文献摘要

環甲肌涉及與否對於單側聲帶麻痺中內收肌群復原性的影響
The impact of cricothyroid involvement on adductor recovery in unilateral vocal fold paralysis

Volume 4, Issue 4

關鍵字 :
單側聲帶麻痺,注射式喉成型術,肌電圖,再極化,喉返神經,上喉神經, Unilateral vocal fold paralysis, injection laryngoplasty, electromyography, reinnervation, recurrent laryngeal nerve, superior laryngeal nerve

作者 :
Tuan-Jen Fang, MD, FICS ; Hsiu-Feng Chuang, MS; Hui-Chen Chiang, PhD; Yu-Cheng Pei, MD, PhD

譯者 :
林口長庚醫院 耳鼻喉部 辛立仁 醫師

摘要:


Objectives/Hypothesis: Wide variation in postinjury functional recovery is a hallmark of unilateral vocal fold paralysis (UVFP), ranging from zero to full recovery. The present study examined the impact of cricothyroid (CT) muscle involvement on recovery using quantitative laryngeal electromyography (LEMG) of the thyroarytenoid–lateral cricoarytenoid (TA-LCA) muscle complex at multiple times postinjury.


Study Design: Prospective cohort study in a medical center.


Methods: Eighty-one patients with UVFP (37 males and 44 females) received an initial assessment of quantitative LEMG, stroboscope, acoustic voice analysis and 36-Item Short Form Survey quality-of-life questionnaire at 3 to 6 months after UVFP onset and a follow-up assessment at 12 months after UVFP onset.


Results: The initial and follow-up assessments were performed at 4.3 ±  1.9 and 12.5 ± 1.3 months after UVFP onset, respectively. The peak turn frequency of the TA-LCA muscle complex on the lesion side was improved at the follow-up (470 ± 294 Hz) compared with the initial assessment (300 ± 204 Hz) (P < .001). Patients were also divided into two groups with (n = 27) and without (n = 54) CT involvement, respectively. TA-LCA muscle complex turn frequency improved in patients without CT involvement (from 277 ± 198 to 511 ± 301 Hz; P < .001), but not in those with CT involvement (from 345 ± 211 to 386 ± 265 Hz; P = .46). Seventy-one of all patients received early intervention with intracordal hyaluronate injection, showing similar therapeutic effects in those with and without CT involvement.


Conclusions: Acute UVFP with combined TA-LCA muscle complex and CT muscle involvement has a poor prognosis, with poorer recovery of TA-LCA muscle complex recruitment. Early interventions should be considered in patients with UVFP with CT involvement.

專家評論:


環甲肌涉及與否對於單側聲帶麻痺中內收肌群復原性的影響


林口長庚醫院 耳鼻喉部 辛立仁醫師


本研究主要欲探討環甲肌 (cricothyroid [CT] muscle) 機能所受到影響的程度,亦即上喉神經 (superior laryngeal nerve, SLN) 功能損傷的程度,對於單側聲帶麻痺 (unilateral vocal fold paralysis, UVFP) 患者之甲杓肌-外環杓肌複合體 (thyroarytenoid-lateral cricoarytenoid, TA-LCA complex) 的復原情形,即對其神經再極化 (reinnervation) 的影響進行研究。


本篇屬前瞻性研究,納入共 81 名、於出現聲音及吞嚥困難等症狀的 6 個月內,被診斷為單側聲帶麻痺患者。經喉內視鏡及喉肌電圖 (laryngeal electromyography, LEMG) 確認診斷,並依定性與定量 LEMG 的檢查結果,分類為「環甲肌」 (with CT muscle involvement)、與「非環甲肌」 (without CT muscle involvement) 兩組進行比較。分析項目包括:1) 定性喉肌電圖中,由三個最高的轉折值平均後,所得到的為最高轉折值 (peak turn frequency),作為環甲肌功能指標;2) 轉折比 (turn ratio),由患側的最高轉折值,對於正常側的最高轉折值之比例 (peak turn frequency in lesion side / peak turn frequency in normal side);以及 3) 平均聲門間隙面積 (normalized glottal gap area, NGGA),計算方式為:最窄聲門間隙面積/膜狀聲帶長度 X 100 (narrowest glottal-gap area / membranous vocal fold length X 100)。同時也針對患者生活品質,收集所有患者初診斷時,與一年追蹤時的嗓音相關生活品質量表 (voice outcome survey, VOS)、及生活品質量表 (36-Item Short Form Survey quality-of-life questionnaire, SF-36)。結果發現,比較初始與追蹤一年的最高轉折值,在「非環甲肌」組中,患側從 276.8 ± 197.5 Hz 顯著進步到 511.2 ± 301.2 Hz (p < 0.001),同時轉折比也出現顯著差異 (initial: 0.31 ± 0.27 Hz; follow: 0.65 ± 0.41 Hz; p < 0.001);但在「環甲肌」組則皆無顯著進步 (peak turn frequency: p = 0.461; turn ratio: p = 0.473)。進一步比較數值增加的幅度,發現在「非環甲肌」組中,約八成 (43 / 54 = 79.6%) 出現進步,也多數增幅較高;而「環甲肌」組則僅約一半 (13 / 27 = 48.1%) 有進步。本研究中,因 71 位患者選擇接受了玻尿酸注射治療 (hyaluronate injection laryngoplasty, HIL),故追蹤一年期的 NGGAVOSSF-36 等,都在組間無顯著差異。


本研究主要以定量肌電圖方式,闡述關於高位迷走神經 (high vagal level)(上喉神經與喉返神經)在單側聲帶麻痺患者中,出現神經再極化的角色。藉由測量上喉神經所支配的環甲肌之定量肌電圖,我們可以得知上喉神經功能的保存與否,與較佳的患側喉返神經再極化相關。神經解剖學上以 Galen's anastamosis 可以解釋上喉神經與喉返神經的關聯性。此外,本研究也支持上喉神經對於甲杓肌-外環杓肌複合體的運動,有附隨分支 (collateral branches) 的假說。在聲帶麻痺的患者中,上喉神經損傷反映在環甲肌功能低下,並具有較差的預後,應該考慮早期介入治療,以期能回復較佳的功能。


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