【作者】 王琴；

【导师】 刘业海；

【作者基本信息】 安徽医科大学 ， 耳鼻咽喉科， 2016， 博士

【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P<0.05认为差异有统计学意义,P<0.01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。更多还原

【Abstract】 Objective:Laryngeal dyskinesia may cause laryngeal dysfunction such as dysphonia, drinking cough, difficulty in breathing. It affects life and communication quality of patients. Severe cases can be life-threatening. Laryngeal articulation disorder etiology is complex: not only vocal cord mechanical movement disorder caused by cricoarytenoid joint dislocation and cricothyroid joint injury, but also neuromuscular dysfunction caused by recurrent laryngeal nerve and injury laryngeal nerve paralysis. Under normal condition the laryngeal joints (cricoarytenoid joint, cricothyroid joint) trajectory are still questionable. Through cadaver laryngeal arthrography, plasticizing and tissue staining, the research group find the arytenoid cartilage of cricoarytenoid joint may beat in addition to the original rotation, sliding and swing; the inferior horn of the thyroid cartilage of cricothyroid joint not only rotates but also slides in the cricoid cartilage joint fossa. The main purpose of this study are:(1) Throat CT scanning and three-dimensional reconstruction of healthy volunteers and patients are performed at two physiological states of calm breathing and "Yi" sound, respectively. They are observed whether there is sagittal movement of the arytenoid cartilage, how to quantitatively measure the sagittal displacement, whether the cricothyroid joint slides and rotates simultaneously and the movement direction. (2) The projection of muscle process in the thyroid cartilage is observed by spiral CT with 3D reconstruction technique, the preoperative laryngeal cartilage reconstruction on each patient treated is done, the hole is opened on virtual image of thyroid cartilage to operatively locate muscle process and look for optimal thyroid cartilage fenestration method. (3) Based on ultrathin plasticizing and microdissection techniques, the fine three-dimensional map of laryngeal muscles is established and the function of laryngeal muscle is investigated.Methods:1.Imaging examinationSpiral CT scanning combined with three-dimensional reconstruction of those checked are done while calm breathing and making "Yi" sound, respectively, to estimate the change of displacement and position the projection point of the muscular process of laryngeal cartilage.(1) Laryngeal thin slice volume scanning with 3D reconstruction technology was performed for 35 cases(no laryngeal diseases) and 7 patients with unilateral vocal cord paralysis while calm breathing and making "Yi" sound.(2) measurement:(a) The longitudinal displacement of the arytenoid cartilage vocal process and muscular process:The vertical distance from vocal process and muscular process of arytenoid cartilage to the scanning plane of the upper edge of cricoid arch, which was used as a reference surface, while breathing quietly and making "yi" sound, is measured respectively. And the sagittal displacement range of vocal process and muscular process of arytenoid cartilage as pronouncing is calculated.(b) Longitudinal displacement of the cartilage and the cartilage:The vertical distance from the upper edge and the lower edge of cricoid cartilage board to the scanning plane of the upper edge of the 5th cervical vertebra, which is used as a reference surface, and the vertical distance from the superior horn and inferior horn of thyroid cartilage to the reference surface, while breathing quietly and making "yi" sound, are measured respectively. The sagittal displacement range of the upper and the lower edge of the annular cartilage plate and the upper and lower corners of the cartilage plate are calculated respectively.(c) The direction of the slide of the inferior corner of the thyroid cartilage:The vertical distance from inferior horn of thyroid cartilage to the scanning plane of the upper edge of cricoid arch, which is used as a reference surface, is measured while breathing quietly and making "yi" sound, respectively. The vertical distance from inferior horn of thyroid cartilage to the coronal plane of the posterior edge of cricoid plate, which is used as a reference surface, is measured while breathing quietly and making "yi" sound, respectively. The direction of sliding is judged by reviewing the change of displacement.(d) Localization of projection point of muscular process:The distances from the projection point of muscular process on the thyroid cartilage to the superior horn and inferior horn of thyroid cartilage are measured while breathing quietly, respectively.(e) Simulation of thyroid cartilage fenestration on a 3D reconstruction image:The hole is opened forward with center at the midpoint of trailing edge of the thyroid cartilage plate and radius equal to the distance between the midpoint and the projection point of muscular process on the thyroid cartilage plate. By rotating the image, the arytenoid cartilage is explored from various perspectives.