面神經(jīng)改良分離剝脫術(shù)在腮腺切除中的應(yīng)用

面神經(jīng)改良分離剝脫術(shù)在腮腺切除中的應(yīng)用

網(wǎng)絡(luò)出版時(shí)間：2015-10-13網(wǎng)絡(luò)出版地址：http://www.cnki.net/kcms/detail/52.5012.R.20151013.1259.042.html

廖壯群1, 張玉婷2, 唐超2

(1.中山市小欖人民醫(yī)院 口腔科, 廣東 中山528415； 2.中山市小欖人民醫(yī)院 五官科, 廣東 中山528415)

[摘要]目的： 探討面神經(jīng)改良分離剝脫術(shù)在腮腺切手術(shù)中的的應(yīng)用。方法： 96例腮腺切除患者，采用隨機(jī)數(shù)表法均分為觀察組與對(duì)照組；對(duì)照組接受常規(guī)腮腺切除術(shù)，術(shù)中順行剝離面神經(jīng)，觀察組在常規(guī)腮腺切除術(shù)的基礎(chǔ)上行改良分離神經(jīng)剝脫術(shù)，比較兩組患者術(shù)后1 、10 d各類并發(fā)癥發(fā)生情況；采用H-B系統(tǒng)評(píng)價(jià)體系分析兩組患者面神經(jīng)受損情況，檢測神經(jīng)動(dòng)作電位波幅、潛伏時(shí)間和電位持續(xù)時(shí)間并計(jì)算出神經(jīng)損傷的變性率，進(jìn)而評(píng)估兩組患者面神經(jīng)損傷情況。結(jié)果： 與對(duì)照組比較，觀察組患者術(shù)后1 d神經(jīng)動(dòng)作電位波幅升高、潛伏時(shí)間降低(P<0.05)，與同組術(shù)前比較，觀察組患者術(shù)后10 d神經(jīng)損傷變性率、潛伏時(shí)間及動(dòng)作電位持續(xù)時(shí)間降低、波幅升高(P<0.05)，觀察組改善效果最為顯著；觀察組無永久性面神經(jīng)損傷患者，暫時(shí)性面癱13例，F(xiàn)rey’s綜合征7例，并發(fā)癥發(fā)生率明顯低于對(duì)照組(P<0.05)；H-B系統(tǒng)評(píng)分觀察組優(yōu)于對(duì)照組(P<0.05)。結(jié)論： 腮腺切除術(shù)中行改良分離剝脫術(shù)可有效避免手術(shù)對(duì)面神經(jīng)的損傷，防治術(shù)后面癱等并發(fā)癥發(fā)生。

[關(guān)鍵詞]神經(jīng)剝離； 腮腺切除術(shù)； 神經(jīng)損傷； 術(shù)后修復(fù)

[中圖分類號(hào)]R782.7[文獻(xiàn)標(biāo)識(shí)碼] A

Application Value of Modified Separation and Stripping of Facial

Nerve in the Operation of Parotid Gland Excision

LIAO Zhuangqun1, ZHANG Yuting2, TANG Chao2

(1.DepartmentofStomatology,XiaolanPeople'sHospitalofZhongshanCity,Zhongshan528415,Guangdong,China;

2.DepartmentofOphthalmologyandOtorhinolaryngology,XiaolanPeople'sHospitalof

ZhongshanCity,Zhongshan528415,Guangdong,China)

Abstract[] Objective: To explore application value of modified separation and stripping of facial nerve in the operation of parotid gland excision. Methods: Ninty-six cases of patients with parotid resection in our hospital from February 2013 to February 2014 were selected as the research objects, who were divided into observation group and control group using a random number table method, 48 cases of patients in each group. Control group received conventional parotid resection and intraoperative antegrade stripping of facial nerve while observation group received modified isolation and stripping of facial nerve on the basis of conventional parotid resection. The incidence of complications was compared between the two groups. The H-B system evaluation system was adopted to analyze facial nerve damage and detect nerve action potential amplitude, latency and potential duration. Then degeneration rate of nerve injury in two groups were calculated and assessed. Results: There were statistical differences in nerve action potential amplitude, latency duration between two groups (P<0.05) 1 day after surgery. 10 days after surgery, the degeneration rate, potential amplitude, latency and potential duration in two groups were improved significantly compared with normal level, and more significant in observation group. The differences showed statistical significance (P<0.05). No permanent facial nerve injury was observed in observation group. 13 cases of temporary facial paralysis and 7 cases of Frey's syndrome were observed in observation group, and the incidence of complications was significantly lower than their counterparts in control group(P<0.05). The results of H-B system evaluation showed that in observation group the nerve function recovery was significantly better than that of control group(P<0.05). Conclusion: The modified separation and stripping of facial nerve in the operation of parotid gland excision can provide adequate protection for the facial nerve in the operation, reduce the damage of the facial nerve, and prevent the postoperative complications.

