發(fā)布時間：2018-08-04 16:34

【摘要】：目的：喉運動障礙可導(dǎo)致如發(fā)音障礙、飲水嗆咳、呼吸困難等喉功能異常,影響患者生活和交流,嚴(yán)重者可危及生命。喉關(guān)節(jié)運動障礙病因復(fù)雜,既有環(huán)杓關(guān)節(jié)脫位、環(huán)甲關(guān)節(jié)損傷所致的聲帶機械性運動障礙,也有喉返神經(jīng)、喉傷神經(jīng)麻痹所引起的神經(jīng)肌肉功能障礙。正常生理狀態(tài)下喉關(guān)節(jié)(環(huán)杓關(guān)節(jié)、環(huán)甲關(guān)節(jié))的運動軌跡仍有疑點,本課題組前期通過對尸體標(biāo)本的喉關(guān)節(jié)造影、塑化及組織學(xué)染色等發(fā)現(xiàn)環(huán)杓關(guān)節(jié)中杓狀軟骨除原有的旋轉(zhuǎn)、滑動和擺動,可能出現(xiàn)跳動；環(huán)甲關(guān)節(jié)中甲狀軟骨下角不僅在環(huán)狀軟骨的關(guān)節(jié)窩中旋轉(zhuǎn),還有可能滑動。本研究主要目的是(1)對正常志愿者及患者分平靜呼吸、發(fā)”yi”音兩個生理狀態(tài)進行喉部CT掃描及三維重建,觀察杓狀軟骨是否存在矢狀位位移及如何定量測量矢狀位位移;環(huán)甲關(guān)節(jié)是否同時存在滑動和旋轉(zhuǎn)以及運動的方向。(2)利用螺旋CT合并三維重建技術(shù)觀測肌突在甲狀軟骨的投影,術(shù)前對每個病人行喉軟骨重建圖并在虛擬的甲狀軟骨圖像上開窗,以期術(shù)中定位肌突和尋找最佳甲狀軟骨開窗方法。(3)基于超薄塑化與顯微解剖技術(shù),確立喉內(nèi)肌精細的三維構(gòu)筑圖,探討喉內(nèi)肌的功能肌束。方法：1.影像學(xué)檢查對檢查者平靜呼吸和發(fā)”yi”進行螺旋CT掃描結(jié)合三維重建技術(shù),測算喉軟骨的位移變化及肌突投影點的定位。(1)掃描對35例檢查者(無喉部疾病)和7例單側(cè)聲帶麻痹的患者平靜呼吸和發(fā)“yi”聲分別行喉部薄層容積掃描結(jié)合三維重建。(2)測量(a)杓狀軟骨聲帶突、肌突的縱向位移：以通過環(huán)狀軟骨弓最上緣的掃描平面作為參考面,測量發(fā)音時杓狀軟骨的聲帶突和肌突相對于參考面的垂直距離,并分別計算出發(fā)音時杓狀軟骨的聲帶突和肌突的矢狀位位移范圍；(b)環(huán)狀軟骨、甲狀軟骨的縱向位移：以通過第五頸椎最上緣的掃描平面作為參考面,測量平靜呼吸和發(fā)“yi”聲時環(huán)狀軟骨板上緣和下緣相對于參考面的垂直距離,和甲狀軟骨上、下角相對于參考面的垂直距離,分別計算出發(fā)音時環(huán)狀軟骨板上、下緣和甲狀軟骨上、下角的矢狀位位移范圍；(c)甲狀軟骨下角滑動的方向：以通過環(huán)狀軟骨弓最上緣的掃描平面作為參考面,測量平靜呼吸和發(fā)“yi”聲時甲狀軟骨下角相對于參考面的垂直距離；以通過環(huán)狀軟骨板后緣的冠狀面作為參考面,測量發(fā)音時甲狀軟骨下角相對于參考面的垂直距離,通過位移變化判斷滑動的方向。(d)肌突投影點的定位：測量平靜呼吸時肌突在甲狀軟骨上投影點距離甲狀軟骨上角和下角的距離。(e)在三維重建圖像上模擬甲狀軟骨板開窗：以甲狀軟骨板后緣的中點為圓心,以中點和肌突在甲狀軟骨板上的投影點之間的距離為半徑,向前開窗,通過旋轉(zhuǎn)圖像,從各視角觀察杓狀軟骨體。(3)統(tǒng)計分析實驗數(shù)據(jù)以均數(shù)土標(biāo)準(zhǔn)差(X±s)表示,采用SPSS 22.0軟件分析數(shù)據(jù),進行混合線形分析和t檢驗。以P0.05認為差異有統(tǒng)計學(xué)意義,P0.01認為具有高度統(tǒng)計學(xué)意義。2.解剖學(xué)研究顯微解剖與超薄塑化技術(shù)相結(jié)合,觀察各喉內(nèi)肌(環(huán)杓側(cè)肌、甲杓肌、環(huán)杓后肌及環(huán)甲肌)內(nèi)肌束的數(shù)量、走向、起止點及與喉軟骨和聲帶的三維結(jié)構(gòu)關(guān)系。(1)喉部尸體標(biāo)本組織塊,經(jīng)脫水脫脂塑化后制成全透明硬組織塊,沿水平、冠狀、矢狀位制作150-200μm厚的全透明系列超薄塑化切片：切片經(jīng)普通顯微鏡、高清掃描儀、激光共聚焦顯微鏡收集圖像資料,并進行觀察。(2)另取喉部尸體標(biāo)本組織,在體式顯微鏡下行精細的外科手術(shù)解剖,收集資料。(3)觀察指標(biāo)：(a)明確各喉內(nèi)肌之間的毗鄰關(guān)系。(b)確定各喉內(nèi)肌的分部。(c)確定喉內(nèi)肌的各肌束的起止點。(d)確定喉內(nèi)肌的各肌束走行及各肌束與參考平面的夾角。結(jié)果1.環(huán)杓關(guān)節(jié)(1)生理狀態(tài)下,在發(fā)“yi”音和平靜呼吸時杓狀軟骨的聲帶突矢狀位位移距離大于肌突。(2)杓狀軟骨的肌突和聲帶突的矢狀軸位移距離在不同的年齡、性別、側(cè)別均不同。(3)單側(cè)聲帶麻痹的患者,患側(cè)與健側(cè)的肌突垂直距離差為1.5mm,聲帶突為0.8mm,患側(cè)的聲帶突和肌突均高于健側(cè)。(4)環(huán)狀軟骨和杓狀軟骨的肌突可以在三維重建圖像中較好地顯影。2.環(huán)甲關(guān)節(jié)(1)生理狀態(tài)下,發(fā)“yi”音時環(huán)狀軟骨相對于頸椎發(fā)生矢狀位位移,甲狀軟骨幾乎沒有。(2)在發(fā)“yi”音和平靜呼吸時甲狀軟骨的下角相對于環(huán)狀軟骨面發(fā)生了滑動。3.肌突的定位及甲狀軟骨板開窗喉部薄層容積掃描及三維重建圖像可以清楚顯示肌突在甲狀軟骨的投影及喉軟骨的三維空間關(guān)系,故喉部框架手術(shù)時應(yīng)常規(guī)行該項檢查,以便提高肌突定位的準(zhǔn)確性。重建圖像可以在三維方向上旋轉(zhuǎn),進行不同視角的觀察,可在虛擬圖像上反復(fù)進行開窗,設(shè)計最佳手術(shù)進路。4.三維構(gòu)筑環(huán)杓側(cè)肌分上下兩部,上部粗大,與環(huán)狀軟骨弓參考面夾角為65°。甲杓肌分內(nèi)外兩部,甲杓外肌中部肌束粗大,與參考面夾角為50°。環(huán)杓后肌中部肌束粗大,與參考面的夾角為40°。結(jié)論：1.環(huán)杓關(guān)節(jié)正常生理狀態(tài)下杓狀軟骨除了沿環(huán)狀軟骨關(guān)節(jié)面做滑動、旋轉(zhuǎn)及搖擺運動外,還離開環(huán)狀軟骨關(guān)節(jié)面在矢狀位上做上下的“彈跳”運動。2.環(huán)甲關(guān)節(jié)在正常生理狀態(tài)下,發(fā)“yi”音時,環(huán)狀軟骨旋轉(zhuǎn)的同時,還沿環(huán)甲關(guān)節(jié)面向前上滑行。3.創(chuàng)立完善的聲帶縱向運動定量檢測法對被檢測者平靜呼吸和發(fā)“yi”音時行螺旋CT掃描結(jié)合三維重建技術(shù),定量化測量雙側(cè)聲帶垂直位置差,并將杓狀軟骨矢狀位位移的定量分析作為臨床評價聲帶功能的依據(jù)之一。4.喉框架手術(shù)的定位喉部薄層容積掃描及三維重建圖像可以清楚顯示肌突在甲狀軟骨的投影,故喉部框架手術(shù)時應(yīng)常規(guī)行該項檢查,以便提高肌突定位的準(zhǔn)確性。重建的圖像可以在三維方向上旋轉(zhuǎn),進行不同視角的觀察,在虛擬圖像上反復(fù)進行開窗,設(shè)計最佳手術(shù)進路。5.喉內(nèi)肌的三維構(gòu)筑圖環(huán)杓側(cè)肌上部肌束、甲杓外肌中部肌束、環(huán)杓后肌中部肌束分別為所在喉內(nèi)肌的功能肌束,杓狀軟骨內(nèi)收術(shù)的牽拉方向應(yīng)根據(jù)喉內(nèi)肌的功能肌束方向設(shè)定。
