【摘要】：第一部分低劑量多層螺旋CT三維重建技術在肋軟骨評估的應用目的：將CT冠狀掃描技術與常規(guī)軸位掃描技術進行比較,評價冠狀掃描技術應用的價值,探索一種肋軟骨評估的影像學方法。方法：選擇60例于2011年1月到2013年5月行全耳廓再造和聽力重建的小耳畸形患兒進行前瞻性對照研究。43例5-7歲患兒行低劑量多層螺旋CT(multi-slice CT, MSCT)冠狀掃描,在早期階段隨機選擇17例6-8歲患兒行常規(guī)軸式掃描。兩組間患兒身體質量指數(shù)(BMI)無明顯差別。術前采用GE Light Speed VCT 64排螺旋CT機(GE公司,美國)掃描患者雙側第1～12肋。低劑量冠狀掃描組利用特殊的醫(yī)用靠背支架掃描,常規(guī)軸位掃描組取平臥位常規(guī)檢查,并應用鉛衣保護患兒頸部、下腹部及會陰部,避免不必要的輻射。兩組采用如下相同的掃描參數(shù)：螺旋模式,管電壓100kV,管電流145mA,轉速0.4s,層厚5mm,重建層厚0.625mm,螺距1.379。兩組有不同的掃描范圍：軸位掃描組為250±25.2mmm；冠狀掃描組為60±12.2mm。將掃描獲得的原始數(shù)據(jù)輸入圖像后處理工作站(ADW4.2, GE Medical Systems),應用容積重建(volume rendering technique, VRT)和最大密度投影技術(maximum intensity projection, MIP)三維重建肋軟骨和肋骨圖像,通過圖像觀察第5-9肋軟骨形態(tài)并測量。從CT檢查后患者的資料欄中記錄CT掃描的容積CT劑量指數(shù)(volume CT dose index, CTDIvol),劑量長度乘積(dose-length product, DLP)的數(shù)值。CTDIvol顯示為2.16HU。由兩位經(jīng)驗豐富的副高級以上放射學醫(yī)師對圖像進行雙盲法評價,意見不一致時共同協(xié)商確定。通過對觀察指標包括：圖像噪聲背景、呼吸偽影干擾程度、肋軟骨的完整性、肋軟骨三維輪廓及肋軟骨弓橫斷面結構的清晰度及對比度等的評價,將圖像分為優(yōu)、良、差三級。將兩組間圖像質量、噪聲、輻射劑量進行比較。結果：1圖像質量圖像質量評分中,冠狀掃描組優(yōu)、良、差例數(shù)分別為34、8、1,優(yōu)良以上的比例約為97.67%(42/43)；軸位掃描組優(yōu)、良、差例數(shù)分別為8、7、2,優(yōu)良以上的比例為88.24%(15/17)；與軸位掃描組相比,冠狀掃描組圖像質量與之相同(x2=6.33,p0.05)。兩組圖像噪聲分別在T7平面,T11平面,L2平面進行測量；結果顯示,各平面噪聲相近：兩組噪聲總體相近,差異無統(tǒng)計學意義(F=1.88,p0.05)。2輻射劑量兩組掃描參數(shù)相同,CDTIvol值相同。DLP在冠狀掃描組和軸位掃描組分別為19.44±3.25HU,68.00±12.36HU。與軸位掃描組相比,冠狀掃描組DLP減少約71.41%。冠狀掃描組的輻射劑量顯著低于軸向掃描組(t=15.98,p0.001)。結論：與常規(guī)軸位掃描技術相比,低劑量冠狀掃描技術獲得的圖像質量與之相近,為需耳廓再造的低齡小耳癥兒童肋軟骨發(fā)育的評估提供了一較好的影像學檢查方法。第二部分小耳畸形患者肋軟骨的發(fā)育及對手術時機選擇的指導意義目的：應用低劑量螺旋CT三維重建肋軟骨形態(tài)并測量,探索5-10歲小耳癥兒童肋軟骨的發(fā)育規(guī)律；并參照健側耳廓軟骨支架評估肋軟骨的發(fā)育,尋找一種指導低齡兒童耳廓再造手術時機的方法。方法：對2011年1月至2014年9月期間接受全耳廓再造和聽力重建的121例年齡在5-10歲的小耳癥患者進行研究。其中右側小耳畸形78例,左側43例。耳垂型84例,耳甲腔型33例,不典型4例。每個年齡組中性別分布無明顯差異。所有患者均排除了胸壁疾患、胸部創(chuàng)傷史(包括手術、外傷、放療史等)、胸痛癥狀、腫瘤史及心肺慢性疾病。患者術前行低劑量顳部及胸部CT掃描。顳部乳突掃描應用低劑量掃描參數(shù)設置進行,胸部掃描除在研究早期部分對照組患兒應用常規(guī)軸式掃描方式進行外,所有患者均應用低劑量冠狀掃描或應用低劑量的自動管電流調制技術進行。將掃描獲得的原始數(shù)據(jù)輸入圖像后處理工作站(ADW4.2, GE Medical Systems),應用最大密度投影(maximum intensity projection, MIP)及容積重建技術(volume rendering technique, VRT)對肋軟骨、肋骨及健側耳廓軟骨支架圖像進行三維重建。通過圖像觀察第5-9肋軟骨形態(tài)；對雙側第6、7肋軟骨聯(lián)合的寬度和第8肋軟骨長度進行測量；其中第8肋軟骨的測量從骨軟骨交界處至軟骨與胸骨連接處或至軟骨的游離緣遠端。健側耳廓軟骨支架的有效耳輪長度的測量從耳輪腳始至耳輪融入耳垂交界處,約在與耳屏間切跡平齊水平。術中切取患耳對側第6、7、8肋軟骨。術中肋軟骨采集后即刻應用顯微外科游標卡尺對切取的第6、7肋軟骨聯(lián)合的寬度進行測量,應用外科直尺對第8肋軟骨全長進行測量。所有測量重復3次,取均值作為最終測量結果。將術前測定的患耳對側的第8肋軟骨長度與健側耳廓軟骨支架耳輪的長度相配比,并同時參考患兒父母耳廓的大小,決定手術時機。若二者接近,同時患兒耳廓大小尺寸與其父母耳廓大小尺寸無較大差別,手術醫(yī)生決定開始一期手術；若術前測定的擬切取的患耳對側的第8肋軟骨的長度明顯短于健側耳廓軟骨支架耳輪的長度,超過2.5cm,手術醫(yī)生通過告知、勸說患者及父母后推遲手術。一期手術的結果由手術醫(yī)生和患者父母共同評價。兩方對結果均滿意為結果滿意,患者一方滿意為結果可接受,患者不滿意或二者均不滿意為結果不良。評價標準從再造耳廓的外形、大小尺寸、耳廓的位置、和再造耳廓結構的細節(jié)顯示等方面進行,其中對耳輪腳的形態(tài)和耳輪耳垂融合處形態(tài)是否流暢、有無凹陷切跡重點評估。其中,滿意結果標準為：外形良好、大小尺寸精準,耳廓位置與對側對稱,再造耳廓形態(tài)逼真,耳輪腳形態(tài)顯示良好,耳輪與耳垂融合處形態(tài)流暢；可接受結果為：外形良好、大小尺寸精準,耳廓位置與對側對稱,再造耳廓形態(tài)逼真,耳輪腳長度稍短,耳輪與耳垂融合處形態(tài)基本流暢；不良結果為：外形差,耳輪腳形態(tài)顯示不佳,耳輪與耳垂融合處形態(tài)不流暢,存在切跡。對擬切取的患耳對側的肋軟骨術前測量與術后測量數(shù)據(jù)的一致性進行了線性回歸與相關分析,對第6、7肋軟骨聯(lián)合和第8肋軟骨發(fā)育的趨勢進行了描述和比較。對手術結果進行了分析。