环状软骨上喉部分切除环舌根会厌吻合术保留一侧杓状软骨手术方法及发声的观察

目的：探讨环状软骨上喉部分切除环舌根会厌吻合术中保留一侧杓状软骨的手术方法及在改善患者术后发声的作用。方法：26例双声带受累的声门型喉癌（T1b、T2和T3分别为11、12和3例）病变重侧均行半喉全部切除，病变轻侧声带受累未超过膜部的2／3，离杓状软骨的声带突尚有3mm的安全界，在保留杓状软骨的同时保留该侧甲状软骨板后下1／3，以防喉返神经损伤，从而确保杓状软骨的正常运动。上提修复后的残喉体与舌根、会厌吻合，重建新喉。结果：全部病例术后7～23d内恢复正常饮食。25例拔除气管套管，拔管率为96．2％（25／26）。全部病例恢复了发声功能，术后有不同程度的声嘶，18例发声时有响声，能胜任室内言语交流，言语可被清楚理解；8例发声时响度较低，1m内近距离言语交流无障碍，在安静环境下言语可被清楚理解。术后无咽瘘和肺部并发症，2例局部感染者7d内治愈。术后局部复发率为3．8％（1／26），颈部淋巴结转移率为3．8％（1／26）。用直接法计算生存率，术后满3年者17例，死亡1例、失访1例，3年生存率为88．2％（15／17）；术后满5年者10例，死亡2例，5年生存率为80．0％（8／10）。结论：经过选择的双声带受累病例，保留一侧杓状软骨有助于改善患者术后发声质量。杓状软骨主动的前内方向运动和会厌的相向运动可能是发声质量得以改善的原因。

Study of reserving unilateral arytenoid cartilage to improve voice quality in supracricoid partial laryngectomy with anastomosis of cricoid cartilage, base of tongue and epiglottis

Objective:To study the surgical technique of reserving unilateral arytenoid cartilage and the effects on improving voice quality in supracricoid partial laryngectomy with anastomosis of cricoid cartilage,base of tongue and epiglottis.Method:Twenty -six glottic carcinomas (T_ 1b 11 cases,T_2 12 cases,T_3 3 cases ) were summarized from Jan. 1995 to Oct. 2003. Both vocal cords were affected. On arytenoid reserved side, invasion of vocal cord was below 2/3 and there was 3 mm safety distance to vocal process; also posto-inferior 1/3 part of thyroid cartilage was preserved to prevent injury of laryngeal recurrent nerve and assure normal motion of arytenoid cartilage.On non- reserved side, the half larynx was excised completely. Anastomosis of cricoid cartilage,base of tonge and epiglottis was used to reconstruct laryngeal function.Result:All cases restored their normal swallow during postoperative 7 to 23 days.Twenty-five cases were decannulated and the decannulation rate was 96.1%(25/26).All cases restored phonation. Different degree of hoarseness existed. In 18 cases the loudness of voice made them be competent for indoor communication and the speech could be easily understood; in 8 cases the loudness of voice made them be able to communicate within 1 meter distance and the speech could be understood under quiet circumstance.There were no pharyngeal fistula and pulmonary complications. Local infection was found in 2 cases and cured in 7 days. Local recurrence and cervical lymph node metastasis rate were 3.8%(1/26),3.8%(1/26) respectively. Lost patients were assumed to death and direct method was used to calculate survival rate. In 17 patients postoperative period was above 3 years, 1 died in 3 years and 1 was lost. 3-year survival rate was 88.2%(15/17). In 10 patients postoperative period was above 5 years and 2 died in 5 years. 5-year survival rate was 80.0%(8/10).Conclusion:In selected cases with invasion of both vocal cords, unilateral arytenoid cartilage can be reserved and it will be helpful to improve voice quality. The active motion of arytenoid cartilage toward antero-median position and the corresponding motion of epiglottis maybe the reason to improve voice quality.