喉功能主观评估系统的建立及对颈袢喉返神经修复术疗效的评价

发布时间：2018-04-25 13:42

本文选题：声带麻痹 + 颈袢神经　；参考：《第二军医大学》2011年博士论文

【摘要】：单侧声带麻痹是耳鼻咽喉科较常见疾病,其病因有医源性、肿瘤源性、特发性和外伤性等。患者往往表现为声音嘶哑,饮水呛咳等临床症状,这些症状严重影响了患者的生活质量。临床上治疗单侧声带麻痹的手术,主要有声带注射术、甲状软骨成形术杓状软骨内收术、喉神经修复术等。其中声带注射术、甲状软骨成形术和杓状软骨内收术均能有效的改善声嘶症状,但由于没有恢复喉肌的神经再支配,嗓音的远期疗效尚不满意。随着显微外科技术的发展,声带麻痹神经修复的治疗已取得了很大的进步。颈袢喉返神经修复术是国际上最为常用的喉神经修复术之一。但目前文献报道该种手术的病例数量相对较少,且缺乏针对远期疗效的研究。不同失神经病程对于手术疗效的影响尚未见文献报道。至今文献中尚缺乏确凿的证据证明对侧颈袢喉返神经修复术的疗效。本课题目的有以下几点:1、研究颈袢主支喉返神经修复术和颈袢分支喉返神经修复术的远期疗效;2、比较颈袢主支喉返神经修复术与颈袢分支喉返神经修复术的疗效差异;3、研究不同失神经病程对于颈袢喉返神经修复术疗效的影响;4、评估对侧颈袢喉返神经修复术治疗单侧声带麻痹的疗效。为了正确且全面的评估手术疗效,需要使用不同评价方法多维度全面系统地评估治疗效果。然而目前国内嗓音医学刚刚起步,尚缺乏嗓音听感知评估的标准方法。动态喉镜是观察喉部结构和功能状态不可或缺的检查方法,至今文献中尚缺乏针对单侧声带麻痹的可靠且有效的主观评估方法,所以本研究尝试建立国内嗓音RBH主观听感知评估系统的汉语普通话版,验证其可信度和效度。同时建立可靠且有效的单侧声带麻痹动态喉镜主观视感知评估表,全面系统评价喉返神经修复治疗效果。故本研究共分为四个部分: 第一部分建立国内嗓音RBH主观听感知评估系统的汉语普通话版。目的:尝试建立国内嗓音RBH主观听感知评估系统的汉语普通话版。方法:首先设计一篇普通话朗读文本,从声母、韵母、声调三者构成比与中科院声学研究所提出的汉语相应音素构成比做相似性检验,并对该文本进行易读性检验。收集正常嗓音40例和病理性嗓音160例的持续长元音和朗读声样本,同步测量长元音基频微扰、振幅微扰、噪谐比、最长声时、平均气流率、嗓音障碍指数。请3位专家初步制定RBH主观听感知评估系统汉语普通话版。然后让7位听评委依据初订的RBH主观听感知评估系统对160例嗓音样本进行评估,评委间一致性检验采用组内相关系数,而评委自身稳定性检验采用Kappa系数,并检验其效度。结果:设计的标准普通话朗读文本的声母、韵母、声调三者构成比与汉语相应构成比高度相似性,易读性良好。RBH三指标粗糙声、气息声、嘶哑声的评委间一致性分别为0.86、0.81、0.89。听评委的自身一致性在0.45-0.72之间。在嘶哑声的四个等级中组,基频微扰、振幅微扰、噪谐比、最长声时、平均气流率、嗓音障碍指数在每相邻两个等级之间比较均有统计学意义(p均0.05)。在粗糙声的四个等级中组,基频微扰、振幅微扰、噪谐比在每相邻两个等级之间比较均有统计学差异(p均0.05)。在气息声的四个等级中组,噪谐比、最长声时、平均气流率在每相邻等级之间比较均有统计学差异。(p均0.05)。结论:设计的标准化朗读短文《害人终害己》的音素构成比与中科院汉语相应音素构成比高度相似且易读性良好。嗓音RBH听感知评估系统汉语普通话版的信度和效度良好。第二部分单侧声带麻痹的动态喉镜主观知评分表的建立。目的:建立单侧声带麻痹的动态喉镜视感知评分表,为量化评估声带麻痹奠定基础。方法:根据文献并结合声带麻痹特点,选择声带振幅、声门上运动、患侧声带位置、声门闭合程度、闭合商、声带振动的对称性和规律性组成初步评估表,以11名评委对不同声嘶程度的单侧声带麻痹患者48例进行评估,用组内相关系数统计评委间一致性,Kappa系数分析评委自身稳定性。用手术疗效明确的单侧声带麻痹患者76例作为检验评分表效度的工具,检验评估表的各项指标在手术前后有无差异。结果:选择自身稳定性高的评委有利于提高评委间一致性,以5名自身稳定性最高评委的评估结果,观察指标中有6个指标较为满意,患侧声带位置、声门闭合程度、闭合商、患侧声带边缘直线、声带振动的对称性和规律性的评委一致性在0.55-0.80之间。声带振幅(左、右)和声门上运动(前后、左、右)的评估这5个观察指标的评委间一致性较低,不适合评估声带麻痹,故将它们从主观视感知评分表去除,最终确定的评估表中6个观察指标在手术前后差异明显(p均0.001)。该评估表检验手术疗效的效果良好。结论:单侧声带麻痹动态喉镜视感知评分表的各项指标评委之间一致性较好,且效果良好,说明最终制定的评估表可作为评估单侧声带麻痹诊断及疗效评估的有效评估工具。第三部分颈袢神经修复喉返神经治疗单侧声带麻痹的疗效分析。目的:研究颈袢主支喉返神经修复术和颈袢分支喉返神经修复术的远期疗效;比较颈袢主支喉返神经修复术与颈袢分支喉返神经修复术的疗效差异;研究不同失神经病程对于颈袢主支喉返神经修复术疗效的影响。