本文關(guān)鍵詞：表面肌電圖在吞咽功能檢查中的應(yīng)用　出處：《南方醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 表面肌電圖 吞咽 吞咽障礙 咽異感癥 扁桃體切除術(shù) 疼痛

【摘要】：研究背景 吞咽是食物經(jīng)咀嚼而形成的食團(tuán)由口腔經(jīng)咽和食管入胃的整個(gè)過程,吞咽不是一個(gè)單純的隨意活動(dòng),是人類復(fù)雜而必需的行為之一。吞咽分為口腔期、咽期和食管期三個(gè)階段,受大腦皮層、皮質(zhì)延髓束、腦干神經(jīng)核、吞咽中樞和第Ⅴ、Ⅶ、Ⅸ、Ⅹ、Ⅺ、Ⅻ對腦神經(jīng)控制,每個(gè)階段細(xì)微的功能紊亂均可導(dǎo)致吞咽功能紊亂或障礙。隨著我國步入老齡時(shí)代,生活方式的巨變導(dǎo)致腦卒中和顱頸部外傷明顯增多。腦外傷、顱內(nèi)和顱底手術(shù)的廣泛開展、頭頸腫瘤手術(shù)和放療等因素,各種原因引起的吞咽障礙的發(fā)病率明顯增高。吞咽障礙涉及多個(gè)學(xué)科,主要有耳鼻咽喉頭頸外科、神經(jīng)內(nèi)科、神經(jīng)外科、消化內(nèi)科、放療科、康復(fù)醫(yī)學(xué)科等,但沒有受到這些學(xué)科的重點(diǎn)關(guān)注。當(dāng)前吞咽功能檢查方法較多,各有優(yōu)缺點(diǎn),大體上包括臨床評估與儀器檢查。臨床評估可分為：①主觀評估：指醫(yī)生根據(jù)患者的主訴,詢問病史,從主觀上發(fā)現(xiàn)患者是否存在吞咽障礙；②客觀評估主要有反復(fù)唾液吞咽試驗(yàn)、洼田飲水試驗(yàn)和經(jīng)口攝食功能量表。它們的優(yōu)點(diǎn)是快速、簡單、無創(chuàng),而缺點(diǎn)是需要患者認(rèn)真配合,依據(jù)患者的臨床癥狀及主觀感受來對吞咽功能進(jìn)行評估,其敏感性和特異性各家報(bào)道差別較大。儀器檢查中吞咽造影檢查和內(nèi)鏡檢查用的比較廣泛。吞咽造影檢查(Videofluoroscopic swallowing examination, VFSE),又稱動(dòng)態(tài)吞咽檢查(Dynamic swallow study, DSS),即在X線透視下,針對口、咽、喉、食管的吞咽運(yùn)動(dòng)所進(jìn)行的特殊造影,通過對錄像的逐幀分析了解吞咽狀況,臨床上目前使用較廣泛,缺點(diǎn)是有放射線；內(nèi)鏡吞咽檢查法是用纖維喉鏡等檢查咽喉的解剖結(jié)構(gòu)及唾液的潴留情況,其操作方法簡便靈活,不同程度的患者都可接受此檢查,能在床旁、甚至在ICU中進(jìn)行,此檢查還能發(fā)現(xiàn)喉部黏膜水腫情況、有無肉芽、潰瘍和聲帶麻痹、喉氣管狹窄等異常變化,但是其缺點(diǎn)是,著重于局部的觀察,對吞咽的全過程、解剖結(jié)構(gòu)與食團(tuán)的關(guān)系以及環(huán)咽肌和食管的功能方面得到的信息不多。由于吞咽時(shí)內(nèi)鏡的視野消失,僅可在吞咽前后進(jìn)行觀測,不能觀測食團(tuán)在吞咽時(shí)的基本運(yùn)動(dòng)情況,同時(shí)對咽期的檢測仍不夠全面,不能評測口腔期和食管期的變化以及舌和喉之間的運(yùn)動(dòng)協(xié)調(diào)性。表面肌電圖,也稱動(dòng)態(tài)肌電圖,是一種安全、簡單、無創(chuàng)有關(guān)肌肉功能狀況的檢查手段。近20年來,國外已有學(xué)者運(yùn)用表面肌電圖作為吞咽障礙的篩查診斷的首選方法,它可以對所查肌肉進(jìn)行工作情況、工作效率的量化,指導(dǎo)患者進(jìn)行神經(jīng)、肌肉功能訓(xùn)練,但國內(nèi)尚無此類研究的報(bào)道。 目的 1.通過對正常成人做表面肌電圖研究,建立吞咽過程中肌肉活動(dòng)持續(xù)時(shí)間和振幅的正常數(shù)據(jù)庫。 2.研究咽異感癥患者吞咽表面肌電圖變化,探討咽異感癥的病因。 3.研究吞咽表面肌電圖用于評估扁桃體切除術(shù)后病人疼痛程度的可能性。 方法 1.研究對象： 1.1第一章選取126例健康成人志愿者,所有受試者均通過社會招募,在簽署知情同意書后在海軍總醫(yī)院耳鼻喉科肌電圖室進(jìn)行吞咽的表面肌電圖檢查,該研究經(jīng)過海軍總醫(yī)院倫理委員會批準(zhǔn)。志愿者招募時(shí)間為2012年5月至2012年12月,入選標(biāo)準(zhǔn)：①年齡≥18歲,≤65歲；②神志清楚；③無耳鼻喉科及胃腸病病史,無吞咽困難、吞咽痛病史；④愿意接受評定。最終招募了126位成年人,其中女性60例,男性66例；年齡范圍18-65歲,并按年齡分成4組：30歲組、40歲組、50歲組和≥50歲組。 1.2第二章咽異感癥組均為有吞咽不適主訴到我科就診的病人,入組標(biāo)準(zhǔn)：①沒有耳鼻喉科和胃腸病病史,沒有吞咽困難、吞咽痛病史,沒有醫(yī)學(xué)疾病或藥物可能影響吞咽的病史；②耳鼻咽喉科內(nèi)鏡檢查和下咽食管造影均無異常器質(zhì)性病變和誤吸,所有的受試者都有正常的口腔解剖結(jié)構(gòu)。凡有扁桃體病變,咽部角化癥、下咽惡性腫瘤、會厭囊腫、莖突過長等都排除。