【作者】 王荣国；

【导师】 胡俊兰； 赵瑞力；

【作者基本信息】 河北医科大学 ， 耳鼻咽喉科学， 2004， 硕士

【摘要】 目的：喉及下咽癌是耳鼻咽喉－头颈外科最常见的肿瘤之一。手术切除是治疗喉癌及下咽癌的首选方法。但术后患者将丧失说话和经鼻呼吸的功能。如何使患者重新获得言语功能，一直是耳鼻咽喉－头颈外科医师的研究焦点。虽然关于发音重建有各种尝试，但目前国内外较少对其发音功能进行评价。 本研究回顾性的分析了气管食管瘘（改良 Amatsu）及我科自行设计改良的喉近全切除术（改良 Pearson）的手术及术后发音情况。采用主观评价指标－Jiyan 分级评分法（即四档五级评分法）及客观评估－嗓音学分析、电声门图分析及最大发音时间，对发音重建患者的发音进行评估，并且与同期住院的行喉垂直部分切除术的患者及健康人相比较。 方法：全部研究对象均选自河北医科大学第四医院耳鼻咽喉-头颈外科自1996年到2004年2月住院手术的喉癌及下咽癌患者，根据患者具体情况，分别实施了改良 Amatsu 及改良 Pearson 发音重建手术。根据其术后的发音及其随访情况，进行了临床分析。 另随机选取发音重建成功的喉癌及下咽癌患者 30 例。其中 12 例行改良 Amatsu，18 例行改良 Pearson，作为改良Pearson及改良 Amatsu 组，并且与同期住院治疗行喉垂直部分切除的患者及健康组比较。分别进行了嗓音学分析，电声门图分子、发音最长时间的分析及 Jiyan 分级评分法的分析。 1<WP=4>中 文 摘 要 结果：(1)随访结果 43 例行改良Pearson 手术，26 例行改良 Amatsu 手术。术后改良 Pearson 未有明显的误吸发生，有 10 例改良 Amatsu 出现误吸。术后 5例行放射治疗，其中4 例改良 Pearson 均发音成功，而 1 例改良 Amatsu 未发音成功。术后1年内发音成功的改良Pearson有37例，改良Amatsu有 22 例。术后 1 年以上的未再有发音失败病例。3 年随访时，25 例改良 Pearson有 22 例存活，11 例改良 Amatsu 有 4例存活。5 年随访时，5 例改良 Pearson 有 4 例存活，未有改良Amatsu 病例。(2)嗓音学分析 改良 Pearson 与改良 Amatsu的基频接近，同 VHL 及健康人亦接近。改良 Pearson 及改良Amatsu 的基频微扰、振幅微扰、噪声能量及谐噪比均增加，改良 Amatsu 增加的更为明显，并同喉垂直部分切除术接近，但均高于健康人。(3)电声门图分析 改良 Pearson 与改良Amatsu 的基频同喉垂直部分切除术接近，但低于健康人。基频微扰、振幅微扰及噪声能量均增加，改良 Amatsu 增加的更明显。同喉垂直部分切除术接近，但高于健康人。(4)最大发音时间 改良Pearson及改良Amatsu的最大发音时间接近，但均明显少于 VHL 及健康人。(5)Jiyan 分级评分法 改良Pearson及改良 Amatsu 的连贯流利度、音强响亮度、清晰可懂度及总得分接近，但均较 VHL 及健康人差。 结论: 本研究回顾分析了喉癌及下咽癌行喉近全切除（改良 Pearson）及气管食管瘘（改良 Amatsu）手术，并采用嗓音学，电声门图，最大发音时间及主观评价指标进行手术发音功能的评价。1. 改良 Pearson 与改良 Amatsu 手术的发音成功率分别为 86.1%，84.6%，并且安全可靠。手术失败的主要原因是 2<WP=5>中 文 摘 要 术后伤口感染及进气道塌陷。改良 Pearson 可能比改良 Amatsu 更能耐受术后放疗。2. 改良 Pearson手术的误吸率低于改良 Amatsu，更适宜老年 伴有心肺疾患的患者，并且适用于全喉下咽切除食管内翻 拔脱胃代食管的患者。3. 改良 Pearson与改良 Amatsu 的嗓音学分析与 VHL 接近， 但与健康人有明显差别。4. 改良 Pearson 与改良 Amatsu 的嗓音学分析及电声门图分 析接近于 VHL，但与健康人有明显差别。5. VHL 的主观评价高于改良 Pearson 及改良 Amatsu，并且 改良 Pearson 比改良 Amatsu 更容易接受。6. 在临床工作中，评价喉全切除或近全切除术后发音重建功 能时，应主客观指标联合应用。7. 在对喉癌及下咽癌患者选择发音重建手术方式时，改良 Pearson 应为首选。改良 Amatsu 可以作为补充。更多还原

