咽后壁瓣术后蒂端局部组织血管重建的实验研究

目的　探讨上、下蒂型咽后壁瓣术后蒂端咽后壁组织血管重建的一般规律。方法　将 1 0条杂种犬随机分为 2组 ,每组 5条 ,分别作上、下蒂型咽后壁瓣手术 ,并分别于术后即刻、3、7、30、90d处死 ,另 1条犬作正常对照 ,直接处死 ,用血管造影X线片研究咽后壁血管重建情况。结果　正常犬咽后壁的主干血管呈横行或斜行于咽缩肌筋膜下 ,通过肌肉穿支在同侧和对侧间相互吻合成网。上蒂型咽后壁瓣术后蒂端咽后壁组织血管重建主要发生在瓣蒂上方的咽后壁组织内 ,血管呈横向走行 ,自瓣蒂上方分支进入瓣内 ,构成瓣的纵行血管网 ,供瓣区没有血管进入瓣内。下蒂型咽后壁瓣术后蒂端咽后壁组织血管重建主要发生在瓣蒂下方的咽后壁组织内 ,其正中血管逐步纵行化 ,自瓣蒂下方进入瓣内 ,构成瓣蒂端的纵行血管网。结论　上、下蒂型咽后壁瓣术后蒂端咽后壁组织内血管分别呈横行和纵行改建     

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。     

鼻咽后推用于治疗腭咽闭合不全

按通常的方法作腭裂修补术时,软腭后推常受到鼻咽侧壁组织的牵制。为了增加软腭后推量,作者建议作鼻咽后推,此法结合Cronin鼻粘膜瓣或当需要最大限度后推时,结合蒂在上方的咽瓣使用。此法比单纯把软     

改良的软腭咽成形术修复软腭大面积缺损

腭成形术后有些患者功能效果不满意,主要是术后缺损范围大,有的用带蒂皮瓣修复,其缺点是手术次数多,转移的组织过厚,遗留颈部畸形。采用咽后壁粘膜肌肉瓣治疗腭成形术后软腭缺损较小的腭咽闭合功能不全,有一定效果。但软腭缺损范围较大,采用通常的     

软腭缺损的即刻修复

临床资料 :本组 5例 ,男 3例 ,女 2例 ,年龄在 2 3～ 6 7岁。腺样囊性癌 2例 ,软腭部鳞癌 2例 ,腺泡细胞癌 1例。 5例均采用带腭大神经血管束的粘骨膜瓣加咽后瓣修复。全部成活 ,效果满意。　　手术方法 :软腭部恶性肿瘤 ,局部扩大切除 ,同时行根治性颈淋巴结清扫术。根据缺损大小 ,分别制备带腭大神经血管束和蒂在上的咽后壁组织瓣。关闭创面 ,将设计好的咽后壁瓣沿鼻腔侧切缘对位缝合 ,作为软腭衬里 ,再将制备好的粘骨膜瓣旋转 180°移植到该创面上 ,形成口腔面。　　讨论　软腭肿瘤切除术后往往造成软腭缺损 ,导致语音功能障碍。使患者在…     

电子纤维鼻咽喉镜对腭咽环扎术疗效的评价

目的 应用电子纤维鼻咽喉镜观察腭咽环扎术后患者腭咽闭合功能，评价该手术的远期疗效。方法 选择腭咽环扎术后16年的腭裂患者23例，用电子纤维鼻咽喉镜观察患者在吞咽和发音时的咽侧壁、咽后壁、软腭的运动情况。结果 电子纤维鼻咽喉镜系统直接观察到发音时咽侧壁的运动及软腭的上、下、前、后运动，软腭与咽后壁的关系，软腭长度及在矢状面上提升的高度。结论 腭咽环扎术能有效地改善腭咽闭合功能；电子纤维鼻咽喉镜可直接观察到腭咽部的运动情况，是评价术后腭咽闭合功能的有效方法。     

咽后壁组织瓣转移术治疗先天性腭咽闭合功能不全的初步研究

目的　初步研究咽后壁组织瓣转移手术治疗先天性腭咽闭合功能不全(CVPI)的疗效。方法　选择29例 CVPI患者施行蒂在上的咽后壁组织瓣转移术,手术前后由专业的语音病理师审听语音清晰度,同时行吹水泡试验, 比较手术前后语音清晰度、异常语音和吹水泡试验的变化,并与20例正常语音者进行比较。结果　29例CVPI患 者的语音清晰度均值从术前的33·86%改善到术后的43·19%,吹水泡试验从术前的4·60 s提高至术后的17·72 s, 经配对t检验,二者均有统计学差异(P<0·01),但患者术后的语音清晰度仍与正常者有较大差距。结论　咽后壁 组织瓣转移术可有效改善CVPI患者的腭咽闭合状况,减少鼻漏气,增加口腔内压,是治疗中极为重要的一步。     

