摘要
目的：评价全喉切除术后患者的嗅觉功能，观察嗅粘膜的大体与超微形态学改变，测试患者的残余嗅觉，探讨影响术后残余嗅觉的因素及嗅功能下降的原因，总结术后嗅觉的重建方法。方法：常规前鼻镜、鼻内窥镜对40例喉癌全喉切除术后的患者与40例正常对照组鼻腔大体形态进行观察，鼻内窥镜下钳取嗅区粘膜行投射电镜超微结构观察。用T&T嗅觉测试法测试实验组与对照组的嗅功能。观察患者自发的闻嗅方式，指导患者用NAIM法重建嗅觉。结果：1．对照组均鼻腔通畅，呼吸区粘膜呈粉红色，光滑、湿润，卷棉子轻触柔软而富有弹性。嗅粘膜呈淡的棕黄色，表面湿润。无喉者鼻腔宽大，呼吸区各结构呈萎缩性改变。粘膜变薄，色泽变为苍白色、青白色、灰白色不等，且弹性差，粘膜表面多有白色稀薄分泌物，对卷棉子反应灵敏，内窥镜下嗅区粘膜肉眼观变化不大。2．对照组嗅上皮投射电镜下为典型的假复层柱状上皮，可见微绒毛细胞、支持细胞、嗅细胞、基底细胞，构成良好的三层结构。细胞排列整齐，可见嗅泡伸出的嗅纤毛，微绒毛细胞和支持细胞伸出的微绒毛。上皮未见萎缩及增生。粘膜固有层中的粘液分泌细胞粘液颗粒丰富。粘膜下微血管内皮结构完整，可见薄层基板，血管周细
硕全好兑几竺…夕世必丈沪戈材要
胞未见坏死及凋亡像。无喉者组见嗅上皮三层结构尚可见。细胞间
连接部分中断，细胞间间隙变大，细胞膜皱缩，染色质浓缩，呈凋
亡改变，部分视野可见典型的凋亡小体。柱状上皮趋向立方形。固
有层的粘液分泌细胞分泌颗粒减少。间质微血管内皮增生，管腔狭
窄，周细胞有凋亡改变。嗅上皮中凋亡细胞所占的比例以术后两年
的最高，术后时间愈长，凋亡细胞的比例减少，但萎缩的柱状上皮
增多。 3.所有无喉者均主诉有明显的嗅觉下降，对日常生活的影
响较大。同时，71%患者述有味觉障碍。与客观测试结果基本相符。
4.性别、术前吸烟史、术后时间，是否行发音重建对无喉者残余嗅
觉具相关性。而年龄与之无相关性。5.NAIM嗅觉重建法能明显提
高无喉者的嗅功能。结论:1.缺乏呼吸气流与嗅素的刺激，无喉者
鼻腔各结构萎缩，粘膜变薄，色泽改变，弹性差，粘膜表面多有.白
色稀薄分泌物，对卷棉子反应灵敏。投射电镜下嗅区粘膜细胞间间
隙变大，细胞膜皱缩，染色质浓缩，可见凋亡小体，呈凋亡改变。
柱状上皮趋向立方形。固有层的粘液分泌细胞分泌颗粒减少。间质
微血管内皮增生，管腔狭窄，周细胞有凋亡改变。嗅上皮的超微结
构改变是嗅觉下降的原因之一。2.全喉切除术后患者并未完全失
嗅，尚有不同程度的残余嗅觉，选择适当的方法进行嗅觉重建，可
以明显改善患者的生活质量。3.全喉切除术后残余嗅觉女性优于男
硕毖班绘全月笋世居丈叭丈卿要
性，术前有吸烟史者差于无吸烟史者，随术后时间延长，残余嗅觉
有下降趋势。与患者的年龄尚未发现有相关性。4.NAIM法是一种
简单、方便、有效的嗅觉重建方法。5.气管食管裂隙状发音孔发音
重建不仅可使患者恢复言语功能，而且有嗅觉重建意义。
Objective: To study the olfactory function in patients after total laryngectomy. To investigate the morphologic and ultrastructure change of the olfactory mucosa. The residual olfactory function was tested and the factor affected the residual olfactory function were evaluated. The methods to restore the residual olfactory function were considered. Method: The nasal cavity of 40 laryngectomees and 40 normal control subjects was examined with anterior rhinoscope and nasal endoscopy. The ultrastructure of the nasal mucosa in olfactory region was observed with electron-microscopy .The olfactory function of the patients and the control group was tested by using T&T olfactometry, and the residual olfactory function was rehabilitated through nasal airflow-inducing maneuver. Results: 1. In normal control subjects, there was no obstruction, no secretion found in the nasal cavity. The nasal mucosa in respiratory region was smooth,moist, pink in color, and terderness and elastic in touching, the n asal
mucosa in olfactory region was brow-yellowish in color and moisture. In patients' group, the nasal cavity widened. The nasal mucosa in respiratory region was
sensitive to touching. It was thin, rigid,and white, white-blue or pale in color. There was thin mucus on it. The nasal mucosa in olfactory region, however ,only showed little changes under nasal endoscopy. 2. In control group, typical pseudostratified columnar epithelium, composed of three layers, could be seen under shoot electron-microscopy in olfactory mucosa. The ciliated olfactory cells, microcillar cells, supporting cells and basal cells were arranged normally with no hyperplasia and atrophy .the cilia and microcilia could also be seen. The Bowman' s gland, deep in the lamina propria, had abundant grains. The endothelium of the microvessels below the mucosa was integrity with thin lamina could be seen. There was no apoptosis or necrosis in Pericyte. In patients' group, under electron microscopy, the three layer of olfactory epithelium could be seen, but the connection between the cell was partly interrupted, and the interval between the cell widened. The cell membrance crimpled, chromatin condensed, which showed a picture of apoptosis. Typical apoptosis bodies could be seen sometimes, columnar epithelium tended to the cuboidal epithelium. The number of grain in the Bowman' s gland was decreased. Endodermis of microvessels proliferated and the diameter of
the vessels decreased. There was apoptosis in pericyte . The proportion of apoptosis cell reached to its highest two years after operation. As the time went on , the propotion of apoptosis cell droped, but the atrophy columnar epithelium increased. 3.A11 laryngectomees complained obviously decline of their olfaction after operation, which disturbed their daily life. And 71% of the patients also reported a deterioration of gestation, which conformed by the result of objective test. 4.Gerder, smoking history, time since operation, voice rehabilitation were all related to residual olfaction, excepted age. S.The method of nasal airflow-inducing maneuver can improve laryngectomees' residual olfactory function. Conclusions: 1.shortage of stimulating by the smell odorants in patients group, the nasal cavity widen. The nasal mucosa is sensitive to touching. It is thin, rigid,and changed in color. There is thin mucus on it. In olfactory epithelium,under electron microscopy, the connection between the cell is partly interrupted, and the interval between the cell widen. The cell membrance crimple, chromatin condense, which show a picture of apoptosis. Typical apoptosis bodies can be seen sometimes, columnar epithelium tend to the cuboidal epithelium. The number of grain in the Bowman' s gland is decreased.
Endodermis of microvessels proliferated and the diameter of the vessels decrease. There is apoptosis in pericyte. The ultrastructure change of olfactory epithelium is one reason of losing olfactory. 2.The laryngectomees have some residual olfactory
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