【作者】 柴灵莺；

【导师】 蒋家琪； 魏春生；

【作者基本信息】 复旦大学 ， 耳鼻咽喉科学， 2010， 博士

【摘要】 吸烟引起呼吸道疾病发生率增高,导致喉部的各类疾病例如喉部慢性炎症,返流性喉炎,任克氏间隙水肿,从而引起各种嗓音疾病。目前已经有研究对吸烟引起的嗓音基频下降进行了报道,空气动力学方面研究发现最长发声时间下降,但对于吸烟相关嗓音分析的综合性研究较少。非线性动力学研究克服了传统嗓音研究的缺点,目前已经用于大量的病理性及非病理的嗓音样本中,但是吸烟相关嗓音的非线性动力学分析仍然是空白。本文拟对吸烟者及非吸烟者的嗓音进行全面的微扰分析、非线性动力学分析以及空气动力学分析。在此基础上,定量探索吸烟对于喉功能引起的损害的性质,以期建立无创性评估吸烟者嗓音及声带受损程度的检查方法,从而对无症状吸烟者进行宣教,促进无烟运动。一、成年男性吸烟者的嗓音微扰分析及非线性动力学分析目标：吸烟导致嗓音变化,若使吸烟者及时察觉嗓音异常改变,可鼓励其进行戒烟。嗓音变化通常是声带病理改变的首发表现。对嗓音的评估研究主要集中在传统的嗓音分析,然而,非线性动力学分析方法已经被证明是客观可靠的评估嗓音的方法。我们将这两种方法一起用于分析正常者及吸烟者的嗓音。方法：本项目为前瞻性研究。共包括73名研究对象,36名非吸烟者及37名吸烟者。每个研究对象录制一段持续的元音发声。数据使用了嗓音分析及关联维数分析。结果用Mann-Whitney秩和检验,回归分析及受试者工作特征(Receiver Operating Characteristics, ROC)对各项研究结果进行分析。结果：吸烟组的D2值明显要比非吸烟组高(p<0.001),频率微扰和振幅微扰分析的参数在抽烟组中较高。逻辑回归分析提示关联维数(Correlation Dimension, D2)有较高的预测能力,ROC分析两种方法未发现有显著性差异。讨论：本研究提示关联维数对于吸烟相关的变化是非常敏感的,临床上可以提示嗓音异常。进一步研究可以集中于用非线性动力学分析方法创建正常嗓音数据库,建立标准阈值,监控吸烟所致的嗓音变化。二、成年男性吸烟者的空气动力学分析目标:空气动力学反映的是喉作为传感器将声门下空气动力能转换为声能时的一系列参数。最小发声气流(Phonation Threshold Flow, PTF)作为发声所需最小气流,对于喉部组织、声门结构的微小变化较敏感。我们将比较男性吸烟者与非吸烟者的一系列空气动力学参数,包括PTF、平均气流(Mean Flow Rate, MFR)等,以研究吸烟引起的喉部结构改变。方法：本项目为前瞻性研究。共包括73名研究对象,36名非吸烟者及37名吸烟者。每个研究对象分别进行空气动力学测量。结果用Mann-Whitney秩和检验进行分析。结果：可见吸烟组的声门下压(Subglottal Pressure, SGP)平均均值高于非吸烟组,吸烟组的PTF以及MFR均值低于非吸烟组,但是无统计学意义(p>0.05)。讨论：影响空气动力学结果的因素较多,PTF作为新的空气动力学参数,运用于临床还需要进一步的完善操作规范和技术。进一步研究可以集中于将空气动力学与临床的声学、影像学等结合,以达到全面定量诊断吸烟对于喉功能的影响的作用。更多还原

【Abstract】 Cigarette smoking is a major disposing factor for an assortment of potentially fatal respiratory ailments. Chronic use of cigarettes often leads to laryngeal problems, such as chronic inflammation, laryngeal reflux, and all kinds of voice disorders. Previous research reported a lower fundamental frequency among smokers’ voice. Aerodynamic studies reveal shorter maximum phonation times. However, no systematic voice analysis for smokers has yet been carried out. Nonlinear dynamic analysis is capable of analyzing voice samples that are not suitable for perturbation analysis and has been applied to both pathological and nonpathological voice samples. Nonlinear dynamic analysis has not been previously applied to voices of smokers. In this study, we try to quantify the effects of smoking on voice with systematic perturbation analysis, nonlinear dynamic analysis and aerodynamic analysis. Next, we try to establish a noninvasive system to estimate smokers’voice and laryngeal health, as to educate on no chief complaint smokers and to propaganda nonsmoking movement.Part one:Perturbation and nonlinear dynamic analysis of adult male smokers Objective:Smoking results in a voice change and the perception by smokers of an abnormal voice may encourage quitting behavior. Moreover, a disordered voice is often the first sign of vocal pathology. Efforts to evaluate voice have focused on classical acoustic analysis; however, nonlinear dynamic analysis has been shown to be a reliable objective method for the evaluation of voice. We compare the discriminatory ability of these two methods applied to normal and smokers’voices. Study Design:Prospective study. Methods:The study included 73 subjects,36 nonsmokers and 37 smokers. A segment of sustain vowel production was obtained from each subject. Acoustic and correlation dimension (D2) analysis was applied to the data. Results were compared with a Mann Whitney rank sum test, regression and ROC analysis. Results:D2 values for smokers were significantly higher than for nonsmokers (p<0.001). Jitter and shimmer analysis showed higher values for these parameters among smokers. Logistic regression indicated a higher predictive power with D2 and ROC analysis found no significant difference between the analysis methods. Discussion:This study indicated that correlation dimension is highly sensitive to changes associated with smoking and has the potential to be implemented clinically as an indicator of abnormal voice. Further research could focus on using nonlinear dynamic analysis to create a normative database, producing standards for monitoring voice changes caused by cigarette smoking.Part two:Aerodynamic analysis of adult male smokers Objective:Larynx is an energy transducer that transfers subglottal aerodynamic energy into acoustic energy. Aerodynamic analysis includes a serie of parameters that reveal the laryngeal function. As the minimum airflow required to initiate phonation, PTF is sensitive to subtle changes in laryngeal tissue properties, glottal configuration, and vocal tract loading. We compare the discriminatory ability of the aerodynamic parameters applied to normal and smokers’voices to find out the changes of glottal structure, including PTF and MFR. Study Design:Prospective study. Methods:The study included 73 subjects,36 nonsmokers and 37 smokers. Each subject was measured aerodynamic analysis. Results were compared with a Mann Whitney rank sum test. Results:Mean SGP values for smokers were higher than for nonsmokers, mean PTF and MFR values for smokers were lower than for nonsmokers, but without significant difference (p>0.05). Discussion:Aerodynamic results are influenced by many factors. As a new parameter, PTF requires further technique improvement in order to be applied in the clinic. Further research could focus on combining aerodynamic measurements, acoustic analysis and clinical rigid scope examinations in order to quantitatively diagnose the effects of smoking on larynx.更多还原