方法:收集自1996年3月至2008年3月接受颈袢喉返神经修复术的资料完整的361例,分为颈袢主支喉返神经修复术(主支组)和颈袢分支喉返神经修复术(分支组)。主支组又按失神经病程分为三个亚组:A组(失神经病程为6-12个月组,156例)、B组(失神经病程为13-24个月组, 108例)、C组(失神经病程大于25个月组,45例)。采用动态喉镜评分表、嗓音RBH听感知评估、嗓音客观分析和肌电图评估手术疗效。结果:1、在主支组和分支组中,动态喉镜提示术后患侧声带位置、声门闭合程度、闭合商、患侧声带边缘直线性、声带振动的对称性和规律性均比术前明显改善(p均0.001);术后患侧甲杓肌最大随意运动募集相均比术前明显改善(p均0.001);术后听感知评估粗糙声、气息声和嘶哑声均比术前明显改善(p均0.001);术后基频微扰、振幅微扰、噪谐比、最长声时均比术前值明显改善(p均0.001)。2、术后主支组的基频微扰、振幅微扰、噪谐比均明显小于分支组相应的参数值(p均0.05);术后主支组的最长声时要大于术后分支组相应的参数值组相应的参数值(p均0.05)。3、A组与B组比较,术后的基频微扰、振幅微扰、噪谐比和最长声时均无显著差异(p均0.05);而A组术后的基频微扰、振幅微扰、噪谐比均明显小于C组而最长声时明显大于C组(p均0.001);B组术后的基频微扰、振幅微扰、噪谐比均明显小于C组而最长声时明显大于C组(p均0.001)。结论:1、颈袢主支喉返神经修复术和颈袢分支喉返神经修复术均能明显改善单侧声带麻痹患者的嗓音且远期疗效较满意。2、颈袢主支喉返神经修复术的疗效要优于颈袢分支喉返神经修复术。3、失神经2年内行颈袢喉返神经修复术的患者疗效明显优于失神经时间2年以上的患者。第四部分对侧颈袢神经修复喉返神经治疗单侧声带麻痹的疗效分析。目的:研究对侧颈袢喉返神经修复术治疗单侧声带麻痹的疗效。方法:自1996年3月至2008年3月接受对侧颈袢喉返神经修复术的资料完整的病例56例,采用动态喉镜评分表、嗓音RBH听感知评估、嗓音客观分析和肌电图评估手术疗效。结果:动态喉镜显示术后声门闭合、患侧声带位置、患侧声带边缘、声带振动规律性和对称性、声门闭合商均比术前明显改善(p均0.001)。术后的粗糙声、气息声和嘶哑声比术前均有显著改善(p均0.001)。术后基频微扰、噪谐比、振幅微扰比术前均明显减小(p均0.001)。术后最长声时比术前明显增大(p均0.001)。术后最大随意运动募集相比术前明确改善(p均0.001)。结论:对侧颈袢喉返神经修复术可以改善单侧声带麻痹患者的嗓音。所以它是一种较为理想的治疗单侧声带麻痹的手术方法。全文结论:设计的标准化朗读短文《害人终害己》的音素构成比与中科院声学研究所提出汉语相应音素构成比高度相似且易读性良好。嗓音RBH听感知评估系统汉语普通话版的信度和效度良好,可作为可靠的嗓音评估工具。单侧声带麻痹动态喉镜主观视感知评分表经研究最终确定的各项评估指标评委之间一致性较好,且效度良好,故该评估表可作为评价单侧声带麻痹的的诊断与心理治疗评估工具。颈袢主支喉返神经修复术和颈袢分支喉返神经修复术均能明显改善单侧声带麻痹患者的嗓音,且远期疗效较满意。颈袢主支喉返神经修复术的疗效要优于颈袢分支喉返神经修复术。失神经2年内行颈袢喉返神经修复术的患者疗效明显优于失神经时间2年以上的患者。对侧颈袢喉返神经修复术可以改善单侧声带麻痹患者的嗓音且远期疗效较满意。
[Abstract]:Unilateral vocal cord paralysis is a common disease in the otorhinolaryngology department. Its etiology is iatrogenic, tumor origin, idiopathic and traumatic. Patients often appear to be hoarseness, drinking and cough and other clinical symptoms. These symptoms seriously affect the quality of life of the patients. In clinical treatment of unilateral vocal cord paralysis, there are mainly vocal cord injections, nail shape. Chondroplasty, arytenoid adduction and laryngeal nerve repair, vocal cord injection, thyroid cartilage forming and arytenoid adduction can effectively improve the hoarseness, but the long term effect of the voice is not satisfactory because of the