腭帆间隙解剖学研究与腭咽成形术

目的研究软腭解剖学，探讨腭咽成形术中病变组织的切除及正常结构的保护，指导手术方式的改良。方法测量阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome，OSAHS)患者软腭解剖参数71例，非OSAHS成人软腭解剖参数30例；于手术中解剖OSAHS患者部分软腭组织71例，观察OSAHS患者软腭的形态学变化、脂肪及肌肉的分布；取尸体软腭标本6例，行轴位及矢状位连续切片观察。结果OSAHS患者软腭较正常人明显增长，是形成气道狭窄的重要解剖学基础；软腭粘膜于游离缘折返处、悬雍垂肌与腭帆张肌及腭帆提肌交界处粘膜下组织疏松，是OSAHS患者脂肪沉积的主要部位，有重要的临床意义，将其命名为腭帆间隙。结论腭帆间隙因OSAHS患者脂肪沉积而扩大，该间隙脂肪组织切除不仅可缩短软腭、扩大咽腔，同时可提高软腭张力，并对软腭功能无明显影响。     

腭咽成形术中保留悬雍垂的意义

目的　改进经典悬雍垂腭咽成形术 (uvulopalatopharyngoplasty ,UPPP)手术方法 ,探讨术中保留悬雍垂的意义 ,提高UPPP手术疗效、减少术后并发症。方法　治疗睡眠呼吸暂停综合征患者 30例。①在主观症状改善的基础上 ,应用多导睡眠图分析及咽腔解剖参数测量等项指标 ,术后随访 6个月以上 ,对术前术后所获资料进行统计学分析。②手术改进特点 :力求维持咽腔正常生理解剖形态 ,完整保留悬雍垂 ,解剖切除腭帆间隙脂肪组织 ,扩大软腭成形范围 ,平均软腭切除最高点在悬雍垂根部两侧上 1 9cm。结果　主观症状明显改善者占 87 0 % ,以AHI下降 >5 0 %为判定标准 ,有效率为5 3 3 % ,对轻、中度患者 (AHI<5 0 )有效率达 73 3 % ,无 1例出现腭咽关闭不全、咽腔瘢痕狭窄、误咽等并发症。术后咽腔解剖测量 :完整保留的悬雍垂术后 2周左右开始回缩 ,3～ 6个月接近并达到正常水平。结论　此术式可有效扩大咽腔 ,避免腭咽关闭不全等并发症 ,提高UPPP手术疗效 ;完整保留的悬雍垂依靠术后悬雍垂肌、腭帆提肌、腭帆张肌的运动及两侧软腭愈合引起的向上向外的牵拉作用 ,可以逐步回缩至正常生理水平     

腭咽成形术中保留悬雍垂的意义

目的 改进经典悬雍垂腭咽成形术（ＵＰＰＰ）手术方法，探讨术中保留悬雍垂的意义，提高ＵＰＰＰ手术疗效、减少术后并发症。方法 治疗睡眠呼吸暂停综合征患者３０例。①在主观症状改善的基础上，应用多导睡眠图分析及咽腔解剖参数测量等项指标，术后随访６个月以上，对术前术后所获资料进行统计学分析。②手术改进特点：力求维持咽腔正常生理解剖形态，完整保留悬雍垂，解剖切除腭帆间隙脂肪组织，扩大软腭成形范围，平均软腭切除     

改良悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停低通气综合征

目的改进传统的悬雍垂腭咽成形术（uvul opalatopharyngoplasty,UPPP）治疗阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）的疗效,探讨减少术后并发症的方法。方法对68例OSAHS患者行改良UPPP。手术要点：维持咽腔正常解剖生理形态,保留悬雍垂,切除腭帆间隙脂肪组织,对软腭和咽侧壁进行成形,充分扩大咽腔。术后随访6个月以上,12个月时行多道睡眠图（polysomnography,PSG）监测。结果患者憋气、打鼾、嗜睡等症状均于6个月内明显减轻或消失,术后12个月经PSG监测,其有效率为95.6%。结论改良UPPP可充分扩大咽腔空间,避免并发症,提高手术效果。     

