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。     

重建腭咽部肌肉对腭裂修复术后腭咽闭合状况的影响

目的 通过两组不同腭裂修复术后患者的X线造影比较观察，了解腭咽部肌肉重建对腭咽闭合状况的影响。方法 将62例腭裂及腭咽闭合不全患者分为腭咽部肌肉重建腭裂修复组(重建组)和改良兰氏腭裂修复术(非重建组)，并采用鼻咽部钡造影X线侧位片检查摄取静止和发Ⅲ音时的侧位片，对鼻咽腔面积、可移动鼻咽腔距离及腭咽闭合方式进行观察和测量，所得数据进行统计学处理。结果 重建组在腭咽闭合功能、鼻咽腔面积缩小率、静态可移动鼻咽腔中份腭咽距离和静、动态可移动鼻咽腔下份腭咽距离等方面优于非重建组，并可形成多种形式的咽后隆突-软腭闭合方式；非重建组腭咽闭合完全良好的患者在鼻咽腔面积缩小率方面要优于腭咽闭合不良的患者。结论 腭裂修复术后腭咽闭合的主要功能区在可移动鼻咽腔中份。腭裂修复术时重建腭咽肌肉有助于缩小鼻咽腔面积和提供协调的腭咽闭合活动。     

应用鼻咽纤维镜对腭裂术后患者腭咽闭合状况的动态观察

目的观察腭裂术后腭咽腔的静止形态分型和腭咽闭合的运动相,探讨腭裂术后腭咽闭合不全与手术形式的关系。方法应用鼻咽纤维镜经鼻腔对腭裂术后腭咽腔的静止形态和腭咽闭合时的运动情况进行观察,并记录、分析。结果经典性后推手术的腭咽闭合三要素运动良好,腭咽闭合不全的主要原因是软腭后推不足和瘢痕牵拉。非经典性腭咽瓣手术破坏了生理结构,几乎全部的病例都存在腭咽闭合不全的现象。结论经典性后推手术应被列为腭裂修复治疗的首选手术方式。     

过宽裂隙的腭裂修复术探讨

目的：探讨修复过宽腭裂的方法，以获得良好的腭咽闭合功能。方法；对治疗26例过宽腭裂的手术方法及疗效进行回顾性总结。结果：26例过宽腭裂修复术后均获得了满意疗效，腭咽闭合功能有不同程度的改善。结论：过宽腭裂修复手术中，增大腭大血管神经束的游离度，重建软腭肌环是保证手术成功的首要条件。     

后推、减张、缩咽综合手术修复腭裂

为修复腭裂畸形1992年1月以来,应用硬腭粘膜瓣后推,软腭鼻腔粘膜 Z 成形术,腭帆提肌吊带重建,颊肌粘膜瓣移转修复硬腭裂隙及腭部创面,选择性地施行去神经的(足母)短伸肌游离移植行腭咽环扎等综合手术,修复20例腭裂及腭裂术后腭咽闭合不全患者,效果满意。     

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。     

两种术式对大龄腭裂患儿术后瘘发生率及语音清晰度改善的影响

目的探讨腭帆单纯提肌重建以及腭帆提肌重建联合带蒂颊脂垫瓣和咽后壁瓣两种术式,对大龄腭裂患儿术后瘘发生率及语音清晰度的影响。方法 60例大龄腭裂患儿(4~9岁),随机分为2组,分别予以单纯腭帆提肌重建(A组)及腭帆提肌重建联合颊脂垫瓣和咽后壁瓣修复(B组),观察并比较术后腭瘘的发生率及语音清晰度情况。结果术后A组瘘发生率明显高于B组(P<0.05);两组术后语音清晰度均较术前提高(P<0.05),且B组优于A组(P<0.05);腭部瘢痕情况B组优于A组(P<0.05)。结论对于大龄腭裂患儿,腭帆提肌重建联合咽后壁瓣及带蒂颊脂垫瓣的术式有效降低了腭瘘的发生率,可获得更好的语音清晰度,并可避免裸露骨面,减少腭部瘢痕形成及对上颌骨生长发育的影响,是一种值得推荐的功能性腭裂修复术式。     