[Abstract]:Objective: laryngeal dyskinesia can cause abnormal function of larynx, such as dysphonia, choking of drinking water, dyspnea and other laryngeal dysfunction, which may affect life and communication of the patients. The cause of severe larynx movement is complicated, including the dislocation of the arytenoid joint, the vocal cord mechanical dyskinesia caused by the injury of the ring nail joint, and the recurrent laryngeal nerve and laryngeal nerve paralysis. There are still doubtful points in the movement of the laryngeal joint (arytenoid joint, ring armour joint) in normal physiological state. In the earlier period, we found that the arytenoid cartilage in the arytenoid joint, except for the original rotation, slipping and swinging, may appear beating through the laryngarthrography, plasticization and histological staining of the cadaver specimens. The subchondral angle in the armour joint is not only rotated in the articular fossa of the cricoid cartilage, but also may slide. The main purpose of this study is (1) to observe the two physiological states of normal volunteers and patients, and to make a three-dimensional reconstruction of the larynx in the two physiological states of the "Yi" sound, and to observe the sagittal displacement of the arytenoid bone and how to measure the sagittal quantitative vector. (2) a spiral CT combined with three-dimensional reconstruction was used to observe the projection of the myocutaneous process in the thyroid cartilage. Before operation, the laryngeal cartilage reconstruction was performed on each patient and the virtual thyroid cartilage was opened to find the best thyroid cartilage in the operation. (3) based on the ultrathin plasticization and microanatomy technique, the fine three-dimensional architecture of the laryngeal muscles was established and the functional myosus of the larynx muscles was explored. Methods: 1. imaging examinations were performed to calculate the displacement of the larynx and the location of the projection points of the muscularis, with the technique of spiral CT scanning and three-dimensional reconstruction of the tranquil breathing and hair of the examiners. (1) scanning (1) 35 cases (no larynx disease) and 7 cases of unilateral vocal cord paralysis were examined for the tranquil breathing and "Yi" in 7 cases of unilateral vocal cord paralysis. The laryngeal thin layer volume scan combined with three-dimensional reconstruction. (2) measured (a) the arytenoid cartilage vocal process and the longitudinal displacement of the myocutaneous process: the diplike softener was measured by the scanning plane of the most superior edge of the cricoid arch. The vocal process of the bone and the vertical distance of the muscle process relative to the reference surface, and the range of the sagittal displacement of the vocal process and the myocutaneous process of the arytenoid cartilage were calculated respectively. (b) the longitudinal displacement of the cricoid cartilage and the thyroid cartilage: the scanning plane of the upper edge of the fifth cervical spine was used as the reference surface to measure the ring-shaped soft breath and the "Yi" sound. The vertical distance between the upper edge and the lower edge of the bone plate relative to the reference surface, and the vertical distance from the inferior angle to the reference surface on the thyroid cartilage and the lower angle relative to the