2010-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646295摘要：鼻咽癌是台灣常見而重要的腫瘤，是屬麟狀細胞的惡性腫瘤，目前以放射線治療加上化學治療有很好的存活率。但放射線治療也造成局部組織的破壞，而造成一些不可避免的後遺症。放射線治療造成鼻咽癌的後遺症包括有口乾，牙關咬緊，聽力喪失，吞嚥障礙，構音異常，頸肌僵直等。其中又以口乾，聽力喪失及吞嚥障礙三項最常見而影響病人的生活品質。吞嚥障礙不只影響病患生活品質，若不小心造成吸入性肺炎，甚至危及病人生命。放射線治療後鼻咽癌患者，吞嚥障礙的比例約有50～100％，因不同的定義及研究方法而異，較嚴重而需求醫者約占15～20％。過去對於這類患者治療之相關研究寥寥無數。只有一篇研究提及於放射線治療後給予口咽運動可減少吞嚥功能的惡化，另一篇研究以頭頸腫瘤患者（非全鼻咽癌）為對象，進行代償性的姿勢發現對病患的吞嚥確實有所幫助。臨床上，對於已發生吞嚥障礙患者確實不知其標準之治療方式。對於接受放射線治療後較嚴重吞嚥障礙的患者，依據1988 及2003 我們兩篇對鼻咽癌患者的研究中發現，其主要的異常在於咽喉的上升不足及環咽肌的放鬆不全，而其中又以咽喉上升不足為首要之異常。因此本研究擬用三年的時間來建立接受放射線治療後有吞嚥障礙鼻咽癌患者的評估及治療方式。第一年我們將由本院過去10 年接受放射線治療之鼻咽癌患者（約1000 名）中，利用電話訪談了解其吞嚥情形，其中篩選出吞嚥障礙中度以上（利用吞嚥障礙評估表）者約30名，接受吞嚥電視螢光錄影檢查，並以自己開發軟體建立咽喉上升及環咽肌放鬆不全之客觀定量評估法。第二年我們將對25 名接受射線治療之鼻咽癌而有吞嚥障礙患者進行功能性電刺激訓練，另25 名為控制組，治療前後皆進行電視螢光錄影吞嚥檢查及吞嚥障礙生活品質問卷評估。如此，便能了解功能性電刺激對因放射線治療造成吞嚥障礙的鼻咽癌患者是否有效，並建立功能性電刺激對這類患者的治療模式。第三年我們將於電腦斷層及肌電圖的引導下對20 名這類患者的環咽肌進入肉毒桿菌素的注射。這群患者必須因放射線治療造成吞嚥障礙之鼻咽癌患者並於電視螢光錄影吞嚥檢查有明顯的梨狀竇滯留（環咽肌放鬆不全）。患者於注射前後接受5 次問卷評估及3 次電視螢光錄影吞嚥檢查，藉此了解肉毒桿菌素對這類患者的療效。在這三年計畫中，我們將了解接受放射線治療後鼻咽癌患者吞嚥功能的變化，建立定量測量電視螢光錄影吞嚥檢查參數的方法，了解功能性電刺激對這類患者的療效，及了解肉毒桿菌素注射對這類患者的療效。<br> Abstract: Nasopharyngeal carcinoma (NPC) is a common tumor in Taiwan. It is a malignant squamouscell carcinoma and well responded to chemoradiotherapy(CRT). Although the high survivor rateof NPC after CRT, radiotherapy (RT) also causes the local tissue damage and results in serevalunavoidable side effects.The side effects of RT include xerostomia, trismus, hearing loss, dysphagia, dysarthria,stiffness of the neck muscle and et al. Of all these side effects, xerostomia, hearing loss anddysphagia are reported to be related with the quality of life of the patients. Moreover, dysphagiamight cause aspiration pneumonia and mortality. There are 50 to 100% of the patients havingdysphagia after RT according to the different researches. 15 to 20 % of the patients might seek thehelp for dysphagia because the symptoms are so severe to influence their life. However, thereports regarding the management of dysphagia in NPC patients after RT are limited. One reportmentioning the early exercise after RT can postpone the developing of dysphagia. Anotherresearch mentioned that the compensation techniques can reduce the risk of aspiration andimprove the swallowing ability in head and neck caner patients after RT. The evidence-basemanagement of dysphagia in NPC patients after RT is still wondering.According to the works of our groups in 1998 and 2003, the major swallowing problems ofdysphagia in NPC patients after RT are inadequate larynx elevation and incomplete relaxation ofcricopharyngeal muscle (CP muscle). Moreover, the inadequate larynx elevation might beresponsible with the dysphagia in this group of patients. This three-year work attempts to establishthe standard evaluation and management strategy of dysphagia in NPC patients after RT.In the first year, we will use the phone-contact to interview the swallowing status of 1000patients, who having received RT for NPC in our hospital in past 10 years. From the interview, 30patients with moderate dysphagia according to the evaluation battery will be invited to accept thevideofluoroscopic examination of swallowing (VFSS). Self-designed quantitative analysis methodwill be applied to measure the larynx elevation, the severity of aspiration, and the amount ofresidue in pyriform sinuses (CP muscle relaxation). In the first year’s work, we will know thestatus of dysphagia in NPC patients after RT, establish the method of quantitative measurement ofVFSS, and record the changes of the important parameters of swallowing in this group patient.In the second year, we will apply function electric stimulation in 25 NPC patients withdysphagia after RT. Another 25 patients will be included as control without management. Bothgroups will receive evaluation of quality of life and VFSS before and after treatment. The secondyear’s work will establish the basic knowledge of functional electrical stimulation in NPC patientswith dysphagia after RT and investigate the treatment efficiency.In the third year, we will perform the botulinum toxin injection under computer tomographyand EMG guidance to CP muscle of 20 NPC patients, who having dysphagia after RT and CPmuscle dysfunction. The patients will be followed up for six months, including five evaluationbattery and three VFSS. The third year work will determine the effect of botulinum toxin injectionin NPC patients after RT with dysphagia and CP muscle dysfunction.With the three year’s project, we will establish the swallowing status of NPC patients afterRT, establish the objective quantitative method to measure the parameters of VFSS, test theefficiency of functional electrical stimulation in this group of patients, and determine the effect ofbotulinum injection in CP muscle of this specific group of patients.鼻咽癌吞嚥電刺激肉毒桿菌素Nasopharyngeal carcinomadeglutitionelectrical stimulationbutulinum toxin