改良悬雍垂腭咽成形术和鼻部手术治疗重度阻塞性睡眠呼吸暂停低通气综合征

Treatment of severe obstructive sleep apnea hypopnea syndrome with combination of nasal operation and modified uvulopalatopharyngoplasty

目的对合并鼻部和口咽部阻塞的重度阻塞性睡眠呼吸暂停低通气综合征(ob-structive sleep apnea hypopnea syndrome,OSAHS)患者进行鼻部手术和改良悬雍垂腭咽成形术(uvulo-palatopharyngoplasty,H-UPPP),探讨二者手术及不同顺序对疗效的影响。方法 OSAHS诊断和评估手术疗效采用多道睡眠呼吸监测(polysomnography,PSG)、嗜睡量表(Epworth sleep score,ESS)评分、体重指数(kg/m2,body mass index,BMI)和主观症状。患者按照单、双日的半随机方法分为A、B两组,A组61例先行鼻部手术,B组57例先行H-UPPP。A组术后3～5个月复查评估,B组术后6～8个月复查评估。A、B两组中无效者分别再行H-UPPP或鼻部手术。两组患者均在第二次手术后随访1年以上。结果 A组单纯鼻部手术后有效率为0,均再行H-UPPP,1年后复查评估有效率78.7%(48/61)。B组单纯H-UPPP有效率47.4%(27/57),1年后随访复发4例;其余30例再行鼻部手术,1年后复查评估有效率70%(21/30)。A组总有效率78.7%(48/61),B组总有效率77.2%(44/57),两组总有效率无统计学意义(χ2=0.697,P>0.05)。A、B两组联合手术者与单纯行鼻部手术或H-UPPP术的有效率有统计学意义(χ2=81.89,P<0.05;χ2=4.070,P<0.05)。A、B两组联合手术者有效率差异无统计学意义(χ2=1.208,P>0.05)。A组单纯鼻部手术有效率与B组单纯H-UPPP有效率有统计学意义(χ2=37.468,P<0.05)。结论治疗合并鼻部和口咽部阻塞的重度OSAHS患者,原则上可先行H-UPPP;无效或效果差者再行鼻部相关手术,从本组病例观察H-UPPP联合鼻部相关手术可提高有效率。

Objective Treatment strategy including nasal operation and H-uvulopalatopharyngoplasty （H-UPPP） was adopted in severe obstructive sleep apnea hypopnea syndrome （OSAHS） patients with both oropharyngeal and nasal obstruction. This study was designed to investigate the influence of operation order on outcome. Methods The diagnosis of OSAHS was confirmed; surgical effect was evaluated with polysomnography （PSG）,Epworth sleep score （ESS）,body mass index（BMI）,and patients＇ subjective symptoms. Patients were divided into group A （61 cases） and group B （57 cases） randomly. Patients in Group A underwent nasal operation （including septalectomy,radiofrequency reduction of the inferior turbinate,adenoidectomy,and functional endoscopic operation）; while those in group B received H-UPPP. All patients in group A and group B were separately followed up and given therapeutic effect evaluation 3 to 5 months and 6 to 8 months postoperatively. Those who failed to reach the criteria of effectiveness in group A or group B received H-UPPP or nasal operation respectively. The efffective rates between the two groups after each phase of operation were compared. Results In group A,the effective rate after phase one operation was 0% （0/61） and all the patients received H-UPPP operation again with an effective rate of 78.7% （48/61） one year after operation. In group B,the effective rate after H-UPPP was 47.4% （27/57） but 4 cases recurred one year after operation. The other 30 cases underwent the second phase nasal operation with an effective rate of 70% （21/30） after following-up one year postoperatively. The total postoperative effective rate of group A and group B were 78.7% （48/61） and 77.2% （44/57） respectively. As for the operation order,the difference of effective rates was statistically insignificant （P0.05）. The difference of the effective rates was statistically significant between those received previous nasal operation with or without H-UPPP in group A （P0.05）,and that was also statistically significant between those received previous H-UPPP with or without nasal operation in group B （P0.05）. The difference of effective rates of nasal operation combined with H-UPPP between group A and group B was statistically insignificant （P0.05）. The effective rate of H-UPPP in group B and that of nasal operation in group A was significantly different （P0.05）. Conclusion H-UPPP is the preferred selection in treatment of severe OSAHS patients with both oropharyngeal and nasal obstruction. Additional nasal operation should be applied to those fail to respond to H-UPPP. H-UPPP combined with nasal operation can increase the effective rate.