lack of reinnervation of the laryngeal muscles. With the development of microsurgical technique, vocal cord paralysis nerve repair The treatment of loop recurrent laryngeal nerve is one of the most commonly used laryngeal nerve repair in the world. However, it is reported that the number of cases of this operation is relatively small and lacks a study on the long-term effect. The influence of different course of denervation on the effect of the operation has not yet been reported. There is still a lack of conclusive evidence to prove the curative effect of recurrent laryngeal nerve repair on the lateral cervical loop. There are several points in this lesson: 1, the long-term effect of the repair of recurrent laryngeal nerve and recurrent laryngeal nerve repair of the loop branch of the loop of the neck; 2, the difference in the curative effect of the recurrent laryngeal nerve repair and the loop recurrent laryngeal nerve repair of the loop of the neck; 3, study The effect of different course of denervation on the efficacy of loop recurrent laryngeal nerve repair; 4. Evaluate the curative effect of recurrent laryngeal nerve repair to unilateral vocal cord paralysis. In order to correctly and comprehensively evaluate the curative effect, different evaluation methods should be used to evaluate the curative effect in a comprehensive and systematic way. The dynamic laryngoscope is an indispensable examination method to observe the structure and function of the larynx. So far, the literature still lacks a reliable and effective subjective evaluation method for the unilateral vocal cord paralysis. Therefore, this study tries to establish the Chinese voice RBH subjective auditory perception assessment system in Chinese. To verify its reliability and validity, a reliable and effective subjective visual perception assessment table for dynamic laryngoscope is set up and a comprehensive and systematic evaluation of the effect of recurrent laryngeal nerve repair. This study is divided into four parts:
The first part is to establish a Putonghua version of the RBH subjective voice perception assessment system in China.
