腭裂修复术中凿断翼钩对腭咽闭合功能影响的研究

本文应用Ｘ线检查方法,对８３例单侧腭裂术后患者进行了术中凿断翼钩是否影响患者术后腭咽闭合功能的研究。结果表明：（１）腭裂术中凿断翼钩后,患者鼻咽腔的横向收缩力明显减小;软腭抬高角度也有减小的趋势。（２）两大瓣术中凿断翼钩可使闭合条件明显提高,说明该手术方法如凿断翼钩有延长软腭的作用。     

5岁以下腭裂患儿术后腭咽闭合功能变化规律的研究

目的 探讨低龄腭裂患儿术后腭咽闭合功能恢复规律,及与年龄、腭裂类型和不同复诊时间等因素的相关关系。方法 本研究纳入有2次以上复诊记录的5岁以下腭裂患者,回顾其术后腭咽闭合功能的连续性评估结果,分别进行单因素和多因素logistic回归检验,分析术后腭咽闭合功能变化的规律及影响因素。结果 共纳入165例患者,其中31例患者出现前后腭咽闭合功能不一致,即初次复诊判定为腭咽闭合不全（VPI）而在二次复诊转为腭咽闭合完全（VPC）,占总数18.79%;134例患者前后复诊腭咽闭合功能一致。腭咽闭合功能前后一致的患者平均年龄显著小于不一致的患者。手术年龄越小,在初次复诊时,患者的腭咽闭合功能更容易达到稳定。患者在术后15、28、40个月时,腭咽闭合功能达到稳定的比例为80%、90%、95%。结论 腭裂术后腭咽闭合功能的恢复是一个动态过程,早期的VPI可能发展为VPC,但VPC不会再转变为VPI。复诊时间是腭咽闭合功能评估结果前后一致性最重要的相关因素,选择合适的复诊时间,有利于获得稳定准确的腭咽闭合功能评估结果。     

翼钩凿断和板间切开对中耳功能的影响

目的:了解翼钩凿断和板间切开对中耳功能的影响。方法:对20只新西兰大耳白兔行翼钩凿断和板间切开后,观察腭腱膜及中耳腔粘膜的变化,以明确手术对中耳功能的影响。结果:翼钩组均出现腭帆张肌松弛,中耳腔粘膜杯状细胞明显增多;板间切开组无1例出现上述变化。结论:翼钩凿断不利于咽鼓管的开张,而板间切开影响较小,因而主张腭裂手术时应尽量不凿断翼钩以保持其解剖位置和功能。     

双侧腭裂整复术中凿断翼钩与否对上颌骨发育的影响

目的对比在双侧腭裂修复术中凿断翼钩与否,术后患者的上颌骨发育情况.方法选择在3岁以内做双侧腭裂修复手术,术中不凿断翼钩的患者16例,编入试验组.另再选择3岁以内做双侧腭裂修复手术,术中凿断翼钩的患者10例,编入对照组.两组的年龄范围9～12岁,术后追踪9～10年.拍摄每例患者的头颅侧位片,并作头影测量分析,对比两组患者的上颌骨发育情况.结果两组的上颌骨都有明显的矢状向发育不足,下颌骨发育基本正常.测量上颌骨发育的各项目（SNA、A-NP、PP-SN、ANS-FHp、Ptm-A等）的组间差别不明显,说明手术中有无凿断翼钩,对患者的上颌骨发育并无影响.结论在双侧腭裂修复手术中,有无凿断翼钩,对患者的上颌骨发育并无明显影响,但不凿断翼钩有利于保护腭帆张肌,同时也能减少手术创伤,简化手术过程.     

腭裂修复术后软腭形态多样性的研究

目的通过X线头颅侧位片研究腭裂修复术后腭咽闭合不全(VPI)患者及腭裂修复术后腭咽闭合完全(VPC)患者的软腭形态,为腭裂修复的研究提供参考。方法对腭裂修复术后的113例患者进行分析,观察其软腭在X线头颅侧位定位片上的静态形状特点,并分析术后VPI与术后VPC患者软腭类型分布的差异以及术后VPI患者中不同年龄组和性别组间构成比的差异。结果术后VPI和VPC患者的软腭在X线头颅侧位定位片中表现为6种类型,分别为梭叶型、月牙型、钝角三角型、条带型、粗短型、不规则型;术后VPI与术后VPC患者软腭类型分布的构成有差异;术后VPI患者两年龄组间各类型构成比无差异,两性别组间有差异。结论在数字化头影侧位片中,腭裂修复术后的软腭静态形状呈多样性。     

