Clinical application of orofacial myofunctional therapy combined with muscle functionnal appliance in postoperative rehabilitation of children with OSA
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摘要: 目的 探讨口面肌功能训练联合肌功能矫治器在儿童阻塞性睡眠呼吸暂停(OSA)术后康复治疗中的应用价值。方法 60例儿童诊断为中重度OSA(AHI≥5)并入院接受相应的腺样体和(或)扁桃体手术治疗。根据患儿腺样体和(或)扁桃体术后是否愿意接受口面肌功能训练及佩戴肌功能矫治器，将其分为治疗组(30例)和对照组(30例)。两组手术前后均行X线头颅侧位片、便携式多导睡眠监测(PSG)，并由监护人在医护人员指导下填写儿童OSA-18量表。治疗组术后同时配合口面部肌功能训练及佩戴肌功能矫治器。结果 ① 全身状况及主观症状变化：治疗组术前OSA-18总分为65.15±11.25，术后1个月为49.83±7.09;对照组术前OSA-18总分为64.69±10.23，术后1个月为48.07±6.87;两组患儿在OSA术后睡眠障碍、身体症状、情绪状况、白天嗜睡和精力状态及对监护人的影响程度均得到明显改善(P < 0.01);治疗组术后半年、1年问卷总分及睡眠障碍、身体症状、白天情况及对监护人的影响程度的变化量均大于对照组(P < 0.05)。②睡眠呼吸功能PSG监测的改变情况：两组患儿术后呼吸暂停低通气指数(AHI)、呼吸暂停指数(AI)均降低，最低血氧饱和度(LSaO2)均升高，差异均有统计学意义(P < 0.01);治疗组术后半年及1年AHI降低、LSaO2升高(P < 0.01)。③头颅测量颌面畸形改变：术后半年、1年时治疗组蝶鞍中心-鼻根点-下齿槽座点角(SNB角)明显增大，上下齿槽座角(ANB角)明显减小，与对照组比较差异有统计学意义(P < 0.01);术后半年、1年气道测量中软腭后-后咽壁距(SPP-SPPW)、腭垂尖-中咽壁距(U-MPW)、后气道间隙(TB-TPPW)测量值增大，差异有统计学意义(P < 0.01)，表明OSA术后经口面肌功能训练联合肌功能矫治器治疗后，下颌骨发生明显前移，上气道宽度明显增加。结论 儿童OSA术后口面肌功能训练联合肌功能矫治器的应用对改善患儿口呼吸、上气道矢状结构、睡眠呼吸状况更为显著，患儿不良的口腔习惯也可得到有效矫正。Abstract: Objective To explore the clinical significance of orofacial myofunctional therapy combined with muscle functional appliance in postoperative rehabilitation of children with OSA.Methods Sixty children were diagnosed as moderate-to-severe OSA with AHI≥5 and underwent adenoid and/or tonsillar surgery. Children were divided into two groups based on whether they were willing to receive orofacial myofunctional therapy and muscle functional appliance after surgery. Lateral cephalogram and portable polysomnography were performed, and the pediatric OSA-18 scale was filled under the guidance of medical staff. The treatment group received combined treatment with orofacial myofunctional therapy and muscle functional appliance.Results ① General condition and subjective symptoms: The total score of OSA-18 in the treatment group was 65.15±11.25 preoperatively and 49.83±7.09 1-month postoperatively, while the score in the control group was 64.69±10.23 preoperatively and 48.07±6.87 1-month postoperatively. The results showed that postoperative sleep, physical symptoms, emotional status, daytime lethargy and energy status of patients, and their influence on their guardians were significantly improved in both groups(P < 0.01). The improvement of sleep disturbance, physical condition, daytime lethargy, the influence on their guardians were greater in the treatment group than in the control group 6-month and 12-month post-operatively(P < 0.05). These findings suggested that oral and facial muscle functional training combined with muscle functional appliance can provide greater improvement in general condition and subjective symptoms in the treatment group. ②PSG: Postoperative AHI and OAI were significantly decreased in both groups, while LSaO2 was significantly increased (P < 0.01), indicating that sleep respiratory function was significantly improved in both groups after treatment. Patients in treatment group showed greater AHI reduction and LSaO2 improvement 6-month and 12-month postoperatively(P < 0.01), indicating that oral and facial muscle functional training combined with muscle functional appliance can provide greater improvement in airway obstruction symptoms and sleep respiration. ③Radiological changes: SNB Angle was increased(P < 0.05) and ANB Angle was decreased significantly(P < 0.05), while SPP-SPPW, U-MPW and TB-TPPW increased significantly in airway measurement 6-month and 12-month postoperatively (P < 0.01), indicating that after combined treatment with oral muscle functional training and muscle functional appliance, the mandible was moved forward and rotated clockwise.Conclusion The combined treatment with oral muscle functional training and muscle functional appliance is more effective in improving oral breathing, upper airway sagittal structure and sleep breathing, and can correct oral habits of children. The long-term effect needs further investigation.