Objective: to try to establish a Chinese language version of the Chinese voice RBH subjective auditory perception assessment system. Method: first design a text of Mandarin reading aloud, from the consonants, vowels and tones of the three components compared with the Chinese Academy of acoustics of the corresponding phoneme composition compared with the Chinese Academy of acoustics, and the text is easy to read. 40 cases of voice and 160 cases of pathological voice are continuous long vowels and reading sound samples, synchronous measurement of long vowel fundamental frequency perturbation, amplitude perturbation, noise harmonic ratio, the longest sound, the average airflow rate, voice barrier index. 3 experts are invited to formulate the Chinese speech version of the RBH subjective auditory perception evaluation system. Then 7 hearing judges are based on the initial RBH subjective. 160 voice samples were evaluated by the auditory perception assessment system. The correlation coefficient was used in the evaluation of the conformance test among the judges, while the Kappa coefficient was used to test the stability of the judges, and the validity was tested. The results showed that the consonants, vowels and tones of the standard Mandarin reading text were highly similar to the corresponding composition of Chinese, and were easy to read. The good.RBH three indicators of rough sound, breath sound and hoarseness are the self consistency of the 0.86,0.81,0.89. hearing judges in 0.45-0.72. In the hoarseness four levels, the fundamental frequency perturbation, the amplitude perturbation, the noise harmonic ratio, the longest sound, the average airflow rate, and the voice barrier index are compared between two adjacent levels. There were statistical significance (P 0.05). In the four grades of rough sound, the base frequency perturbation, the amplitude perturbation, the noise harmonic ratio between each adjacent two grades were statistically different (P 0.05). In the four grades of the breath sound, the noise harmonic ratio and the longest sound, the average airflow rate was statistically different between each adjacent grade (P 0.05 ).
Conclusion: the phoneme composition of the standardized reading short text < the victim's final victim > is similar to the Chinese corresponding phoneme composition of the Chinese Academy of Sciences and has a good readability. The reliability and validity of the Mandarin Chinese version of the voice RBH auditory perception evaluation system is good.
Objective: to establish a dynamic laryngoscope subjective score table for the second part of unilateral vocal cord paralysis. Objective: to establish a dynamic laryngoscope visual perception score of unilateral vocal cord paralysis for quantitative evaluation of vocal cord paralysis. Methods: according to the literature and the characteristics of vocal cord paralysis, the amplitude of vocal cords, the motion of the glottis, the position of the vocal cords, the degree of glottis closure, are selected. A preliminary assessment of the symmetry and regularity of the vocal cord vibration was made up. 48 cases of unilateral vocal cord paralysis with different degree of hoarseness were evaluated by 11 judges. The consistency between the judges was statistically analyzed with the intra group correlation coefficient and the Kappa coefficient was used to analyze the stability of the judges. 76 patients with unilateral vocal cord paralysis with surgical efficacy were tested as tests. The evaluation of the indicators of the assessment table had no difference before and after the operation. Results: the selection of the judges with high self stability was helpful to improve the consistency among the judges, with the results of the evaluation of the 5 highest self stability judges, 6 of the indexes were satisfactory, the position of the vocal cords, the degree of glottis closure, the closure of the quotient, and the risk of closure. The conformance of the sides of the lateral vocal cord, the symmetry and the regularity of the vibration of the vocal cords is between the 0.55-0.80. The evaluation of the 5 indexes of the vocal band amplitude (left, right) and the supra glottal motion (front, left, right) is low, and it is not suitable for evaluating the vocal cord paralysis. Therefore, they are removed from the subjective perception score table, and the final evaluation is determined. The 6 observation indexes were significantly different before and after the operation (P 0.001). The results of the assessment table were good. Conclusion: the evaluation table of the dynamic laryngoscope visual perception score of the unilateral vocal cord paralysis is good, and the effect is good. It shows that the final assessment table can be used as the diagnosis and treatment of unilateral vocal cord paralysis. An effective assessment tool for evaluation.