reference surface, calculated the sagittal displacement range on the cricoid cartilage board, the lower edge and the thyroid cartilage, and the lower angle of the inferior articular cartilage; (c) the direction of the lower angle of the thyroid cartilage: the scan level through the most superior edge of the cricoid arch. As a reference surface, the vertical distance of the lower angle of thyroid cartilage to the reference surface at the time of tranquil breathing and "Yi" sound is measured. The vertical distance between the subchondral angle of the thyroid cartilage relative to the reference surface is measured and the direction of the slide is judged by displacement. (D) the projection point of the muscle process. Location: to measure the distance between the projecting point of the thyroid cartilage and the upper angle and the lower angle of the thyroid cartilage. (E) a three-dimensional reconstruction image is used to simulate the window of the thyroid cartilage: the middle point of the posterior edge of the thyroid cartilage plate is the center, and the distance between the middle point and the projecting point on the thyroid cartilage plate is radius. The arytenoid cartilaginous body was observed from all angles. (3) the statistical analysis experimental data were represented by the standard deviation (X + s), and the SPSS 22 software was used to analyze the data, and the mixed linear analysis and t test were carried out. The difference was statistically significant by P0.05, and P0.01 considered the high statistical significance of.2. anatomy to study microanatomy and ultrathin plastic. The number of intrataryngeal muscles (circum arytenoid muscle, arytenoid muscle, posterior dipper and cicarus) intrataryngeal muscles were observed by chemical technology. (1) the structure of the laryngeal cartilage and vocal cord. (1) the tissue block of the laryngeal cadaver specimens, after dehydration and desiccation of the tissue, made a fully transparent hard tissue block and made 150-200 Mu thick along the horizontal, coronal and sagittal position. All transparent series of ultrathin plasticized section: slice through ordinary microscope, high definition scanner, laser confocal microscope to collect image data and observe. (2) take the tissue of larynx cadaver, fine surgical anatomy under the body microscope, collect data. (3) observation index: (a) clear the adjacent relationship between various larynx muscles. (b) Determine the division of the intrarenal muscles. (c) determine the starting point of the intramuscular myocutaneous muscles of the larynx. (d) determine the angle of the intramuscular myocutaneous muscles of the larynx and the angle between the muscles and the reference plane. Results the displacements of the vocal cords in the arytenoid cartilage in the 1. ring arytenoid (1) physiological state are greater than that of the muscularis. (2) the muscle of the arytenoid cartilage. The displacement distance of the sagittal axis of the sudden and vocal process was different at different age, sex and side. (3) the patients with unilateral vocal cord paralysis, the vertical distance difference between the affected side and the healthy side of the muscular process was 1.5mm, the vocal process was 0.8mm, the vocal process and the muscle process in the affected side were higher than the healthy side. (4) the cricoid and arytenoid cartilage can be better in the three-dimensional