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。     

后推、减张、缩咽综合手术修复腭裂

为修复腭裂畸形１９９２年１月以来，应用硬腭粘膜瓣后推，软腭鼻腔粘膜Ｚ成形术，腭帆提肌吊带重建，颊肌粘膜瓣移转修复硬腭裂隙及腭部创面，选择性地施行去神经的　短伸肌游离移植行腭咽环扎等综合手术，修复２０例腭裂及腭裂术后腭咽闭合不全患者，效果满意。     

双侧颊粘膜肌瓣腭裂修复术

目的探索腭裂修复减轻对上颌骨生长发育的影响,又能达到腭咽闭合。方法应用双侧颊粘膜肌瓣对腭裂进行修复手术。结果应用该手术方法修复16例腭裂患者,效果满意。结论该方法有以下优点:①手术不剥离硬腭区粘骨膜,对上颌骨的损伤很小,减轻了上颌骨的发育障碍;②采用两块带蒂颊粘膜且几瓣重建了腭帆提肌功能,促使异位的提肌悬吊再形成;③血运良好的颊粘膜肌瓣插入于软硬腭交界处,能使软腭充分后退,实现腭咽闭合,而且可有效地防止瘘孔的发生。     

A modified procedure for velopharyngeal sphincteroplasty in primary cleft palate repair and secondary velopharyngeal incompetence treatment and its preliminary results.

During cleft repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve the surgical treatment for cleft palate and secondary velopharyngeal incompetence (VPI), a carefully designed modified procedure for primary palatoplasty and secondary VPI was presented. Fifty-six patients (48 for primary cleft palate repair and eight for secondary VPI of previously repaired clefts) underwent this procedure from 1988 to 2001. The modified procedure is a combination of the tunnelled palatopharyngeus myomucosal flap for dynamic circular reconstruction of the pharyngeal element of the velopharyngeal sphincter and the double-reversing Z-plasty with levator velo palatini muscles reposition in the velar element of the sphincter. The satisfactory velopharyngeal competence (complete velopharyngeal closure and marginal velopharyngeal closure) was achieved in 23 of 25 patients with primary cleft palate repair examined by nasendoscopy and the nasality, speech articulation and intelligibility are also assessed in 25 primary cleft palate repaired patients with 92% satisfactory result (normal speech and speech with mild VPI) in single word test and 88% in continuous speech evaluation. Based on our experience, we believe that this modified procedure is a reasonable choice for primary cleft repair and secondary VPI treatment because it is in accord with normal physiology and anatomy of the velopharyngeal sphincter, can lengthen the soft palate, decrease the enlarged velopharynx, augment the posterior pharyngeal wall, and enhance the relationship between the muscles of velopharyngeal sphincter which results in a dynamic neo-sphincter in palatopharyngoplasty. Further study of the procedure is needed. The theoretical basis, operative highlights, velopharyngeal function, advantages and disadvantages of the modified procedure were discussed.     

Unilateral absence of levator veli palatini muscle: an extraordinary presentation in cleft palate

Levator veli palatini (LVP) is the “key” muscle for velar elevation and speech. All cleft palate repair procedures emphasize on the correction of abnormally positioned levator palatini muscle. We encountered a case of unilateral absence of LVP muscle while operating for cleft palate in a non-syndromic 12-year-old male child. The velar space was in turn occupied by dense connective tissue. We also noticed a hypoplastic tendon of the tensor veli palatine (TVP) on the same side. Palatal repair was done in layers but the LVP “sling” could not be reconstructed. The 2-month-postoperative magnetic resonance imaging scan revealed absence of the velar portion of the LVP muscle and hypoplasia of extravelar portion of LVP and TVP muscles on the same side. Speech evaluation and fiberoptic nasopharyngoscopy performed after 3 months of palatoplasty verified the presence of velopharyngeal insufficiency (VPI). Superiorly based pharyngeal flap pharyngoplasty was performed to correct VPI. Presently, the child is on speech therapy and the results are encouraging. A thorough search on PubMed and Google on the unilateral absence of LVP muscle in an incomplete cleft palate did not show any similar case report or reference. A somewhat similar and rare clinical condition is unilateral velopharyngeal hypoplasia or hemipalatal hypoplasia. Level of Evidence: Level V, diagnostic study     

Does MRI contribute to the investigation of palatal function?