[Key words] nerve dissection; parotid gland excision; nerve injury; postoperative repair

腮腺切除術(shù)是臨床口腔科常見的外科手術(shù)之一，主要用于治療腮腺良惡性腫瘤，具有較好的臨床療效[1]。但在正常生理解剖學(xué)中，面神經(jīng)穿行與腮腺腺體內(nèi)部，因而在腮腺切除術(shù)中常導(dǎo)致面神經(jīng)的損傷，進(jìn)而導(dǎo)致術(shù)后暫時(shí)性或永久性面癱等并發(fā)癥發(fā)生，嚴(yán)重影響患者臨床預(yù)后結(jié)局以及生活質(zhì)量[2]。因此在臨床腮腺切除術(shù)中應(yīng)注意避免對(duì)面神經(jīng)的損傷，因而術(shù)中面神經(jīng)剝離技術(shù)顯得尤為重要。本研究通過比較改良分離剝脫面神經(jīng)與常規(guī)順行剝離面神經(jīng)在腮腺切術(shù)手術(shù)中對(duì)神經(jīng)損傷、術(shù)后康復(fù)的影響，評(píng)價(jià)改良面神經(jīng)分離剝脫術(shù)的臨床應(yīng)用價(jià)值。

1資料與方法

1.1　臨床資料

2013年2月～2014年2月行腮腺切除術(shù)患者96例，其中男性52例，女性44例， 30～62歲，平均(46.9±2.5)歲，病程15 d～13個(gè)月，平均病程(3.2±0.5)月；25例患者術(shù)前腫瘤針吸細(xì)胞學(xué)檢查，71例患者行術(shù)中快速病理確診；腫瘤病理類型為腮腺多形性腺瘤68例，沃辛瘤25例，肌上皮瘤3例，腫瘤直徑在1.0～6.5 cm，平均(3.9±1.2)cm；納入標(biāo)準(zhǔn)：所有患者對(duì)本研究完全知情同意，均符合腮腺切除術(shù)手術(shù)指征，行腫瘤及腮腺全切術(shù)。排除標(biāo)準(zhǔn)：嚴(yán)重心肝腎功能不全者，手術(shù)不耐受者，甲狀腺疾病患者，免疫功能障礙、凝血功能異常者。采用隨機(jī)數(shù)表法將所有患者分為觀察組與對(duì)照組，每組患者48例，兩組患者年齡、性別、病情等資料比較無統(tǒng)計(jì)學(xué)意義，具有可比性。

1.2　研究方法

兩組患者術(shù)前均給予相應(yīng)的支持對(duì)癥治療，對(duì)照組患者常規(guī)腮腺切除術(shù)中面神經(jīng)處理方法采用常規(guī)面神經(jīng)分支解剖術(shù)，觀察組術(shù)中行改良面神經(jīng)分離剝脫術(shù)；腮腺腫瘤、淺葉或部分腮腺切除患者選擇逆向解剖法處理面神經(jīng)，定位面神經(jīng)一處分支后逆行確定面神經(jīng)總干，進(jìn)而確定面神經(jīng)的其余全部分支，暴露腮腺導(dǎo)管定位面神經(jīng)頰支，沿面神經(jīng)各分支解剖至面神經(jīng)主干；術(shù)中操作翻瓣時(shí)應(yīng)進(jìn)行銳性分離，上翻皮瓣至腺體前緣及咬肌時(shí)應(yīng)采用鈍性分離，與腮腺前面逐層分離面神經(jīng)并依層切除腮腺組織，術(shù)中緊急行腮腺深層切除分離，暴露腺體或面神經(jīng)是需采用紗布浸泡生理鹽水后覆蓋，保持紗布及腺體、面神經(jīng)濕潤，研究腺體及面神經(jīng)直接暴露于外環(huán)境中；腮腺淺葉切除術(shù)中離斷腺體組織后，于前面進(jìn)行腺體組織縫合，無需進(jìn)行深層腺體瓣縫合，術(shù)中嚴(yán)禁過度或長時(shí)間牽拉面神經(jīng)。

