腭裂患儿术后腭咽闭合功能变化特点及其影响因素分析

目的：探讨腭裂患儿术后腭咽闭合功能变化特点及其影响因素。方法：回顾性分析2015年10月-2019年10月笔者医院收治的80例腭裂患儿资料,术后随访12个月,根据腭咽闭合功能,将其分为腭咽闭合不全组和腭咽闭合完全组,分析腭咽闭合功能变化特点,统计腭裂患儿术后腭咽闭合不全发生率,对比两组患儿临床特征,采用Logistic回归分析影响腭裂患儿术后腭咽闭合不全的因素。结果：术后6个月、12个月腭咽闭合不全率分别为62.50%、53.75%;术后12个月,闭合不全组患儿性别、手术方式构成比及年龄、腭裂宽度、上颌宽度、软腭长度、腭咽比、腭裂指数与闭合完全组患儿比较,差异无统计学意义(P>0.05),闭合不全组患儿腭裂类型构成比以及手术年龄、咽腔深度与闭合完全组患儿比较,差异有统计学意义(P<0.05);Logistic多因素回归分析显示双侧完全性腭裂、手术年龄、咽腔深度均是腭裂患儿术后腭咽闭合不全的独立危险因素(OR=3.304,2.617,2.469)。结论：双侧完全性腭裂、手术年龄、咽腔深度均是腭裂患儿术后腭咽闭合不全的独立危险因素,应适当提前手术年龄,采取针对性手术方案,以创造...     

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。     

改良兰氏+反向双Z法腭裂手术对患儿发音影响的临床研究

目的:探讨改良兰氏+反向双Z法腭裂手术对患儿发音的影响。方法:选取2013年2月-2016年1月行改良兰氏法+软腭双层"Z"形三角瓣修复法的30例腭裂患儿为观察组,选取既往予以兰氏两瓣法进行治疗的30例腭裂患儿为对照组。比较两组患儿手术前后腭咽闭合不全率、元音[i]的第二共振峰(F2)、第三共振峰(F3)、F1振幅能量值(A1)、辅音样本冲直条、擦音乱纹出现率以及语音清晰度。结果:两组患儿术后腭咽闭合不全率均低于术前(P0.05);观察组患儿术后腭咽闭合不全率低于对照组(P0.05)。与手术前相比,两组患儿术后F2、F3高于术前,A1低于术前,差异有统计学意义(P0.05);观察组患儿术后F2、F3高于对照组,A1低于对照组(P0.05)。观察组患儿术后辅音样本冲直条、擦音乱纹出现率高于对照组,差异有统计学意义(P0.05)。两组患儿术后语音清晰度均高于手术前(P0.05);观察组患儿术后语音清晰度优于对照组,差异有统计学意义(P0.05)。结论:腭裂手术软腭延长能有效改善腭裂患儿腭咽闭合功能,改善发音。     

大龄腭裂患者两种手术模式的临床评估

目的 探讨不同年龄腭裂患者的手术治疗模式,以提高大龄腭裂患者术后的腭咽闭合率和语音清晰度.方法 2010年5月至2012年4月,52例大龄腭裂患者按年龄不同分为A组(8～16岁,n=18)和B组(16岁以上,n=34),A组进行改良兰氏法同期腭咽肌瓣咽成形术,B组进行改良兰氏法同期咽后壁瓣咽成形术.所有患者术后随访10～18个月,观察创口愈合情况、语音清晰度、高低鼻音、鼻漏气及鼻咽纤维内镜检查情况.结果 语音评估显示,A组和B组患者高鼻音和鼻漏气程度均显著下降,语音清晰度提高;32例患者术后腭咽闭合完全,余20例患者术后虽仍有腭咽闭合不全,但在鼻咽纤维镜下腭咽闭合率达80％以上.结论 针对不同年龄的腭裂患者制定个体化手术方式,可显著提高腭裂患者术后腭咽闭合率和语音清晰度.     

腭裂术后腭咽闭合不全的一种修复方法

目的　　探讨腭黏膜瓣后推及选择性应用去神经肌肉游离及腭咽环扎术 ,修复腭裂术后腭咽闭合不全的效果。　方法　 1 987年～ 2 0 0 0年 ,采用腭黏膜瓣后推及选择性应用去神经肌肉游离移植行腭咽环扎术治疗腭裂术后腭咽闭合不全 ,经治疗并获随访的患者 2 5例 ,随访时间 1～ 1 3年 ,平均 2年 6个月。　结果　 2 5例术后均取得了良好的腭咽闭合 ,语言清晰。　结论　此手术方法治疗腭裂术后腭咽闭合不全可以达到完全的腭咽闭合 ,并获得良好的语言功能。     