最終34例咽異感癥病人入組,年齡20—66歲,其中女性17人,男性17人。 1.3第三章選取2013年5月-2013年12月份在我院行扁桃體切除術(shù)的患者32名,男性15名,女性17名。年齡分布20-60歲。選取標(biāo)準(zhǔn)：①患者年齡20歲,60歲；②均在全身麻醉下行射頻輔助雙側(cè)扁桃體切除術(shù),術(shù)中出血量5～20ml,所有患者皆未出現(xiàn)術(shù)后出血,術(shù)后未用止痛藥；③無其它耳鼻咽喉科及胃腸科病史,無吞咽困難,吞咽痛等病史；④排除神經(jīng)、精神疾病,肺部疾患,無嚴(yán)重?zé)�、酒等物質(zhì)濫用情況。 2.肌電圖記錄技術(shù)及方法 2.1設(shè)備：用于記錄表面肌電圖的設(shè)備是丹麥Alpine Biomed公司的KEYPOINT全功能肌電誘發(fā)電位儀。采用的軟件是Keypoint. Classic。記錄每次吞咽時(shí)肌肉活動(dòng)的持續(xù)時(shí)間以及振幅。 2.2表面電極放置的位置：與吞咽相關(guān)的肌群主要有以下4對：①口輪匝��；②咬��；③頦下肌群包括二腹肌前腹、下頜舌骨肌、頦舌��；④舌骨下肌群。這些肌肉位置表淺,能通過表面電極記錄吞咽時(shí)它們的肌電活動(dòng)。由于正常的吞咽活動(dòng)是以上肌肉協(xié)調(diào)運(yùn)動(dòng)的結(jié)果,且電活動(dòng)具有傳導(dǎo)性,所以我們選擇頸部正中甲狀軟骨上方1cm為電極放置位置。兩表面電極之間的距離為1cm,即兩表面電極距中線0.5cm。主要記錄咽期的吞咽活動(dòng)。一側(cè)手腕部位為接地電極。用酒精紗布輕輕地擦電極接觸的位置,并且涂電極凝膠以降低電阻。 3.試驗(yàn)程序及記錄 電極安置完畢后,每個(gè)受試者進(jìn)行3種吞咽方式的測試記錄。 3.1空吞咽：指示受試者“干咽一次”。 3.2吞咽20ml水：指示受試者“先把20ml水全部含在嘴里,一口咽下去”。 3.3吞咽40ml水：指示受試者“先把40ml水全部含在嘴里,盡量一口咽下去,一口咽不完,可以分兩口”。(第二章、第三章省略此步驟) 以上測試全部測2次,取平均值,為防止?fàn)C傷,選擇室溫涼白開水。記錄吞咽時(shí)肌電活動(dòng)的最大振幅及持續(xù)時(shí)間。 4.視覺模擬評分法(VAS)是將疼痛的程度用0至10共11個(gè)數(shù)字表示,0表示無痛,10代表最痛,病人根據(jù)自身疼痛程度在這11個(gè)數(shù)字中挑選一個(gè)數(shù)字代表疼痛程度。0分：無疼痛；3分以下：有輕微的疼痛,患者能忍受；4-6分：患者疼痛并影響睡眠,尚能忍受,可給予臨床處置；7-10分：患者有漸強(qiáng)烈的疼痛,疼痛劇烈或難忍。分別記錄患者術(shù)后1天以及2天的數(shù)值。(此步驟僅用于第三章) 結(jié)果 1.健康成年男性空吞咽、吞咽20ml水、吞咽40ml水時(shí)肌電活動(dòng)持續(xù)時(shí)間平均(z±s,下同)分別為(1.133±0.209)s、(1.097±0.208)s和(1.510±0.432)s,振幅分別為(0.332±0.115)mV、(0.308±0.095)mV和(0.399±0.139)mV。健康成年女性同樣吞咽時(shí)肌電活動(dòng)持續(xù)時(shí)間分別為(1.118±0.170)s、(1.085±0.209)s和(1.765±0.463)s,振幅分別為(0.292±0.100)mV、(0.261±0.113)mV和(0.342±0.129)mV。所有的吞咽方式中男性受試者吞咽時(shí)的振幅均大于女性(P值均0.05),除吞咽40ml水的吞咽持續(xù)時(shí)間女性長于男性(t=3.199,P0.05)外,其余吞咽方式的持續(xù)時(shí)間差異均無統(tǒng)計(jì)學(xué)意義(P值均0.05)。所有受試者吞咽40ml水的時(shí)間均長于空吞咽和吞咽20ml水時(shí),吞咽20ml水和空吞咽時(shí)差異無統(tǒng)計(jì)學(xué)意義；吞咽40ml水的振幅大于空吞咽,空吞咽的振幅大于吞咽20ml水時(shí)。不同年齡組男性受試者的肌電圖持續(xù)時(shí)間和振幅差異均無統(tǒng)計(jì)學(xué)意義(P值均0.05)；女性受試者除年輕組(30歲)吞咽40ml水的時(shí)間長于年長組外(P0.05),其余吞咽方式肌電圖參數(shù)差異均無統(tǒng)計(jì)學(xué)意義(P值均0.05)。 2.對照組空吞咽、20m1水吞咽時(shí)肌電活動(dòng)持續(xù)時(shí)間分別為(1.128±0.191)s、(1.091±0.208)s,振幅分別為(0.313±0.11)mV、(0.286±0.106)mV。咽異感癥組空吞咽、20m1水吞咽時(shí)肌電活動(dòng)持續(xù)時(shí)間分別為(1.178±0.252)s、(1.127±0.178)s,振幅分別為(0.341±0.116)mV、(0.316±0.094)mV。咽異感癥組空吞咽、20m1水吞咽時(shí)肌肉活動(dòng)時(shí)間和振幅與對照組沒有明顯差異。進(jìn)一步按不同性別再進(jìn)行比較,咽異感癥組男性空吞咽、20m1水吞咽時(shí)肌肉活動(dòng)時(shí)間和振幅與對照組沒有明顯差異,咽異感癥組女性空吞咽、20m1水吞咽時(shí)肌肉活動(dòng)時(shí)間和振幅與對照組也沒有明顯差異。 