1.3　觀察指標(biāo)

采用日本MEM-3102神經(jīng)肌電圖檢查評(píng)估患者神經(jīng)損傷情況，配套雙向鎢針刺激電極、電刺激器對(duì)患者治療前后各項(xiàng)面神經(jīng)功能進(jìn)行檢查，觀察兩組患者術(shù)前及術(shù)后1 d、10 d檢測患者動(dòng)作電位波幅、潛伏時(shí)間及電位持續(xù)時(shí)間，3項(xiàng)指標(biāo)與術(shù)前比較波動(dòng)越小則表示神經(jīng)功能損傷程度越輕；并采用H-B系統(tǒng)評(píng)分法評(píng)估兩組患者術(shù)后各時(shí)期神經(jīng)功能損傷及預(yù)后情況，分級(jí)標(biāo)準(zhǔn)為常規(guī)I～VI級(jí)法：Ⅰ級(jí)表示患者面神經(jīng)功能完全正常，Ⅱ級(jí)為輕度面神經(jīng)功能失調(diào)，Ⅲ級(jí)為中度面神經(jīng)功能失調(diào)，Ⅳ級(jí)為中等面神經(jīng)嚴(yán)重功能失調(diào)，明顯面肌力弱或毀容的不對(duì)稱，Ⅴ級(jí)為嚴(yán)重功能失調(diào)，Ⅵ級(jí)為全麻痹，面神經(jīng)功能完全喪失。

1.4　統(tǒng)計(jì)學(xué)處理

2結(jié)果

2.1　手術(shù)時(shí)間及術(shù)中出血量

觀察組患者術(shù)中出血量及手術(shù)時(shí)間略高于對(duì)照組，但差異不具有統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。

表1　兩組患者手術(shù)用時(shí)及術(shù)中出血量比較結(jié)果

2.2　面神經(jīng)波幅、潛伏時(shí)間及改變程度

兩組患者術(shù)前面神經(jīng)動(dòng)作電位波幅、潛伏時(shí)間及神經(jīng)損傷變性率比較差異無統(tǒng)計(jì)學(xué)意義，但與對(duì)照組比較，觀察組患者術(shù)后1 d動(dòng)作電位波幅升高，潛伏時(shí)間降低，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)；與同組術(shù)前比較，術(shù)后10 d兩組患者神經(jīng)損傷的變性率、潛伏時(shí)間及動(dòng)作電位持續(xù)時(shí)間均降低而波幅升高(P<0.05)，觀察組改善最為顯著。見表2。

2.3　面癱及其他并發(fā)癥發(fā)生率

觀察組并發(fā)癥發(fā)生率明顯低于對(duì)照組(P<0.05)，差異有統(tǒng)計(jì)學(xué)意義。見表3。

表2　兩組患者面神經(jīng)波幅、潛伏時(shí)間、改變程度比較

(1)與對(duì)照組同時(shí)間比較，P<0.05；(2)與同組術(shù)前比較，P<0.05

表3　兩組患者面癱及其他并發(fā)癥發(fā)生率( n,%)

2.4　術(shù)后各時(shí)期H-B系統(tǒng)評(píng)分

對(duì)兩組患者術(shù)后各時(shí)期進(jìn)行H-B系統(tǒng)評(píng)分并比較，觀察組患者神經(jīng)功能恢復(fù)情況明顯優(yōu)于對(duì)照組，并且速度明顯快于對(duì)照組，兩組患者不同采集時(shí)間H-B系統(tǒng)分級(jí)比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表4。

