腭咽部肌群重建腭裂修复术与改良兰氏腭裂修复术后软腭运动的比较观察

LATERAL RADIOGRAPHIC COMPARISON FOR VELAR MOVEMENT BETWEEN PALATOPLASTY WITH VELOPHARYNGEAL MUSCULAR RECONSTRUCTION AND MODIFIED VON LANGENBECK'S PROCEDURE

目的 通过腭咽部肌肉重建腭裂修复术与改良兰氏腭裂修复术后患者的X线片比较，了解腭咽部肌肉重建对软腭运动功能恢复的作用。方法1988年10月-2000年10月，治疗腭裂及腭咽闭合不全患者62例。其中腭咽部肌肉重建腭裂修复术（A组）32例，年龄2～26岁；改良兰氏腭裂修复术（B组）30例，年龄4～23岁。采用鼻咽部钡造影X线侧位片检查方法摄取静止和发“i”音时的侧位片，进行X线片定点。测量指标包括：①腭咽闭合状态，②软腭运动长度，③软腭运动角度，④解剖提肌隆突点（levator eminence in anatomy，LEA）一腭咽闭合水平线（velopharyngeal closure line，VCL）距离，⑤LEA变化值，⑥LEA与运动提肌隆突点（levator eminence in phonation，LEP）值的比较，⑦LEA与LEP的差值，⑧后鼻棘点（posterior nasal spine，PNS）-软腭鼻腔侧连线（soft palate line，SPL）-LEA与PNSSPL-LEP值。结果A、B组的腭咽闭合完全优良率状态分别为83．3％和53．3％（P〈0．01）；软腭运动长度：A组静止时和发“i”音时分别为36．77±4．23mm和39．57±5．80mm（P〈0．05），B组静止和发“i”音时分别为36．70±5．81mm和39．15±6．89mm（P〉0．05）；软腭运动角度：A组为18．97±11．13°，B组为25．55±13．02°（P〈0．05）；LEA-VCL距离：静止时A组为-5．57±5．26mm，B组为-13．47±4．21mm（P〈0．001）；LEA变化值A组为7．63±5．29mm，B组为13．10±9．13mm（P〈0．01）；LEA与LEP值的比较：A组分别为21．79±3．18mm和20．33±4．29mm（P〉0．05），B组分别为21．56±4．11mm和19．41±3．50mm（P〉0．05）；LEA和LEP的差值比较差异无统计学意义（P〉0．05），组内比较A组（P〉0．05），B组（P〈0．01）；PNS-SPL-LEA与PNS-SPL-LEP值：组间比较差异无统计学意义（P〉0．05），组内比较A组（P〉0．05），B组（P〈0．05）。结论腭裂修复术时重建腭咽肌肉有助于软腭运动和腭咽闭合功能的恢复。软腭运动角度及软腭向上运动范围并不是构成理想腭咽闭合的主要因素，而腭咽部肌肉重建后的协调运动则更为重要。

Objective To verify the effect of palatoplasty with or without velopharyngeal muscular reconstruction on the velar movement through the lateral radiography. Methods From October 1988 to October 2000, 62 patients with cleft palate and velopharyngeal insufficiency were treated. Of them, 32 were repaired by velopharyngeal muscular reconstruction （group A） and 30 by modified yon Langenbeck＇s procedure （group B）. The lateral radiographs and cephalometric analysis were taken. The velopharyngeal closure, velar extensibility, the angle changes of velar elevation, the distance changes of velar levator eminence based on anatomy （LEA） to velopharyngeal closure line （VCL）, the varieties in LEA, the comparison of LEA and velar levator eminence based on phonation （LEP）, the distance comparison between posterior nasal spine （PNS） to LEA and LEP through soft palate line （SPL） were measured. Results During the phonation, group A was significantly greater than group 13 in the velopharyngeal closure rate（P〈0. 01）, the velar extensihility（P〈0. 05） and the location comparison between LEA and LEP（P〈0.01）; group B was significantly greater than group A in velar elevation angle （P〈0. 05）, the varieties in LEA（P〈0. 05）. In velar rest position, the distance of LEA to VCL was greater in B group than in A group（P〈0.01）. There was significant difference in the distance comparison between LEA and LEP（P〈0. 05）, difference between LEA and LEP （P〈0. 01） and the distance PNS-SPL-LEA and PNS-SPL-LEP（P〈0. 05） within group B; contrary to the results within group A （P〈0.05）. Conclusion The velopharyngeal muscular reconstruction in palatoplasty can result in a near normalization of anatomic measurement of velar levator muscles and improve the velar function and velopharyngeal competence. Repositioning of velar muscles in a more anatomic correct, transverse position is more important to improve the velar length and accordant velar movement with velopharyngeal muscles in functional palatoplasty. The velar angle change and velar elevation during phonation are not determinative factors for velopharyngeal competence.