reconstruction image. Under the development of.2. ring nail (1) physiological state, when the "Yi" sound was sent, the cricoid cartilage had a sagittal displacement relative to the cervical vertebra, and the thyroid cartilage was almost not. (2) the location of the gliding.3. musculus in the lower corner of the thyroid cartilage relative to the cricoid cartilage when the "Yi" sound and the calm respiration were sent and the thin layer volume scan of the thyroid cartilage plate opening window and the thin volume scan of the larynx. The three-dimensional reconstruction image can clearly show the projection of the muscle process in the thyroid cartilage and the three-dimensional spatial relationship of the laryngeal cartilage. Therefore, this examination should be performed in the laryngeal frame operation so as to improve the accuracy of the localization of the muscle process. The reconstructed image can be rotated in the three-dimensional direction, and can be observed in different angles of view, and the window can be repeatedly opened on the virtual image. The optimal operation route.4. was designed to construct two parts of the arytenoid muscle, the upper part was large, the angle of the cricoid arch reference surface was 65 degrees, the internal and external two parts of the arytenoid muscle, the middle muscle in the middle of the arytenoid muscle and the angle of the reference plane were 50 degrees. The muscular bundle in the middle of the posterior CRICO muscle and the angle of the reference surface were 40 degrees. Conclusion: the normal physiology of the 1. ring arytenoid joint is normal. The arytenoid cartilage is not only sliding, rotating and swaying, but also leaving the articular surface of the cricoid in the sagittal position to do the "bounce".2. ringed joint in normal physiological state. When the "Yi" sound is sent, the cricoid cartilage rotates at the same time, but also along the cicara joint facing up to the front sliding.3. and perfect. The quantitative measurement of the sound band longitudinal motion was used to measure the vertical position difference of the bilateral vocal cords by spiral CT scan combined with three-dimensional reconstruction of the detected Yi sound, and the quantitative analysis of the sagittal displacement of the arytenoid cartilage was used as a basis for the evaluation of the function of the vocal cords in the larynx of the.4. larynx surgery. Layer volume scanning and three-dimensional reconstruction can clearly show the projection of the muscle process in the thyroid cartilage. Therefore, this examination should be performed in the laryngeal frame operation so as to improve the accuracy of the localization of the muscle process. The reconstructed image can be rotated in the three-dimensional direction, the observation of different angles is carried out, the window is repeated on the virtual image, and the best hand is designed. The three dimensional structure of the intralutaneous muscle of.5. is designed to map the upper muscular bundle of the arytenoid muscle, the middle muscle bundle of the outer dipper muscle, the central muscle bundle of the posterior cricpadus muscle as the functional muscle of the inner laryngeal muscle, and the direction of the traction of the arytenoid adduction should be set according to the direction of the functional muscle in the laryngeal muscles.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R767;R322