(3) statistic analysisThe experimental data were expressed as mean±tandard deviation (X±s), and the data were analyzed by SPSS 22.0 software. The mixed linear analysis and t test are performed. If P<0.05, the data has statistics difference. And the difference is statistically significant in P<0.01.2. anatomical studyUsing microsurgical anatomy combined with ultrathin sheet plastination technique, the number, trend, start and end points of laryngeal muscles (lateral cricoarytenoid muscle, thyroarytenoid muscle, cricoarytenoid posterior muscle and cricothyroid muscle), and the three-dimensional structure relationship between muscles and larynx cartilage and vocal cords are checked.(1) Transparent hard tissue block is made with cadaver throat tissue block by degreasing, dewatering and plasticizing.150-200um thick transparent slices of ultrathin plastination are produced along the horizontal, coronal and sagittal direction. Images of slices are collected and observed by microscope, HD scanner and laser confocal microscopy.(2) Laryngeal specimen is fine dissected under the stereoscopic microscope to collect the data(3) Indicators(a)To identify the relationship between the muscles of the throat.(b)To determine the distribution of the muscles of the throat(c)To locate the starting and ending points of the laryngeal muscle bundle.(d)To find the direction and angle between laryngeal muscle bundle and the reference plane.Results:1. cricoarytenoid joint:(1) Under normal physiological conditions, the sagittal displacement of vocal process of arytenoid cartilages is greater than muscle process while breathing quietly and making "yi" sound.(2) The sagittal axis displacement of muscle process and vocal process of arytenoid cartilages in different age, gender and laterality are different.(3) The vertical distance between the diseased side and the contralateral side of muscular process of patients with unilateral vocal cord paralysis is 1.5mm, and it is 0.8mm for vocal process. The vocal process and muscular process in the diseased side are higher than those in the contralateral side.(4) The muscle process and vocal process of cricoid and arytenoid cartilage can be developed properly in 3D reconstruction image.2.cricothyroid joint(1) Under normal physiological conditions, the cricoid cartilage moves relative to the cervical spine when the "yi" sound is made while the thyroid cartilage barely moves.(2) The inferior horn of thyroid cartilage slides relative to the cricoid cartilage surface while breathing quietly and making "yi" sound.3. Localization of the muscle process and the window of the thyroid cartilage plate: Throat thin slice volume scanning and three-dimensional reconstruction images can clearly show the projection of muscular process on the thyroid cartilage and 3D structure of laryngeal cartilage. Therefore, the examination should be routinely performed before laryngeal framework surgery so as to improve positioning accuracy for the muscular process. The reconstructed image can be rotated in three-dimensional direction, observed under different angles. It is allowed to open windows on the virtual Image repeatedly and design the best surgical approach4.3D construction:Lateral cricoarytenoid muscle consists of two parts, the upper part is thick, and the angle to the arch of cricoid cartilage surface is 65°. Thyroarytenoid muscle consists of two parts. One is inside and another is outside. The central lateralis thyroarytenoid muscle is thick and the angle to the reference plane is 50°. The central posterior cricoarytenoid muscle is thick and the angle to the reference plane is 40°.Conclusion:1. cricoarytenoid joint: Under normal physiological conditions, the arytenoid cartilage bounces up and down around the sagittal leaving from the cricoid cartilage articular surface besides sliding, rotating and rocking motion along the cricoid cartilage articular surface.2. cricothyroid joint: Under normal physiological conditions, the cricoid cartilage glides forward and up along the cricothyroid joint surface and rotates at the same time when the "yi" sound is made.3. Creating an accelerated method of quantitative detection of longitudinal motion of the vocal cords:Spiral CT scanning combined with three-dimensional reconstruction of those checked are done while calm breathing and making "Yi" sound, respectively, to quantitative measure bilateral vocal cord vertical position difference. The quantitative analysis of arytenoid sagittal displacement is taken as one basis for clinical assessment of vocal function.4. Positioning of laryngeal frame surgery:Throat thin slice volume scanning and three-dimensional reconstruction images can clearly show the projection of muscular process on the thyroid cartilage and 3D structure of laryngeal cartilage. Therefore, the examination should be routinely performed before laryngeal framework surgery so as to improve positioning accuracy for the muscular process. The reconstructed image can be rotated in three-dimensional direction, observed under different angles. It is allowed to open windows on the virtual Image repeatedly and design the best surgical approach 5. Three dimensional model of laryngeal muscles:The upper fasciculus of lateral cricoarytenoid muscle, the central fasciculus of lateralis thyroarytenoid muscle and the central fasciculus of posterior cricoarytenoid muscle are functional fasciculus. The pulling direction of arytenoid adduction should be set according to the direction of the laryngeal functional fasciculus.更多还原