本文選題：睡眠呼吸暫停 + 阻塞性��； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：1.研究背景 阻塞性睡眠呼吸暫停低通氣綜合征(obstructive sleep apnea-hypopnea syndrome OSAHS)是指睡眠時(shí)上氣道塌陷阻塞引起呼吸暫停和低通氣,通常伴有打鼾、睡眠結(jié)構(gòu)紊亂,頻繁發(fā)生血氧飽和度下降,白天嗜睡、記憶力下降等病癥。目前認(rèn)為,上呼吸道解剖結(jié)構(gòu)異常導(dǎo)致的呼吸道狹窄、上呼吸道擴(kuò)張肌張力異常等是OSAHS發(fā)生發(fā)展的主要致病因素。其中睡眠時(shí)上氣道塌陷阻塞是本病癥發(fā)生的根本原因,上呼吸道狹窄阻塞部位主要有三個(gè)平面(鼻腔、腭咽部、舌根部)。大量的臨床及基礎(chǔ)研究已經(jīng)證實(shí),腭咽部阻塞是最常見且重要的阻塞平面之一,睡眠時(shí)容易發(fā)生軟組織塌陷性狹窄,這與軟腭及口咽部解剖結(jié)構(gòu)及功能異常有著直接關(guān)系。已有研究表明,在軟腭內(nèi)存在兩個(gè)重要間隙(腭帆間隙和軟腭前間隙),間隙內(nèi)有較多脂肪組織沉積,是腭咽區(qū)狹窄的重要解剖因素。對(duì)存在嚴(yán)重腭咽部阻塞的患者,外科手術(shù)目前仍是重要的治療手段之一。 針對(duì)腭咽部阻塞的傳統(tǒng)術(shù)式為1981年由Fujita等首先應(yīng)用的腭咽成形術(shù)(uvulopalatopharyngoplasty, UPPP),手術(shù)切除部分肥厚軟腭、懸雍垂及多余的咽側(cè)壁軟組織,用以擴(kuò)大咽腔。但由于其有限的療效及部分患者術(shù)后出現(xiàn)腭咽關(guān)閉不全、咽腔瘢痕性狹窄等諸多并發(fā)癥,臨床應(yīng)用受到限制。此后,學(xué)者們針對(duì)該傳統(tǒng)術(shù)式提出了多種改良手術(shù)方法,如保留懸雍垂的腭咽成形術(shù)(H-UPPP)、腭帆成形術(shù)(VPP)、Z形腭咽成形術(shù)(ZPP)、功能性咽部擴(kuò)大成形術(shù)(FEP)等。上述改良手術(shù)方法,均強(qiáng)調(diào)切除腭咽腔多余組織的同時(shí),盡最大可能保留咽腔解剖結(jié)構(gòu)及功能,以減少并發(fā)癥發(fā)生。臨床實(shí)踐中發(fā)現(xiàn),雖然患者術(shù)后腭咽腔得到擴(kuò)大,但仍有部分患者術(shù)后治療效果不佳,對(duì)于中老年患者該問(wèn)題尤其突出。我們推測(cè),這可能與術(shù)后軟腭緊張度未得到有效改善有關(guān),目前臨床需要一種微創(chuàng)條件下解除腭咽腔解剖性狹窄的同時(shí),兼顧改善軟腭塌陷性狹窄的手術(shù)設(shè)計(jì)。 近幾年來(lái),我們?cè)贠SAHS的外科手術(shù)方法上,進(jìn)行了大膽的探索。針對(duì)以腭咽部狹窄為主的OSAHS患者,通過(guò)改良腭咽部手術(shù)切口,借助低溫等離子射頻消融技術(shù),在保留腭咽部肌肉完整性的同時(shí),消融切除軟腭間隙內(nèi)肥厚粘膜及沉積的脂肪組織,并利用相應(yīng)切口行軟腭肌肉及粘膜的張力性縫合,增加了軟腭緊張度,擴(kuò)大了軟腭后區(qū)氣道的截面積,很好的解決了軟腭塌陷性狹窄的問(wèn)題。 