結果：1術前測量與術后測量結果的一致性術前測定的擬切取的第6,7肋軟骨聯(lián)合的寬度、第8肋軟骨的長度分別與術中測定的真實結果接近。第6、7肋軟骨聯(lián)合寬度的術前圖像測量與術中測量的真實寬度滿足線性回歸關系(r=0.60,P0.05)。第8肋軟骨長度的術前圖像測量與術中測量真實長度滿足線性回歸關系(r=0.58,P0.05)。2肋軟骨和健側耳廓軟骨支架耳輪的發(fā)育5～10歲,第6、7肋軟骨聯(lián)合寬度的生長發(fā)育較緩慢,呈非線性狀態(tài)。第8肋軟骨的發(fā)育呈非線性狀態(tài),變化較大。可能由于第8肋軟骨從與胸骨相連狀態(tài)到變成浮肋狀態(tài)的年齡不確定性比較大有關。總體上,第6、7肋軟骨聯(lián)合寬度男女相近,在女性稍大；第8肋軟骨的發(fā)育沒有明顯性別差異。總體上第6、7肋軟骨聯(lián)合寬度左右相近,左側稍寬；第8肋軟骨的發(fā)育無側別的差異。5-10歲,健側耳廓軟骨支架耳輪的生長發(fā)育較緩慢,呈非線性狀態(tài)�？傮w上,健耳軟骨支架耳輪的發(fā)育無性別差異。3臨床手術結果根據(jù)術前測定的患耳對側第8肋軟骨長度與健側耳廓支架耳輪長度的相近程度,對121例患者進行了手術治療或推遲手術治療。76(62.8%)例患者第8肋軟骨長度與健側耳廓軟骨支架耳輪長度接近,應用完整的第8肋軟骨雕刻形成再造耳支架耳輪和耳輪腳,取得滿意手術結果；18(14.9%)例患者第8肋軟骨長度較健側耳廓軟骨支架耳輪長度略短,相差1.0cm,通過調整再造耳廓支架耳輪腳長度,縮短耳輪腳從而達到外耳輪向耳垂部延長,亦取得滿意結果。17(14.0%)例患者第8肋軟骨長度較健側耳廓軟骨支架耳輪長度短,相差1.5cm,應用第8肋軟骨與零碎軟骨條雕刻拼接形成再造耳廓支架耳輪,使耳輪長度達到與耳垂銜接處,取得可接受結果。9(7.4%)例患者由于第8肋軟骨長度較短,與健側耳廓軟骨支架耳輪長度相差較大,超過2.5cm,推遲了手術。1(0.8%)例早期的患者長度不足,第8肋軟骨長度較健側耳廓軟骨支架耳輪長度短約2.3cm,在患者父母的強烈要求下手術,由于我們早期經(jīng)驗不足,未取得良好結果。手術結果在不同年齡組間的分布顯示：各組間手術結果滿意率相近(p0.05),但隨年齡增大手術結果的滿意率有增加的趨勢。結論：5～10歲小耳畸形兒童第6、7肋軟骨聯(lián)合的生長比較遲緩；第8肋軟骨的發(fā)育變化較大,無規(guī)律可循。將第8肋軟骨的長度參照健側耳廓軟骨支架耳輪的長度可指導耳廓再造的手術時機,并開啟低齡兒童耳廓再造的個體化治療。肋軟骨CT三維重建評估并指導低齡小耳患者耳廓再造提供了一可預測手術結果的方法,既保證了再造耳廓的形態(tài),又可盡早解決患兒的心理發(fā)育問題。
[Abstract]:Part I Application of low-dose multi-slice spiral CT three-dimensional reconstruction technique in costal cartilage evaluation Objective: To compare CT coronal scanning technique with conventional axial scanning technique, evaluate the application value of coronal scanning technique, and explore an imaging method for costal cartilage evaluation. A prospective controlled study was conducted in 43 children aged 5-7 years with microtia who underwent low-dose multi-slice spiral CT (MSCT) coronal scan. 17 children aged 6-8 years were randomly selected for routine axial scan at the early stage. There was no significant difference in body mass index (BMI) between the two groups. 64-slice spiral CT (GE, USA) scans bilateral ribs 1-12. Low-dose coronal scans were performed with special medical backrest scaffolds. Routine axial scans were performed in the supine position. Lead coats were used to protect the neck, lower abdomen and perineum from unnecessary radiation. In spiral mode, the tube voltage is 100kV, the tube current is 145mA, the rotational speed is 0.4s, the layer thickness is 5mm, the reconstructed layer thickness is 0.625mm, the pitch is 1.379. The two groups have different scanning ranges: the axial scanning group is 250 + 25.2mmm, the coronal scanning group is 60 + 12.2mm. The volume rendering technique (VRT) and the maximum intensity projection (MIP) were used to reconstruct the costal cartilage and rib images. The shape of costal cartilage was observed and measured by the images. The volume CT dose index (CTDIvol) and the dose-length multiplication were recorded from the data bar of the patients after CT examination. CTDIvol was displayed at 2.16HU. Two experienced radiologists at or above the deputy senior level evaluated