重度阻塞性睡眠呼吸暂停低通气综合征的联合手术治疗

Effectiveness of combined surgery for treating severe obstructive sleep apnea hypopnea syndrome

目的探讨悬雍垂腭咽成形术（uvulopalatopharyngoplasty，UPPP）联合颏舌肌前移舌骨悬吊术（genioglossus advancement hyoid mytomy，GAHM）在治疗重度阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome，OSAHS）患者的应用及疗效影响因素。方法18例经多道睡眠监测（polysomnography，PSG）确诊为重度OSAHS的患者呼吸暂停低通气指数（apnea hypopnea index，AHI）〉40次／h，并经电子鼻咽喉镜检查结合Müller试验、头影测量分析及上气道CT检查确定为存在腭咽及舌咽平面阻塞。所有患者于术前先行经鼻持续正压通气治疗（nasal continuous positive airway pressure，nCPAP）治疗5～7d，然后同期行UPPP联合GAHM手术，术后至少6个月复查并分析影响疗效的可能因素。结果18例术后随访6～24个月，手术前后除体重指数外各相关测量值的变化均具有统计学意义（P〈0．05）。平均（x^-±s，以下同）呼吸暂停低通气指数（apnea hypopnea index，AHI）从（63．8±16．3）次／h下降到（23．6±19．5）次／h，平均最低血氧饱和度从0．72±0．07上升至0．81±0．13。按杭州会议标准，治愈1例，显效11例，有效3例，无效3例，总有效率83％；按AHI〈20次／h且下降〉50％计，成功率67％。获得手术成功的患者的平均年龄（39．1±7．4）岁、后气道间隙（8．3±0．9）mm，血氧饱和度低于0．90的时间占总睡眠时间百分比（CT90）为（18．5±10．9）％；失败患者以上数据分别为（52．5±9．4）岁、（6．8±1．3）mm、（37．7±23．6）％；经比较两者差异具有统计学意义。结论UPPP联合GAHM是目前治疗腭咽及舌咽平面阻塞的重度OSAHS患者的一种手术方案，年龄、后气道间隙及CT90是影响其疗效的可能因素。

Objective To explore the efficiency of a comprehensive surgical approach of genioglossus advancement and hyoid suspension （GAHM） plus uvulopalatopharyngoplasty （UPPP） for treating severe obstructive sleep apnea hypopnea syndrome （OSAHS） and to evaluate related factors on surgery outcomes. Methods Eighteen patients with severe OSAHS （apnea hypopnea index, AHI 〉 40/h） confirmed with polysomnography received genioglossus advancement and hyoid suspension plus uvulopalatopharyngoplasty. The obstruction in both the oropharynx and the hypopharynx were evaluated by preoperative physical examination, fiberoptic pharyngolaryngoscopy, cephalometry, and computed tomography of the upper airway. The follow up was at least 6 months postoperatively. The Wilcoxon signed rank test was used to compare the preoperative and postoperative results by SPSS 11.0 for windows. The Mann-Whitney test was used to analyze the difference between responders and nonresponders. Results The follow up time ranges from 6 to 24 months, there were statistically significance in all but body mass index （BMI） between preoperative and postoperative measurements. Mean AHI was reduced from preoperative （x^-±s, 63.8±16.3）/h to postoperative （23.6±19.5）/h, lowest mean oxygen saturation increased from 0.72±0.07 to 0.81±0.13（x^-±s）. According to criterion at home, the 6-month rate of responder is 83%, if AHI〈20/h and decreased by at least 50% as success, the rate of success is 67%. The age, posterior airway space （PAS） and percentage of time with oxyhemoglobin saturation below 0.90 （CT90） were （39.1±7.4） years, （8.3±0.9） mm, （18.5±10.9） % in responder, while （52.5±9.4） years, （6.8±1.3） mm, （37.7±23.6）% in nonresponder, and there are statistically significant between responder and nonresponder. Conclusions GAHM plus UPPP is effective surgical approach for patients with severe OSAHS who suffer from oropharyngeal and hypopharyngeal obstruction. Age, PAS and CT90 were possible affective factors on surgical outcomes.