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。     

腭咽闭合功能不全后并发症的防治

腭咽闭合功能不全是腭裂修复术后最常出现的现象,据报道,腭成形术后定性分析有25%～38%的患者存在腭咽闭合功能不全[2],主要是由于腭成形术时没有足够后推软腭延长其长度,术后软腭过短,鼻咽腔过深或手术损伤致术后软腭活动度差,或咽侧壁向中线移动差等原因造成腭咽闭合功能不全     

兰氏法修复60例不完全性腭裂效果的回顾性分析

目的：通过对2006年3月～2008年3月就诊于第四军医大学口腔医学院60例行改良兰氏法修复不完全性腭裂患者进行回访,评估该法临床治疗效果,为临床工作提供参考。方法：对60例改良兰氏法修复不完全性腭裂患者术后语音恢复情况进行评估分析,并做鼻咽内窥镜检查,统计腭咽闭合完全（Velopharyngeal competence,VPC）和腭咽闭合不全（Velopharyngeal incompetence,VPI）分别所占的比率。结果：在60例行语音清晰度检查的患者中,有78.3%手术后的患儿达到70分以上;在行鼻咽镜检查的46例患儿中,84.8%的术后患儿恢复了腭咽闭合功能。结论：改良兰氏法能有效改善患者腭咽闭合（Velopharyngeal,VP）功能,是一种较好的不完全性腭裂患者的修复术式。     

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。     

腭裂宽度与术后腭咽功能相关性的分析

目的 探究腭裂宽度与腭咽功能差异的相关性。方法 收集2012-2020年44例腭裂患者,均采用Furlow法修复裂隙。根据术前腭裂裂隙宽度的不同,分为较窄组、中等宽度组、较宽组,对各组患者进行腭咽功能检测并对比分析,检测内容包括主观语音判听、鼻咽纤维镜检查。结果 主观语音判听结果显示,3组术后腭咽闭合不全者为20%,而鼻咽纤维镜检测结果显示为18%,两种检测结果无统计学差异（P>0.05）;两种检测结果显示,较窄组腭咽闭合不全率显著低于中等宽度组及较宽组（P<0.05）,中等宽度组与较宽组腭咽闭合不全率无统计学差异（P>0.05）;Pearson相关性分析显示,腭裂宽度与术后语音清晰度评分、鼻咽纤维镜评分均呈正相关（r分别为0.570、0.560,P<0.05）,即腭裂裂隙越宽,术后腭咽闭合不全率越高。结论 Furlow法术后腭咽闭合功能具有差异性,与术前裂隙宽度大小显著相关。     

Cleft palate with congenital midline teratoma

A 4-year-old girl presented with hypernasal speech. On examination, in addition to velopharyngeal incompetence noted by speech examination, a palatal tumor was found in between the cleft palate. The computed tomographic and magnetic resonance imaging examinations were suspicious for midline teratoma. Total excision of the nasopalatal tumor was performed, and the pathology revealed benign teratoma. After 6 months of follow-up, no recurrence was noted. A two-flap palatoplasty with a superior-based pharyngeal flap was then performed to reconstruct the palatal defect and to correct the velopharyngeal incompetence. An anterior oronasal fistula developed after the operation, but a tongue flap was transferred to cover the defect successfully. The purpose of this case report is to present the relationship between a congenital midline nasopalatal tumor and cleft palate.     

运用声学技术分析腭裂患者术后的辅音特点

目的:研究腭裂术后不同腭咽闭合状况患者的语音声学特征,为腭裂患者语音矫治过程中的语音评价提供新的方法。方法:运用语音分析软件Speech Analyzer1.5对健康人、腭裂术后VPI患者、腭裂术后VPC患者进行/pa/ /ka/ /si/ /xi/ /zi/ /qi/音的语图分析,比较各组空白间隙、冲直条、噪音乱纹的出现率。结果:术后VPI组患者与VPC组患者在塞音、塞擦音冲直条、空白间隙以及擦音乱纹出现率上均有显著性差异,P <0.05;而术后VPC患者与正常组在上述各指标方面也有显著性差异,P <0.05。结论:计算机语音分析技术可以评估患者的腭咽闭合状况,腭咽闭合不是影响腭裂患者语音发育的唯一条件,腭裂术后语音矫治的重点应在辅音训练上。     