the images by double-blind method and agreed to determine if they disagreed. The image quality, noise and radiation dose were compared between the two groups. Results: 1 In the image quality score, the coronal scan group was excellent, good, and the difference cases were 34, 8, 1, respectively. The ratio of excellent and above was 97.67% (42/43). Compared with the axial scan group, the image quality of the coronal scan group was the same (x2 = 6.33, p0.05). The image noise of the two groups were measured in T7 plane, T11 plane and L2 plane respectively. The results showed that the noise of each plane was similar: the noise of the two groups was similar in general, and the difference was similar. There was no significant difference between the two groups (F = 1.88, p0.05). 2 Radiation dosage of the two groups was the same, the CDTIvol value was the same. DLP in the coronal scan group and the axial scan group was 19.44 (+ 3.25) HU, 68.00 (+ 12.36) HU, respectively. Compared with the axial scan group, the DLP in the coronal scan group decreased about 71.41%. The radiation dosage in the coronal scan group was significantly lower than that in the axial scan group (t = 15.98, p0.001). CONCLUSION: Compared with conventional axial scanning, low dose coronal scanning provides a better imaging method for the evaluation of costal cartilage development in children with microtia requiring auricle reconstruction. Part II The development of costal cartilage in patients with microtia and its guiding significance for the timing of surgery. Objective: To explore the development of costal cartilage in children with microtia aged 5-10 years by using low-dose spiral CT three-dimensional reconstruction and measurement of costal cartilage morphology, and to evaluate the development of costal cartilage with reference to healthy lateral auricular cartilage scaffold, so as to find a method to guide the timing of auricular reconstruction in young children. Total auricle reconstruction and auditory reconstruction were performed in 121 patients aged 5-10 years with microtia, including 78 cases of right microtia, 43 cases of left microtia, 84 cases of lobe type, 33 cases of concha cavity type, and 4 cases of atypia. Preoperative low-dose temporal and thoracic CT scans were performed. Temporal mastoid scans were performed with low-dose scanning parameters. Thoracic scans were performed with low-dose coronal or low-dose coronal scans, except for routine axial scans in some of the early control groups. Low-dose automatic tube current modulation technique was used to input the original data obtained from the scanning into the image post-processing workstation (ADW4.2, GE Medical Systems) and to apply maximum intensity projection (MIP) and volume rendering technique (VRT) to the cartilage branches of costal cartilage, rib and contralateral auricle. 