发音重建技术在喉癌手术中的应用
作者：马力学， 赵波， 吕锦峰， 金娜， 娄丽娜。
【摘要】 目的：介绍全喉和部分喉切除术后重建发音功能的几种方法。方法：全喉切除后进行气管食管瘘手术建立发音功能，垂直半喉或垂直超半喉切除术后应用转移带蒂胸骨舌骨肌或胸骨舌骨肌骨瓣形成发音皱襞和喉框架结构重建发音功能，近全喉切除术后应用残余喉黏膜制作发音管结构建立发音功能。结果：气管食管瘘手术6例，术后成功发音5例；转移带蒂的胸骨舌骨肌制作人造声带并利用甲状软骨膜修复喉内创面7例，6例术后发音基本满意；8例行带蒂胸骨舌骨肌舌骨瓣重建声带和喉框架结构的患者，术后发音呼吸均无困难；喉发音管重建（pearson式手术）7例，术后发音效果一般，但患者自我评价满意。结论：全喉或部分喉切除后应同期完成喉发音重建手术，以提高术后生存质量。在部分喉切除术中，利用带舌骨的胸骨舌骨肌瓣修复重建喉软骨框架结构和声带皱襞，可以有效避免喉狭窄和提高术后发音质量。
Application of the pronunciation reconstruction technique in the operation of larynx cancer。
Abstract：Objective：To introduce a few kinds of methods of rebuilding voiced functions after the whole larynx and parts of larynx resections. Methods: The voiced functions were set up by trachea oesophagus fistula operation after the whole larynx resection, and by breastbone—hyoid muscle with pedicel or breastbone—hyoid muscle pedicel with hyoid transferred to form pronunciation plica and larynx frame structure after the operation of the plumb half larynx or the plumb over half larynx, and by remnants larynx mucosa used to make a voiced construction after resection of mostly larynx. Results: There were six cases treated by trachea oesophagus fistula operations and five cases among them were successful. There were seven cases, whose the breastbone—hyoid muscles with pedicel were transferred to create man—made vocal cords and thyroid cartilage membrane were used to repair wound inside the larynx, six cases among them were successful. Eight patients had no difficulties to pronounce and breathe after operation, which was to rebuild vocal cord and to larynx structure by breastbone—hyoid muscle with pedicel and hyoid petal. There were 7 cases operated by the larynx pronunciation tube rebuild (pearson’s operation), whose effects of pronunciation were general after operation and whose evaluations on their own were good. Conclusion: To improve postoperative existing quality, surgical operation of larynx pronunciation reconstruction should be completed when the whole larynxes or parts of larynxes were resected. During partial laryngectomy, larynx gristle structure and vocal cords plica rebuilt by breastbone hyoid muscle petal with hyoid can effectively avoid a larynx narrow and improve pronouncing quality after operations. Key words: pronunciation rebuild; larynx cancer; operation。
喉癌患者手术后是否重建发音功能是影响手术后生存质量的重要因素。我院1995—2005年完成喉癌切除同时行发音功能重建手术28例，术后发音效果报道如下。
1 资料与方法。
1.1 一般资料 1995—2005年共完成接受发音功能重建的喉癌手术患者28例，其中男25例，女3例，年龄40～77岁，平均60.5岁。本组病例均有病理学诊断依据，除1例为喉部恶性纤维组织细胞瘤外，其余全部为鳞状细胞癌，其中1例患者喉鳞癌合并血管肉瘤。部位分类：声门上型14例，声门型22例，跨声门型4例，部位不明2例，下咽癌侵犯喉部3例。肿瘤TNM分期：T1 2例，T2 8例，T3 25例，T4 8例，分类不明2例；颈部淋巴结转移情况：N0 30例，N1 6例，N2 7例，N3 2例；所有患者均无远处转移（M0）。
1.2 治疗方法 全喉切除手术中同期完成气管食管瘘手术6例；垂直半喉或垂直超半喉手术中应用带蒂胸骨舌骨肌瓣转移制作人造声带并利用甲状软骨膜修复喉内创面7例，带蒂胸骨舌骨肌舌骨瓣重建甲状软骨和声带8例；7例近全喉切除手术患者全部施行喉发音管重建（pearson术式）。
1.2.1 气管食管瘘技术 全喉切除后，封闭咽瘘之前，用尖刀于第1、2气管环后壁纵行切透气管后壁和食道前壁，长度约1 cm。将食道黏膜牵出，与相对应部位气管黏膜缝合，形成人为瘘口，即人造声门。发音时手指密封颈前部喉瘘口，自肺内呼出的空气通过人造瘘口进入咽部从口腔、鼻腔排除，发出声音。
1.2.2 人造声带技术 行垂直半喉或垂直超半喉切除手术时，切除甲状软骨之前，先分离制备带蒂胸骨舌骨肌瓣或胸骨舌骨肌舌骨瓣，肌蒂位于胸骨端，待被肿瘤侵犯的声带切除后，将肌肉转入声带缺损处，修整肌肉边缘，使其与原声带结构相似，用可吸收缝线缝合固定于保留的组织边缘，甲状软骨膜覆盖肌肉并缝合固定。用舌骨骨瓣修复缺损的甲状软骨时，应用耳脑胶将其与残余的甲状软骨或环状软骨粘和固定，形成喉体保护性支架，用耳脑胶将制作的人造声带粘和于重建喉体的合适位置。
1.2.3 喉发音管技术（pearson术式） 近全喉切除后，利用残留喉黏膜缝合制成一发音管，下端接气管环或环状软骨，上端通达舌根部位，内置一个12号导尿管，两端分别从鼻腔和气管切开口处引出，手术后7～10 d取出导尿管。发音时先深吸口气，然后按压气管瘘口处防止漏气，呼气时发音。
2 结果。
2.1 发音情况。
2.1.1 气管食管瘘技术 全喉切除术同期行气管食管瘘手术的患者6例，术后能发音者5例，另1例患者瘘口严重水肿狭窄，最后粘连闭锁而不能发音。能发音者发出的声音小、沙哑，大于耳语音量、发音较费力，初期进食时尤其进食液体食物时均有轻重不同的呛咳过程。经过1～6个月的适应性练习，均能逐渐克服呛咳，进食时不能发音。
2.1.2 人造声带技术 施行转移带蒂的胸骨舌骨肌制作人造声带并利用甲状软骨膜修复喉内创面的患者7例，术后发音效果较好，进食同时可以说话，但1例患者术后1月起出现喉狭窄并导致呼吸困难，后行T形硅胶管植入法扩张声门，半年后取出硅胶管后呼吸困难解除。施行带蒂胸骨舌骨肌舌骨瓣重建声带和甲状软骨板的患者8例，术后发音、呼吸均无困难，声音嘶哑程度也较单独应用转移带蒂胸骨舌骨肌制作人造声带轻。