表面肌电图在吞咽功能检查中的应用

发布时间：2018-01-16 04:08

  本文关键词：表面肌电图在吞咽功能检查中的应用　出处：《南方医科大学》2014年硕士论文　论文类型：学位论文

  更多相关文章： 表面肌电图 吞咽 吞咽障碍 咽异感症 扁桃体切除术 疼痛

【摘要】：研究背景 吞咽是食物经咀嚼而形成的食团由口腔经咽和食管入胃的整个过程,吞咽不是一个单纯的随意活动,是人类复杂而必需的行为之一。吞咽分为口腔期、咽期和食管期三个阶段,受大脑皮层、皮质延髓束、脑干神经核、吞咽中枢和第Ⅴ、Ⅶ、Ⅸ、Ⅹ、Ⅺ、Ⅻ对脑神经控制,每个阶段细微的功能紊乱均可导致吞咽功能紊乱或障碍。随着我国步入老龄时代,生活方式的巨变导致脑卒中和颅颈部外伤明显增多。脑外伤、颅内和颅底手术的广泛开展、头颈肿瘤手术和放疗等因素,各种原因引起的吞咽障碍的发病率明显增高。吞咽障碍涉及多个学科,主要有耳鼻咽喉头颈外科、神经内科、神经外科、消化内科、放疗科、康复医学科等,但没有受到这些学科的重点关注。当前吞咽功能检查方法较多,各有优缺点,大体上包括临床评估与仪器检查。临床评估可分为：①主观评估：指医生根据患者的主诉,询问病史,从主观上发现患者是否存在吞咽障碍；②客观评估主要有反复唾液吞咽试验、洼田饮水试验和经口摄食功能量表。它们的优点是快速、简单、无创,而缺点是需要患者认真配合,依据患者的临床症状及主观感受来对吞咽功能进行评估,其敏感性和特异性各家报道差别较大。仪器检查中吞咽造影检查和内镜检查用的比较广泛。吞咽造影检查(Videofluoroscopic swallowing examination, VFSE),又称动态吞咽检查(Dynamic swallow study, DSS),即在X线透视下,针对口、咽、喉、食管的吞咽运动所进行的特殊造影,通过对录像的逐帧分析了解吞咽状况,临床上目前使用较广泛,缺点是有放射线；内镜吞咽检查法是用纤维喉镜等检查咽喉的解剖结构及唾液的潴留情况,其操作方法简便灵活,不同程度的患者都可接受此检查,能在床旁、甚至在ICU中进行,此检查还能发现喉部黏膜水肿情况、有无肉芽、溃疡和声带麻痹、喉气管狭窄等异常变化,但是其缺点是,着重于局部的观察,对吞咽的全过程、解剖结构与食团的关系以及环咽肌和食管的功能方面得到的信息不多。由于吞咽时内镜的视野消失,仅可在吞咽前后进行观测,不能观测食团在吞咽时的基本运动情况,同时对咽期的检测仍不够全面,不能评测口腔期和食管期的变化以及舌和喉之间的运动协调性。表面肌电图,也称动态肌电图,是一种安全、简单、无创有关肌肉功能状况的检查手段。近20年来,国外已有学者运用表面肌电图作为吞咽障碍的筛查诊断的首选方法,它可以对所查肌肉进行工作情况、工作效率的量化,指导患者进行神经、肌肉功能训练,但国内尚无此类研究的报道。 目的 1.通过对正常成人做表面肌电图研究,建立吞咽过程中肌肉活动持续时间和振幅的正常数据库。 2.研究咽异感症患者吞咽表面肌电图变化,探讨咽异感症的病因。 3.研究吞咽表面肌电图用于评估扁桃体切除术后病人疼痛程度的可能性。 方法 1.研究对象： 1.1第一章选取126例健康成人志愿者,所有受试者均通过社会招募,在签署知情同意书后在海军总医院耳鼻喉科肌电图室进行吞咽的表面肌电图检查,该研究经过海军总医院伦理委员会批准。志愿者招募时间为2012年5月至2012年12月,入选标准：①年龄≥18岁,≤65岁；②神志清楚；③无耳鼻喉科及胃肠病病史,无吞咽困难、吞咽痛病史；④愿意接受评定。最终招募了126位成年人,其中女性60例,男性66例；年龄范围18-65岁,并按年龄分成4组：30岁组、40岁组、50岁组和≥50岁组。 1.2第二章咽异感症组均为有吞咽不适主诉到我科就诊的病人,入组标准：①没有耳鼻喉科和胃肠病病史,没有吞咽困难、吞咽痛病史,没有医学疾病或药物可能影响吞咽的病史；②耳鼻咽喉科内镜检查和下咽食管造影均无异常器质性病变和误吸,所有的受试者都有正常的口腔解剖结构。凡有扁桃体病变,咽部角化症、下咽恶性肿瘤、会厌囊肿、茎突过长等都排除。最终34例咽异感症病人入组,年龄20—66岁,其中女性17人,男性17人。 1.3第三章选取2013年5月-2013年12月份在我院行扁桃体切除术的患者32名,男性15名,女性17名。年龄分布20-60岁。选取标准：①患者年龄20岁,60岁；②均在全身麻醉下行射频辅助双侧扁桃体切除术,术中出血量5～20ml,所有患者皆未出现术后出血,术后未用止痛药；③无其它耳鼻咽喉科及胃肠科病史,无吞咽困难,吞咽痛等病史；④排除神经、精神疾病,肺部疾患,无严重烟、酒等物质滥用情况。 2.肌电图记录技术及方法 2.1设备：用于记录表面肌电图的设备是丹麦Alpine Biomed公司的KEYPOINT全功能肌电诱发电位仪。