3-D reconstruction of the scaffolds was performed. The shape of the 5-9 costal cartilage was observed. The width of the 6,7 costal cartilage Union and the length of the 8 costal cartilage were measured. The 8 costal cartilage was measured from the junction of the cartilage and the sternum to the distal end of the free edge of the cartilage. The 6,7,8 costal cartilage of the contralateral side of the affected ear was harvested during the operation. The width of the 6,7 costal cartilage syndesmosis was measured immediately after harvesting the costal cartilage. The 8 costal cartilage was measured with a surgical ruler. Quantity. All measurements were repeated three times and the mean was taken as the final measurement. The eighth costal cartilage length of the contralateral side of the affected ear was matched with the length of the contralateral auricular cartilage bracket ear wheel, and the timing of the operation was determined by referring to the size of the parents'auricles. If the two were close, the size of the affected ear and the size of the parents' auricles would be the same. If the length of the contralateral costal cartilage measured before surgery is significantly shorter than that of the contralateral ear cartilage bracket ear wheel, exceeding 2.5 cm, the surgeon advises the patient and his parents to postpone the operation. Parents shared the evaluation. Both sides were satisfied with the results, one side was satisfied with the results, the other was acceptable, the other was unsatisfied or both were unsatisfactory. The evaluation criteria included the shape, size, location of the reconstructed auricle, and the detail display of the reconstructed auricle structure, including the shape of the auricle wheel foot and the ear. Whether the fusion of the earlobes is smooth or not, and whether there is concave notch, the criteria of satisfactory results are: good shape, accurate size, symmetrical location of the auricle and the opposite side, realistic shape of the reconstructed auricle, good appearance of the foot of the auricle, smooth shape of the fusion of the earlobes and the earlobes; acceptable results are: good shape, size and size. Accurate, symmetrical and contralateral auricle position, realistic reconstructed auricle shape, slightly shorter auricular wheel foot length, ear wheel and earlobe fusion of the basic smooth shape; the bad results are: poor shape, ear wheel foot shape display is not good, ear wheel and earlobe fusion of the shape is not smooth, there is a notch. The consistency of the measurement data was analyzed by linear regression and correlation analysis, and the development trend of the 6th and 7th costal cartilage Union and the 8th costal cartilage were described and compared. The preoperative image measurement of the joint width of costal cartilage and the real width measured during the operation were linear regression (r = 0.60, P 0.05). The preoperative image measurement of the eighth costal cartilage and the real length measured during the operation were linear regression (r = 0.58, P 0.05). 