3討論

面神經(jīng)損傷是口腔腮腺手術(shù)中較為重要的一個(gè)并發(fā)癥，常規(guī)腮腺切除術(shù)中往往對(duì)面神經(jīng)具有較大的醫(yī)源性損傷，不能夠?qū)γ嫔窠?jīng)提供有效的保護(hù)[3-4]，因此患者術(shù)后短暫性面癱、Frey’s綜合癥發(fā)病率較高，嚴(yán)重影響患者生活質(zhì)量及臨床療效[5]。而本組研究的改良面神經(jīng)分離剝脫術(shù)可根據(jù)腮腺不同類型的切除手術(shù)進(jìn)行適應(yīng)性改變，可有效降低面神經(jīng)在腮腺切除術(shù)中所受損傷，降低術(shù)后并發(fā)癥發(fā)生率。

表4　兩組患者術(shù)后各時(shí)期H-B系統(tǒng)評(píng)分

臨床研究表明面神經(jīng)損傷與腫瘤大小、術(shù)中牽拉程度、面神經(jīng)暴露時(shí)間長短密切相關(guān)[6]。由于牽拉可引起神經(jīng)脫離組織，影響了神經(jīng)的血供，導(dǎo)致修復(fù)不理想；牽拉會(huì)引起面神經(jīng)軸突被膜的破壞，引起逆行性變形，影響神經(jīng)的傳導(dǎo)功能；牽拉常引起神經(jīng)的軸突斷裂，軸突再生較為緩慢[7]。腫瘤體積越大其累及周圍組織程度越種，腫瘤產(chǎn)生的占位效應(yīng)對(duì)面神經(jīng)的壓迫效果也越大。并且有學(xué)者通過臨床實(shí)驗(yàn)證實(shí)，面神經(jīng)直接暴露于空氣中的時(shí)間越長，患者面神經(jīng)功能及實(shí)質(zhì)性損傷程度就越重，并且隨著暴露時(shí)間的延長患者面神經(jīng)變形率呈指數(shù)增長，并可在一定程度上轉(zhuǎn)化損傷類型導(dǎo)致潛伏時(shí)的顯著延長，神經(jīng)變性程度加重導(dǎo)致面神經(jīng)軸突或神經(jīng)外膜結(jié)構(gòu)的改變[8]。本組研究結(jié)果顯示，改良面神經(jīng)分離剝脫術(shù)組患者面癱及其他并發(fā)癥發(fā)生率僅為45.84%，明顯低于對(duì)照組的70.84%，同時(shí)觀察組患者H-B系統(tǒng)評(píng)分優(yōu)于對(duì)照組，在相同采集時(shí)間比較中，觀察組I、II級(jí)所占比例明顯高于對(duì)照組；觀察組患者神經(jīng)功能恢復(fù)速度更快、損傷程度更輕，同時(shí)在面神經(jīng)神經(jīng)肌電檢測中較對(duì)照組具有明顯優(yōu)勢(shì)。通過實(shí)驗(yàn)回顧分析可知，觀察組患者術(shù)中平均出血量為(43.5±4.7)mL，平均手術(shù)用時(shí)(82.9±20.1)mL,對(duì)照組平均出血量為(39.6±11.9)mL，平均手術(shù)用時(shí)(79.5±15.4)mL,雖然觀察組手術(shù)用時(shí)略高于對(duì)照組，但統(tǒng)計(jì)學(xué)分析顯示兩組患者術(shù)中出血量與手術(shù)用時(shí)比較并無顯著差異，表明兩組患者術(shù)中面神經(jīng)暴露等因素并不對(duì)術(shù)后預(yù)后結(jié)局產(chǎn)生影響，排除并發(fā)癥影響自變量，同時(shí)也表明改良術(shù)式并不會(huì)延長手術(shù)用時(shí)及增大術(shù)中出血量[9-10]。在對(duì)神經(jīng)肌電圖監(jiān)測結(jié)果及并發(fā)癥發(fā)生情況的分析可知，改良術(shù)式對(duì)面神經(jīng)功能損傷更低，患者術(shù)后神經(jīng)功能恢復(fù)更迅速。

綜上所述，腮腺切除術(shù)行改良分離剝脫術(shù)可對(duì)在術(shù)中對(duì)面神經(jīng)提供充足的保護(hù)，降低面神經(jīng)器質(zhì)及功能行損傷，有效防治術(shù)后面癱等并發(fā)癥發(fā)生率，具有臨床應(yīng)用及推廣價(jià)值。

4參考文獻(xiàn)

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(2015-08-02收稿，2015-09-20修回)

中文編輯： 劉平； 英文編輯： 劉華