喉关节纵向运动的影像学及显微解剖学研究

发布时间：2018-08-04 16:34

【摘要】：目的：喉运动障碍可导致如发音障碍、饮水呛咳、呼吸困难等喉功能异常,影响患者生活和交流,严重者可危及生命。喉关节运动障碍病因复杂,既有环杓关节脱位、环甲关节损伤所致的声带机械性运动障碍,也有喉返神经、喉伤神经麻痹所引起的神经肌肉功能障碍。正常生理状态下喉关节(环杓关节、环甲关节)的运动轨迹仍有疑点,本课题组前期通过对尸体标本的喉关节造影、塑化及组织学染色等发现环杓关节中杓状软骨除原有的旋转、滑动和摆动,可能出现跳动；环甲关节中甲状软骨下角不仅在环状软骨的关节窝中旋转,还有可能滑动。本研究主要目的是(1)对正常志愿者及患者分平静呼吸、发”yi”音两个生理状态进行喉部CT扫描及三维重建,观察杓状软骨是否存在矢状位位移及如何定量测量矢状位位移;环甲关节是否同时存在滑动和旋转以及运动的方向。(2)利用螺旋CT合并三维重建技术观测肌突在甲状软骨的投影,术前对每个病人行喉软骨重建图并在虚拟的甲状软骨图像上开窗,以期术中定位肌突和寻找最佳甲状软骨开窗方法。(3)基于超薄塑化与显微解剖技术,确立喉内肌精细的三维构筑图,探讨喉内肌的功能肌束。方法：1.影像学检查对检查者平静呼吸和发”yi”进行螺旋CT扫描结合三维重建技术,测算喉软骨的位移变化及肌突投影点的定位。(1)扫描对35例检查者(无喉部疾病)和7例单侧声带麻痹的患者平静呼吸和发“yi”声分别行喉部薄层容积扫描结合三维重建。(2)测量(a)杓状软骨声带突、肌突的纵向位移：以通过环状软骨弓最上缘的扫描平面作为参考面,测量发音时杓状软骨的声带突和肌突相对于参考面的垂直距离,并分别计算出发音时杓状软骨的声带突和肌突的矢状位位移范围；(b)环状软骨、甲状软骨的纵向位移：以通过第五颈椎最上缘的扫描平面作为参考面,测量平静呼吸和发“yi”声时环状软骨板上缘和下缘相对于参考面的垂直距离,和甲状软骨上、下角相对于参考面的垂直距离,分别计算出发音时环状软骨板上、下缘和甲状软骨上、下角的矢状位位移范围；(c)甲状软骨下角滑动的方向：以通过环状软骨弓最上缘的扫描平面作为参考面,测量平静呼吸和发“yi”声时甲状软骨下角相对于参考面的垂直距离；以通过环状软骨板后缘的冠状面作为参考面,测量发音时甲状软骨下角相对于参考面的垂直距离,通过位移变化判断滑动的方向。(d)肌突投影点的定位：测量平静呼吸时肌突在甲状软骨上投影点距离甲状软骨上角和下角的距离。(e)在三维重建图像上模拟甲状软骨板开窗：以甲状软骨板后缘的中点为圆心,以中点和肌突在甲状软骨板上的投影点之间的距离为半径,向前开窗,通过旋转图像,从各视角观察杓状软骨体。(3)统计分析实验数据以均数土标准差(X±s)表示,采用SPSS 22.0软件分析数据,进行混合线形分析和t检验。以P0.05认为差异有统计学意义,P0.01认为具有高度统计学意义。2.解剖学研究显微解剖与超薄塑化技术相结合,观察各喉内肌(环杓侧肌、甲杓肌、环杓后肌及环甲肌)内肌束的数量、走向、起止点及与喉软骨和声带的三维结构关系。(1)喉部尸体标本组织块,经脱水脱脂塑化后制成全透明硬组织块,沿水平、冠状、矢状位制作150-200μm厚的全透明系列超薄塑化切片：切片经普通显微镜、高清扫描仪、激光共聚焦显微镜收集图像资料,并进行观察。(2)另取喉部尸体标本组织,在体式显微镜下行精细的外科手术解剖,收集资料。(3)观察指标：(a)明确各喉内肌之间的毗邻关系。(b)确定各喉内肌的分部。(c)确定喉内肌的各肌束的起止点。(d)确定喉内肌的各肌束走行及各肌束与参考平面的夹角。结果1.环杓关节(1)生理状态下,在发“yi”音和平静呼吸时杓状软骨的声带突矢状位位移距离大于肌突。(2)杓状软骨的肌突和声带突的矢状轴位移距离在不同的年龄、性别、侧别均不同。(3)单侧声带麻痹的患者,患侧与健侧的肌突垂直距离差为1.5mm,声带突为0.8mm,患侧的声带突和肌突均高于健侧。(4)环状软骨和杓状软骨的肌突可以在三维重建图像中较好地显影。2.环甲关节(1)生理状态下,发“yi”音时环状软骨相对于颈椎发生矢状位位移,甲状软骨几乎没有。(2)在发“yi”音和平静呼吸时甲状软骨的下角相对于环状软骨面发生了滑动。3.肌突的定位及甲状软骨板开窗喉部薄层容积扫描及三维重建图像可以清楚显示肌突在甲状软骨的投影及喉软骨的三维空间关系,故喉部框架手术时应常规行该项检查,以便提高肌突定位的准确性。重建图像可以在三维方向上旋转,进行不同视角的观察,可在虚拟图像上反复进行开窗,设计最佳手术进路。4.三维构筑环杓侧肌分上下两部,上部粗大,与环状软骨弓参考面夹角为65°。甲杓肌分内外两部,甲杓外肌中部肌束粗大,与参考面夹角为50°。环杓后肌中部肌束粗大,与参考面的夹角为40°。结论：1.环杓关节正常生理状态下杓状软骨除了沿环状软骨关节面做滑动、旋转及摇摆运动外,还离开环状软骨关节面在矢状位上做上下的“弹跳”运动。2.环甲关节在正常生理状态下,发“yi”音时,环状软骨旋转的同时,还沿环甲关节面向前上滑行。3.创立完善的声带纵向运动定量检测法对被检测者平静呼吸和发“yi”音时行螺旋CT扫描结合三维重建技术,定量化测量双侧声带垂直位置差,并将杓状软骨矢状位位移的定量分析作为临床评价声带功能的依据之一。4.喉框架手术的定位喉部薄层容积扫描及三维重建图像可以清楚显示肌突在甲状软骨的投影,故喉部框架手术时应常规行该项检查,以便提高肌突定位的准确性。重建的图像可以在三维方向上旋转,进行不同视角的观察,在虚拟图像上反复进行开窗,设计最佳手术进路。5.喉内肌的三维构筑图环杓侧肌上部肌束、甲杓外肌中部肌束、环杓后肌中部肌束分别为所在喉内肌的功能肌束,杓状软骨内收术的牵拉方向应根据喉内肌的功能肌束方向设定。
[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.
【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R767;R322

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