本研究以“微創(chuàng)條件下解除腭咽部解剖性狹窄,兼顧軟腭功能重建”為基本手術(shù)設(shè)計(jì)理念,強(qiáng)調(diào)軟腭解剖結(jié)構(gòu)(軟腭間隙及軟腭肌肉)與功能的重塑。 2研究目的 2.1探討一種針對(duì)腭咽部阻塞(軟腭松弛、塌陷為主)的改良腭咽成形手術(shù)方法,在微創(chuàng)條件下解除腭咽部解剖性狹窄的同時(shí),通過(guò)軟腭張力性縫合增加軟腭緊張度。 2.2研究本改良手術(shù)方法的主要適應(yīng)癥 2.3分析改良手術(shù)療效 2.4觀察手術(shù)后并發(fā)癥發(fā)生情況 3資料與方法 3.1研究對(duì)象選取 選取2010年12月至2012年12月間,在北京軍區(qū)總醫(yī)院耳鼻咽喉頭頸外科住院治療的OSAHS患者55例,其中男性52例,女性3例；年齡23-67歲,平均(43.27±10.5)歲；體質(zhì)量指數(shù)(BMI)20.5-38.3Kg/m2,平均(28.78±4.18)Kg/m2。55例中,合并高血壓16例(其中重度OSAHS10例,中度OSAHS患者6例),糖尿病3例,高脂血癥13例。有9例因存在明顯鼻腔狹窄,已于至少3個(gè)月前先行鼻中隔成形術(shù)或其他鼻腔擴(kuò)容手術(shù)(鼻腔手術(shù)前,9例均為重度病例,鼻腔手術(shù)后三個(gè)月復(fù)查PSG有7例變成中度病例)。 納入標(biāo)準(zhǔn) (1)成人患者,主觀癥狀明顯,本人有手術(shù)治療愿望 (2)常規(guī)檢查可見軟腭松弛、呈幔狀低垂,伴(或不伴)腭扁桃體肥大及腭弓肥厚 (3)多道睡眠呼吸監(jiān)測(cè)明確診斷為阻塞性為主的睡眠呼吸暫停低通氣綜合征 (4)電子鼻咽喉鏡檢查、喉咽CT三維重建顯示腭咽部阻塞為主 剔除標(biāo)準(zhǔn) (1)多道睡眠監(jiān)測(cè)提示中樞性為主的睡眠呼吸暫停 (2)已經(jīng)診斷明確的全身其他疾病所導(dǎo)致的OSAHS (3)相關(guān)檢查確定主要阻塞平面位于鼻腔或舌部的患者 (4)存在明確的鼻腔及舌平面阻塞,需同期行鼻腔或舌部手術(shù)的患者 3.2臨床特點(diǎn) 主觀癥狀：主訴睡眠打鼾伴憋氣,晨起咽干、白日嗜睡 咽腔特點(diǎn)：軟腭形態(tài)描述,根據(jù)Friedman軟腭位置評(píng)分系統(tǒng)(Friedman palate position score FPP),55例中,Ⅱ級(jí)5例,Ⅲ級(jí)40例,Ⅳ級(jí)10例；扁桃體肥大描述,采用Friedman扁桃體肥大分級(jí)法：扁桃體肥大Ⅰ級(jí)4例Ⅱ級(jí)42例,Ⅲ級(jí)9例； 電子鼻咽喉鏡結(jié)合Muller試驗(yàn)檢查：55例中,單純軟腭平面阻塞45例,軟腭及舌根平面阻塞10例。 CT三維重建測(cè)量均值：軟腭厚度(10.23±1.75)mm,軟腭長(zhǎng)度(38.5±5.5)mm,懸雍垂與咽后壁最短距離(3.5±0.5)mm。 多道睡眠監(jiān)測(cè)結(jié)果(PSG)：以呼吸暫停低通氣指數(shù)(AHI)、最低血氧飽和度(LSaO2)為主要觀測(cè)指標(biāo),55例中,重度43例,中度12例； 3.3研究用儀器及方法 3.3.1電子鼻咽喉鏡檢查并行Muller試驗(yàn),用于對(duì)阻塞部位的形態(tài)學(xué)觀察。 