The third part of the loop nerve repair of recurrent laryngeal nerve in the treatment of unilateral vocal cord paralysis. Objective: To study the long-term effect of recurrent laryngeal nerve repair and loop recurrent laryngeal nerve repair, and to compare the difference between the main branch of the recurrent laryngeal nerve repair and the recurrent laryngeal nerve repair of the loop of the neck; to study the different course of the denervation. Methods: 361 cases of loop recurrent laryngeal nerve repair were collected from March 1996 to March 2008. The results were divided into three subdivisions of the recurrent laryngeal nerve repair (main branch) and loop recurrent laryngeal nerve repair (Branch Group). The main branch group was divided into three subgroups according to the denervation course. Group A (6-12 months of denervation course, 156 cases), group B (group of denervation for 13-24 months, 108 cases), group C (denervation course more than 25 months, 45 cases). Dynamic laryngoscope score, voice RBH auditory perception assessment, voice objective analysis and electromyography evaluation of surgical effect. Results: 1, dynamic laryngoscopy in main branch and branch group, dynamic laryngoscope hints. The position of the affected side of the vocal cord, the degree of closure of the glottis, the closed quotient, the straightness of the affected side of the vocal cord, the symmetry and regularity of the vocal cord vibration were significantly improved (P 0.001). The maximum voluntary recruitment of the dipper muscle after the operation was significantly better than that before the operation (P), and the auditory perception evaluation of rough sound, breath sound and hoarseness were compared after the operation. The preoperation was significantly improved (P 0.001); after the operation, the fundamental frequency perturbation, the amplitude perturbation, the noise harmonic ratio and the longest sound were significantly improved (P 0.001).2. The basic frequency of the main branch group after the operation was slightly disturbed and the amplitude was slightly disturbed, and the noise harmonic ratio was obviously smaller than the corresponding parameter value of the branch group (P 0.05); the longest sound of the main branch in the post operation was larger than the corresponding parameters of the post operation branch group. Value group corresponding parameter values (P 0.05).3, A group and B group compared with the base frequency perturbation, amplitude perturbation, noise harmonic ratio and the longest sound no significant difference (P 0.05), and A group after the basic frequency perturbation, amplitude perturbation, the noise harmonic ratio is obviously smaller than the C group and the longest sound is larger than C group (P 0.001); B group after the fundamental frequency perturbation, amplitude perturbation, noise noise, noise The harmonic ratio was significantly smaller than that in group C, but the longest time was significantly greater than that in group C (P 0.001).
Conclusion: 1, the recurrent laryngeal nerve repair and recurrent laryngeal nerve repair of the loop of the loop of the neck can obviously improve the voice of the patients with unilateral vocal cord paralysis and the long-term effect is satisfactory. The effect of the recurrent laryngeal nerve repair of the main branch of the loop of the neck is better than that of the loop recurrent laryngeal nerve repair of the loop of the loop of the larynx.3, and the patient with the loop recurrent laryngeal nerve repair in the 2 year of the denervation is.2. The curative effect is obviously better than that of the denervated patients for more than 2 years.
The fourth part is an analysis of the effect of recurrent laryngeal nerve repair with recurrent laryngeal nerve repair in the treatment of unilateral vocal cord paralysis. Objective: To study the effect of reversion of the lateral cervical loop of recurrent laryngeal nerve in the treatment of unilateral vocal cord paralysis. Methods: from March 1996 to March 2008, 56 cases of recurrent laryngeal nerve reversion to the lateral cervical loop were accepted, and the dynamic laryngoscope score was used. The voice RBH auditory perception assessment, the voice objective analysis and electromyography evaluation of the surgical effect. Results: the dynamic laryngoscope showed the closure of the glottis, the position of the vocal cords, the vocal cords edge, the vocal band vibration regularity and symmetry, the glottal closure was significantly improved (P 0.001) before the operation. The rough sound, breath sound and hoarseness were all before the operation. Significant improvement (P 0.001). The postoperative basal frequency perturbation, noise harmonic ratio and amplitude perturbation were significantly decreased (P 0.001). The longest sound time after operation was significantly higher than before operation (P 0.001). The maximum random movement after operation was clearly improved (P 0.001) before operation. Conclusion: the repair of recurrent laryngeal nerve in the lateral cervical loop can improve the patients with unilateral vocal cord paralysis. Voice. Therefore, it is an ideal surgical method for unilateral vocal cord paralysis.
The phoneme composition of the standardized reading short text < the victim of the victim > is similar to the corresponding phoneme composition proposed by the Institute of acoustics of the Chinese Academy of Sciences. The reliability and validity of the Chinese Mandarin version of the voice RBH auditory perception evaluation system is good. It can be used as a reliable voice assessment tool. The dynamic laryngoscope subjective perception score table has a good consistency and good validity between the evaluation indexes determined by the study. Therefore, the assessment table can be used as a diagnostic and psychotherapy assessment tool for the evaluation of unilateral vocal cord paralysis. The reconstructive surgery of the main loop of the neck and the loop of the loop of the loop of the larynx can be improved obviously. The voice of the unilateral vocal cord paralysis is more satisfactory. The effect of the recurrent laryngeal nerve repair of the main loop of the loop of the neck is better than the loop recurrent laryngeal nerve repair. The curative effect of the loop recurrent laryngeal nerve repair in 2 years of the denervation is obviously better than that of the patients with the denervated time more than 2 years. The repair of the recurrent laryngeal nerve in the lateral neck loop can be improved. The voice of patients with unilateral vocal cord paralysis has a long term effect.

【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2011
【分类号】：R767.91

【参考文献】