三维磁共振对腭裂术后患者腭咽结构的观察和测量

目的探讨三维磁共振技术观察测量腭咽结构的可行性,并比较腭裂术后成年患者与正常成年人腭咽结构的差异,用于指导腭裂修复术手术方式的选择。方法根据入选标准选择2018年2月至2018年8月就诊于蚌埠医学院第一附属医院整形烧伤科的6例成年男性腭裂修复术后患者(腭裂组),年龄18~26岁,平均21.8岁。招募6例皖北地区健康成年男性(正常组),年龄19~28岁,平均23.3岁。对2组测量对象进行语音检测,评估语音发音和腭咽闭合情况。行正中矢状面静态三维和动态磁共振扫描,在矢状面、冠状面和腭帆提肌平面(斜冠面)测量软腭长、有效软腭长度、腭咽比、腭高、腭帆提肌长度及厚度等32个数据,共测量2次。采用Pearson积矩相关系数对2次数据进行相关性检验,判断测量结果误差大小。使用两独立样本t检验对2组数据进行组间比较。结果所有研究对象均无语音异常,腭咽闭合均完全。2次测量的Pearson积矩相关系数r值范围在0.789~0.925(P<0.05),即2次测量结果误差在可接受范围内。正常组腭帆提肌形态较为流畅,而腭裂组腭帆提肌形态不规则,中线处可观察到不连续现象,且提肌插入软腭时角度明显不同。腭裂组具体测量数据中咽宽为(23.83±3.48)mm、咽深为(29.94±3.52)mm、骨性咽深为(39.68±3.63)mm、腭长比为1.18±0.16、腭咽比为0.87±0.91、发/i:/时软腭膝部和鼻后棘、悬雍垂连线的夹角[PVU角(动)]为(105.68±20.54)°、腭帆提肌内侧段长度为(13.13±1.00)mm、腭帆提肌插入间距为(24.63±2.54)mm、腭帆提肌起点角为(58.0±3.3)mm,均大于正常组,差异具有统计学意义(P<0.05)。腭裂组腭宽为(37.5±1.43)mm、软腭厚度为(9.48±1.03)mm、软腭相对伸长度(/ts/)为(1.09±0.05)mm、安静时鼻后棘和鼻前棘、软腭膝部连线的夹角[APV角(静)]为(180.51±8.55)°、腭帆提肌厚度为(4.07±0.25)mm、腭帆提肌起点间距为(52.27±7.08)mm,均小于正常组,差异具有统计学意义(P<0.05)。结论三维磁共振技术测量腭咽结构方法可行,且腭裂成人和正常成人的腭咽结构、软腭动度和腭帆提肌形态结构存在显著差异,在腭裂早期修复时需要注意提肌的解剖复位,尤其是对作用较大的外侧段的保护和延长,以及软腭瓣分离时有效软腭体的延长。     