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表 1 口面肌功能训练内容
练习内容 方法 时间/次数 具体内容 软腭训练 长元音 2 min/组，5组/d 间歇发元音“a”和持续发元音“a”(等长练习)来训练腭咽肌、腭舌肌、悬雍垂、腭帆张肌和腭帆提肌。 唇肌训练 爆破音 2 min/组，5组/d 爆破唇上、下唇内抿至唇红全部包住，发出爆破音 呼吸训练 鼻呼吸 5组/d，2次/组 嘴唇闭合，用鼻呼吸1 min，捏住鼻子，屏住呼吸，开始走路，1秒钟走一步，直到憋不住气。松开手指，缓慢呼吸，记录每次走的步数，3次/d。 舌位训练 弹舌训练 5组/d，2次/组 弹舌训练舌腹吸紧上腭，保持2 s，迅速离开上腭，发出弹响，正确的发声像马达的“哒哒”声。 吞咽训练 口香糖训练 2组/d，20次/组 将口香糖嚼成团状，用舌尖将糖团置于上切牙后5 mm，然后用舌体压住口香糖，同时做吞咽动作，将口香糖在腭部摊平。 
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表 2 两组OSA患儿治疗前后OSA-18问卷调查分析
X±S 检测指标 术前 术后1个月 术后3个月 术后6个月 术后1年 OSA-18总分 治疗组 65.15±11.25 49.83±7.09 40.14±9.84 39.57±12.87 38.45±9.54 对照组 64.69±10.23 48.07±6.87 44.14±11.44 42.57±10.72 40.75±11.24 睡眠障碍 治疗组 18.15±12.05 10.23±9.82 8.14±3.48 5.57±2.87 7.75±4.54 对照组 17.95±9.59 10.27±8.87 9.14±3.14 9.53±4.73 9.15±3.58 身体症状 治疗组 18.25±10.04 13.23±5.82 10.14±3.89 9.45±3.89 7.75±2.62 对照组 17.95±9.59 13.27±8.87 12.44±3.14 9.53±4.73 9.05±2.54 情绪不佳 治疗组 10.85±2.65 8.23±3.17 7.64±1.94 6.57±1.87 6.65±2.52 对照组 10.92±3.74 9.73±3.82 8.94±2.24 8.57±2.07 8.25±1.56 白天功能 治疗组 11.85±3.25 10.83±3.14 9.63±2.93 8.57±1.87 8.67±2.53 对照组 11.93±3.34 10.78±2.82 10.98±2.14 9.97±2.06 10.05±2.58 对监护人的影响 治疗组 18.03±9.05 14.23±8.82 10.14±3.48 9.94±2.67 9.75±4.54 对照组 17.95±9.58 14.27±8.21 13.14±3.14 12.93±4.42 11.97±3.54
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表 3 两组OSA患儿术前、术后PSG变化
X±S 监测指标 术前 术后1个月 术后3个月 术后6个月 术后1年 AHI 治疗组 6.85±2.05 3.23±2.01 2.14±1.47 2.27±1.82 2.15±1.59 对照组 7.05±2.43 4.38±2.72 2.62±2.06 3.07±1.87 3.15±1.14 AI 治疗组 2.45±1.25 1.54±0.89 1.04±0.82 1.07±0.87 1.12±0.98 对照组 2.38±1.34 1.93±1.17 1.74±1.04 1.87±1.72 1.95±1.54 LSaO2 治疗组 78.95±8.24 85.23±7.87 89.84±7.49 92.57±6.87 92.25±5.52 对照组 79.05±7.28 89.23±8.87 88.44±6.89 89.57±7.83 89.05±7.24
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表 4 两组OSA患儿治疗前后头颅测量参数变化
X±S 检测指标 术前 术后1个月 术后3个月 术后6个月 术后1年 SNA角 治疗组 78.35±6.52 80.23±3.87 80.34±5.46 81.57±6.70 80.52±4.59 对照组 79.05±5.15 80.19±5.96 80.28±5.48 80.97±8.87 81.15±5.57 SNB角 治疗组 70.15±6.23 70.89±3.87 71.14±7.43 76.57±6.86 78.5±6.04 对照组 71.05±5.98 70.23±3.87 71.84±5.04 73.57±5.95 73.15±4.93 ANB角上下齿槽座角 治疗组 8.15±3.25 6.36±2.87 5.14±2.49 4.72±2.87 4.58±2.45 对照组 8.63±2.98 7.23±2.95 6.73±3.06 6.19±2.89 6.05±2.83 PNS-R 治疗组 16.36±3.27 16.98±3.07 18.14±3.49 18.07±3.89 18.25±4.54 对照组 16.45±4.05 16.23±3.89 18.49±4.24 18.12±4.07 18.07±3.58 U-MPW 治疗组 8.15±2.67 8.98±3.87 9.14±15.44 9.57±6.87 9.85±3.23 对照组 8.15±2.67 8.28±3.78 8.64±4.04 8.97±3.81 8.85±4.02 SPP-SPPW 治疗组 8.15±2.67 8.92±3.07 9.24±2.49 9.57±6.87 9.89±3.23 对照组 8.15±2.67 8.37±2.78 9.04±4.04 8.94±3.72 8.89±3.95 TB-TPPW 治疗组 8.15±2.67 8.92±3.15 10.43±4.08 10.75±3.87 11.08±4.25 对照组 8.15±2.67 8.37±2.78 9.04±4.04 9.54±4.73 9.29±3.79
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