2 costal cartilage and contralateral auricle. The development of cartilage scaffold Earrings ranged from 5 to 10 years old, and the width of costal cartilage union at 6 and 7 years old was slow and nonlinear. The development of costal cartilage at 8 was nonlinear and varied greatly. This may be due to the age uncertainty of the 8th costal cartilage from sternal to floating costal. In general, the width of costal cartilage Union in the 6th and 7th costal cartilage union is similar to that in the left side, and the development of the 8th costal cartilage has no lateral difference. There was no gender difference in the development of the ear ring. 3 According to the length of the contralateral eighth costal cartilage measured before operation, 121 patients were treated with surgery or postponed surgery. 76 (62.8%) patients had the same length of the eighth costal cartilage as the contralateral ear cartilage. 18 (14.9%) of the patients had a slightly shorter and 1.0 cm difference in the length of the ear ring of the cartilage scaffold on the eighth costal cartilage than that on the healthy side. 17 (14.0%) of the patients had shorter ear ring length of the 8th costal cartilage than that of the healthy ear cartilage stent, the difference was 1.5 cm. The 8th costal cartilage was carved and spliced with fragmentary cartilage strips to form a reconstructed ear ring. The length of the ear ring reached the junction of the earlobe. The acceptable result was obtained in 9 (7.4%) of the patients because the 8th costal cartilage was longer. Short, and the contralateral auricular cartilage stent ear wheel length difference is large, more than 2.5 cm, delayed the operation. 1 (0.8%) cases of early insufficient length, the eighth costal cartilage length is shorter than contralateral auricular cartilage stent ear wheel length about 2.3 cm, in the patient's parents under the strong request of surgery, due to our lack of early experience, did not achieve good results. Distribution among different age groups showed that the satisfactory rate of surgical results was similar among all groups (p0.05), but the satisfactory rate of surgical results increased with age. Conclusion: The growth of costal cartilage Union in children with microtia aged from 5 to 10 years old was relatively slow; the development of costal cartilage in the eighth costal cartilage changed greatly and could not be followed regularly. According to the length of the ear wheel of the healthy side of the auricle cartilage scaffold, the timing of auricle reconstruction can be guided and individual treatment of auricle reconstruction can be opened in young children. Determine the psychological development of children.
【學位授予單位】：山東大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R764.9

【參考文獻】

相關期刊論文 前1條

1 林子豪;先天性小耳畸形的MEDPOR支架耳再造術[J];第二軍醫(yī)大學學報;2005年01期

，

本文編號：2204569