【Abstract】 Objects: Laryngeal and hypopharyneal carcinoma are themost common tumors of otolaryngology. The operativeamputate is still the first choice in laryngeal and hypopharynealcarcinoma treatment. But post-operative voice lose is stillchallenge for head and neck surgeon. Many methods aboutponation reconstruction have been recommended, but only feware refered to the ponation rehilitition at home and abroad. We analyzed retrospectively the condition ofpost-operative phonation reconstruction, the tracheo-esophagealshunt (modified Amatsu) and tracheo-hypopharyneal (modifiedPearson) that was designed by ourself. We also investigated thefunction of the phonation rehabilitition by Jiyan classifiedmethod, acouicis assessment, electroglottography and maximumphonation time, compared with the vertical hemilarygectomyand normal person. Methods: All objects were completely chosen from thepatients with laryngeal and hypopharyneal carcinoma undergonephonation reconstrucion in otolaryngology department of theforth hospital of the Hebei Medical University from December1996 to February 2004. Mofidied Pearson or modified Amatsuoperations are given respectively . According to the results of 4<WP=7>英 文 摘 要phonation rehabilitation and follow-up, we have maken clinicalanalysis. Otherwise, we chose randomly 30 patient with laryngealand hypopharyneal carcinoma obtained phonation rehabilition.Involving, 12 patients were performed modified Pearson and 18patients were performed modified Amatsu. And they werecompared with vertical hemilarygectomy (VHL) and normalperson. They were analyzed respectively by acouse analysis,electroglottography, maximun phonation time and Jiyanclassified method. Results: (1) The follow-up results. There were 43 patientsundergone modified Pearson and 26 patients undergonemodified Amatsu together. Obvious aspiration was not beenfound in modified Pearson group. But 10 patients have thecomplication of aspirations in modified Amatsu group.Post-operative radiotherapies are given in 5 cases together.Involving, 4 cases obtained phonation reconstructions inmodified Pearson group. But 1 patient undergone modifiedAmatsu failed. 37 patients in modified Pearson group and 22patients in modified Amatsu group obtained phonationrehabilitions less than one year after operation. There was nophonation failure case more than one year. The five yearssurvival rate is 4/5 in modified Pearson group. There is nopatient in modified Amatsu in five years. (2) Acouse analysis.Modified Pearson was close to modified Amatsu in thefundamental frequency and close to VHL and normal person. 5<WP=8>英 文 摘 要The jitter, shimmer, noise energy and harmonic noice rate (HNR)of modified Pearson and modified Amatsu increased. ModifiedAmatsu increased more obviously. They were close to VHL. (3)Electroglottography. The fundamental frequency, jitter,shimmer and noise energy of modified Pearson and modifiedAmatsu increased and were close to VHL. But HNR of modifiedPearson and modified Amatsu were close to VHL and normalperson. (4) Maximum phonation time. The Maximumphonation time of modified Pearson was close to modifiedAmatsu and less obviously than VHL and normal person. (5)Jiyan classified method. The fluent degree, loud degree,intelligible degree, acceptable degree and total score of modifiedPearson were close to modified Amatsu. But they were less thanVHL and normal person. Conclusions: We analyzed retrospectively the near-totallaryngotomy (modified Pearson) and tracheo- esophageal shunt(modified Amatsu) about laryngeal and hypopharynealcarcinoma treatment. And the phonation functions was analysedby acousic analysis, electroglottography, maximum phonatintime and Jiyan classified method.1. The successful rates of modified Pearson and modified Amatsu are respectively 86.1% and 84.6%. And they are safe and reliable. T更多还原