腭咽部肌群重建腭裂修复术与改良兰氏腭裂修复术后软腭运动的比较观察

目的通过腭咽部肌肉重建腭裂修复术与改良兰氏腭裂修复术后患者的X线片比较,了解腭咽部肌肉重建对软腭运动功能恢复的作用。方法1988年10月~2000年10月,治疗腭裂及腭咽闭合不全患者62例。其中腭咽部肌肉重建腭裂修复术(A组)32例,年龄2~26岁;改良兰氏腭裂修复术(B组)30例,年龄4~23岁。采用鼻咽部钡造影X线侧位片检查方法摄取静止和发“i”音时的侧位片,进行X线片定点。测量指标包括:1腭咽闭合状态,2软腭运动长度,3软腭运动角度,4解剖提肌隆突点(levatoreminenceinanatomy,LEA)-腭咽闭合水平线(velopharyngealclosureline,VCL)距离,5LEA变化值,6LEA与运动提肌隆突点(levatoreminenceinphonation,LEP)值的比较,7LEA与LEP的差值,8后鼻棘点(posteriornasalspine,PNS)-软腭鼻腔侧连线(softpalateline,SPL)-LEA与PNS-SPL-LEP值。结果A、B组的腭咽闭合完全优良率状态分别为83.3%和53.3%(P<0.01);软腭运动长度:A组静止时和发“i”音时分别为36.77±4.23mm和39.57±5.80mm(P<0.05),B组静止和发“i”音时分别为36.70±5.81mm和39.15±6.89mm(P>0.05);软腭运动角度:A组为18.97±11.13°,B组为25.55±13.02°(P<0.05);LEA-VCL距离:静止时A组为-5.57±5.26mm,B组为-13.47±4.21mm(P<0.001);LEA变化值A组为7.63±5.29mm,B组为13.10±9.13mm(P<0.01);LEA与LEP值的比较:A组分别为21.79±3.18mm和20.33±4.29mm(P>0.05),B组分别为21.56±4.11mm和19.41±3.50mm(P>0.05);LEA和LEP的差值比较差异无统计学意义(P>0.05),组内比较A组(P>0.05),B组(P<0.01);PNS-SPL-LEA与PNS-SPL-LEP值:组间比较差异无统计学意义(P>0.05),组内比较A组(P>0.05),B组(P<0.05)。结论腭裂修复术时重建腭咽肌肉有助于软腭运动和腭咽闭合功能的恢复。软腭运动角度及软腭向上运动范围并不是构成理想腭咽闭合的主要因素,而腭咽部肌肉重建后的协调运动则更为重要。     

Furlow腭成形术治疗腭裂术后腭咽闭合不全的临床疗效

目的探讨采用Furlow腭成形术在腭裂术后腭咽闭合不全(velopharyngeal insufficiency,VPI)整复中的应用价值。方法 2015年8月—2017年1月,采用Furlow腭成形术治疗48例腭裂术后VPI患者。男29例,女19例;年龄4～17岁,平均6.1岁。不完全性腭裂16例,完全性腭裂32例;软腭裂16例,软硬腭裂32例。腭裂手术至该次手术时间为3～13年,平均5.9年。患者均伴有明显过高鼻音,且鼻漏气明显。电子鼻咽纤维内窥镜评估腭咽闭合程度均为Ⅲ级。记录手术时间、术中出血量,术前及术毕时分别测量腭总长度、软腭长度、咽腔深度、咽腭弓宽度,并计算手术前后差值。术后3个月,临床评估腭咽闭合程度,分为腭咽闭合完全(velopharyngeal competence,VPC)、边缘性腭咽闭合(marginal velopharyngeal inadequacy,MVPI)、VPI;摄头颅定位侧位X线片评价软腭及咽后壁关系,分为完全接触、点接触及无接触;电子鼻咽纤维内窥镜检查评估腭咽闭合程度(Ⅰ、Ⅱ、Ⅲ级)。对腭总长度、软腭长度、咽腔深度、咽腭弓宽度手术前后差值的相关性采用Spearman分析;分别对软腭及咽后壁接触程度及腭咽闭合程度进行分组,对上述指标进行统计学分析。结果手术时间35～64 min,平均41 min;术中出血量3～10 mL,平均6 mL。患者均获随访3个月。术后3个月,临床评估腭咽闭合程度为VPC 34例、MVPI 7例、VPI 7例;头颅定位侧位X线片示,软腭与咽后壁完全接触30例、点接触11例、无接触7例;电子鼻咽纤维内窥镜检查示,腭咽闭合功能均有不同程度改善,Ⅰ级29例,Ⅱ级12例,Ⅲ级7例。手术前后腭总长度、软腭长度、咽腔深度和咽腭弓宽度比较,差异均有统计学意义(P0.05)。Spearman相关分析显示,手术前后腭总长度差值与软腭长度差值成正相关(r=0.448,P=0.001)。VPC、MVPI、VPI组腭总长度、软腭长度、咽腔深度手术前后差值组间比较差异有统计学意义(P0.05);咽腭弓宽度手术前后差值比较差异无统计学意义(P0.05)。完全接触、点接触及无接触组腭总长度、软腭长度手术前后差值比较差异有统计学意义(P0.05);咽腔深度及咽腭弓宽度手术前后差值比较差异均无统计学意义(P0.05)。结论采用Furlow腭成形术行腭裂术后VPI整复,可有效延长软腭,减小咽腔深度,恢复腭咽闭合的生理解剖形态,显著改善腭咽闭合功能。     

