Witt P D, Marsh J L, Arlis H, Grames L M, Ellis R A, Pilgram T K
Department of Surgery, Plastic and Reconstructive, St. Louis Children's Hospital at the Washington University School of Medicine, MO 63110, USA.
Plast Reconstr Surg. 1998 Apr;101(5):1205-11. doi: 10.1097/00006534-199804050-00005.
The sphincter pharyngoplasty is a surgical procedure designed to correct velopharyngeal dysfunction. Its advocates cite the theoretical advantage of its induction of dynamic activity of the neovelopharyngeal port, but this dynamic activity has yet to be quantitatively demonstrated in the literature. The purpose of this study was to quantify postoperative velopharyngeal dynamism and to document the results of intervention outcome on sphincteric excursion measurements from minimal-to-maximal orifice closure. We conducted a 7-year retrospective review of speech videofluoroscopy evaluations in patients who had undergone sphincter pharyngoplasty in our center. Between 1989 and 1994, there were 58 patients so treated for postpalatoplasty velopharyngeal dysfunction by two surgeons using the same operative technique. Patients for whom sphincter pharyngoplasty was recommended fulfilled both of the following criteria: (1) velopharyngeal dysfunction caused by an anatomic, myoneural, or combined deficiency of the velopharyngeal sphincter that would not be expected to be managed by speech therapy alone, and (2) preoperative videonasendoscopy and speech videofluoroscopic studies that demonstrated large-gap coronal, circular, or bow-tie closure patterns or velopharyngeal hypodynamism. Of the original 58 patients, 24 underwent postoperative speech videofluoroscopic evaluations with basal views. Of these, 20 of the evaluations (83 percent) were of adequate quality to be included in a research study. Still images showing maximum and minimum excursion of the sphincter in basal view were obtained. To test for observer reliability, the speech videofluoroscopic studies were randomized and presented for measurement to the same individual on two occasions, each session separated by a 1-month time interval. Topographic imaging software was used to obtain maximum and minimum measurements to within 0.1 mm. Partitioning the variance of the data showed that measurement variability was a very small portion of the total, and that difference between the minimum and maximum values was the largest source of variability. Of the total variability in the data, 64.0 percent originated in the minimum/maximum difference, 34.3 percent came from patient variability, and only 1.7 percent resulted from original or repeat measurements. The patient variability may be exaggerated because of variability in the scale of measurement. Results of this study indicate a quantifiable and statistically significant difference in maximum-to-minimum excursion of sphincteric closure. Sphincter pharyngoplasty appears to be dynamic in the majority of cases.
咽括约肌成形术是一种旨在纠正腭咽功能障碍的外科手术。其支持者列举了该手术诱导新腭咽口动态活动的理论优势，但这种动态活动尚未在文献中得到定量证明。本研究的目的是量化术后腭咽动态，并记录从最小到最大口孔闭合的括约肌偏移测量的干预结果。我们对在本中心接受咽括约肌成形术的患者进行了7年的语音视频荧光透视评估回顾性研究。1989年至1994年间，有58例患者由两位外科医生采用相同的手术技术治疗腭裂术后腭咽功能障碍。推荐进行咽括约肌成形术的患者符合以下两项标准：（1）由腭咽括约肌的解剖、肌神经或联合缺陷引起的腭咽功能障碍，预计仅靠言语治疗无法解决；（2）术前视频鼻内镜检查和语音视频荧光透视研究显示大间隙冠状、圆形或领结状闭合模式或腭咽动力不足。在最初的58例患者中，24例接受了术后基础视图的语音视频荧光透视评估。其中，20例评估（83%）质量足够高，可纳入研究。获得了显示基础视图中括约肌最大和最小偏移的静态图像。为了测试观察者的可靠性，语音视频荧光透视研究被随机化，并在两个不同时间呈现给同一个人进行测量，每次测量间隔1个月。使用地形成像软件获得最大和最小测量值，精确到0.1毫米。对数据方差的划分表明，测量变异性在总变异性中占比非常小，最小值和最大值之间的差异是变异性的最大来源。在数据的总变异性中，64.0%源于最小/最大差异，34.3%来自患者变异性，只有1.7%来自原始测量或重复测量。由于测量尺度的变异性，患者变异性可能被夸大。本研究结果表明，括约肌闭合的最大到最小偏移存在可量化且具有统计学意义的差异。在大多数情况下，咽括约肌成形术似乎具有动态性。