改良等离子辅助下的悬雍垂腭咽成形术治疗重度OSAHS

目的:探讨UPPP手术改良的新方法及改良等离子辅助下的UPPP(M-CAUP)治疗重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的疗效。方法:回顾性分析行手术治疗的87例重度OSAHS患者(均经阻塞定位系统ApneaGraph 200监测诊断为腭后区狭窄)。病例选择:术前经PSG结合ApneaGraph 200监测结果示AHI≥30次/h,LSaO2≤85%的患者。M-CAUP手术方法:①70#刀头行双扁桃体被膜外融切术。②70#刀头解剖软腭前间隙,彻底融切软腭前间隙内的脂肪组织,避免损伤腭帆张肌、腭帆提肌及尽量保留悬雍垂肌,保留口咽正常解剖结构。③55#刀头行软腭打孔消融,使软腭适度减容。④成形:缝合以关闭扁桃体窝,腭弓及悬雍垂两侧以丝线间断缝合。术后随访6~18个月并均行PSG。结果:术后患者咽腔扩大,咽腔基本结构完整,无鼻咽反流出现,患者主观症状明显改善。与术前比较,术后AHI值下降、LSaO2升高、Epworth嗜睡量表(ESS)评分下降均有统计学意义(均P<0.01)。术后有效率为89.7%。结论:OSAHS病因复杂,治疗方法多样,对于重度OSAHS,传统UPPP手术效果多不理想;本研究证实M-C...     

采用不同缝合方法的悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停低通气综合征的疗效分析

悬雍垂腭咽成形术(u vulopalatopharyngoplasty,UPPP)是治疗阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndmmes,OSAHS)的重要方法。解剖腭帆间隙,切除黏膜下脂肪组织的手术理念已得到普遍认可,如何缝合术腔,既能扩大咽腔的     

改良悬雍垂腭咽成形术疗效的临床观察

目的:改进经典悬雍垂腭咽成形术(UPPP) 的手术方法,探讨保留悬雍垂的可行性和必要性。方法：全身麻醉下行保留悬雍垂的腭咽成形术,术中完整保留悬雍垂,切除腭帆间隙脂肪,提高软腭最高切点均在2.5?cm 以上。结果：完整保留的悬雍垂术后2周开始回缩,3个月后咽腔接近年轻状态,无腭咽关闭不全及再狭窄。主观问卷调查和PSG客观检测有效率为100%。结论：保留悬雍垂可提高软腭最高切点开大咽腔,扩大软腭鼻咽面和咽后壁间距并防止腭咽关闭不全,可明显提高UPPP手术疗效。     

悬雍垂腭咽成形术治疗中度阻塞性睡眠呼吸暂停综合征的疗效观察

目的；探讨中度阻塞性睡眠呼吸暂停综合征（OSAS）的手术疗效。方法：采用改良悬雍垂腭咽成形术（UPPP），即扩大软腭切除范围，解剖腭帆间隙，保留悬雍垂及咽腔的基本结构治疗64例此种患者。结果：术后随访，6个月时复查多导睡眠监测仪，显效21例（32.8%)。有效24例（37.5%)。总有效率为70.3%。无效19例(29.7%)。结论：改良UPPP是治疗中度OSAS的有效方法。     

鼻、鼻咽、腭咽同期联合手术治疗中、重度OSAHS

目的探讨改良悬雍垂腭咽成形术（UPPP）＋鼻腔手术＋残留腺样体刮除同期联合治疗多平面狭窄的中、重度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）及近、远期疗效。方法选择138例多平面狭窄的中、重度OSAHS患者，术式要点：保留悬雍垂、软腭黏膜，切除腭帆间隙脂肪组织，全层剪开软腭同时剪断双侧腭咽肌，扩大咽峡和鼻咽峡，鼻腔手术包括（FESS术、鼻中隔黏膜下矫正术、下鼻甲射频消融术和残留腺样体刮除术）。结果138例随访1年以上进行结果分析，PSG复查：治愈15例（10．86％）；显效91例（65．94％）；有效32例（23．18％）；患者主观症状明显改善100％。结论多平面狭窄的中、重度OSAHS行3部位同期联合手术，能最大限度的一次解除鼻、鼻咽、腭咽部阻塞，适合FriedmanⅢ型、Ⅳ型，提高治愈率的关键在于避免仰卧时舌体后坠与软腭的重叠，恢复经鼻呼吸。     

