肉毒素注射环甲肌及甲杓肌缓解双侧喉返神经不全麻痹患者呼吸困难的初步疗效分析

Effect of cricothyroid and thyroarytenoid muscle botulinum toxin injection on patients with dyspnea caused by bilateral recurrent laryngeal nerve paresis

目的 探讨小剂量肉毒素注射环甲肌及甲杓肌缓解双侧喉返神经不全麻痹并发急性呼吸困难的临床疗效.方法 选取2015年10月至2017年10月6例并发不同程度呼吸困难、喉肌电图确诊为双侧喉返神经不全损伤并预测神经有自主恢复可能的患者,在环甲肌及甲杓肌上进行小剂量肉毒素注射,收集患者治疗前及治疗后1个月的相关参数,含呼吸困难情况、频闪喉镜下最大吸气相声带前连合夹角、正常发/i/音时的声学参数：基频（fundamental frequency,F0）、基频微扰（Jitter）、振幅微扰（Shimmer）,分别嘱患者在正常音调发/i/音、低频及高频发/i/音时喉部CT影像,并测量声带膜部长度、宽度及声门面积等参数.采用配对t值分析肉毒素注射前后的频闪喉镜图像及声学信号参数,采用方差检验分析三种不同发声时声带的CT参数.同时定期随访.结果 患者均顺利进行肉毒素注射,无严重并发症发生;治疗后患者呼吸困难均明显缓解,其中2例注射前行气管切开的患者在注射后1个月顺利拔除气管套管;治疗后声带前连合夹角较治疗前增大,组间差异有统计学意义（t=2.44,P＜0.05）;F0及Jitter在治疗前后的差异均无统计学意义（t值分别为0.72、1.42,P＞0.05）,Shimmer在治疗后大于治疗前,差异有统计学意义（t=2.61,P＜0.05）;随着发声频率增高,声带长度增加,声带宽度变宽,声门面积增大,肉毒素注射前不同发声状态下3种参数差异有统计学意义（F=10.93,P ＜0.05）,肉毒素注射后不同状态下的3种参数差异无统计学意义（F =6.84,P＞0.05）,肉毒素注射前后3个参数在不同的发声状态下的差异均有统计学意义（P值均＜0.05）;治疗后1个月的喉肌电图显示喉内收肌的募集密度及动作电位幅度较治疗前下降.6例患者的随访时间分别为7个月、1年、1年、18个月、22个月、2年,患者病情稳定,未再发呼吸困难.结论 小剂量肉毒素注射环甲肌和甲杓肌,可缓解双侧声带不全麻痹导致的急性呼吸困难,注射后声音质量稍变差,该方法可作为双侧喉返神经不全损伤缓解呼吸困难的替代治疗方法.

Objective To discuss the clinical effect of small dose of botulinum toxin injection in cricothyroid muscle and thyroarytenoid muscle on patients with incomplete bilateral recurrent laryngeal nerve paresis.Methods Six patients were selected with Ⅰ or Ⅱ or Ⅲ degree of dyspnea diagnosed as bilateral recurrent laryngeal nerve injury by laryngeal electromyography,and small dose of botulinum toxin injection was performed in cricothyroid muscle and thyroarytenoid muscle as a treatment.Degree of dyspnea was assessed one month before and after the treatment,and the stroboscopic laryngoscope results,acoustic parameters and CT image of the patients were collected in the 6 patients.The relevant parameters were also collected one month before and after treatment,including the degree of dyspnea,stroboscopic laryngoscope results,acoustic parameters and CT image of the patients.The angle between bilateral vocal cords in stroboscopy at full inspiratory was calculated,acoustic parameters （F0,jitter,shimmer） were analysed,and vocal length,width and the vocal region were measured.Then,the paired t test was performed for statistical analysis between before and after one month injection,the one way analysis of variance was performed among vocal parameters in CT image.Result Botulinum toxin injection was successfully completed in the 6 patients,followed without any serious complications.The degree of dyspnea was alleviated to some extent after treatment in all 6 patients;the angle between bilateral vocal cords at the end of a deep inspiration was significantly increased （t =2.44,P 〈 0.05） after the treatment.The changes of F0 and jitter between before and after treatment were not statistically significant （t =0.72,t =1.42,P 〉 0.05）.Shimmer was significantly decreased after treatment （t =2.61,P 〈 0.05）.Vocal fold length,width and vocal region increased with F0,there was a statistically significant difference between different F0 before injection,and there was no statistically significant difference between different F0 after injection.The follow-up time was respectively seven months,1 year,1 year,18 months,22 months and 2 years respectively.Conclusion Small dose of botulinum toxin injection in bilateral cricothyroid muscles and thyroarytenoid muscles can relieve the dyspnea caused by bilateral vocal cords paresis to some extent,accompanied without serious complications,despite the sound quality was slightly worse.