咽丛神经切断术在发音重建中的作用

目的　为解除咽缩肌的痉挛 ,提高喉全切除术后用发音管发音重建的成功率。方法　在一侧舌骨大角后内侧咽缩肌的后表面 6 5mm左右 ,可找到咽丛神经支配咽下缩肌的主支或分支 ,将其切断。结果　 16例中 15例咽丛神经切断术后发音重建成功 ,成功率为 93 8%。结论　咽丛神经切断术取代咽缩肌切断术是可行的。咽丛神经切断术能提高Blom Singer发音管发音重建的成功率 ,值得推广应用。     

解除环咽肌失弛缓在发声重建中的临床意义

目的:探讨环咽肌失弛缓对喉全切除术后安装Groningen发声钮发声重建的影响及解除失迟缓的方法。方法:56例喉癌患者中,15例行一侧环咽肌切断术,16例行双侧咽丛神经切断术,25例同时行上述2种术式;比较不同术式的成功率。结果:43例成功,其中进行一侧环咽肌切断术组的发声成功率为60.0%(9/15),双侧咽丛神经切断术组的发声成功率为为62.5%(10/16),同时行一侧环咽肌切断和双侧咽丛神经切断术组的发声成功率为96.0%(24/25),均较其他2组的成功率高(均P<0.05)。结论:同时行一侧环咽肌切断和双侧咽丛神经切断具有更高的发声成功率。     

选择性咽缩肌切断术在全喉切除术后发音重建中的作用

对１０例喉癌患者行全喉切除术后Ⅱ期Ｂｌｏｍ－Ｓｉｎｇｅｒ发音重建，并行选择在咽缩肌切断术，术后８例发音重建成功，并对咽缩肌切断术的作用及要点加以讨论。     

喉全切除术后安装发音假体失败原因分析

目的 探讨喉全切除术后患者Ⅱ期行气管食管穿刺造瘘安装发音假体行发音重建后发音失败的原因,并找出有效的解决措施.方法 34例喉癌、下咽癌患者.喉全切除术后6个月,安装发音假体7天后不能发气管食管音,观察其发音不成功的原因并作相应处理.结果 34例发音失败者中,14例是因为环咽肌或咽下缩肌痉挛所致,切断咽缩肌或行咽缩肌神经丛切除术后.12例发音成功;11例因发音假体大小不合适,更换合适的发音假体后,10例发音良好;9例因造瘘口感染、瓣膜粘连闭合等,经对症处理后均能发出气管食管音.发音不成功的原因可概括为:①咽周嗣肌肉痉挛;②白色念珠菌沉积于瓣膜上或造瘘口感染;③发音假体大小不合适,太长或太短;④发音假体瓣膜变质、粘连闭合等.结论 喉全切除术后安装发音假体失败的主要原因是并发症,可行选择性咽缩肌切断术或咽丛神经切断术、更换发音假体、抗炎治疗等,经过训练,可获得气管食管音.     

食管充气试验在二期发音重建中的作用

目的 尽快恢复无喉者语言功能，减少手术创伤，提高预测二期发音重建手术成功的准确性，客观评价食管充气试验的实际临床意义。方法 对全喉切除术后无喉者行食管充气试验及二期发音重建，特别就食管充气试验阴性患者进行研究分析。结果 ４５例食管充气试验阴性患者行二期发音重建，而不行咽缩肌切断术的发音成功率９４％（３６／３８），阳性患者成功率１００％（７／７）；无论充气试验阴性或阳性患者术后发音效果均好于预测试验     

咽食管括约肌切开术在喉全切除术后发音重建中的作用

目的：探讨咽食管括约肌切开术对减少咽食管括约肌失弛缓对喉全切除术后安装Blom-Singer发音管发音重建的影响。方法：喉全切除术后，咽食管括约肌收缩或是痉挛都会不同程度地影响食管的气流并阻碍发音。咽食管括约肌的解剖位置是环咽肌以及其上的下咽缩肌的一部分和颈段食管上段的一部分。手术操作是在喉全切除术中、术后于气管造瘘口外上方切除长5cm，宽1cm的咽食管括约肌。结果：33例喉全切除术的患者进行咽食管括约肌切开术后有32例发音成功，发音重建的成功率是97％。其中包括12例喉全切除术中I期进行环咽肌切开术，21例是Ⅱ期进行咽食管括约肌切开术的，后者又有9例是安装Blom-Singer发音管后发音不能再行咽食管括约肌切开术的。患者3年存活25例，5年存活18例。同期行喉全切除术和咽食管括约肌切开术的12例患者，Kaplan-Meier法统计3年生存率81．82％，5年生存率42．86％。结论：咽食管括约肌切开术能提高Blom-Singer发音管发音重建的成功率。     

