悬雍垂腭咽成形术中扩大咽峡和鼻咽峡的特点(英文)

Dilatation of oropharyngeal and nasopharyngeal isthmus in uvulopalatopharyngoplasty

背景:传统悬雍垂腭咽成形术式切除部分软腭、悬雍垂和多余的咽侧壁软组织,虽然改善了症状,但部分患者出现腭咽关闭不全、咽腔瘢痕挛缩等并发症,且远期疗效欠佳。目的:观察悬雍垂腭咽成形术中扩大咽峡和鼻咽峡的特点,分析治疗阻塞性睡眠呼吸暂停低通气综合征的疗效。设计:病例观察。单位:青岛大学医学院附属市立医院。对象:选择2001-07/2006-02以睡眠时打鼾、呼吸暂停、憋气、白天嗜睡等症状来青岛大学医学院附属市立医院睡眠呼吸障碍诊疗中心就诊,经多导睡眠图确诊为阻塞性睡眠呼吸暂停低通气综合征患者216例。术前均确定阻塞部位在口咽部,其鼻咽峡较小及舌根无肥大。呼吸暂停和低通气指数≥5次/h。年龄≥25岁,其中男159例,女57例。方法:改良传统悬雍垂腭咽成形术手术方法,维持咽腔正常生理解剖形态,保留悬雍垂,沿腭舌弓切口向软腭方向做斜行直切口,避免倒“U”型切口。对软腭和咽侧壁进行成形,以充分扩大咽峡和鼻咽峡。主要观察指标:①近期效果观察:术后不需要镇痛药物者为轻度疼痛,需使用镇痛药物者为重度疼痛。口腔侧壁在愈合后能保持咽腔设计形态者为愈合好,反之为愈合差。②远期效果观察:根据患者自述来确定患者有无鼻腔返流、咽部异物感等并发症。根据患者家属的观察及多导睡眠监测,来确定患者有无睡眠呼吸暂停症状。经口咽部检查以确定咽腔形态是否接近正常生理结构。结果:216患者均进入结果分析。①216例患者术后不需镇痛药156例(72%),需要镇痛药者60例(28%);咽侧壁光滑者136例(63%),部分裂开者80例(37%)。术后均无憋气及鼻腔返流等并发症。②216例均随访6个月以上,均无吞咽返呛、开放性鼻音等并发症;84例(39%)患者有咽部异物感;169例(78%)睡眠呼吸暂停症状消失,47例(22%)仍有症状,但均较术前改善。术后口腔形态满意203例(94%),13例(6%)不满意。③术前与术后多导睡眠监测结果各项指标比较差异有显著性[呼吸暂停指数:35.45±16.42,12.75±9.62;低通气指数:19.39±9.86,17.43±10.15;呼吸暂停低通气指数:54.29±18.13,28.31±16.23;平均低血氧饱和度:(83.58±7.96)%,(85.53±8.18)%;平均血氧饱和度:(91.98±3.29)%,(93.01±3.02)%,P均<0.05]。结论:改良传统悬雍垂腭咽成形术式可充分扩大咽腔空间,避免了并发症。

BACKGROUND ： Partial soft palate, uvula and the otiose soft tissue of lateral pharyngeal wall are resected in traditional uvulopalatopharyngoplasty. Although the syndrome can be improved, the complications, such as velopharyngeal insufficiency, cicatricial contration of pharyngeal cavity, can occur in some patients, furthermore, the prostecdtive efficacy is below the mark. OBJECTIVE： To investigate efficacy of the dilatation of oropharyngeal and nasopharyngeal isthmus in uvuiopalatopharyngoplasty treating obstructive sleep apnea hypopnea syndrome. DESIGN ： A case-control observation SETTING： The Affiliated Municipal Hospital of Medical College, Qingdao University PARTICIPANTS ： The patients who were hospitalized for snoring, apnea, breathing obstruction and somnolence were selected from the Sleep Respiratory Disorder Diagnosis and Treatment Center in the Affiliated Municipal Hospital of Medical College of Qingdao University from July 2001 to February 2006. We ascertained that the obstruction located at pharynx oralis, no hypertrophy of lingual root, and made a definite diagnosis of OSAHS by pelysomnogram. The apnea hypepnca index （AHI） was ≥ 5 times per hour. Among 216 patients, there were 159 males and 57 females aged older than 25 years. METHODS ： The patients ware treated by modified UPPP which maintained the normal anatomic form of pharyngeal cavity, reserved the uvula, performed oblique straight incision along palatogiossal arch to soft palate, and avoided the incision of inverse U type. Palatoplasty and pharyngoplasty could extend the oropharyngeal isthmus and nasopharyngeal isthmus thoroughly. MAIN OUTCOME MEASURES： （1） The survey of effect in the near future： Defined the pain without pain-killer as pain lightly, or as pain heavily inversely. If the lateral wall of oropharynx could remain the designed morphous, it was a good henosis; it was a bad henosis inversely. （2） The survey of effect in a long term： According to the statement of the patients themselves. Estimated whether the patients had postoperative complications, such as backstreaming in nasal cavity, pharyngeal foreign body sensation, etc. Assessed if the patients had sleep apnea according to the observation of the family member and the monitoring of PSG. And ascertained whether the pharyngeal cavity had approached to normal structure by the examination of oropharynx. RESULTS： All 216 patients were involved in the final analysis. （1） Of the 216 subjects, there ware 156 patients who needed pain-killer （72%）, and 60 patients need not （28%）. The lateral pharyngeal wall of 136 subjects was smooth （63%）, and the other 80 were splited partly （37%）. There were no complications such as breath holding, backstreaming in the nasal cavity. （2） The survey of Iongdated postoperative effect： The 216 patients were followed up for 6 mouths. There was no deglutitive bucking, open rhinolalia. A total number of 84 patients （39%） had pharyngeal foreign body sensation. The syndrome of sleep apnea disappeared in 169 patients, and the other 47 patients still had the syndrome, but improved than before. In 203 patients （94%）, the postoperative morphous of oral cavity were content, and the other 13 patients （6%） were not content.（3） The statistical significance of the preoperative and postoperative result of PSG monitoring of the 216 patients with OSAHS existed and the difference was significant [AI： 35.45±16.42, 12.75±9.62; HI： 19.39±9.86, 17.43±10.15; AHI： 54.29±18.13, 28.31±16.23; the average low saturation of blood oxygen： （83.58±7.96） %, （85.53±8.18） %; the average saturation of blood oxygen： （91.98±3.29） %, （93.01±3.02） %, P 〈 0.05]. CONCLUSION： The modified uvulopalatopharyngoplasty indicates that this approach not only extend the nasopharynx cavity, but also avoids the postoperative complications. The patients have markedly improved symptoms.