下顎位置與上呼吸道三維型態關係之研究

Abstract

目的︰ 本論文研究的目的，便是藉由動、靜態核磁共振影像來比較不同下顎位置對於上呼吸道的立體外型及不同切面的運動情況加以分析，並探討其與阻塞性睡眠呼吸中止症之形成機制，以及口內裝置的治療機轉，並評估台灣地區非肥胖男性之嚴重阻塞性睡眠呼吸中止症患者使用口內裝置的治療效果。 材料和方法︰ 實驗組選取9名20∼60歲的男性，BMI＜25，有OSA的臨床症狀及經由多功能睡眠生理監測儀（PSG）測定之後判定為偏重度阻塞性睡眠呼吸中止症的患者（AHI≧30)。對照組選取9名和實驗組經由年齡、BMI、性別配對之受測者，經由多功能睡眠生理監測儀（PSG）測定後，判定為正常的受測者（AHI＜5）。為受測者製作9組不同下顎位置的固定裝置。檢查時，配戴此固定裝置於上下牙齒之間，平躺於磁振掃瞄台上正常呼吸，以磁振掃瞄（MRI）記錄呼吸時上呼吸道動態及靜態影像。臨床上量測受測者的頸圍，並且紀錄側面測顱攝影。若為實驗組之受測者，將為受測者製作口內裝置，經調整穩定後配戴3個月，並再安排至睡眠中心接受多功能生理檢查（PSG）以評估使用效果。 結果: 實驗組及對照組的上呼吸道基期體積並無顯著差異，不論是完整體積（p=0.998）、軟顎後體積（p=1.000）及舌頭後體積（p=0.991）。兩組測顱攝影唯一有統計上差異為∠NSBa，實驗組小於對照組（p=0.033）。實驗組受測者配戴口內裝置是有顯著治療睡眠呼吸中止症效果的，使得AHI顯著下降（p=0.000）、氧氣去飽和狀態顯著下降（p=0.000）、平均氧氣飽和度顯著上升（p=0.020）、最低氧氣飽和度顯著上升（p=0.003）及氧氣飽和度＜90％發生率顯著下降（p=0.034）。 不同下顎位置與上呼吸道三維體積之關係，歸納如下：實驗組受測者上呼吸道的體積在沒有前突時，中度的開口會比沒有開口時體積顯著減少（完整體積、軟顎後體積、舌頭後體積皆成立）；中度的開口會比輕度開口時體積顯著減少（完整體積、舌頭後體積成立）。在最小開口時，75％最大前突會比50％最大前突體積顯著增加（軟顎後體積成立）。在輕度開口時，75％最大前突會比50％最大前突體積顯著增加（完整體積、舌頭後體積成立）。在中度開口時，75％最大前突會比沒有前突體積顯著增加（完整體積、軟顎後體積、舌頭後體積皆成立）；75％最大前突會比50％最大前突體積顯著增加（軟顎後體積成立）。對照組受測者上呼吸道的完整體積、軟顎後體積、舌頭後體積不論是在何種的開口或前突之下，皆無明顯的變化。 不同下顎位置與上呼吸道動態面積之關係，歸納如下：實驗組不同部位面積因下顎位置不同的變化情形如下:正中矢狀切面面積受到前突及開口交互影響；冠狀切面面積受到前突及開口單純影響；軟顎後軸向切面面積受到前突單純影響；舌頭後軸向切面面積受到開口單純影響。對照組正中矢狀切面面積受到開口影響，其餘無明顯變化。 不同下顎位置與上呼吸道動態長度之關係，歸納如下：實驗組不同部位長度因下顎位置不同的變化情形如下: 軟顎後軸向切面左右徑受到前突單純影響；軟顎後軸向切面前後徑受到前突單純影響；舌頭後軸向切面左右徑受到前突及開口交互影響；舌頭後軸向切面前後徑不受下顎位置之影響。對照組所有動態長度皆無明顯變化。 結論: 口內裝置使用於台灣地區非肥胖（BMI≦25）重度阻塞性睡眠呼終止男性患者可以達到臨床上顯著的效果。對此類患者而言，單純開口而不前突，會使上呼吸道體積減小。配戴口內裝置時，當達到足夠前突程度（75％最大前突），是可以讓其於清醒時呼吸道不同部位的體積增加，以預防睡眠時上呼吸道體積會塌陷的結果（特別是位於軟顎後體積部位）。而對於無阻塞性睡眠呼吸中止症受測者而言，不論下顎位置是如何變動，上呼吸道的體積都無明顯變化，且幾乎皆小於基期體積。 上呼吸道並非一條均質放大或縮小之通道。對重度阻塞性睡眠呼吸中止症患者而言，正中矢狀切面面積受到前突及開口交互影響；冠狀切面面積受到前突及開口單純影響；軟顎後軸向切面面積受到前突單純影響；舌頭後軸向切面面積受到開口單純影響。軟顎後軸向切面左右徑受到前突單純影響；軟顎後軸向切面前後徑受到前突單純影響；舌頭後軸向切面左右徑受到前突及開口交互影響；舌頭後軸向切面前後徑不受下顎位置之影響。

