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经口球囊扩张术联合吞咽训练及电刺激治疗神经源性环咽肌失弛缓症临床研究

作者 / Author:郭静华 谭 军 党宇生

摘要 / Abstract:

目的 观察经口球囊扩张术联合吞咽训练及电刺激治疗神经源性环咽肌失弛缓症的临床疗效。方法 71例神经源性环咽肌失驰缓症患者按随机数表法分成实验组和对照组,实验组35例行经口球囊扩张术联合吞咽训练及电刺激,10 d为1个疗程,连续治疗2个疗程;对照组36例仅行吞咽训练及电刺激,10 d为1个疗程,连续治疗2个疗程。采用饮水试验评分和吞咽功能等级评分比较2组临床疗效。结果 治疗后实验组饮水试验评分、吞咽功能等级评分与对照组相比较差异有统计学意义(P<0.01);实验组临床有效率(91.4%)显著优于对照组(65.7%),差异有统计学意义(P<0.05)。结论 经口球囊扩张术联合吞咽训练及电刺激可显著改善环咽肌失弛缓症患者的吞咽功能。

关键词 / KeyWords:

球囊扩张术,环咽肌失弛缓症,吞咽障碍,门德尔松手法,Shaker训练法
经口球囊扩张术联合吞咽训练及电刺激治疗神经源性环咽肌失弛缓症临床研究
郭静华 谭 军 党宇生
驻马店市中心医院,河南驻马店 463000
作者简介:郭静华,Email:zmdgih0088@163.com
 
摘要 目的 观察经口球囊扩张术联合吞咽训练及电刺激治疗神经源性环咽肌失弛缓症的临床疗效。方法 71例神经源性环咽肌失驰缓症患者按随机数表法分成实验组和对照组,实验组35例行经口球囊扩张术联合吞咽训练及电刺激,10 d为1个疗程,连续治疗2个疗程;对照组36例仅行吞咽训练及电刺激,10 d为1个疗程,连续治疗2个疗程。采用饮水试验评分和吞咽功能等级评分比较2组临床疗效。结果 治疗后实验组饮水试验评分、吞咽功能等级评分与对照组相比较差异有统计学意义(P<0.01);实验组临床有效率(91.4%)显著优于对照组(65.7%),差异有统计学意义(P<0.05)。结论 经口球囊扩张术联合吞咽训练及电刺激可显著改善环咽肌失弛缓症患者的吞咽功能。
关键词】 球囊扩张术;环咽肌失弛缓症;吞咽障碍;门德尔松手法;Shaker训练法
中图分类号】  R746    【文献标识码】  A    【文章编号】  1673-5110(2019)04-0392-06  DOI:10.12083/SYSJ.2019.04.125
 
Clinical study of transoral balloon dilatation combining with swallowing training and electrical stimulation for neurogenic cricopharyngeal achalasia
GUO JinghuaTAN JunDANG Yusheng
Department of RehabilitationZhumadian Central HospitalZhumadian 463000,China
Abstract】  Objective  To observe the clinical effects oftransoral balloon dilatation combining with swallowing training and electrical stimulation on treating neurogenic cricopharyngeal achalasia.Methods  71 neurogenic cricopharyngeal achalasia patients in our hospital from February 2014 to November 2016 were divided into experimental group (35 cases) and control group (36 cases) randomly.The patients in the experimental group were treated with balloon angioplasty combining with swallowing training and electrical stimulation,while those in the control group were treated with swallowing training and electrical stimulation only.Results  After 3 weeks treatment,drinking water test score and swallowing score in the experimental group were higher than that in the control group (P<0.01).The clinical effectiveness rate of the experimental group (91.4%) was higher than that of the control group (65.7%)(P<0.05).Conclusion  The transoral balloon dilatation combining with swallowing training and electrical stimulation can significantly improve the swallowing function of patients with neurogenic cricopharyngeal achalasia.
Key words】  Balloon angioplasty;Cricopharyngeal achalasia;Dysphagia;Mendelsohn method;Shaker method
 