Submucous Cleft Palate

A report is given of 47 patients with submucous cleft palate operated on during the period 1965 to 1974. The average age of the patients when referred for surgery was high (10.8 years). Eleven patients, or nearly one out of four, had tonsillectomy and/or adenoidectomy performed before the correct diagnosis was made. Sixteen of the patients had a history of recurrent middle ear disease, and 18 patients had another congenital anomaly, the most frequent one being a cleft of the primary palate. Nineteen patients were operated upon with a von Langen-beck palatorraphy, and 28 with a von Langenbeck procedure + a superiorly based pharyngeal flap. Three of the patients were operated on twice. The result with regard to velopharyngeal function was recorded as good in 34 cases, fair in 10, and poor in 3 cases. The results were better in patients operated upon under the age of 7 years. The operative procedures now recommended are: A von Langenbeck (or push-back) closure of the palate combined with a levator sling reconstruction and a superiorly based pharyngeal flap. The possibility for an optimal result is best when the operation is performed at an early age, i.e. as soon as a diagnosis of SMCP and velopharyngeal incompetence has been made. For this reason it is important that better information about the symptoms and signs of SMCP is given to doctors, dentists and speech therapists, who refer these patients to the cleft palate clinic.     

The orticochea pharyngoplasty and primary palatoplasty: an evaluation

A primary Orticochea pharyngoplasty with a primary palatoplasty was studied in 15 children with cleft palates. Although all children demonstrated velopharyngeal competence, radiographic, endoscopic, and oral examinations suggested that 54% of the children studied would not have needed a pharyngoplasty. In addition, 27% of the children demonstrated aberrant speech patterns associated with velopharyngeal incompetence. Emphasis is placed on the difficulty in identifying which cleft palate patients will have residual velopharyngeal incompetence and the need for continued study and development of techniques for more accurate prediction of which patients would benefit from a primary pharyngoplasty.     

Tongue posture in cleft palate patients with a pharyngeal flap.

Position of the tongue was studied in lateral cineradiographic pictures of 15 patients with cleft palate and velopharyngeal incompetence, and from ten unaffected reference subjects. The patients were examined before and after pharyngoplasty. Before operation there was no difference in the degree of tongue/velum contact between the patients and the reference subjects, but after the operation, contact was lost in 13 of the 15 patients because the tongue was lowered and the velum raised by the pharyngeal flap. This contradicts the previous theory that the position of the tongue should be expected to be higher to maintain the posterior oral seal. The tongue was in a more posterior position in the patients than in the reference subjects both before and after operation. After operation the tip of the tongue retracted into the anterior oral cavity. The posterior and downward change in position of the tongue may account for part of the posterior and downward growth pattern of the lower third of the face which occurs in children after pharyngoplasty. A loss of tongue-lip balance around the premaxilla may be one of the factors that causes the maxillary retrusion that has been reported after pharyngoplasty in patients with cleft palates.     

Contractility of sphincter pharyngoplasty: Relevance to speech outcomes

BACKGROUND:

Sphincter pharyngoplasty has demonstrated time-tested results as a surgical treatment for velopharyngeal incompetence (VPI). However, controversy surrounding the contractility of the transposed muscles persists. Completely unaddressed in the literature is whether the dynamism of the sphincter affects speech outcomes.

OBJECTIVE:

To determine whether active sphincter contraction following sphincter pharyngoplasty influences velopharyngeal closure, nasal emission and hypernasality.

METHODS:

A prospective analysis of patients with VPI after cleft palate repair undergoing sphincter pharyngoplasty by a single surgeon was performed. Video nasendoscopy and videofluoroscopy were performed preoperatively and postoperatively at three and 12 months. Eighteen consecutive patients with cleft palate with or without cleft lip and VPI were reviewed. The average age of the patients at initial evaluation was 7.3 years, with a range of three to 19 years. Dynamicity of sphincter pharyngoplasty, velar closing ratio (VCR), and lateral wall movement (LWM) were assessed by nasendoscopy and videofluoroscopy. Nasal emission and hypernasality were assessed by perceptual speech examination.

RESULTS:

For longitudinal comparison, three groups were created: dynamic at three and 12 months (n=12); adynamic at three months and dynamic at 12 months (n=4); and adynamic at three and 12 months (n=2). Perceived hypernasality scores significantly improved at three months (P=0.0001) and showed continued improvement at 12 months (P=0.03), despite no change in VCR and LWM from three to 12 months. There were no significant differences among the three groups at any time point.

DISCUSSION:

Sphincter pharyngoplasty effectively treats VPI in appropriately selected patients. Although the VCR and LWM remained stable between three months and one year, four of six adynamic sphincters became dynamic. Considering all patients, hypernasality showed continued improvement from three months to one year.

CONCLUSIONS:

There were no differences between dynamic and adynamic sphincters in terms of speech outcomes or the mechanical properties of velopharyngeal closure.