用Provox发音钮进行全喉切除后的发音重建

传统的发音重建有人工喉和食管发音。人二：喉发音不自然，州外繁＊。；食管发音不易掌握且声音小，语音低。发音钮是声音重建较新的方法，具有语言流畅易懂，容易掌握等优点。但一般发音或均存在两个弱点，气流通过发音钮及食道人口段的高阻力及使用寿命短。文所采用的Provo。发音钮系低阻力自固定，式发音钮，通过瓣膜的改良降低阻力，同时行单侧咽缩肌切开或咽丛神经切断术降低气流阻力，其效果满意。该作者发现真菌感染为影响发音钮寿命的主要原因，所以认为局部用抗真菌药可延长其使用时间。对37例全喉切除后行Provox发音或声音重建的…     

全喉切除安装Blom－Singer发音管的临床应用

目的：为无喉患者重建发音功能。方法：常规全喉切除后，切开咽缩肌在气管后壁做一长4mm横切口，切透气管食管间膜部，形成一气管瘘道，将Blom-Singer发音管安置在瘘道中，用手指堵压气管造口，即可发音。结果：31例中25例能发音，成功率为80．65％，发音音质好，流畅，时值长，最长者已3年，无需更换发音管。发音仍十分满意。结论：该手术是一种效果令人满意的全喉切除发音重建方法。     

食管充气试验在二期发音重建中的作用

目的尽快恢复无喉者语言功能，减少手术创伤，提高预测二期发音重建手术成功的准确性，客观评价食管充气试验的实际临床意义。方法对全喉切除术后无喉者行食管充气试验及二期发音重建，特别就食管充气试验阴性患者进行研究分析。结果４５例食管充气试验阴性患者行二期发音重建，而不行咽缩肌切断术的发音成功率９４％（３６／３８），阳性患者成功率１００％（７／７）；无论充气试验阴性或阳性患者术后发音效果均好于预测试验时。结论食管充气试验对预测术后发音具有一定参考意义，可作为ＢｌｏｍＳｉｎｇｅｒ法二期发音重建术前常规检查，但测试时因受诸多因素影响，不能作为判定术后发音效果的唯一依据。     

Blom-Singer发音管在喉全切除术后的临床应用

目的观察喉全切除术后应用Blom-Singer发音管重建喉发声功能的效果。方法回顾性分析1994年9月～2003年8月15例喉全切除术后行Blom-Singer发音管重建喉发声功能患者的临床资料。结果15例患者中12例行Ⅰ期发音管重建术，10例手术成功(10／12，83．33％)；3例行Ⅱ期发音管重建术，其中2例手术成功，两种术式的总成功率为80％(12／15)。Ⅰ期手术失败2例，与气管食管壁分离过多有关；Ⅱ期手术失败1例，系环咽肌切断不完全所致。结论喉全切除术后应用Blom-Singer发音管重建喉发声功能是一种有效的发声重建方法，环咽肌切断及保留气管食管壁的完整是手术成功的美键。     

Evidence for recurrent laryngeal nerve contribution in motor innervation of the human cricopharyngeal muscle.