        环咽肌位于咽下缩肌下缘,是一组保持张力性收缩的括约肌,分隔咽及食道,保持咽部括约肌张力性收缩,由迷走神经及交感神经共同支配。脑卒中后遗症、脑外伤、放射性脑病、脑炎等脑损伤会导致这两种自主神经在从中枢传导至环咽肌的径路发生器质性或功能性受损引发吞咽功能障碍[1-4]。患者常感觉喉咙有块物感,或食物黏附于食道内,时常伴呛咳、口鼻反流、误咽、流涎等因环咽肌失弛缓症引起的吞咽功能障碍;环咽肌失弛缓症如未能及时有效治疗,会导致反复肺部感染、脱水、营养不良、电解质紊乱等并发症,对康复进程和生活质量造成严重影响[2]。研究显示[13-8],球囊扩张术联合康复手法治疗,可显著改善环咽肌失弛缓症患者的吞咽功能,临床疗效确切。目前临床上多采用经鼻腔用14号导尿管行球囊扩张术,易引发鼻黏膜疼痛等不适感、局部肿胀、出血,并且术前需要麻醉,减轻刺激,术后需行雾化吸入[9-10]。本研究观察经口插入18号导尿管行球囊扩张术联合吞咽训练及电刺激治疗环咽肌失弛缓症的疗效。
 
1  资料和方法
1.1  一般资料 选择驻马店市中心医院康复科2014-02—2016-11收治的神经源性环咽肌失弛缓症患者71例,经吞咽X线荧光透视造影检查(videofluorographic swallowing study,VFSS)确诊为环咽肌失迟缓症,其中脑卒中49例,脑外伤12例,脑部肿瘤10例,均经脑CT、MRI检查确诊。患者及其家属均知情同意。入选标准:意识清楚,生命体征平稳,无食道、咽部及口腔结构异常、重要器官功能衰竭、精神疾病,简易智力状况检查量表(MMSE)评分>24分,能配合检查和治疗。
        采用随机数表法分为实验组(35例)和对照组(36例),实验组男20例,女15例,年龄23~69(45.7±1.5)岁;原发疾病:脑卒中25例,脑炎5例,脑部肿瘤5例。对照组男20例,女16例,年龄23~69(45.5±1.6)岁;原发疾病:脑卒中24例,脑炎7例,脑部肿瘤5例。2组龄、性别、原发疾病及病变部位等比较差异无统计学意义(P>0.05),具有可比性。
1.2  治疗方法 实验组采用球囊扩张术联合吞咽训练及电刺激治疗,对照组仅进行吞咽训练及电刺激而不行球囊扩张术。
1.2.1  经口球囊扩张术:取18号双腔气囊导尿管,经口插入前先将水注入导管内检查球囊是否漏气,然后将水抽出,将18号双腔气囊导尿管经口腔插入食道中20~25 cm深度,进入食道并穿过环咽肌后将导管保持原位,取20 mL注射器与导管相连接,并向导管内注入6 mL生理盐水,顶住针栓防止水逆流回针筒;操作者将导管缓慢向外拉出,直到有卡住感或拉不动时,表明此处为失迟缓的环咽肌下缘所在位置,然后抽出2 mL生理盐水,再缓慢地向外提拉导管,同时嘱患者主动吞咽球囊,当感到阻力锐减时,提示球囊已通过环咽肌,此时将球囊拉出,并将生理盐水抽出,冲洗导管,如此反复操作8~10次,自下而上缓慢移动球囊,充分扩张环咽肌,降低环咽肌张力;每次球囊拉出后均让患者主动清除口咽分泌物。根据环咽肌紧张程度,球囊容积每天增加1~2 mL,以球囊恰好能拉出,且有轻微阻力为适度,球囊容积最大不超过15 mL,治疗频率:以上治疗1次/d,每次25 min,6次/周,连续治疗3周。
1.2.2  吞咽训练及电刺激治疗:①门德尔松手法,可上抬病人喉部,可保持喉部上抬并空吞咽,吞咽时将舌头抵住硬腭,屏住呼吸,维持数秒;治疗师的中指放在环状软骨、食指放在甲状软骨上方,感受上抬喉部;如无力上抬喉部,可进行喉部上推并颈部按摩促进吞咽。②电刺激治疗:应用德国菲兹曼吞咽言语治疗机,把电极放置于患者颈部两侧人迎、上廉泉旁0.8寸的部位,输出电流强度0~60 mA,以患者可耐受及引起肌肉收缩最大强度为宜[5],1次/d,20 min/次,3周为1个疗程;治疗时边刺激边让患者做吞咽动作。③进食指导训练、改变食物性状,采用最容易吞咽的食物,包括米糊、菜泥、蛋羹等,逐步过渡到固体食物。选择90°坐位,身体稍前倾20°,颈稍前屈体位,进食以一口量为原则,摄食训练具体安排根据病人情况予以实施,若进食困难可行经口胃管进食。④针刺治疗,主穴为舌咽、颈项部腧穴,包括廉泉、旁廉泉、双侧金津、玉液、翳风、地仓、合谷等穴,双侧金津、玉液点刺出血,其余腧穴留针30 min,期间施以低频率轻捻转补法,1次/d,3周为1个疗程。
1.3  评定方法 评估2组治疗前后饮水试验评分[6]和吞咽功能等级评分[7],饮水试验评分及摄食-吞咽障碍等级参照以下评估标准:饮水试验分为1~5级,每级1分,总分1~5分,1分为功能正常,分数越高则为病情越严重;吞咽功能等级评分分为10级,每级1分,共10分,10分为功能正常。
1.4  疗效评定 参照以下标准[8]:治愈为饮水呛咳、吞咽障碍症状消失,饮水试验达1级,吞咽功能等级评分达9或10分;好转为饮水、吃饭偶有呛咳,需要时间较正常延长,饮水试验降低≥2级,或吞咽功能等级评分提高≥3分;无效为经治疗,饮水呛咳、吞咽障碍改善不显著,饮水试验降低<2级,或吞咽功能等级评分提高<3分。临床有效率=(显效+有效)/总例数×100%。
1.5  统计学分析 应用SPSS 18.0软件处理数据,计量资料数据服从正态分布且方差齐,以均数±标准差(x±s)表示,进行t检验;如数据不服从正态分布或总体方差不齐,以中位数(四分位间距)[M(Q)]表示,采用Wilcoxon符号秩和检验;计数资料进行χ2检验。P<0.05为差异有统计学意义。
 