The results of a pilot study into the value of MRI scanning in investigation of velopharyngeal function are discussed. MRI offers potential advantage over naso-endoscopy in being noninvasive and over video fluoroscopy in avoiding radiation. However, it requires costly equipment and patient cooperation, which limits its use in young patients. Ten normal volunteers and 15 patients with speech problems underwent MRI of the velopharyngeal port at rest and during sustained phonation of word /a/. Optimal planes for scanning were determined. Images were obtained in mid-sagittal, coronal and horizontal planes at the level of the hard palate and in the plane of the levator axis. Computer assisted measurements were possible of the velopharyngeal closure, forward movement of posterior pharyngeal wall, velar lift, velar extensibility and medial movement of the lateral pharyngeal wall. MRI has a potential role in investigation of velopharyngeal incompetence and planning its surgical repair.     

Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy

INTRODUCTION: The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure. PATIENTS AND METHODS: A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure. RESULTS: All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04). CONCLUSIONS: Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.     

Musculus uvulae and levator palati: their anatomical and functional relationship in velopharyngeal closure

The morphological relationship between the musculus uvulae and levator palati muscles and their importance in velopharyngeal closure was studied in cadavers by simulation of levator action, palate serial section and dissection, and in various subjects by nerve stimulation and blockade. These studies support the cardinal importance of the levator muscles in velopharyngeal closure. The significance of musculus uvulae activity is less clear. While lesser palatine nerve stimulation evoked a response from the musculus uvulae, a nerve block produced no detrimental effect on speech or nasendoscopic appearance in normal subjects.     

Evaluation of velopharyngeal pathophysiology and velopharyngeal insufficiency with magnetic resonance imaging

The disadvantages and limitations of imaging methods to investigate velopharyngeal incompetence have created some difficulties in the management of this condition. Seven normal volunteers and seven patients who were suffering from a speech disorder were examined using magnetic resonance imaging. The velopharyngeal aperture was evaluated at rest and during phonation. In normal volunteers, the velopharyngeal aperture area had a mean value of 1.632 cm² while at rest and complete closure was obtained during the phonation of /s/ sound. Detailed information was obtained about the function of the levator palati muscle. In five patients during the phonation of /s/ sound there was an increase in the area of the velopharyngeal aperture when compared to the volunteers. Investigation with magnetic resonance imaging is helpful in the pretreatment evaluation and postopertive follow-up examination of velopharyngeal insufficiency. As a result, this noninvasive method can be used as an alternative to conventional radiological investigations. Received: 19 September 1996 / Accepted: 26 March 1997     

Primary palatoplasty

Clefts of the secondary palate, either isolated or accompanying a cleft lip, are characterized by a defect in the palate of varying extent and by abnormal insertion of the levator veli palatini muscles. Repair of the palate should be carried out in one stage, shortly before or after 1 year of age, and should include intravelar veloplasty. The technique of von Langenbeck palatoplasty with intravelar veloplasty has been described. This technique should provide velopharyngeal competency in 80 to 90 per cent of patients with clefts of the secondary palate.     

腭咽闭合功能相关因素的Logistic回归分析

目的:探讨影响初期腭裂修复术后腭咽闭合功能的相关因素。方法:对143例非综合征性腭裂术后患者进行回顾性研究,对可能影响腭咽功能的因素如性别、手术年龄、手术方法、腭裂类型等通过SPSS软件进行单因素及多因素Logistic回归分析。结果:单因素分析发现性别与腭裂术后腭咽功能并无相关性(P>0.1)。多因素Logistic分析表明:手术年龄大于2岁后腭咽闭合不全的风险性增加(OR=2.69,P<0.05);腭帆提肌重建术相对于VonLangenbeck法术后腭咽闭合不全率降低(OR=0.22,P<0.05);单侧完全性腭裂(UCCLP)和软腭裂(SCP)患者术后腭咽闭合率分别高于双侧完全性腭裂(BCCLP)和硬软腭裂(HSCP)患者(P<0.05)。结论:手术年龄、腭裂类型以及腭裂修复方法是影响初期腭裂术后腭咽功能的主要因素。手术年龄适当提前、采用功能性腭帆提肌重建修复方法有助于提高腭咽闭合率。