带蒂扁桃体复合组织瓣治疗腭裂术后腭咽关闭不全

目的：探讨腭裂术后腭咽关闭不全的再手术治疗方法。方法：12例腭裂术后腭咽关闭不全患者，手术从下极将腭咽弓黏膜肌肉与扁桃体一同翻起，形成一个蒂在上方的带腭咽肌的复合组织瓣，保留扁桃体上1／3作蒂．将扁桃体复合瓣向后上旋转，在软腭平面缝合于咽后壁创面，两侧腭咽肌在中线拉拢缝合，扁桃体之间留小缝隙。结果：所有病例术后次日开放性鼻音消失．但均有不同程度睡眠打鼾。术后1～1．5年复查．11例患者发音功能基本同正常人，1例患者仍有开放鼻音，扁桃体均部分萎缩，两侧扁桃体之间间隙5～10mm，其中3例扁桃体部分下垂。有6例患者仍有轻度睡眠打鼾现象。结论：蒂在上方扁桃体复合组织瓣治疗腭裂术后腭咽关闭不全，术后发音功能改善明显．是一种有效的治疗方法．     

咽扩约肌成形术治疗腭裂临床效果评价

我科从 1993 0 1～ 1999 12采用咽扩约肌成形术治疗腭裂46例 ,经随访观察效果良好 ,现报告如下 :1　临床资料咽扩约肌成形术 (咽腭肌瓣 ) 46例中 ,男 2 8例 ,女 18例。一期手术 3 4例 ,二期手术 12例。年龄 6岁以下者 10例 ,7岁以上者 3 6例 ,最小年龄 4岁 ,最大 2 0岁。其中软腭裂 9例 ,单侧完全性腭裂 15例 ,双侧完全性腭裂 10例 ,腭咽闭合不全 12例。全部病例均在经口插管全麻下进行。2　手术方法2 .1　设计利用双侧咽腭弓的粘膜和咽腭肌组织形成蒂在上 (软腭部 )粘膜肌瓣 ,与咽后壁瓣联合 ,使咽后壁突起成嵴 ,并与软腭协调运动产生扩约…     

改良咽后壁组织转移瓣在VPI患者的临床应用和研究

目的：客观评价改良咽后壁组织转移瓣效果。方法：对30例行改良咽成形术者术前、术后的吹气试验，汉语语音清晰度以及过度度鼻音进行了定量分析。结果：改良咽后壁组织转移瓣术后的吹气试验，汉语语音清晰度以及过度鼻音有了明显的改善。结论：改良咽后壁组织转移瓣能有效地改善VPI患者的腭咽闭合功能。     

A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results

The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12-58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.     

咽后壁瓣断蒂对腭咽闭合影响的探讨

目的 探讨咽后壁瓣成形术后腭咽闭合功能不全(velopharyngeal insufficiency,VPI)及其并发症阻塞性睡眠呼吸暂停低通气综合征(OSAHS)治疗中咽后壁瓣断蒂的作用.方法 1993至2008年于北京大学口腔医学院·口腔医院唇腭裂治疗中心接受咽后壁瓣断蒂术患者20例(不完全腭裂11例、完全性唇腭裂9例),20例断蒂术前均行鼻咽纤维镜、头颅定位侧位X线片检查及语音录音,对有OSAHS主述者行睡眠呼吸监测.全部患者术后48 h后进行语音评价.术中单纯断蒂14例,断蒂后重新改变咽成形术式6例.结果 ①14例成形术后语音改善不明显,仍存在过高鼻音,咽后壁瓣断蒂术后语音改善明显;②3例成形术后虽发音正常但出现呼吸道阻塞症状,断蒂术后呼吸睡眠状况改善,语音仍正常;③3例成形术后发音正常,因正颌手术的麻醉需要断蒂,断蒂后的语音无明显改变.结论 咽后壁瓣成形术后出现OSAHS或仍存在VPI,需手术断蒂或其他类型咽成形术治疗;断蒂的时间应在咽后壁瓣成形术半年后.     

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.     

Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art.

Surgical management of velopharyngeal insufficiency by attachment of posterior pharyngeal flap or construction of sphincter pharyngoplasty is reviewed. Posterior pharyngeal flap surgery is well established, with a long history dating back to the 19th century. Flaps have been based superiorly, inferiorly, or laterally. There have been reports of airway obstruction and obstructive sleep apnea associated with posterior pharyngeal flap surgery. The concept of surgical creation of a dynamic sphincter pharyngoplasty to provide velopharyngeal closure was first introduced by Hynes in 1950. Hynes and others have proposed several subsequent anatomic modifications. Airway dysfunction has also been reported following sphincter pharyngoplasty, but may not be as frequent or severe as with posterior pharyngeal flap. While several studies have compared posterior pharyngeal flap and sphincter pharyngoplasty in terms of speech outcome or complications, there is not, as yet, a consensus regarding the specific choice of one versus the other for surgical management of velopharyngeal insufficiency.     

