不同咽成形术式对腭裂术后继发腭咽闭合功能不全合并睡眠呼吸障碍的影响

A retrospective analysis of sleep breathing disordered after pharyngoplasty for velopharyngeal insufficiency secondary to cleft palate

目前国际上治疗腭裂继发腭咽闭合不全的常用术式包括咽后壁瓣成形术、腭咽肌瓣成形术和Furlow瓣(双反向Z形瓣)。多导睡眠监测(polysomnography,PSG)结合主诉症状表明,部分腭裂术后腭咽闭合不全患者在接受咽成形术后会出现不同程度的阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea-hypopnea syndrome,OSAHS),轻症者可自行缓解,严重者需采用吸氧或呼吸机治疗,极少数需手术摘除或松解咽瓣。儿童与成人在咽后壁瓣成形术后发生OSAHS的概率无显著差异,但儿童的病情较成人严重。术前已有OSAHS的患者,咽成形术后症状可能加重。在对不同术式患者的短期随访(≤6个月)中发现,Furlow瓣术后发生OSAHS的概率最低,腭咽肌瓣成形术次之,咽后壁瓣成形术最高。大于1年的随访显示,3种手术后OSAHS发病率无显著差异。目前对腭裂患者腭咽闭合不全的手术治疗尚无统一术式,各种手术方法术后OSAHS的发病率仍存在争议,应将PSG检查作为咽成形术围术期常规检查,以便更准确地评估不同术式对睡眠呼吸障碍的影响。

The commonly used surgical methods for velopharyngeal insufficiency secondary to cleft palate include pharyngeal flap, sphincter pharyngoplasty and Furlow palatoplasty(double-opposing Z-plasty). Polysomnography(PSG)combined with the chief complaints indicated that some patients who had underwent pharyngoplasty for velopharyngeal insufficiency would have different levels of obstructive sleep apnea-hypopnea syndrome(OSAHS). Some patients with mild symptoms could be relieved by themselves, while those with severe symptoms need to be treated by oxygen inhalation or continuous positive airway pressure(CPAP), and very few had to have the flap removed or loosened through another surgery. There was no significant difference in the morbidity of OSAHS between children and adults, but the condition of children was more serious than that of adults. Patients with preoperative OSAHS might have their symptoms aggravated after surgery. In the short-term follow-up(≤6 months) of patients with different surgical procedures, the incidence of OSAHS was the lowest in Furlow palatoplasty, followed by sphincter pharyngoplasty, and the highest was posterior pharyngeal flap. However, long term follow-up(>12 months) demonstrated that there was no significant difference in the morbidity. At present, there is no unified operation for velopharyngeal insufficiency secondary to cleft palate, and the morbidity of OSAHS after various operation methods is still controversial. PSG should be applied as a routine examination during the perioperative period of pharyngoplasty, so as to evaluate the impact of different operation methods on sleep disordered breathing more accurately.