Objectives: The aim of this study is to analyze upper airway morphology changes and dynamic movement at different sections affected by mandible position by using dynamic and static magnet resonance imaging technique. The study also discusses the formation mechanism of obstructive sleep apnea syndromes and function mechanism of the oral appliance, as well as the evaluation of the clinical results of the oral appliance on non-obese male patients with severe obstructive sleep apnea in Taiwan. Materials and Methods: 9 non-obese (BMI<25) severe OSA (AHI＞30) male patients between the age of 20 to 60 and 9 gender, BMI and age matched control (AHI＜5) were recruited for this study. Nine bite index were made for the different mandible positions of the subjects. Upper airway was imaged by using static and dynamic MRI of each subject wearing the bite index while lying on the MRI scanning table. This study also measures the circumference and takes the lateral cephalometric imaging of each subject. Oral appliances were made and fitted for the experimental group subjects, who wore them for three months, after which they transferred to the Sleep Center and underwent PSG examination to evaluate therapeutic effects of theappliances. Results: There was no significant difference in upper airway volume between the experimental group or control group in total volume (p=0.998), retropalatal volume (p=1.000), or retroglossal volume (p=0.991). The only statistical difference found between the two sets of lacteral cephalometric imaging was ∠NSBa, in which the experimental group value was smaller than that of the control group (p=0.033). The oral appliance worn by the experimental group shows a significant therapeutic effect in treating sleep apnea, by lowering AHI (p=0.000), lowering oxygen desaturation event (p=0.000), raising average oxygen saturation (p=0.020), increasing lowest oxygen saturation (p=0.003), and decreasing saturation＜90％ (p=0.034). The relationship between different mandible positions and upper airway three-dimensional volume is as follows: Among experimental group subjects, when the mandible is at no protrusion level, the upper airway volume of moderate opening position is significantly smaller than that of no opening position (valid for total volume, retropalatal volume, and retroglossal volume); and the volume of moderate opening position is significantly smaller than that of slight opening position (valid for total volume and retroglossal volume). When the mandible is at minimal opening level, the upper airway volume of 75％ maximum protrusion position is significantly larger than that of 50％ maximum protrusion position (valid for retropalatal volume). When the mandible is at slight opening level, the upper airway volume of 75％ maximum protrusion position is significantly larger than that of 50％ maximum protrusion position (valid for total volume and retroglossal volume). When the mandible is at moderate opening level, the upper airway volume of 75％ maximum protrusion position is significantly larger than that of no protrusion position (valid for total volume, retropalatal volume, and retroglossal volume); the upper airway volume of 75％ maximum protrusion position is significantly larger than that of 50％ maximum protrusion position (valid for retropalatal volume).There was no significant change in the total, retropalatal, or retroglossal volumes of the upper airways in control group at different mandible positions. The relationship between different mandible positions and dynamic area of the upper airway is as follows: Among the experimental group subjects, the area of midsagittal section was influenced by interactive effect of protrusion and opening; the area of coronal section is influenced by simple effect of protrusion and opening; the area of retropalatal axial section is simply affected by protrusion; and the area of retroglossal axial section is simply affected by opening. The control group subjects displayed no significant changes, except for an influence of opening on the midsagittal section area. The relationship between different mandible positions and dynamic length of the upper airway is as follows: Among the experimental group subjects, the L length of retropalatal axial section is simply affected by protrusion; the AP length of retropalatal axial section is simply affected by protrusion; the L length of retroglossal axial section is influenced by interaction effect of protrusion and opening; the AP length of retroglossal axial section is not influenced by mandible position. The dynamic length for control group subjects shows no significant change. Conclusion: This study shows the significant clinical effect for using of oral appliance on non-obese (BMI≦25) male patients with severe obstructive sleep apnea in Taiwan. In these patients, simply mandible open without protrusion decreases the upper airway volume. The volume of different portion of the upper airway was increased in conscious subjects when protrusion reached sufficient levels (75% maximum protrusion), thus preventing the collapse of airway volume especially in retropalatal volume during sleep. Normal subjects show no significant changes in upper airway volume in any mandible position, and each volume almost was smaller than base line volume. The upper airway is not a channel which enlarges or contracts evenly. For patients with severe obstructive sleep apnea, the midsagittal section area is interactively affected by protrusion and opening; the coronal section area is simply affected by protrusion and opening; the retropalatal axial section area is simply affected by protrusion; and the retroglossal axial section area is simply affected by opening. The L length and AP length of the retropalatal axial section is simply affected by protrusion; the L length of the retroglossal axial section is affected by interaction effect between protrusion and opening; and the AP length of the retroglossal axial section is not affected by mandible position.