2  结果
2.1  2组治疗前后饮水试验及吞咽功能等级评分比较 治疗前2组饮水试验评分、吞咽功能等级评分差异无统计学意义(P>0.05),治疗后实验组饮水试验评分明显降低,较对照组降低明显,而吞咽功能等级评分较对照组明显升高,差异均有统计学意义(P<0.01)。见表1。
2.2  2组临床效果比较 实验组总有效率显著优于对照组,差异有统计学意义(χ2=7.71,P<0.01)。见表2。
表1  2组治疗前后饮水试验及摄食-吞咽功能评分比较  (x±s,分)
Table 1  Comparison of drinking water test and feeding-swallowing functionscores before and after treatment in two groups of patients  (x±s,score)
组别 n 饮水试验评分   吞咽功能等级评分
治疗前 治疗后   治疗前 治疗后
实验组 35 4.3±0.7 1.2±0.1   2.1±1.2 6.7±2.5
对照组 36 4.2±0.8 3.5±0.7   2.0±1.3 3.6±1.7
t   0.56 19.24   0.34 6.13
P   0.58 <0.01   0.74 <0.01
表2  2组临床效果比较  [n(%)]
Table 2  Comparison of clinical effects in 2 groups  [n(%)]
组别 n 显效 有效 无效 总有效
实验组 35 23(65.7) 9(25.7) 3(8.6) 32(91.4)
对照组 36 18(50.0) 5(13.9) 13(36.1) 23(65.7)
 