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.     

不同咽成形术式对腭裂术后继发腭咽闭合功能不全合并睡眠呼吸障碍的影响

目前国际上治疗腭裂继发腭咽闭合不全的常用术式包括咽后壁瓣成形术、腭咽肌瓣成形术和Furlow瓣(双反向Z形瓣).多导睡眠监测(polysomnography,PSG)结合主诉症状表明,部分腭裂术后腭咽闭合不全患者在接受咽成形术后会出现不同程度的阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apne...     

Comparison of Hogan pharyngeal flap and sphincter pharyngoplasty in postoperative velopharyngeal function

The purpose of this study was to compare speech and breathing after sphincter pharyngoplasty and the Hogan pharyngeal flap in the management of cleft-related velopharyngeal insufficiency (VPI). We reviewed 78 patients with VPI who had either the Hogan flap (n = 30) or sphincter pharyngoplasty (n = 48) between 2009 and 2011. Velopharyngeal function, nasal patency, and speech were compared. In the Hogan flap group, 25 patients had achieved velopharyngeal competence and nine had normal speech. In the sphincter pharyngoplasty group, 29 patients achieved velopharyngeal competence and 20 normal speech. The Hogan flap group had a higher rate of velopharyngeal competence (n = 25) than the sphincter pharyngoplasty group (p = 0.033), but there was no significant difference in intelligibility of speech. Eighteen patients in the Hogan flap group and 33 in the sphincter pharyngoplasty group reported symptoms of snoring, with no significant difference in nasal ventilation. Our results suggest that a posterior pharyngeal flap is a more effective technique for managing VPI after repair of cleft palate than sphincter pharyngoplasty, and causes no more postoperative complications in nasal breathing.     

A case of maxillary duplication with a soft palate reconstruction using a forearm flap

Maxillary duplication is a rare congenital anomaly that occurs in the jaw/mouth area. It is generally regarded as sporadic in nature. Total or subtotal soft palate reconstruction for oropharyngeal defects, which include post-surgical and congenital defects, presents a difficult surgical challenge. A maxillary duplication in which the soft palate is reconstructed using a vascularized forearm flap is described. The velopharyngeal insufficiency in the present case is caused by the almost complete deficiency of the soft palate, suggesting that a conventional pharyngeal flap operation with localized mucosal myocutaneous flaps would not produce favorable results in terms of postoperative contractions in the pharyngeal flaps. In such cases, the reconstruction of the soft palate using vascularized free forearm flaps, guided by flexibility regarding the size and adequate thickness of the flaps, may be useful.     

应用CT检测术后咽后壁瓣瓣宽收缩率

目的：应用CT检测术后咽后壁瓣瓣宽的收缩率。方法：20例腭裂术后腭咽闭合功能不全患者行改良咽后壁瓣转移修复术，术前测量瓣宽，术后6～12个月应用CT及其Aw4．1重建软件测量瓣宽，计算瓣宽的收缩率。采用SPSS11．0软件包对数据进行配对t检验。结果：20例患者术后咽后壁瓣整体瓣宽的收缩率为36．7％～67．2％．平均52.3％；前段瓣宽的收缩率为29．2％～62.3％，平均44.4％；中段瓣宽的收缩率为47．5％～72．5％．平均62．7％；后段瓣宽的收缩率为29．2％-64．2％，平均45．9％。前后两段瓣宽的收缩率小于中段瓣宽的收缩率（P〈0．01）。结论：应用CT及其重建软件能精确测量咽后壁瓣的瓣宽，并计算瓣宽术后的收缩率，可以辅助术前咽后壁瓣的设计，提高手术疗效，弥补了其他检测方法的不足。     

CT辅助咽后壁瓣手术设计

目的 建立CT辅助设计咽后壁瓣的方法,以提高治疗效果。方法 应用CT测量26例腭咽闭合不全者在静止和发“i”时腭咽腔的宽度和长度,观察分析咽后壁瓣成形术所需的宽度、长度和咽后壁瓣蒂的位置和与软腭的附着位置。结果 静止时腭咽腔的宽度15.10-37.25mm,平均27.01mm,长度12.54-30.39mm,平均22.10mm;发“i”时腭咽腔的宽度为9.11-34.06mm,平均17.69mm;咽后壁瓣蒂的位置都在第一颈椎平面或以上;与软腭的附着位置大部分在软腭的中后1/3处。结论 CT作为一种定量评价腭咽闭合功能的方法,能够辅助设计咽后壁瓣手术方法。