OBJECTIVE: To study the functional motor nerve supply of the upper esophageal sphincter in humans. STUDY DESIGN: Intraoperative electromyographic study. METHODS: The contribution of the recurrent laryngeal nerve and the pharyngeal plexus in the motor nerve innervation of the cricopharyngeal muscle and the inferior pharyngeal constrictor muscle was examined intraoperatively. RESULTS: Electromyography showed that there is a considerable overlap in the innervation of the cricopharyngeal muscle and the inferior pharyngeal constrictor muscle. The recurrent laryngeal nerve functionally contributes to the motor innervation of the cricopharyngeal muscle in all patients and contributes to the motor innervation of the inferior pharyngeal constrictor muscle in most patients. The pharyngeal plexus functionally contributes to the motor innervation of the inferior pharyngeal constrictor muscle but does not always contribute to the motor innervation of the cricopharyngeal muscle. CONCLUSIONS: This is the first report which provides evidence that the recurrent laryngeal nerve functionally contributes to the motor innervation of the cricopharyngeal and inferior pharyngeal constrictor muscle. Furthermore, this study shows that intraoperative electromyography in humans is a feasible method to analyze the physiology of the motor innervation of the upper esophageal sphincter.     

Cineradiography of the pharyngoesophageal segment in postlaryngectomy patients

The use of tracheoesophageal voice prostheses has gained wide acceptance in the field of vocal rehabilitation after total laryngectomy. In a randomized study with 3 arms, alaryngeal speech proficiency was assessed in 60 postlaryngectomy patients: 20 patients underwent primary unilateral pharyngeal myotomy, 21 patients underwent neurectomy of the pharyngeal plexus in addition to pharyngeal myotomy, and 19 patients did not undergo an additional surgical procedure. Pharyngoesophageal (PE) dynamics were examined during esophageal and tracheoesophageal speech. A single vibrating PE segment was seen in good alaryngeal speakers. Hypertonicity, spasm, strictures, and hypotonicity of the PE segment were correlated significantly with poor or moderate alaryngeal speech. Unilateral myotomy with or without unilateral neurectomy prevented hypertonicity or spasm of the PE segment. The acquisition of alaryngeal speech did not differ significantly between the 2 groups who had undergone an additional surgical procedure. Evaluation of anatomic and physiological factors may be helpful in subsequent clinical management to achieve effective alaryngeal speech.     

Operative prevention and management of voice-limiting pharyngoesophageal spasm

Voice-limiting pharyngoesophageal spasm presents a challenge to the surgeon who is trying to optimize functional voice outcomes in the laryngectomy patient. Modified closure techniques, adjunctive myotomy, and pharyngeal plexus neurectomy have the ability to improve or prevent pharyngoesophageal spasm. Attempts to maximize vocal outcome should be considered at the original time of laryngectomy and tracheoesophageal voice restoration because salvage treatment can be challenging.     

Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation

Pharyngeal constrictor and cricopharyngeal spasm have been implicated as deterrants to esophageal speech acquisition as well as tracheoesophageal phonation. Recent efforts to reduce the resultant hypertonicity include pharyngeal constrictor myotomies and modifications of pharyngeal reconstruction during laryngectomy. Investigation of the innervation of the muscular wall of the pharynx led to the development of a pharyngeal plexus neurectomy technique to alter the tonicity of the pharynx without myotomy. The resultant alaryngeal speech is fluent, and acoustic parameters compare favorably to esophageal speech.     

Tracheoesophageal speech failure in the laryngectomee: The role of constrictor myotomy

Drs. Singer and Blom pioneered the development of a valved voice prosthesis and controlled fistula between the tracheal and esophagcal wall to generate fluent esophageal speech in laryngectomy patients. Since then numerous voice prostheses with different performance capacities have entered the marketplace. In spite of optimal choices and fitting of devices, there remains a population of patients refractory to this type of rehabilitation. It is our experience that a number of patients ultimately benefit from middle and inferior constrictor myotomy with marked improvement in their speech. Patient selection, evaluation, and operative techniques are discussed. Five patients who were unable to speak even after introduction of various commercially available devices showed marked improvement after middle and inferior constrictor surgical myotomy. Minimal complications were encountered even in irradiated patients. These patients were preoperatively injected with Xylocaine to produce a partial blockade. Their speech improved dramatically for the duration of Xylocaine blockade. Esophageal video fluoroscopy of attempted speech with the voice prosthesis in place confirmed constrictor spasm that opposed air flow to the oropharynx. Inferior and middle constrictor myotomy appears to be very beneficial in rehabilitation of failed alaryngeal speakers who demonstrate pharyngeal constrictor spasm.     