阻塞性睡眠呼吸暂停低通气综合征患者腭咽组织病理学观察

目的：观察阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者腭咽组织病理学变化特点，探讨腭咽组织中脂质异位积累在OSAHS发生、发展机制中的作用。方法：以OSAHS患者（OSAHS组）和无鼾症患者（对照组）各19例为研究对象，按体质指数（BMI）配对研究。取2组软腭及咽腭弓组织分别用苏木精-伊红及油红-O脂肪染色，镜下观察2组腭咽组织病理学特点及脂质异位积累情况。结果：OSAHS组腭咽组织中存在明显的脂质浸润，同时伴有小唾液腺类型改变，其超微结构呈现相应变化及细胞缺氧性改变；对照组腭咽组织无异常改变。结论：脂质在腭咽组织中的异位积累可能是导致OSAHS患者睡眠时咽部气道塌陷的重要原因，与OSAHS的发生、发展关系密切。     

低温等离子辅助软腭外展加折叠术治疗阻塞性睡眠呼吸暂停低通气综合征

目的　探讨腭咽成形术的改良手术方法,在解除腭咽部解剖性狭窄的同时,通过软腭外展增强软腭紧张度,避免睡眠中软腭功能性塌陷,提高手术疗效。方法 手术治疗以腭咽部狭窄、软腭松弛为主的阻塞性睡眠呼吸暂停低通气综合征患者55例（重度43例,中度12例）,利用软腭两侧斜三角形以及悬雍垂软腭交界处横矩形黏膜瓣切口,在低温等离子刀辅助下,解剖切除双侧腭帆间隙及软腭前方间隙内肥厚黏膜及沉积的脂肪组织,同时行黏膜切缘连同深部肌肉拉拢缝合,缝合后使软腭向两侧外展,悬雍垂-软腭前倾。分别于术前及术后6个月进行Epworth嗜睡量表评分及多道睡眠图监测,对所获得的资料进行统计学分析。结果　55例患者中,治愈8例,显效41例,有效3例,无效3例,手术成功率89.1%。术后Epworth嗜睡量表评分、呼吸暂停低通气指数、最低动脉血氧饱和度与术前比较均有显著性差异（P <0.001）。未出现术后开放性鼻音、长期饮食反流、鼻咽腔瘢痕性狭窄等并发症。结论　低温等离子辅助下软腭外展加悬雍垂-软腭折叠术,使软腭向两侧牵拉外展,悬雍垂及软腭前倾,软腭紧张度增加,可有效解除软腭塌陷,手术疗效满意,无严重并发症发生。     

Determination of obstructive site in obstructive sleep apnea

Patients with obstructive sleep apnea syndrome (OSAS) may have airway obstruction at various levels, including the uvula-soft palate complex, base of tongue, and/or possibly other sites. For patients with tongue base and/or laryngeal obstruction, uvulopalatopharyngoplasty (UPPP, ppp) will not alleviate the obstruction. Prior authors have proposed that the hyoid bone position as determined by cephalometric x-rays can predict which patients have obstruction at a lower site than the soft palate. In this study, patients with obstructive sleep apnea syndrome were evaluated with polysomnographic testing, fiberoptic endoscopy, and cine-CT scans (Imatron Scanner with multiple level rapid sequence scans) in an attempt to determine precisely the site of airway obstruction. Measurements of airway size taken at the time of fiberoptic pharyngoscopy were compared with those determined by the cine-CT studies. Initial results revealed that fiberoptic pharyngoscopy in the sitting and supine positions was helpful in confirming pharyngeal airway sites with smaller diameters in awake patients. However, the cine-CT exam performed in both sleeping and awake states provided more direct data regarding the airway during sleep. We feel that with more clinical experience the cine-CT technique will prove to be the most helpful study for identification of the obstructive airway site in obstructive sleep apnea syndrome.     

