【作者】 白文忠；

【导师】 孙建军； 孔维佳；

【作者基本信息】 华中科技大学 ， 耳鼻咽喉头颈外科， 2009， 博士

【摘要】 目的在软腭解剖学的基础上，建立腭帆成形术手术(VPP)模型，并收集OSAHS患者手术前、后腭咽腔形态学变化，总结其技术特点。通过术中腭咽腔测量及系统的腭咽腔CT测量，探讨其手术机理。方法30例经PSG确诊OSAHS患者施行腭帆成形术，进行术中腭咽腔测量，测量项目包括：软腭长度、悬雍垂长度及基部宽度、咽侧间距(腭扁桃体间距)。随机对10例患者进行系统的腭咽CT测量，测量时间为术前、术后3个月、术后6个月；测量方法为：患者在清醒状态下进行平静呼吸时的上气道CT扫描，范围自听眶线至声门。利用CT工作站进行三维重建和测量。CT扫描时患者取仰卧位，牙齿处于正中颌的接触位上。扫描过程中保持头部和身体静止，勿吞咽；测量指标：包括软腭长度、软腭最大厚度、悬雍垂长度及基部宽度、咽侧间距(腭扁桃体间距)、咽后壁厚度、软腭游离缘至咽喉壁间距、腭咽截面积、咽峡截面积。所有患者随访6-12个月，详细询问术后反应，填写ESS表，测量并记录颈围及BMI，口咽拍照，CT扫描；进行PSG复查，按照2002杭州标准进行疗效评定，总结VPP近期疗效，对其手术机理、疗效影响因素进行统计学分析。结果30例OSAHS患者均顺利完成手术，术后可出现短暂的腭咽关闭不全，持续时间为1-2周；出现短暂的急性咽喉痛，持续时间为1-2周；8例患者出现咽部异物感。继发性出血2例，1例为软腭游离缘，1例为扁桃体下极，经电凝止血痊愈。无咽腔瘢痕狭窄、开放性鼻音、误咽等并发症。30例OSAHS患者术中腭咽测量各项指标(软腭长度、悬雍垂长度及基部宽度、咽侧间距(腭扁桃体间距))手术前后均有统计学差异；10例OSAHS患者通过系统的腭咽CT测量，发现口咽形态学改变主要体现在术前和术后12周，各项指标(软腭长、软腭最大厚度、咽侧间距(扁桃体间距)、悬雍垂长度及基部宽度、软腭游离缘至咽喉壁间距、腭咽截面积、咽峡截面积)均有统计学差异；咽后壁厚度无统计学差异。AHI由术前54.6±18.3降至术后25.3±9.5，ESS评分由术前16.5±4.8降至术后5.2±4.1近期有效率为70.0％。结论VPP技术通过切口设计、腭咽弓、扁桃体切除及咽侧粘膜切除与缝合处理，实现腭咽腔软组织的重塑，有效的解除了腭咽腔的阻塞。此术式可达到明显提升腭帆、前移悬雍垂与软腭游离缘、扩大口咽气道的目的；是一种有实用价值的上气道外科技术。更多还原

【Abstract】 Obojective Based on the homologic anatomy study of soft palate, establishthe model of velopharyngoplasty(VPP), and collect OSAHS patientspreoperation and postoperation pharynx morphological changes, summing upits technical characteristics; explore the mechanism of VPP mechnism by themeasurement of velopharyngeal cavity during operation and that of system CTmeasurement.Methods 30 OSAHS patients diagnosed by PSG were included in this study,all cases had velopharyngoplasty(VPP).All had measured the velopharyngealcavity including: length of the soft palate, uvula length and width of the base,parapharyngeal space (distance between the tonsils).10 cases of patients hadthe measurement of velopharyngeal CT, with the time for patients beforeoperation, after the operation of three and six months; measurement methodas follows: patients were in awake quiet breathing, the scope of the upperairway CT scan from the orbital line to the glottis, further using CTworkstation to three-dimensional reconstruct and measure.During CT scan,patients were in supine position, and the teeth in the middle of the contactposition on the jaw; and maintain a static head and body during the scanningprocess, did not swallow; measurement parameters including: soft palatelength, maximum thickness of the soft palate, pharynx lateral spacing (distance between the tonsils), uvula length and base width of the free edge ofsoft palate to the throat wall spacing, velopharyngeal cross-sectional area,angina cross-sectional area,thickness of retropharyngeal wall.All the patientshad follow up for 6-11 months, filled out the ESS table, measuring the neckcircumference and BMI, oropharyngeal photographs, CT scans; for PSGreview, in accordance with the 2002 standards for efficacy assessment ofHangzhou, summarized VPP efficacy, its surgerical mechanism and theimpact of factors.Results 30 cases of OSAHS patients had successful VPP, all with short-termpostoperative velopharyngeal insufficiency, duration of 1 -5 weeks; allshort-term acute throat pain, duration of 1-4 weeks; 8 patients pharyngealforeign body sensation, considered 3 cases complicating with hypopharyngealreflux disease, five cases with unexplained reasons by specialist examination;2 patients had secondary hemorrhage, 1 case for the free edge of soft palate, 1case of tonsil pole cured by electrocoagulation, no pharyngeal scar narrow,open nasal, complications such as aspiration.30 cases had a significantdifference before and after surgery in the measurement ofvelopharyngeal,incluing: soft palate length, base of uvula length and width oflateral pharyngeal space (tonsil spacing); 10 cases had found that themorphological changes of oropharyngeal had a significant difference mainly in preoperative and postoperative 12 weeks, all the measurement ofvelopharyngeal, incluing: soft palate length, maximum thickness of the softpalate, pharynx lateral spacing (distance between the tonsils), uvula length andbase width of the free edge of soft palate to distance between the throat wall,velopharyngeal cross-sectional area,and angina cross-sectional area;however,there was no significant difference in retropharyngeal wall thickness.Apnea and hypopnea index(AHI)were decreased from 54.6±18.3preoperatively to 25.3±9.5 postoperatively, ESS score from 16.5±4.8preoperatively to 5.2±4.1 postoperatively.The recent rate of VPP was70.0%.Conclusion Velopharyngoplasty(VPP) remodeled palatopharyngeal districtand relieved the obstruction of palatal pharyngeal through the designing ofincision,the management of pharyngopalatine arch, tonsillectomy and thesuture of laterapharynx mucisae.This surgerical procedure could obviouslyupgrade the velum palatinum,enlarge the oropharynx airway effectively,andwas a parctical upper airway surgical technique.更多还原