采用的软件是Keypoint. Classic。记录每次吞咽时肌肉活动的持续时间以及振幅。 2.2表面电极放置的位置：与吞咽相关的肌群主要有以下4对：①口轮匝肌；②咬肌；③颏下肌群包括二腹肌前腹、下颌舌骨肌、颏舌肌；④舌骨下肌群。这些肌肉位置表浅,能通过表面电极记录吞咽时它们的肌电活动。由于正常的吞咽活动是以上肌肉协调运动的结果,且电活动具有传导性,所以我们选择颈部正中甲状软骨上方1cm为电极放置位置。两表面电极之间的距离为1cm,即两表面电极距中线0.5cm。主要记录咽期的吞咽活动。一侧手腕部位为接地电极。用酒精纱布轻轻地擦电极接触的位置,并且涂电极凝胶以降低电阻。 3.试验程序及记录 电极安置完毕后,每个受试者进行3种吞咽方式的测试记录。 3.1空吞咽：指示受试者“干咽一次”。 3.2吞咽20ml水：指示受试者“先把20ml水全部含在嘴里,一口咽下去”。 3.3吞咽40ml水：指示受试者“先把40ml水全部含在嘴里,尽量一口咽下去,一口咽不完,可以分两口”。(第二章、第三章省略此步骤) 以上测试全部测2次,取平均值,为防止烫伤,选择室温凉白开水。记录吞咽时肌电活动的最大振幅及持续时间。 4.视觉模拟评分法(VAS)是将疼痛的程度用0至10共11个数字表示,0表示无痛,10代表最痛,病人根据自身疼痛程度在这11个数字中挑选一个数字代表疼痛程度。0分：无疼痛；3分以下：有轻微的疼痛,患者能忍受；4-6分：患者疼痛并影响睡眠,尚能忍受,可给予临床处置；7-10分：患者有渐强烈的疼痛,疼痛剧烈或难忍。分别记录患者术后1天以及2天的数值。(此步骤仅用于第三章) 结果 1.健康成年男性空吞咽、吞咽20ml水、吞咽40ml水时肌电活动持续时间平均(z±s,下同)分别为(1.133±0.209)s、(1.097±0.208)s和(1.510±0.432)s,振幅分别为(0.332±0.115)mV、(0.308±0.095)mV和(0.399±0.139)mV。健康成年女性同样吞咽时肌电活动持续时间分别为(1.118±0.170)s、(1.085±0.209)s和(1.765±0.463)s,振幅分别为(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试者吞咽时的振幅均大于女性(P值均0.05),除吞咽40ml水的吞咽持续时间女性长于男性(t=3.199,P0.05)外,其余吞咽方式的持续时间差异均无统计学意义(P值均0.05)。所有受试者吞咽40ml水的时间均长于空吞咽和吞咽20ml水时,吞咽20ml水和空吞咽时差异无统计学意义；吞咽40ml水的振幅大于空吞咽,空吞咽的振幅大于吞咽20ml水时。不同年龄组男性受试者的肌电图持续时间和振幅差异均无统计学意义(P值均0.05)；女性受试者除年轻组(30岁)吞咽40ml水的时间长于年长组外(P0.05),其余吞咽方式肌电图参数差异均无统计学意义(P值均0.05)。 2.对照组空吞咽、20m1水吞咽时肌电活动持续时间分别为(1.128±0.191)s、(1.091±0.208)s,振幅分别为(0.313±0.11)mV、(0.286±0.106)mV。咽异感症组空吞咽、20m1水吞咽时肌电活动持续时间分别为(1.178±0.252)s、(1.127±0.178)s,振幅分别为(0.341±0.116)mV、(0.316±0.094)mV。咽异感症组空吞咽、20m1水吞咽时肌肉活动时间和振幅与对照组没有明显差异。进一步按不同性别再进行比较,咽异感症组男性空吞咽、20m1水吞咽时肌肉活动时间和振幅与对照组没有明显差异,咽异感症组女性空吞咽、20m1水吞咽时肌肉活动时间和振幅与对照组也没有明显差异。 3.所有的吞咽方式中,术后1天和术后2天干咽时sEMG持续时间和振幅皆小于术前,吞咽20mL水所需时间大于术前,而振幅小于术前。术后1天和术后2天的干咽时间、干咽振幅、20m1水吞咽时间、20mL吞咽振幅和VAS评分都无统计学差异(p0.05) 结论 1.吞咽的表面肌电图是一种简单、无创的评估吞咽功能的检查方法,本研究取得的健康人群吞咽表面肌电图的数据有望为今后开展吞咽功能筛查提供参考。 2.咽异感症病人与健康人吞咽肌电活动没有差别,间接推断患者无客观吞咽功能受损,治疗上应该重视心理干预的作用。 3.吞咽表面肌电图能够观察到扁桃体切除术后患者因疼痛导致的吞咽时的肌肉活动变化,可根据这些变化指导是否需要镇痛药物或停止使用镇痛药物,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.鍋ュ悍鎴愬勾鐢锋，

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