上气道测压在悬雍垂腭咽成形术后失败患者阻塞定位的应用

目的 应用上气道压力测定法判断悬雍垂腭咽成形术（uvulopalatopharyngoplsaty,UPPP）后失败患者气道阻塞部位。方法 对10例UPPP术后仍有打鼾或白天嗜睡的患者同期行整夜睡眠监测和上气道压力测定,判断其呼吸紊乱程度和气道阻塞部位,分析体位对呼吸紊乱低通气指数(apnea hypopnea index,AHI)的影响。结果 3例为中度,7例为重度阻塞性 呼吸暂停。上气道阻塞部位可分上部（主要为腭后区）和下部（主要为舌后区）,10例均为上部和下部联合阻塞,其中6例以上部,4例以下部阻塞为主。仰卧位呼吸暂停AHI（66.52±22.51）次/h,侧卧位AHI（47.82±21.82）次/h,差异有统计学意义（P=0.017）。结论 上气道压力测定法可较好地判断阻塞性睡眠呼吸暂停低通气综合征患者的气道阻塞部位,多数UPPP术后患者以腭后区阻塞为主,且仰卧位较侧卧位更易引起气道塌陷。     

Histopathology of the uvula and the soft palate in patients with mild, moderate, and severe obstructive sleep apnea

OBJECTIVE: To study morphometric and qualitative histopathologic changes of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea. STUDY DESIGN: A prospective, nonrandomized controlled study. METHODS: The distal soft palate and uvula were excised during uvulopalatopharyngoplasty from 34 male patients with obstructive sleep apnea. Control specimens were retrieved from 7 male cadavers with no related disorders. All specimens underwent routine processing and the mid-sagittal sections were studied. Morphometric analysis of the relative proportions of the tissue constituents was carried out. Also, a qualitative assessment was performed to detect possible pathologic changes. RESULTS: The body mass index of patients was significantly higher from that of control subjects. The area fraction occupied by the tissue constituents of the distal portion of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea and in control subjects was similar, with small and insignificant differences regarding the contents of glands, muscle, fat, blood vessels, and the epithelium. Only the connective tissue was significantly greater in patients with moderate obstructive sleep apnea than in those with severe obstructive sleep apnea and control subjects. The qualitative assessment of the specimens disclosed normal tissue architecture without evidence of destruction. Vascular engorgement, fibrosis, edema, inflammatory cell infiltration, and dilated glandular ducts were observed in a portion of patients and control subjects. CONCLUSIONS: The structure of the distal soft palate and uvula of patients with obstructive sleep apnea undergoes insignificant changes and is independent of the body mass index levels, indicating that the pathologic changes are probably the sequela of airway obstruction rather than its cause.     

Retropalatal Airway Characteristics in Uvulopalatopharyngoplasty Compared With Transpalatal Advancement Pharyngoplasty

Uvulopalatopharyngoplasty (UPPP) is reported successful in treatment of obstructive sleep apnea for approximately 50% of patients. Several modifications of the procedure have been described, including transpalatal advancement pharyngoplasty, which resects a portion of posterior hard palate and advances the soft palate anteriorly. Comparing effectiveness of different techniques based on sleep and respiratory data is confounded by multiple variables including clinical failure at nonsurgical sites and imprecise patient selection techniques. Since pharyngeal surgical procedures prevent collapse and obstruction by structurally modifying the upper airway, measuring structural changes in size and collapsibility provides a method to compare techniques. To evaluate whether transpalatal advancement pharyngoplasty is more effective in modifying upper airway characteristics than UPPP, upper airway cross-sectional size and collapsibility were measured after UPPP and transpalatal advancement pharyngoplasty. Six patients were evaluated using a quantitative endoscopic technique. After transpalatal advancement pharyngoplasty maximal retropalatal airway size increased 321% from 29.7 ± 9.9 to 95.3 ± 16 mm² (P < 0.01), and retropalatal closing pressure decreased from 4.7 ± 1.6 to -3.8 ± 0.7 cm/H₂O (P < 0.01) compared with UPPP. Respiratory disturbance index decreased from 74.5 ± 13.5 to 29.2 ± 9 events/hour postoperatively (P < 0.05). Results support the conclusion that transpalatal advancement pharyngoplasty increases retropalatal size and decreases retropalatal collapsibility compared with UPPP. Since these characteristics are postulated to contribute to increased stability during sleep, transpalatal advancement pharyngoplasty may potentially improve UPPP outcome in selected patients with small retropalatal airway areas after traditional surgery.     