大年龄腭裂患者术后腭咽闭合功能的影响因素

目的 研究2岁以上腭裂患者术后腭咽闭合功能的影响因素。方法 对245例2岁以上腭裂患儿术后腭咽闭合功能和可能影响术后腭咽闭合功能的因素（腭咽比值、腭裂类型、手术年龄、术式）进行回顾性研究。结果 腭咽闭合不全（ VPI）组和腭咽闭合完全（ VPC）组术前相对裂隙宽度、腭咽比值差异无统计学意义。不同年龄组、不同腭裂类型术后腭咽闭合率未见明显差异。不同的术式术后腭咽闭合率差异有统计学意义。结论 大年龄腭裂患者的治疗不宜照搬 2岁以下患儿单纯行腭裂整复术的常规治疗方案。裂隙的大小不是影响大年龄腭裂患者术后腭咽闭合功能的主要因素。 Sommerlad腭帆提肌重建术 +腭咽肌瓣咽成形术可明显改善大年龄患者术后腭咽闭合功能,在一期手术时应采用这种腭咽联合手术。     

Hogan法治疗大龄腭咽闭合不全患者的临床疗效分析

目的 探讨使用Hogan法咽后壁组织瓣转移术治疗大龄腭咽闭合不全（VPI）患者的临床疗效。方法收集33例腭裂术后VPI患者，年龄10～35岁，平均年龄20.4岁。所有患者均行Hogan法咽后壁组织瓣转移术治疗腭咽闭合不全。采用汉语语音清晰度测定法评估患者语音情况，鼻咽纤维镜（NPF）评估腭咽闭合程度，并进行分级。平均随访时间13.3个月。结果 33例患者术后创口均达到Ⅰ期愈合。术后语音清晰度明显提高，鼻漏气及高鼻音减少，与术前相比差异有统计学意义（P<0.05）。NPF检查示，术后腭咽闭合功能明显改善，30例（91%）患者腭咽闭合率达到Ⅰ级，3例（9%）患者达到Ⅱ级。结论 Hogan法咽后壁组织瓣转移术可显著改善大龄VPI患者的腭咽闭合状况，减少鼻漏气和高鼻音。     

腭裂修复术对腭裂患者中耳状况及听力的影响

目的 了解腭裂修复术对腭裂患者中耳状况及听力状况的影响。方法 分析23例腭裂患者术前、术后(平均复诊时间8．6个月)声阻抗检查结果及纯音听阈变化情况。结果 腭裂修复术后渗出性中耳炎患病率及平均听闻值均有所下降，但无显著性差异，而耳声反射阳性率有明显提高。结论 腭裂修复术后短时间内，咽鼓管功能及听力恢复表现的不明显，声反射是反映中耳状况较为敏感的指标，可作为腭裂总者术前、术后渗出性中耳性监到的重要指标之一。     

黏膜下腭裂的形态分类与腭咽功能分析

目的 通过观测黏膜下腭裂患者的多项指标,以了解黏膜下腭裂的解剖形态与腭咽功能,以期提高临床诊断和治疗的准确率。方法对2008-2014年就诊的276例黏膜下腭裂患者的资料进行回顾性研究,对其术前腭咽功能、腭部形态、是否伴发唇裂、就诊原因等因素进行分析,观察各指标与腭咽功能的相关关系。结果276例患者中,术前腭咽闭合完全（VPC）者96例（34.78%）,腭咽闭合不全（VPI）者151例（54.71%）,边缘性腭咽闭合不全（MVPI）者29例（10.51%）。单纯黏膜下腭裂者196例（71.01%）,伴发唇裂者80例（28.99%）,伴发唇裂者较单纯的黏膜下腭裂者有更高的术前VPC率。黏膜下腭裂有不同的形态,完全具备Calnan三联征者仅103例（37.32%）。结论不同类型黏膜下腭裂的构成比和腭咽闭合率不同,需综合考虑各个因素与腭咽功能间的可能关系,谨慎选择治疗方案。     

腭裂整复手术的基本理论与临床

一、腭咽闭合的生理基础腭帆提肌的解剖生理腭帆张肌与凿断翼钩的问题咽上缩肌与咽腔解剖派氏垫 ( Passavant ridge)的评价腭咽闭合过程中的生理代偿功能二、腭裂的修复手术1 .手术时间的选择——婴幼儿语言发育时期为一岁左右国际上序列治疗的时间 ,对腭裂修复术为 1 2 -1 8个月早期手术的优点 :1恢复语言功能2避免中耳感染 (十聋九哑 )3有利于软腭的生长发育早期手术的缺点 :手术创伤和腭部裸露的骨面形成的瘢痕 ,影响上颌骨发育导致牙颌畸形故有两期手术的治疗方式 ,兼顾上述优缺点早期——修复软腭手术期——修复硬腭2 .手术方法及其特…     

The effect of hamulus fracture on the outcome of palatoplasty: a preliminary report of a prospective, alternating study.