3  讨论
        环咽肌位于咽下缩肌的下缘,为食管上括约肌。正常情况下,呈张力性连续收缩状态,可缩窄咽部,它是防止腹压增高时食物反流到咽部及吸气时阻止空气吸入胃部的一道重要屏障[911-25],在吞咽的咽-食管期有特殊作用,而在吞咽、嗳气和呕吐时则处于松弛状态。即使在松弛时,此括约肌纤维中仍具有被动弹性闭合力。当吞咽时,在食团大小和重量刺激、舌骨上肌肉系统向上和向前的牵引力量的共同作用下,使环咽肌处于开放状态,这一过程由脑干吞咽中枢调控[1026-35]。在通向环咽肌运动神经元的径路上,存在一个少突触性皮质延髓通道,当此通道受到病理改变的影响时,环咽肌出现超反射性,即失弛缓。在脑梗死尤其脑干梗死引起的吞咽障碍中,环咽肌失弛缓症占80%以上[1036-48]。目前,神经源性环咽肌失弛缓症的治疗已成为吞咽障碍治疗的重要内容[1149-54]
        神经源性环咽肌失迟缓症的治疗,首选治疗是局部分级多次球囊导管渐进均匀性扩张术,操作简单、安全、有效,损伤小,且患者依从性好[12]。但在实际操作中分为经鼻及经口两种途径扩张,不论经鼻还是经口行球囊扩张术,治疗环咽肌失迟缓症致吞咽障碍治疗临床疗效无明显差异[13]。研究表明,经口行球囊扩张术时对患者血氧饱和度影响小,对焦虑情绪改善明显,扩张过程中心率平稳、无鼻黏膜出血、水肿、鼻腔无疼痛,患者接受度较高[14]
        本研究显示,实验组治疗后的饮水试验评分、吞咽功能等级评分均显著优于对照组(P<0.01);实验组临床有效率显著高于对照组(P<0.01),与魏春华、郭君等[14-15]的研究结果大体一致。球囊扩张是通过机械扩张方法恢复环咽肌的弹性、收缩性并降低其张力,改善其顺应性,促进食管上括约肌的松弛程度及增加其松弛时间,使其静止期压力降低,显著改善因环咽肌功能障碍而引发的吞咽困难。在上提球囊被动牵张扩张的同时,嘱咐病人做主动吞咽动作并配合门德尔松手法,从而加大舌骨上肌肉系统向上和向前的牵引力量,增强喉部向前与向上动作力度,可以进一步加大环咽肌开放程度[91655-60]。通过一定强度的低频电刺激可刺激咽部肌肉诱发肌肉运动或模拟正常的自主运动,达到改善或恢复被刺激肌肉和肌群功能的目的[17],通过反复进行球囊扩张配合吞咽训练和电刺激可重建大脑皮质与延髓之间的联系,恢复皮质对脑干吞咽中枢的调控作用,使环咽肌正常收缩与扩张,从而改善吞咽功能。
        目前多数文献报道的使用14号导尿管经由鼻腔插入进行球囊扩张术治疗,基于鼻肺反射理论[18],经鼻行扩张术刺激鼻黏膜可致支气管收缩,影响肺通气致血氧下降,心率增快、血压升高,且有鼻腔黏膜水肿、疼痛、血氧下降、焦虑加重、窒息感等并发症[19],且插管前1%~2%丁卡因进行局麻,术后雾化吸入地塞米松,避免黏膜水肿或鼻黏膜出血加重,安全性小;而经口插管无鼻腔不良刺激,可有效减少鼻黏膜水肿、喉头出血、疼痛等不良反应发生,且插管无需麻醉,患者接受度高[1452]。文献[215]指出,经口进入22号导管可防止鼻腔插入引发鼻黏膜疼痛、肿胀、出血,减少扩张治疗中因多次牵拉导管引发的不适感,同时可简化治疗过程,术前不需要麻醉,术后无需雾化吸入,而本研究组采用18号导管经口进行治疗,使治疗操作更加方便,减小了患者痛苦,降低并发症,提高了临床疗效。
 
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(收稿2018-11-25)
本文责编:夏保军
本文引用信息:郭静华,谭军,党宇生.经口球囊扩张术联合吞咽训练及电刺激治疗神经源性环咽肌失弛缓症临床研究[J].中国实用神经疾病杂志,2019,22(4):392-397.DOI:10.12083/SYSJ.2019.04.125

Reference informationGUO JinghuaTAN JunDANG Yusheng.Clinical study of transoral balloon dilatation combining with swallowing training and electrical stimulation for neurogenic cricopharyngeal achalasia[J]Chinese Journal of Practical Nervous Diseases201922(4)392-397.DOI10.12083/SYSJ.2019.04.125

 

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