腭裂修复术腭咽肌肉重建与否的鼻咽内窥镜的比较观察

目的通过是否进行腭咽肌肉重建的两组腭裂修复术后患者鼻咽内窥镜的比较观察,了解腭咽部肌肉重建术后腭咽闭合状况的改变。方法将41例腭裂术后患者,按照在腭裂修复时是否进行腭咽肌肉重建分为重建组(22例)和非重建组(19例),以鼻咽纤维内窥镜记录静态和发音时腭咽闭合运动状况,对两组患者腭咽闭合运动类型和状况进行比较。结果重建组静态腭咽腔形态较非重建组明显缩小,各壁光滑丰满,未见软腭鼻腔面V型缺损畸形;动态时以环状闭合为主。非重建组静态腭咽腔形态较大,可见软腭鼻腔面V型缺损畸形;动态时以冠状闭合为主。经比较重建组腭咽闭合良好率(90.91%)明显优于非重建组(37.31%)。结论鼻咽内窥镜观察证实腭咽肌肉重建腭裂修复术后腭咽闭合功能恢复明显优于非重建组。腭裂修复术时重建腭咽肌肉有助于缩小腭咽腔和更易于达到良好的腭咽闭合状态。     

腭咽部肌群重建腭裂修复术与改良兰氏腭裂修复术后软腭运动的比较观察

目的通过腭咽部肌肉重建腭裂修复术与改良兰氏腭裂修复术后患者的X线片比较,了解腭咽部肌肉重建对软腭运动功能恢复的作用。方法1988年10月~2000年10月,治疗腭裂及腭咽闭合不全患者62例。其中腭咽部肌肉重建腭裂修复术(A组)32例,年龄2~26岁;改良兰氏腭裂修复术(B组)30例,年龄4~23岁。采用鼻咽部钡造影X线侧位片检查方法摄取静止和发“i”音时的侧位片,进行X线片定点。测量指标包括:1腭咽闭合状态,2软腭运动长度,3软腭运动角度,4解剖提肌隆突点(levatoreminenceinanatomy,LEA)-腭咽闭合水平线(velopharyngealclosureline,VCL)距离,5LEA变化值,6LEA与运动提肌隆突点(levatoreminenceinphonation,LEP)值的比较,7LEA与LEP的差值,8后鼻棘点(posteriornasalspine,PNS)-软腭鼻腔侧连线(softpalateline,SPL)-LEA与PNS-SPL-LEP值。结果A、B组的腭咽闭合完全优良率状态分别为83.3%和53.3%(P<0.01);软腭运动长度:A组静止时和发“i”音时分别为36.77±4.23mm和39.57±5.80mm(P<0.05),B组静止和发“i”音时分别为36.70±5.81mm和39.15±6.89mm(P>0.05);软腭运动角度:A组为18.97±11.13°,B组为25.55±13.02°(P<0.05);LEA-VCL距离:静止时A组为-5.57±5.26mm,B组为-13.47±4.21mm(P<0.001);LEA变化值A组为7.63±5.29mm,B组为13.10±9.13mm(P<0.01);LEA与LEP值的比较:A组分别为21.79±3.18mm和20.33±4.29mm(P>0.05),B组分别为21.56±4.11mm和19.41±3.50mm(P>0.05);LEA和LEP的差值比较差异无统计学意义(P>0.05),组内比较A组(P>0.05),B组(P<0.01);PNS-SPL-LEA与PNS-SPL-LEP值:组间比较差异无统计学意义(P>0.05),组内比较A组(P>0.05),B组(P<0.05)。结论腭裂修复术时重建腭咽肌肉有助于软腭运动和腭咽闭合功能的恢复。软腭运动角度及软腭向上运动范围并不是构成理想腭咽闭合的主要因素,而腭咽部肌肉重建后的协调运动则更为重要。     