【參考文獻】

相關(guān)期刊論文 前6條

1 王琴;涂麗莉;張銘;徐勝春;;食管縱行肌上附著點的巨微解剖[J];解剖學(xué)雜志;2006年02期

2 張世文;李曉江;劉宗良;鄭明秀;王正強;;喉內(nèi)結(jié)構(gòu)在甲狀軟骨板上的投影位置關(guān)系[J];臨床耳鼻咽喉科雜志;2006年09期

3 汪超;王斌全;皇甫輝;;杓狀軟骨的定位研究及其意義[J];中國臨床解剖學(xué)雜志;2010年06期

4 郝媛媛;孫建軍;;注射成形技術(shù)在聲門閉合不良治療中的應(yīng)用[J];中國眼耳鼻喉科雜志;2015年03期

5 張寶營;梁亮;喬明亮;張夢楠;武艷;張銘;;組織化學(xué)染色技術(shù)在超薄生物塑化標(biāo)本中的應(yīng)用[J];解剖學(xué)報;2014年03期

6 陳世彩;陳東輝;王偉;施劍斌;劉菲;鄭宏良;;雙蒂肌轉(zhuǎn)入充填聯(lián)合杓狀軟骨內(nèi)移喉成形術(shù)治療單側(cè)聲帶麻痹[J];中華耳鼻咽喉頭頸外科雜志;2010年09期

，

本文編號：2164463