腭裂修复术腭咽肌肉重建与否的鼻咽内窥镜的比较观察

目的通过是否进行腭咽肌肉重建的两组腭裂修复术后患者鼻咽内窥镜的比较观察,了解腭咽部肌肉重建术后腭咽闭合状况的改变。方法将41例腭裂术后患者,按照在腭裂修复时是否进行腭咽肌肉重建分为重建组(22例)和非重建组(19例),以鼻咽纤维内窥镜记录静态和发音时腭咽闭合运动状况,对两组患者腭咽闭合运动类型和状况进行比较。结果重建组静态腭咽腔形态较非重建组明显缩小,各壁光滑丰满,未见软腭鼻腔面V型缺损畸形;动态时以环状闭合为主。非重建组静态腭咽腔形态较大,可见软腭鼻腔面V型缺损畸形;动态时以冠状闭合为主。经比较重建组腭咽闭合良好率(90.91%)明显优于非重建组(37.31%)。结论鼻咽内窥镜观察证实腭咽肌肉重建腭裂修复术后腭咽闭合功能恢复明显优于非重建组。腭裂修复术时重建腭咽肌肉有助于缩小腭咽腔和更易于达到良好的腭咽闭合状态。     

唇腭裂患者经上颌前方牵引治疗后其语音功能的影响研究

目的:比较唇腭裂术后患者经上颌前方牵引治疗反牙合前后语音功能的变化,研究前方牵引是否会对此类患者的语音功能产生影响。方法:根据纳入指标选取20例唇腭裂术后反牙合患者为实验组,采用上颌前方牵引;选取未经上颌前方牵引治疗的18例单纯牙性错牙合的同类患者为对照组,比较两组治疗前后的腭咽部气道情况、鼻音化率、腭咽闭合不全率的变化,统计分析唇腭裂患者经上颌前方牵引治疗后的语音功能变化。结果:治疗组前方牵引治疗后与治疗前比较,上气道腭咽部横截面积、矢状向测量指标均明显增大,差异具有统计学意义,冠状向各项测量指标差异无统计学差异;唇腭裂术后患者经过上颌前方牵引治疗后,鼻音化率由(65.00±3.28)%增加到(68.00±4.91)%,腭咽闭合不全率由(48.32±3.72)%增加到(52.19±4.31)%,差异具有统计学意义。结论:上颌前方牵引对单侧完全性唇腭裂患者上气道腭咽部狭窄改善明显,但伴随着腭咽部狭窄的改善,腭咽闭合功能减弱,表现为鼻音化率明显增加,腭咽闭合不全率明显升高。     

腭后推上提和颊肌黏膜瓣修复10岁以上患者过宽腭裂

目的 探索修复10岁以上患者过宽腭裂畸形的手术方法.方法 通过腭后推、上提、腭大孔凿开、腭骨水平板凿断、双侧软腭后推、宋儒耀软腭上提术,结合一侧带蒂颊肌黏膜瓣转移修复过宽腭裂畸形.结果 2002年以来,运用该方法治疗13例10～25岁的腭裂患者,术后颊肌黏膜瓣完全成活,双侧软腭与咽后壁上提的组织瓣愈合良好,软、硬腭同时得到延长,腭咽闭合不全获得充分矫正,语音有明显改善,无腭瘘发生.结论 该方法具有无张力关闭过宽裂隙,软腭延长效果显著、持久,腭咽闭合效果良好,语音改善较明显的优点,尤其适合修复10岁以上患者过宽腭裂畸形.     

271例婴幼儿完全性唇腭裂一期修复及初步观察

目的 探索婴幼儿完全性唇腭裂一期修复的可行性，并对其效果进行初步观察。方法 对3－12个月婴儿安全性唇腭裂进行了一期修复，同时对24例裂隙宽大的患儿进行术前腭部矫治，对术后1－4年的116例患儿唇的外形及事音进行了初步评价。结果 271例婴幼儿完全性唇腭裂修复手术，术后除2例发生呼吸困难，6例腭部瘘孔形成及5例作品渗血外，全部愈合良好。研究发现19例单侧完全性唇腭裂术前腭部矫治后，齿槽部裂隙左右距离轿治前平均缩小6．1mm；前后距离轿较矫治前平均缩小6．6mm；唇外菜评价优良率达93．1％，语音评价优良率达94．8％。结论 婴幼儿完全性唇腭裂一期是完全的、可行的。术前腭部桥治可明显缩小齿槽部的裂隙，有利于宽大裂隙的修复。婴幼儿完全性唇腭裂一期修复可获良好唇外形及语音功能恢复。     

Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术修复大龄患者腭裂的临床研究

目的:探讨Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术修复大龄患者腭裂的临床疗效,并观察术后对腭咽功能及语音效果的影响。方法:选择2013年5月-2017年8月在口腔颌面外科就诊的58例大龄腭裂患者为研究对象。实验组:31例,男18例,女13例,年龄(15.3±6.4)岁,均在全麻下行Sommerlad腭帆提肌重建联合腭咽肌瓣咽成形术修复;对照组:27例,其中男16例,女11例,年龄(17.7±7.5)岁,全麻下行Sommerlad腭帆提肌重建术修复。术后随诊6～36个月,采用头颅侧位X线片及鼻咽纤维镜检测腭咽功能,主观语音评估鼻腔共鸣、鼻漏气、语音清晰度。结果:所有患者创口愈合良好,实验组20例获得腭咽闭合,腭咽闭合率61.3%;对照组7例获得腭咽闭合,腭咽闭合率24.4%,两者之间比较有统计学差异(P0.05)。实验组鼻腔共鸣、鼻漏气、语音清晰度症状改善程度优于对照组(P0.05)。结论:Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术同期修复大龄腭裂可提高术后的腭咽功能,改善语音效果。     

兰氏和双反Z法腭裂修复术后患儿语音清晰度对比

目的比较兰氏和双反Z法腭裂修复术后患儿的语音清晰度,寻找重建腭咽闭合的最佳手术方法。方法选取2009年至2013年在我院口腔颌面外科就诊的先天性软腭裂患儿69例,其中行双反Z法腭裂修复术35例(双反Z法组),行兰氏法腭裂修复术34例(兰氏法组)。患儿3.5岁后随访,由3名语音师进行单盲性审听,比较两组患儿术后语音清晰度。结果语音测评结果显示,双反Z法组患儿术后患者语音清晰度平均达到88.72%±6.05%,明显高于兰氏法组的71.31%±3.46%,语音改善明显。结论双反Z法能够充分缩小咽腔、延长软腭,重建软腭肌肉结构,更有利于恢复良好的腭咽闭合功能。     

咽后壁组织瓣转移术在腭裂治疗中的应用

目的:探讨咽后壁组织瓣转移术对腭裂患儿语音清晰度的影响。方法:对23例6-12岁腭裂患儿实施咽后壁组织瓣转移术,术后4周开始接受语音训练,训练周期三个月。测试并记录训练前后的语音清晰度。结果:患儿的语音清晰度从术前的30％提高到92％,提高了62％,经t检验,具有极显著的差异(P<0.0001)。结论:咽后壁组织瓣转移术只要选择合适的适应症,方法得当,术后配合适当的语音训练,最终可使患儿的语音达到或接近正常效果,是成功治疗腭裂的一种良好的手术方法。     

The Abbé flap in cleft lip and palate repair

Abstract

The Abbé flap is a procedure where the volume of the upper lip is increased at the expense of the lower lip. This study reviewed the Abbé flaps done at Skåne University Hospital during the years 1991–2006 and identified 14 patients. Data was collected from medical records. Eleven patients were deemed fit for interviews and were called to the hospital by standard mail. Six patients responded and were interviewed, examined, and photographed. One patient was interviewed over the telephone. Median age at surgery was 14 years (range = 6–22). The operation time was 152 minutes (range = 90–215). The Abbé flap was divided after 12 days (range = 11–16). All 14 flaps survived and no complications were noted. Secondary corrections were done in nine patients. Three patients experienced having their lips sutured together as difficult, and four patients described this period as easy. All patients described their lips as having better appearance after the operation and, in three of four cases, where a simultaneous columella lengthening was done, the patients described their noses as having better appearance. The scar on the lower lip was negative but also a prerequisite for the operation. All seven patients said the operation was worth all the effort and would recommend it to patients in similar situations. This data supports that the Abbé flap is a safe technique that effectively improves the appearance of the upper lip and satisfies the cleft lip and palate patients.     