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。     

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。     

Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术修复大龄患者腭裂的临床研究

目的:探讨Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术修复大龄患者腭裂的临床疗效,并观察术后对腭咽功能及语音效果的影响。方法:选择2013年5月-2017年8月在口腔颌面外科就诊的58例大龄腭裂患者为研究对象。实验组:31例,男18例,女13例,年龄(15.3±6.4)岁,均在全麻下行Sommerlad腭帆提肌重建联合腭咽肌瓣咽成形术修复;对照组:27例,其中男16例,女11例,年龄(17.7±7.5)岁,全麻下行Sommerlad腭帆提肌重建术修复。术后随诊6～36个月,采用头颅侧位X线片及鼻咽纤维镜检测腭咽功能,主观语音评估鼻腔共鸣、鼻漏气、语音清晰度。结果:所有患者创口愈合良好,实验组20例获得腭咽闭合,腭咽闭合率61.3%;对照组7例获得腭咽闭合,腭咽闭合率24.4%,两者之间比较有统计学差异(P0.05)。实验组鼻腔共鸣、鼻漏气、语音清晰度症状改善程度优于对照组(P0.05)。结论:Sommerlad腭帆提肌重建术联合腭咽肌瓣咽成形术同期修复大龄腭裂可提高术后的腭咽功能,改善语音效果。     

三维立体概念和整形外科学原则在腭裂修复术中的应用

目的：提出腭裂修复手术方法中的三维立体概念和应遵循的整形外科学原则。方法：以兰氏手术和腭粘膜瓣后推手术修复的腭裂患者各取30例，进行回顾性分析，分析腭裂修复手术方法中的三维立体概念和应遵循的整形外科学原则。以侧位X线片和鼻咽内窥镜显示腭咽闭合情况，测量软腭的解剖学长度和生理性动度。结果：兰氏手术后患者24例腭咽闭合不全；腭粘膜瓣后推手术后患者只有1例腭咽闭合不全。结论：由于腭粘膜瓣后推手术修复腭裂符合三维立体概念并且遵循了整形外科举原则，因而手术后的效果优于兰氏手术。     

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。     

腭裂手术后腭咽闭合不全的再次手术治疗

目的　通过再次手术使腭裂修覆手术后腭咽闭合不全的患者达到完全的腭咽闭合 ,从而获得良好的语言功能。方法　采用腭粘膜瓣后推及去神经肌肉游离移植、腭咽环扎手术方法。手术前后应用腭咽侧位X片、高新语音频谱技术、录音对比等进行客观评价。结果　 78例应用兰氏手术方法修覆后的腭裂患者 ,再次手术后 ,均取得了良好的腭咽闭合 ,语言清晰。结论　腭裂手术后腭咽闭合不全的患者应用本方法通过再次手术治疗可以达到完全的腭咽闭合 ,从而获得良好的语言功能 ,具有推广应用价值。     

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     

磁共振成像对腭咽闭合不全的诊断和术前评估

目的探讨腭咽磁共振成像对腭咽闭合不全诊断及术前评估的可行性及准确性。方法2002年以来,通过对6例腭裂术后腭咽闭合不全患者进行正中矢状面、横断面和冠状面扫描,并与头颅侧位X线片及颅底位片对照,通过手术直视测量证实。结果腭裂术后腭咽闭合不全患者磁共振成像主要表现为咽腔深、软腭短、咽后壁及侧壁运动障碍等,可精确定量,结果准确,可重复性好,与临床表现及术中探察一致。结论磁共振成像易操作、无创且可精确定量、可重复,可对腭咽闭合不全患者进行有效的术前评估,对其诊断及手术方案的选择有重要指导作用。     

A modified procedure for velopharyngeal sphincteroplasty in primary cleft palate repair and secondary velopharyngeal incompetence treatment and its preliminary results.

During cleft repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve the surgical treatment for cleft palate and secondary velopharyngeal incompetence (VPI), a carefully designed modified procedure for primary palatoplasty and secondary VPI was presented. Fifty-six patients (48 for primary cleft palate repair and eight for secondary VPI of previously repaired clefts) underwent this procedure from 1988 to 2001. The modified procedure is a combination of the tunnelled palatopharyngeus myomucosal flap for dynamic circular reconstruction of the pharyngeal element of the velopharyngeal sphincter and the double-reversing Z-plasty with levator velo palatini muscles reposition in the velar element of the sphincter. The satisfactory velopharyngeal competence (complete velopharyngeal closure and marginal velopharyngeal closure) was achieved in 23 of 25 patients with primary cleft palate repair examined by nasendoscopy and the nasality, speech articulation and intelligibility are also assessed in 25 primary cleft palate repaired patients with 92% satisfactory result (normal speech and speech with mild VPI) in single word test and 88% in continuous speech evaluation. Based on our experience, we believe that this modified procedure is a reasonable choice for primary cleft repair and secondary VPI treatment because it is in accord with normal physiology and anatomy of the velopharyngeal sphincter, can lengthen the soft palate, decrease the enlarged velopharynx, augment the posterior pharyngeal wall, and enhance the relationship between the muscles of velopharyngeal sphincter which results in a dynamic neo-sphincter in palatopharyngoplasty. Further study of the procedure is needed. The theoretical basis, operative highlights, velopharyngeal function, advantages and disadvantages of the modified procedure were discussed.     

Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy

INTRODUCTION: The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure. PATIENTS AND METHODS: A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure. RESULTS: All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04). CONCLUSIONS: Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.     

兰氏和双反Z法腭裂修复术后患儿语音清晰度对比

目的比较兰氏和双反Z法腭裂修复术后患儿的语音清晰度,寻找重建腭咽闭合的最佳手术方法。方法选取2009年至2013年在我院口腔颌面外科就诊的先天性软腭裂患儿69例,其中行双反Z法腭裂修复术35例(双反Z法组),行兰氏法腭裂修复术34例(兰氏法组)。患儿3.5岁后随访,由3名语音师进行单盲性审听,比较两组患儿术后语音清晰度。结果语音测评结果显示,双反Z法组患儿术后患者语音清晰度平均达到88.72%±6.05%,明显高于兰氏法组的71.31%±3.46%,语音改善明显。结论双反Z法能够充分缩小咽腔、延长软腭,重建软腭肌肉结构,更有利于恢复良好的腭咽闭合功能。     

Evaluation of velopharyngeal insufficiency with magnetic resonance imaging and nasoendoscopy

Several radiological methods have been utilized to assess velopharyngeal function. The more recent imaging technique, magnetic resonance imaging (MRI), which has a number of advantages over radiographic and computed tomographic imaging, has been used rarely for evaluating velopharyngeal insufficiency. In this study, 5 normal volunteers and 10 patients with surgically repaired cleft palate were examined with MRI using midsagittal, coronal, and axial images. Nasoendoscopy was also performed to complete and confirm the diagnoses. Complete and tight closure of the velopharynx and full backward and upward movement of the soft palate was observed in volunteers. In coronal images, medial movement of lateral pharyngeal walls could also be seen. Despite this, patients with surgically repaired cleft palate had some degree of motion of the soft palate, ranging from no movement to maximal movement. In most of the patients, short soft palates with restricted motion was seen. MRI visualizes the velopharyngeal sphincter in all planes and provides high-resolution images of the soft tissues. Objective measurements can be made as well. In this study, MRI and nasoendoscopy were used together in the diagnosis of velopharyngeal insufficiency and gave satisfactory results.     

Cleft palate speech and velopharyngeal insufficiency: surgical approach

Velopharyngeal insufficiency is the main morbidity associated with clefting of the secondary palate. Therefore, it is important to monitor speech production in all children with a history of cleft palate. Diagnosis and management of velopharyngeal insufficiency is an important function of the cleft palate team. The surgical approach used in the Craniofacial Center at Children's Hospital and Regional Medical Center, Seattle, Washington, USA is presented. Assessment of velopharyngeal function, as it relates to surgical intervention and measurement of outcome, is reviewed. Surgical management using Furlow palatoplasty and sphincter pharyngoplasty is discussed.     

Teleradiographic analysis of velopharyngeal insufficiency in CATCH 22 association

The CATCH 22 association (Cardiac defect, Abnormal facies, Thymic hypoplasia, Cleft palate, Hypocalcemia) combines certain signs common to various syndromes (Di-George syndrome, velocardiofacial syndrome, etc.) in combination with a 22q11 chromosomal microdeletion. Velopharyngeal insufficiency can be a complementary sign, or even a presenting sign of this chromosomal anomaly. After clinical examination of these patients, velopharyngeal insufficiency appeared to be due to a deep nasopharynx rather than to a short soft palate. We therefore reviewed 11 patients with teleradiography. We studied the length of the soft palate, the depth of the nasopharynx, the ratio of the depth of the nasopharynx over the length of the soft palate, and we compared our results with those observed in reference populations. The results demonstrate nasopharyngeal disproportion with a normal length of the soft palate and increased depth of the nasopharynx. This anatomical finding therefore encourages us to propose sphincteroplasty rather than velopharyngoplasty.