Botulinum neurotoxin for pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration

OBJECTIVES/HYPOTHESIS: The purpose of the study was to evaluate the effectiveness of Botulinum neurotoxin (Botox) for elimination of pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration. STUDY DESIGN: A retrospective review was made of 62 patients between 1991 and 2002 who had Botox as the initial treatment for pharyngeal constrictor muscle spasm. METHODS: One hundred units of Botox properly diluted in 3 mL saline was instilled unilaterally under electromyographic guidance after fluoroscopic identification and marking of the contracted pharyngeal constrictor muscles. The patients were divided into three groups based on their response to the first Botox injection: group I, complete relaxation of the pharyngeal constrictors resulting in fluent voice, intratracheal phonation pressure of 20 to 40 cm H2O, and the ability to say 15 to 20 uninterrupted syllables; group II, hypertonic or incomplete relaxation of the pharyngeal constrictors resulting in intratracheal phonation pressure of 45 to 70 cm H2O and the ability to say 7 or 8 syllables; and group III, failure to produce relaxation of the pharyngeal constrictors. RESULTS: After the first injection of Botox, 49 (79%) patients were in group I or II (41 in group I and 8 in group II) and group III consisted of 13 patients. Thirty-four patients (55%) had group I (28) or II (6) responses for greater than 6 months. A second Botox injection enabled 6 of the 13 failures to move into group I. In all, 8 pharyngeal constrictor muscle myotomies (13%) were ultimately required in the 62 patients. The group I speaker for the longest period has enjoyed 11 years of fluency and successful daily use of a tracheostoma valve after two Botox injections. CONCLUSION: Botox relaxation of the pharyngeal constrictor muscles has proven to be effective, has replaced secondary pharyngeal myotomy for the initial treatment of pharyngeal muscle spasm, and is the only treatment in patients who are not candidates for elective surgery. Radiographic assessment, electromyographically monitored injection, and the number of Botox units appear to be important to successful outcomes.     

咽食管括约肌切开术在喉全切除术后发音重建中的作用

目的　探讨咽食管括约肌切开术对减少咽食管括约肌失弛缓对喉全切除术后安装Blom Singer发音管发音重建的影响。方法　喉全切除术后 ,咽食管括约肌收缩或是痉挛都会不同程度地影响食管的气流并阻碍发音。咽食管括约肌的解剖位置是环咽肌以及其上的下咽缩肌的一部分和颈段食管上段的一部分。手术操作是在喉全切除术中、术后于气管造瘘口外上方切除长 5cm ,宽 1cm的咽食管括约肌。结果　 3 3例喉全切除术的患者进行咽食管括约肌切开术后有 3 2例发音成功 ,发音重建的成功率是 97%。其中包括 12例喉全切除术中I期进行环咽肌切开术 ,2 1例是Ⅱ期进行咽食管括约肌切开术的 ,后者又有 9例是安装Blom Singer发音管后发音不能再行咽食管括约肌切开术的。患者 3年存活 2 5例 ,5年存活 18例。同期行喉全切除术和咽食管括约肌切开术的 12例患者 ,Kaplan Meier法统计 3年生存率 81 82 % ,5年生存率 42 86%。结论　咽食管括约肌切开术能提高Blom Singer发音管发音重建的成功率。     

Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part I: Speech characteristics

The speech characteristics of 29 patients with primary tracheoesophageal puncture who received either a pharyngeal constrictor myotomy, a unilateral pharyngeal plexus neurectomy, or a unilateral pharyngeal plexus neurectomy with drainage myotomy limited to the cricopharyngeus were studied. All patients used a Blom-Singer low-pressure voice prosthesis. Audio recordings of each patient speaking with both the Blom-Singer tracheostoma valve and manual occlusion of the tracheostoma were recorded at 3 weeks, 6 months, and 12 months after surgery. The three surgical variations were equally effective at preventing pharyngospasms; only 1 patient (10%) in each group had some loss of fluency during the 12 month study period. Neurectomized patients produced significantly higher fundamental frequencies during reading than did patients in the other groups. Residual resting tone in the neurectomized pharyngoesophageal segment may contribute to more favorable speaking frequencies in this group.