OBJECTIVE: To determine whether, in performing palatoplasty, fracture of the pterygoid hamulus is beneficial, detrimental, or neutral with respect to intraoperative and perioperative complications, hearing outcome, and speech outcome. DESIGN: Prospective, alternating. SETTING: Institutional, tertiary cleft palate center, Chang Gung Memorial Hospital, Taipei, Taiwan. PARTICIPANTS: A total of 173 patients enrolled in the study, of whom 161 had charts available for analysis. INTERVENTIONS: During the performance of palatoplasty, 85 patients received hamulus fracture and 76 patients did not. All palatoplasties were performed by the same surgeon. MAIN OUTCOME MEASURES: (1) Surgical outcomes, including patient demographic data, palatoplasty type and duration, blood loss, incidences of oronasal fistulae, temporary mucosal dehiscence, and postoperative bleeding; (2) otolaryngological outcomes, including hearing results as judged by auditory brainstem response testing, myringotomy tube data describing rates of tube extrusion, and culture results from sampled effusions; and (3) preliminary speech outcomes as described by judgments of overall velopharyngeal function from perceptual speech samples. RESULTS: No statistically significant differences in any of the measured surgical, otolaryngological, or preliminary speech outcomes were found between the groups who did and did not receive hamulus fracture. CONCLUSIONS: On the basis of these results, we are unable to advocate the performance of hamulus fracture as an operative maneuver during the performance of primary palatoplasty. The historical rationale and theoretical advantage of this maneuver have not been demonstrated here nor have any detrimental effects of the maneuver been measured.     

Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern.This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed.There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea.Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.     

Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis.

OBJECTIVE: To evaluate the speech intelligibility of patients with clefts before and after placement of a speech prosthesis. DESIGN: Cross-sectional. SETTING: Hospital for Rehabilitation of Craniofacial Anomalies, University of S?o Paulo (HRAC/USP), Bauru, Brazil. PATIENTS: Twenty-seven patients with unoperated cleft palate or operated cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatoplasty, treated with speech prosthesis, aged 8 to 63 years. INTERVENTIONS: Patients were fitted with palatopharyngeal obturators or pharyngeal bulbs, suitable to their dental needs. Five speech-language pathologists blindly evaluated speech samples of the patients with and without the prosthesis. MAIN OUTCOME MEASURES: Classification of speech samples according to a scoring system developed for speech intelligibility problems: 1 (normal), 2 (mild), 3 (mild to moderate), 4 (moderate), 5 (moderate to severe), and 6 (severe). Results were evaluated by the calculation of means of all judges for each patient in both situations. RESULTS: The judges presented significant agreement (W=.789, p<.01). Speech intelligibility was significantly better after placement of the prosthesis for both unoperated patients (Z=1.93, p=.02) and operated patients with VPI after primary palatoplasty (Z=1.78, p=.03). CONCLUSIONS: Speech intelligibility may be improved by rehabilitation of patients with cleft palate using a speech prosthesis. Speech therapy is needed to eliminate any compensatory articulation productions developed prior to prosthetic management.     

腭咽闭合功能生理参数的研究

目的 为区分腭裂术后生理性和病理性腭咽闭合不全，必须提出健康人群生理性ＶＰＩ－这一客观指标。     

腭裂修复术同期鼓室置管的疗效及并发症防治

目的　探讨腭裂伴渗出性中耳炎患儿的联合治疗。方法　比较38例(49侧耳)单纯性腭裂修复术与24 例(39侧耳)腭裂修复同期行鼓膜切开、PE管置入术对中耳积液的消除及听力的影响,并对置管术的适应证、操作要点、并发症的防治进行讨论。结果　腭裂修复同期鼓膜切开置管组术后6月48·7%的患耳中耳积液消失,明显高于单纯腭裂修复组。听力损害的患儿置管后听力平均提高17 dB。结论　有中耳积液的腭裂患儿在腭裂修复术同期行鼓室切开、PE管置入术,有助于改善患儿的中耳功能。     