3.3.2腭咽部CT三維重建。采用GE discovery HD750CT機(jī)進(jìn)行掃描,AW4.5圖像后處理工作站進(jìn)行喉咽部三維重建。重點(diǎn)觀察口咽腔左右徑、軟腭厚度、軟腭與咽后壁最短距離、舌根與咽后壁最短距離等指標(biāo)。 3.3.3多道睡眠監(jiān)測(cè)儀器。采用飛利浦Alice Le多道睡眠監(jiān)測(cè)儀,對(duì)患者進(jìn)行整夜至少7小時(shí)睡眠監(jiān)測(cè),由專業(yè)醫(yī)師(技師)對(duì)監(jiān)測(cè)波形及數(shù)據(jù)進(jìn)行分析,重點(diǎn)觀察呼吸暫停指數(shù)(AHI)、最低血氧飽和度(LSa02)等指標(biāo)。 3.3.4低溫等離子射頻消融儀。由美國(guó)Arthrocare公司生產(chǎn),術(shù)中使用EVac XtraHP一體化等離子刀頭。 3.4手術(shù)方法：所有患者均在全身麻醉插管下進(jìn)行。圍手術(shù)期其他處理同常規(guī)腭咽成形術(shù)。 3.4.1對(duì)扁桃體及腭弓的處理 使用EVac Xtra HP一體化等離子刀頭,行雙側(cè)扁桃體被膜外切除術(shù),同時(shí)切除咽側(cè)壁多余粘膜組織,強(qiáng)調(diào)盡可能保護(hù)咽腭弓。切開咽腭弓與懸雍垂之間的幔狀粘膜連接,將咽腭弓向外上方牽拉,用3-0可吸收縫線行扁桃體窩肌層(主要為腭舌肌及腭咽肌)縫合,使咽腭弓覆蓋扁桃體手術(shù)創(chuàng)面,縫合后,咽后壁粘膜向外側(cè)方展平。咽腭弓上端暫不做縫合。 3.4.2對(duì)懸雍垂和軟腭的處理 使用等離子刀于軟腭兩側(cè)做頂點(diǎn)朝向上頜后磨牙、底邊在腭帆間隙的三角形切口,解剖切除三角形內(nèi)肥厚粘膜及粘膜下脂肪組織,注意保護(hù)深部肌肉。將三角形兩側(cè)腰粘膜緣連同深部肌肉(主要為腭帆提肌水平部)一起拉攏縫合�？p合后軟腭向外側(cè)展平,此時(shí),軟腭緊張度明顯增加。將咽腭弓上端向外上方牽拉,斜條形切除咽腭弓上端肥厚粘膜,端緣與軟腭外側(cè)方粘膜縫合。將懸雍垂側(cè)方脂肪組織消融切除(勿傷及懸雍垂肌肉組織),懸雍垂前后粘膜對(duì)位縫合。于懸雍垂與軟腭交界處上方,用低溫等離子刀橫矩形切除懸雍垂-軟腭粘膜瓣,并消融切除局部脂肪組織(切除粘膜瓣的大小依據(jù)懸雍垂長(zhǎng)度及軟腭下垂的程度決定),注意勿傷及深部肌肉。將粘膜斷緣連同深部肌肉上下對(duì)位縫合,懸雍垂及部分軟腭明顯前傾,軟腭后區(qū)氣道明顯擴(kuò)大。 4療效評(píng)價(jià) 主觀評(píng)價(jià) 應(yīng)用Epworth嗜睡量表(Epworth sleepiness scale,ESS)評(píng)價(jià)OSAHS引起的嗜睡程度；應(yīng)用視覺(jué)模擬量表(visualanalogue scale, VAS)評(píng)價(jià)術(shù)前、術(shù)后疾病對(duì)患者總體生活質(zhì)量的影響情況。 客觀評(píng)價(jià) 根據(jù)PSG檢查結(jié)果評(píng)定療效：治愈：AHI5次/h；顯效：AHI20次/h,且降低幅度≥50%；有效：AHI降低幅度≥50%。手術(shù)成功定義為：治愈和顯效者為手術(shù)成功。 