3.所有的吞咽方式中,術(shù)后1天和術(shù)后2天干咽時(shí)sEMG持續(xù)時(shí)間和振幅皆小于術(shù)前,吞咽20mL水所需時(shí)間大于術(shù)前,而振幅小于術(shù)前。術(shù)后1天和術(shù)后2天的干咽時(shí)間、干咽振幅、20m1水吞咽時(shí)間、20mL吞咽振幅和VAS評分都無統(tǒng)計(jì)學(xué)差異(p0.05) 結(jié)論 1.吞咽的表面肌電圖是一種簡單、無創(chuàng)的評估吞咽功能的檢查方法,本研究取得的健康人群吞咽表面肌電圖的數(shù)據(jù)有望為今后開展吞咽功能篩查提供參考。 2.咽異感癥病人與健康人吞咽肌電活動(dòng)沒有差別,間接推斷患者無客觀吞咽功能受損,治療上應(yīng)該重視心理干預(yù)的作用。 3.吞咽表面肌電圖能夠觀察到扁桃體切除術(shù)后患者因疼痛導(dǎo)致的吞咽時(shí)的肌肉活動(dòng)變化,可根據(jù)這些變化指導(dǎo)是否需要鎮(zhèn)痛藥物或停止使用鎮(zhèn)痛藥物,但其不能用于判定疼痛的程度。
[Abstract]:Research background
Swallowing is formed by chewing food bolus from the mouth through the whole process of pharynx and esophagus into the stomach, swallowing is not a simple casual activities, is one of the most complex and essential behavior. Swallowing is divided into oral, pharyngeal and esophageal in three stages by the cerebral cortex, brainstem CORTICONUCLEAR tract. Nucleus, Central swallowing and V, VII, IX, x, Xi, XII nerve control, each stage of slight dysfunction can cause swallowing dysfunction or disorder. As China entered the aging era, changes in lifestyle lead to stroke and craniocervical trauma increased significantly. Traumatic brain injury, intracranial and to carry out a wide range of skull base surgery, surgery and radiotherapy for head and neck cancer and other factors, dysphagia caused by various reasons. The incidence of dysphagia involves multiple disciplines, mainly of Otolaryngology Head and neck surgery, Department of Neurology, Department of Neurosurgery, Department of Gastroenterology, put Department of rehabilitation medicine, treatment, etc., but not paying close attention to these subjects. More current examination of swallowing methods, each has advantages and disadvantages, generally including clinical assessment and examination equipment. Clinical evaluation can be divided into: subjective evaluation: refers to the doctor according to the patient's medical history, from the subjective complaints, whether patients found there is an objective assessment of swallowing disorder; the repeated saliva swallowing test, Watian drinking water test and oral intake function scale. Their advantages are rapid, simple, noninvasive, but the drawback is the need of patients with serious, according to the clinical