46.7%). (Incidental) apnoea was reported by 337 (89%) of the patients, with a sensitivity of 0.92 and a specificity of 0.13. The predictive value – as related to the gold standard, i.e. sleep registration, of a negative test and of a positive test for OSAS is low (0.56 and 0.59, respectively). Hypersomnia was reported by 280 (74%) of the patients, with a sensitivity of 0.29 and a specificity of 0.72. The predictive value of a negative test and a positive test for OSAS is also low, 0.45 and 0.56, respectively. These data confirm that apnoea and hypersomnia in the history do not have a reliable predictive value of an obstructive sleep apnoea syndrome. We conclude that sleep registration is indicated in all patients with SUS, to rule out or confirm the presence of OSAS.     

鼾症手术治疗的远期疗效分析

目的探讨鼾症腭咽成形术(UPPP)的远期疗效.方法随访睡眠呼吸暂停综合征46例行UPPP后的疗效.46例中男39例,女7例,32～66岁,平均46岁,均有睡眠时打鼾、夜间憋气、惊醒、胸闷、白天嗜睡、咽干燥等症状1～40年,平均7.4年.46例中有高血压史13例.33例局部麻醉,13例气管插管全身麻醉.6例同期行鼻中隔矫正术,7例同时行下鼻甲骨黏膜下切除术.术后随访12～96月,平均32月.结果46例中45例(98%)均在手术后1～3d鼾声消失或减轻,憋气、惊醒症状消失.1例无改善.手术中无并发症.远期随访40例(87%),其中呼吸暂停消失23例(57%),好转11例(28%),无好转6例(15%).鼾声消失17例(43%),好转12例(30%),无好转11例(27%).白天嗜睡消失12例(30%),好转19例(48%),无好转9例(22%).口咽干消失10例(25%),好转18例(45%),无好转12例(30%).症状复发者都在术后3个月后.随访5年以上的8例憋气消失4例(50%),好转4例(50%),嗜睡消失5例(62%),好转3例(38%);鼾声消失5例(62%),好转3例(38%);口咽干消失3例(38%),好转4例(50%),无效1例(12%).13例术前高血压,术后6例(46%)血压不再升高,远期随访无复发.复发4例作睡眠呼吸测定,气道狭窄部位都在舌根部,软腭部位无明显狭窄,鼾声都大于80dB,极端氧饱和度低至50%以下,呼吸暂停时间最长达到50s.结论远期疗效中呼吸暂停好转率较高.嗜睡、鼾声、口干也有明显改善.伴随的高血压可随鼾症消失.睡眠测定有助于正确定位和评定疗效,对鼾症行UPPP手术有效.