5統(tǒng)計(jì)學(xué)分析 全組數(shù)據(jù)應(yīng)用Microsoft exce12003建立數(shù)據(jù)庫(kù)。數(shù)據(jù)在SPSS17.0上分析,組間差異性比較用配對(duì)t檢驗(yàn),P0.05為差異有統(tǒng)計(jì)學(xué)意義。 6結(jié)果 6.1術(shù)后療效：術(shù)后半年復(fù)查PSG結(jié)果顯示,55例患者中,治愈8例；顯效41例；有效3例,無(wú)效3例,手術(shù)成功率89.1%；手術(shù)總有效率94.55%；34例(61.82%)LSaO20.85,17例(30.91%)LSa020.65-0.85,4例(7.27%)LSaO.,0.65。 6.2術(shù)后主客觀指標(biāo)評(píng)價(jià)結(jié)果 客觀評(píng)價(jià)指標(biāo)：呼吸紊亂指數(shù)(AHI)降低,最低血氧飽和度(LSa02)升高,與術(shù)前比較均有極顯著性差異(P0.01) 主觀評(píng)價(jià)指標(biāo)：ESS得分減低,VAS分值降低,與術(shù)前比較均有極顯著性差異(P0.01)。 6.3術(shù)后咽腔形態(tài)觀察：術(shù)后一周內(nèi)軟腭及懸雍垂粘膜水腫,軟腭及懸雍垂前傾,與舌根無(wú)明顯接觸。術(shù)后6個(gè)月復(fù)查,所有患者咽腔形態(tài)結(jié)構(gòu)基本穩(wěn)定,軟腭呈明顯向左右兩側(cè)牽拉外展形狀,軟腭游離緣及懸雍垂明顯前傾。 6.4關(guān)于手術(shù)并發(fā)癥 6.4.1術(shù)區(qū)出血：55例患者術(shù)中平均出血量約20毫升；無(wú)一例出現(xiàn)術(shù)后原發(fā)性及繼發(fā)性出血。 6.4.2術(shù)后呼吸梗阻：術(shù)后一周內(nèi)腭咽腔術(shù)區(qū)粘膜水腫,但不影響正常呼吸。未出現(xiàn)術(shù)后上氣道梗阻需氣管插管或氣管切開病例。 6.4.3鼻腔返流：32例患者術(shù)后一周內(nèi)飲水時(shí)偶有鼻腔返流,其中持續(xù)3天20例,持續(xù)5天10例,持續(xù)7天2例.手術(shù)一周后無(wú)鼻腔返流病例。 6.4.4術(shù)后開放性鼻音：所有術(shù)后患者咽腔疼痛緩解、正常講話后,無(wú)一例出現(xiàn)開放性鼻音。 6.4.5咽部瘢痕性狹窄：術(shù)后隨訪,無(wú)一例出現(xiàn)口咽部及腭后區(qū)瘢痕性狹窄及粘連。 7.結(jié)論 7.1低溫等離子輔助下軟腭外展加軟腭-懸雍垂折疊術(shù)是一種微創(chuàng)條件下解除腭咽部解剖性狹窄,同時(shí)兼顧軟腭功能重建的改良腭咽成形手術(shù)。本改良手術(shù)的優(yōu)點(diǎn)在于：通過(guò)軟腭側(cè)方斜三角形和軟腭中部橫矩形兩個(gè)切口,解剖切除腭帆和軟腭前兩個(gè)間隙內(nèi)沉積脂肪組織,并通過(guò)切口及深部肌肉的張力性縫合,達(dá)到增加軟腭張力、防止軟腭下垂的目的,手術(shù)安全、有效。 7.2手術(shù)適應(yīng)癥：(1)多道睡眠監(jiān)測(cè)提示阻塞性睡眠呼吸暫停低通氣綜合征 (2)阻塞部位以腭咽部為主,軟腭松弛塌陷、呈幔狀低垂；伴或不伴扁桃體肥大 (3)不耐受或不接受持續(xù)正壓通氣治療的腭咽部阻塞患者
[Abstract]:1 . Background of the study