symptoms and the subjective experience of patients to assess swallowing function, its sensitivity and specificity various reports vary greatly. In contrast examination and examination of swallowing endoscopy used widely. Swallowing angiography (Videofluoroscopic swallowing examination, VFSE), also known as the dynamic swallowing Check (Dynamic swallow study, DSS), which is under fluoroscopy, needle mouth, pharynx, larynx, esophagus special contrast swallowing of the video frame, through the analysis and understanding of clinical swallowing status is used widely, there is a disadvantage of Radiology; endoscopic examination of swallowing method is the use of retention the situation of anatomical structure and fiber laryngoscope examination saliva throat, the operation method is simple and flexible, different patients can accept this check, can beside the bed, even in ICU, this check can find laryngeal mucosa edema, there is no granulation, ulcer and vocal cord paralysis, laryngotracheal stenosis and abnormal changes however, the disadvantage is that focuses on local observation, the whole process of swallowing function, anatomical structure and food and the relationship between the cricopharyngeal muscle and esophagus obtained much information. Because swallowing endoscopic vision disappeared, only before swallowing After the observation, the basic motion can not be observed in the bolus during swallowing, the detection of pharyngeal stage is still not comprehensive, the movement coordination between changes in oral and esophageal not evaluating period, tongue and throat. Also called dynamic surface electromyography, EMG, is a safe, simple, noninvasive on muscle function the means of inspection. Over the past 20 years, foreign scholars using the surface EMG as the preferred method of screening and diagnosis of dysphagia, it can work for the check of muscle, the efficiency of quantization, guiding patients with nerve and muscle function training, but there is no domestic reports.
objective
1. the normal database of the duration and amplitude of muscle activity during swallowing was established by the study of the surface electromyography of normal adults.
2. the changes in the swallowing surface electromyography of patients with pharynx were studied, and the etiology of pharynx was discussed.