AlloDerm revision for failed pharyngoplasty

Velopharyngeal insufficiency (VPI) occurs in more than 20% of patients with a cleft palate after primary palatoplasty. Surgical treatment focuses on pharyngoplasty to narrow the nasopharyngeal space and to decrease the distance needed for palatal closure. Persistent VPI after pharyngoplasty affects more than 20% of patients.From September 2007 to December 2009, 16 children (10 boys and 6 girls) with a mean age of 9.5 years (4-15 years) underwent surgical revision using an AlloDerm sling for persistent VPI after at least 1 previous failed pharyngoplasty. Ten children had previous sphincter pharyngoplasties, and 6 had previous pharyngeal flaps. Surgical technique involves creation of a submucosal tunnel through the limbs of the previous pharyngoplasty or pharyngeal flap. A strip of AlloDerm is threaded circumferentially, and the port is adjusted to the desired aperture.All patients underwent preoperative and postoperative analysis of VPI, including oral pharyngeal and perceptual speech examination by speech pathology with a mean follow-up of 441 days. Acoustic nasometry was used to objectively compare preoperative and postoperative nasalance values. A significant improvement in perceptual resonance was seen in 93.8% of patients, and 87.5% of patients improved to normal or mild resonance (P < 0.001). There was a significant mean reduction of nasalance using the MacKay-Kummer Simplified Nasometric Assessment Procedure test (P < 0.001). Two patients developed postoperative flap dehiscence, with one being revised ultimately to have normal speech resonance.Revision pharyngoplasty using an AlloDerm sling can safely and effectively improve speech in patients with persistent VPI after failed pharyngoplasty. Long-term follow-up studies are ongoing.     

The effect of early insertion of grommets on the development of speech in children with cleft palates

The aim of this study was to find out whether simultaneous primary palatoplasty and myringotomy was advantageous in the management of otitis media with effusion in children with cleft lip and palate and whether this combined operation resulted in improvement in the early development of speech. Assessments of hearing and speech were made in 50 consecutive patients with cleft lip and palate who had the combined operation (the cleft group). The results were compared with those of an age- and sex-matched control group. The incidence of otitis media with effusion in the cleft group was 24%, compared with 14% in the control group. Assessment of speech using the cleft audit protocol for speech showed that 90% of patients with clefts had speech-intelligibility ratings that were either normal or showed only minor defects, compared with 98% of controls. Among patients with clefts, there was no evidence of cleft-type characteristics of speech in 58%.     

Longitudinal follow-up of obstructive sleep apnea following Furlow palatoplasty in children with cleft palate: a preliminary report.

OBJECTIVE: To longitudinally investigate the incidence and severity of obstructive sleep apnea (OSA) following Furlow palatoplasty for velopharyngeal insufficiency (VPI) in children with cleft palate. SUBJECTS: Ten children, six boys and four girls, mean age 5.1 years, at Furlow palatoplasty. DESIGN: Prospective analysis. MAIN OUTCOME MEASURES: Overnight polysomnographic studies were used to determine the incidence and severity of sleep apneas 1 day prior to Furlow palatoplasty, 1 week postoperatively, and approximately 3 and 6 months postoperatively. RESULTS: None of the patients suffered OSA prior to Furlow palatoplasty. A high incidence of mild OSA (100%) occurred during the early postoperative period (p <.001) but resolved within 3 months in all but two patients (20%). Only one OSA (10%) persisted 6 months postoperatively. CONCLUSIONS: Furlow palatoplasty for VPI in children with cleft palate might induce temporary and mild OSA.     

行为疗法在语音治疗中的应用研究

目的 为提高语音障碍的治疗效果。应用行为疗法治疗腭咽闭合功能不全型（VPI）患者，方法 20例VPI患者，其中先天性腭咽闭合功能不全5例，咽成形术术后10例，腭成形术术后5例，男性10例，女性10例，年龄4.0-38.4岁，平均年龄17.8。采用行为疗法进行语音治疗，并在治疗前后定量检测汉语语音清晰度和吹气实验。结果 治疗效果满意，治疗后的汉语语音清晰度和吹气实验较治疗前有显著提高。结论 行为疗法是一种行之有效的语音治疗方法，但要注意严格掌握适应证和个体化应用。