Ⅲ度唇裂并牙槽裂不伴腭裂患者的鼻底整复术

目的：探讨Ⅲ度唇裂并牙槽裂不伴腭裂患者的鼻底修复方法。方法：通过在唇裂裂隙健侧缘设计粘膜-牙龈瓣以补充延长鼻底。结果：用本法治疗3例患儿术后伤口均Ⅰ期愈合,鼻外形改善无口鼻前庭瘘。结论：应用唇裂裂隙健侧缘粘膜-牙龈瓣修复Ⅲ度唇裂并牙槽裂不伴腭裂患者的鼻底可延长原位置较后的鼻底,减少并发症的发生。     

Speech after repair of isolated cleft palate and cleft lip and palate.

The speech of children with isolated cleft palate (CP) repaired by one surgeon has been compared with the speech of children with some form of unilateral cleft lip and palate (CLP) repaired by the same surgeon. All palate repairs included an intravelar veloplasty. We identified 57 children (5--12 years old) with cleft palates repaired in infancy, of which three patients with other medical problems were excluded. Of the 54 patients, 44 (81%) attended for review (27 CP, 17 CLP). Video recordings were analysed by two speech and language therapists, using the Cleft Audit Protocol for Speech. The CP patients had no evidence of permanent fistulas. Final speech outcomes were similar for CP and CLP patients. Intelligibility was normal in 10 (37%) CP and nine (53%) CLP patients. Mild consistent hypernasality was present in five (18.5%) CP and four (23.5%) CLP patients. No patients had moderate or severe hypernasality or nasal emission. Mild consistent hyponasality was present in five (18.5%) CP and five (29%) CLP patients. Moderate consistent hyponasality was present in one (4%) CP patient. Dysphonia was present in eight (30%) CP and seven (41%) CLP patients. Cleft-type characteristics were noted in 11 (41%) CP and nine (53%) CLP patients. No CLP patients but 10 (37%) CP patients had required a pharyngoplasty (P=0.004, Fisher's exact test). Possible reasons for this (age, cleft type, surgeon and surgery) are discussed.     

Anatomical closure technique of the nasal floor for patients with complete unilateral cleft lip and palate

Abstract

We describe a new technique for the reconstruction of the nasal floor at the same time as cheiloplasty in patients with complete unilateral cleft lip and palate. We operated on patients aged between 3 and 36 months in public secondary and tertiary level institutions. None of these patients had had a previous operation for the correction of the cleft lip or palate. The operation required the design of two mucous flaps, one lateral and one medial to the defect, to reposition the tissues anatomically and repair the congenital deficiency. Three hundred and fifty-eight patients have been treated using this technique, most of whom (n = 233, 65%) were boys, and 288 (80%) presented with a right complete unilateral cleft. Postoperative evaluation showed that 22 patients (6%) had asymmetry of the nasal base equal to or less than 1 mm, 18 (5%) had nasovestibular fistulas, and 5 (1%) required revision. We conclude that this technique greatly reduces the number of asymmetrical nasal floors and the incidence of nasovestibular fistulas.     

Gastroschisis associated with cleft lip and palate

Gastroschisis is a common congenital abdominal wall defect. Rarely, it is associated with extraabdominal midline congenital anomalies. Oral clefts are the commonest craniofacial congenital midline defects. They can be associated with other midline defects like omphalocele. We believe these are the first 3 case reports of gastroschisis and cleft palate occurring in the same patient.     

Anaesthesia for cleft lip and palate surgery

The first 150 words of the full text of this article appear below. Key points A high index of suspicion for conditions associatedwith cleft lip and palate should be maintained. A difficultview at laryngoscopy is a more frequent finding than a difficultairway; the anaesthetist should be prepared for either. Patientsshould be extubated when fully awake with close observationfor signs of airway obstruction. Analgesia is an importantpart of the balanced anaesthetic technique. Children with cleftsshould be managed by a multidisciplinary team of experts.