Obstructive sleep apnea - phlegm syndrome ( Obstructive sleep apnea - obstructive syndrome ) is the main cause of the development of obstructive sleep apnea - syndrome syndrome . It is usually accompanied by snoring , disordered sleep , frequent occurrence of decreased blood oxygen saturation , daytime drowsiness , and decreased memory . A large number of clinical and basic studies have shown that the obstruction of the palate is one of the most common and important obstruction planes . It has a direct relationship with the anatomy and function of soft palate and oropharynx .

In order to reduce the complications , it is pointed out that although the palatopharyngoplasty ( H - UPPP ) , palatopharyngoplasty ( vpp ) , Z - shaped palatopharyngoplasty ( ZPP ) , functional pharyngeal dilation ( FEP ) , etc .

In recent years , we have carried out a bold exploration in the surgical method of obstructive sleep apnea syndrome . With the improvement of the surgical incision of the palate pharynx , the soft palate and the fat tissue of the soft palate are ablated . The soft palate tension is increased , the cross - sectional area of the airway in the posterior region of the soft palate is enlarged , and the problem of stenosis of the soft palate is well solved .

This study focused on the reconstruction of soft palate anatomy ( soft palate gap and soft palate muscle ) and function by removing the anatomic stenosis of the palate under " minimally invasive conditions " and combining the soft palate function reconstruction " as the basic surgical design concept .

2 Purpose of study

2.1 To explore a modified palatopharyngoplasty procedure aiming at the obstruction of the palate ( soft palate relaxation and collapse ) , and the soft palate tension is increased through the soft palate tension suture while the anatomical stenosis of the palate is relieved under minimally invasive conditions .

2.2 Main indications for the study of the modified procedure

2.3 Analysis of Modified Surgical Efficacy

2.4 Observe the occurrence of postoperative complications

3 Materials and Methods

3.1 Selection of research objects

From December 2010 to December 2012 , 55 patients were hospitalized in Beijing Military Region General Hospital , who were hospitalized in the throat of the throat and throat , including 52 males and 3 females .
Age 23 - 67 years , mean ( 43.27 鹵 10.5 ) years old ;
Body mass index ( BMI ) 20.5 - 38.3Kg / m2 , average ( 28.78 鹵 4.18 ) Kg / m2 . In 55 cases , there were 16 cases of hypertension complicated with hypertension ( including 6 cases of severe OSA HS10 , 6 cases with moderate obstructive sleep ) , 3 cases of diabetes mellitus and 13 cases of hyperlipemia .

Inclusion criteria

( 1 ) Adult patients , subjective symptoms are obvious , I have the wish of surgical treatment

( 2 ) The normal examination shows that the soft palate is loose , and the soft palate is low , with ( or without ) the hypertrophy of the palate and the hypertrophy of the palatine arch .

( 3 ) Clear diagnosis of obstructive sleep apnea with obstructive sleep apnea syndrome

( 4 ) The CT three - dimensional reconstruction of the pharynx and pharynx of the electronic nose shows the main obstruction of the palate pharynx .

Exclusion Criteria

( 1 ) Sleep apnea with central focus on multi - channel sleep monitoring

( 2 ) has been diagnosed with clear systemic other diseases caused by obstructive sleep apnea syndrome

( 3 ) The correlation check determines that the primary obstruction plane is located in the nasal or lingual patient

( 4 ) There is definite obstruction of nasal cavity and lingual plane , and patients undergoing nasal or tongue surgery should be performed simultaneously .

3.2 Clinical characteristics

Subjective symptoms : complaints of sleep snoring with breath hold , morning pharyngeal dryness , white - day sleep

Features of pharyngeal cavity : description of soft palate configuration , in 55 cases , grade 鈪，

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