Transpalatal advancement pharyngoplasty for obstructive sleep apnea

Uvulopalatopharyngoplasty (UPPP) is a commonly performed procedure for obstructive sleep apnea (OSA). However, results are inconsistent. Patients in whom the UPPP procedure has failed have a smaller change in airway size as compared to responders, and also many demonstrate continued obstruction at the palate. We present a modification, transpalatal advancement pharyngoplasty, that increases upper oropharyngeal and retropalatal airway size by advancing the soft palate. Eleven patients with severe OSA and multiple sites of airway narrowing were corrected by this method. Three patients had prior UPPP and 5 patients had concomitant tongue-base procedures. Overall results demonstrate clinical enlargement of the retropalatal space. In the 6 patients who had transpalatal advancement pharyngoplasty alone, 4 (67%) were successful responders as defined by a respiratory disturbance index (RDI) of less than 20 events per hour. RDI decreased from 52.8 ± 12.2 to 12.3 ± 2.8 events per hour. For the entire group, RDI decreased from 73.3 ± 29.4 to 25.1 ± 28.2 events per hour (P<.001). There were four complications, including a transient oronasal fistula(1), transient dysphagia(2), and serous otitis media(1). Transpalatal advancement pharyngoplasty potentially may offer an alternative to increasingly aggressive resection with UPPP in an effort to increase the upper oropharyngeal and retropalatal airway and may be appropriate in carefully selected patients as part of the surgical treatment of OSA.     

Resolution of obstructive sleep apnea following facial surgery

Compared to uvulopalatopharyngoplasty (UPPP), maxillo-facial surgery is rarely performed in Canada for treatment of obstructive sleep apnea. However, in patients with retrolingual obstruction, UPPP cannot be expected to result in good surgical outcome. We describe a patient with retrognathia causing airway obstruction at the base of the tongue, in whom sagittal mandibular osteotomy with hyoid bone advancement resulted in resolution of snoring and sleep apnea.     

Palatal aponeurosis and the insertion of the tensor muscle of the soft palate. An anatomic study and clinical applications

INTRODUCTION: Knowledge of the anatomy of soft palate muscles is of great interest in cleft palate surgery, in surgical correction of obstructive sleep apnea syndrome and in excision of maxillo-facial carcinomas. Some authors described the palatal aponeurosis as the expansion of the tendon of the two tensor veli palatini muscles, others stated that the palatal aponeurosis is a distinct anatomic entity. METHOD: Ten dissections of the soft palate have been performed to improve our knowledge of its anatomy. RESULTS: The palatal aponeurosis is a distinct anatomic entity continuous with the periosteum of the nasal cavity. The tendon of the tensor veli palatini terminated on the inferior side of the aponeurosis. One fifth of the tensor's tendinous fibers terminated on the posterior border of the palatine bone and the others are spreading on the anterior and inferior side of the palatal aponeurosis. DISCUSSION: In cleft palate patients, this aponeurosis is absent, the palatal muscles are attached to the posterior border of the palatine bones. So it seems to be logical to recommend a soft-palate "pushback" to create a new space between the posterior border of the palatine bones and the soft-palate muscles.     

硬腭截短软腭前移-悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停综合征

目的：探讨硬腭截短软腭前移-悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停综合 征（Obstructive sleep apnea syndrome,OSAS）的疗效。方法：对16例OSAS患者准确定位上气道阻塞平面,行硬腭截短软腭前移-悬雍垂腭咽成形术,对比手术前后《欧洲率中量表》(ESS)评分、多导睡眠监测(PSG)、Muller试验、头影侧位片检查。结果：手术前后ESS评分、睡眠呼吸紊乱指数(AHI)及最低SaO2差异均有统计学意义（P＜0.05）,头影测量显示上气道间隙较术前扩大,Muller氏实验中吸气时咽壁塌陷程度减轻。结论：硬腭截短软腭前移术可有效扩大骨性鼻咽腔及腭咽前后位狭窄,联合悬雍垂腭咽成形术不仅提高了手术有效率,治愈率也明显提高。