3. of the surface EMG was used to assess the possibility of swallowing pain after tonsillectomy.
Method
1. research object:
In Chapter 1.1, a total of 126 healthy adult volunteers, all subjects were recruited through social, after signing the informed consent of the surface EMG examination of swallowing in the Department of ENT of Navy General Hospital electromyogram room, Navy General Hospital ethics committee approved the study. Volunteer Recruitment time from May 2012 to December 2012, the inclusion criteria: 18 years of age or older than 65 years. The conscious; no; the Department of ENT and gastrointestinal disease, dysphagia, odynophagia and history; willing to accept the assessment. Finally recruited 126 adults, including 60 female cases and 66 male cases; age range 18-65, and divided into 4 groups by age: 30 years old group, 40 years old group, 50 years old group and above 50 years old group.
The 1.2 chapter second pharyngeal paraesthesia group were swallowing complaints to my clinic patients group: no Department of ENT and gastrointestinal disease, no history of dysphagia, odynophagia, no medical diseases or drugs may affect swallowing history; the otolaryngology Kone bronchoscopy and hypopharynx and cervical esophagus angiography showed no abnormal pathological changes and aspiration, all subjects had normal anatomic structure. All lesions of oral pharyngeal tonsil, keratosis, hypopharyngeal malignant tumor, cyst of epiglottis, styloid process are excluded. Finally 34 cases of pharyngeal paraesthesia patients into the group, aged 20 - 66 years old among them, 17 female, 17 male.
The 1.3 chapter selects third May 2013 -2013 year in December in our hospital for tonsillectomy in 32 patients, 15 males and 17 females. The age distribution of 20-60. Selection criteria: age of patients 20 years of age, 60 years; the all downlink RF assisted tonsillectomy under general anesthesia, intraoperative bleeding was 5 ~ 20ml, hemorrhage are not all patients, no postoperative pain; the other department of Otolaryngology, Gastroenterology and history, there is no difficulty in swallowing, swallowing pain history; the exclusion of nerve, mental disease, lung disease, no serious smoke, wine and other substance abuse.
2. electromyogram recording techniques and methods
The 2.1 device: the device for recording surface electromyography is the KEYPOINT full function electromyographic evoked potential instrument of Alpine Biomed of Denmark. The software is Keypoint. Classic., which records the duration and amplitude of muscle activity during each swallowing.
Place the 2.2 surface electrode position: associated with swallowing muscles are mainly in the following 4: 1 of the orbicularis oris muscle; the masseter muscle; the submental muscles including two abdominal anterior abdominal, mylohyoid, genioglossus; the infrahyoid muscles. The superficial position, through surface electrodes recorded. When they swallow EMG activity. Because swallowing activity is more than normal muscle results, and the electrical activity has conductivity, so we choose the middle of the neck thyroid cartilage above 1cm position is between the two electrodes. The surface of the electrode distance is 1cm, namely two surface electrodes from the middle line of 0.5cm. were recorded the pharyngeal phase of swallowing activity one side of the wrist. As the ground electrode. Gently rub with alcohol gauze electrode contact position and coated electrode gel to reduce resistance.
3. test procedures and records
After the placement of the electrode, each participant was tested for 3 ways of swallowing.
3.1 empty swallowing: instruct the subject "to swallow once".
3.2 swallowing 20ml water: instruct the subjects to "contain all the 20ml water in the mouth, one oropharynx down".
3.3 swallowing 40ml water: instruct the subjects to "put 40ml water in their mouths first, and swallow them as much as possible, and they can be divided into two mouths by one swallow". (second chapters, third chapters omitted this step).
All the above tests were measured 2 times, and the average value was taken to prevent the scald. Select the cool and white water at room temperature. Record the maximum amplitude and duration of myoelectric activity during swallowing.
4. visual analogue scale (VAS) is the degree of pain by 0 to 10 a total of 11 numbers, 0 said the 10 represents the most pain, pain, pain in patients according to their degree of these 11 figures selected a number represents the degree of pain.0: no pain; the following 3 points: mild pain, patients can endure; 4-6: pain and sleep, still can bear, can be given to clinical disposal; 7-10: Patients with more intense pain, severe pain or unbearable. Were recorded 1 days after surgery and 2 day value. (this step only for Chapter third)
Result
1.鍋ュ悍鎴愬勾鐢鋒，

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