屈曲传感器在喉运动监测中的有效性验证及其在吞咽中与舌压传感器的同步应用
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摘要
吞咽是指食物进入口腔，经由咽部、食管，最终到达胃部的全过程；它可以分为口腔期、咽期和食管期。作为一个复杂的生理行为，吞咽由吞咽中枢调控，以自主神经肌肉运动开始，随后为非自主神经肌肉运动，整个过程需要众多生理结构的协同参与。首先，摄入的食物经过咀嚼形成合适性状的食团，然后舌-硬腭接触产生舌压将食物后送，当食物流到达咽部时刺激这一区域的感受器激发吞咽反射开始，随后一系列的生理运动按照一定节奏有序进行，包括舌骨-喉复合体的上抬前移、会厌的翻转倒置、真声襞和假声襞的关闭以及食管上括约肌的开放，在有效运送食团通过咽喉进入食管的同时避免误吸的发生，最后食团在自上而下食管蠕动波的作用下进入胃部。吞咽功能的正常发挥对于食物下咽、营养摄取、身体发育乃至生命延续至关重要，这一过程中任何结构的运动异常或者协调性偏差都可能引发吞咽困难，轻者损害健康，重者危及生命。
在临床中，中风、帕金森病、阿尔茨海默症、偏瘫、重症肌无力等疾病导致的吞咽障碍已成为现代医学日益关注的问题之一，许多神经内科、耳鼻喉、康复医学等专业的专科医生开始将越来越多的精力放在吞咽功能评估以及各种疾病引起的吞咽困难诊治工作中来。在口腔医学中，牙列缺损患者、牙列缺失患者、唇腭裂患者以及口颌面部创伤、肿瘤术后患者，由于咀嚼功能的降低、腭咽闭合不全、口腔颌面部畸形或者舌和舌骨等生理器官运动功能障碍等原因，同样饱受吞咽困难的困扰。因此，口腔医生在针对口腔常见疾患进行义齿修复、正畸治疗、头颈部创伤或肿瘤手术及愈后康复训练的同时，也要考虑患者在疾病诊断前、治疗中以及医治后的吞咽功能，这一点对于患者口腔机能的康复至关重要。如果在口腔临床工作中能够借助简便、有效的仪器方法进行吞咽功能评估以及吞咽困难早期诊治，不仅可以降低医生临床工作强度、提高医疗质量，而且也有助于减轻病患疾苦，提高病人生活质量。
目前临床上被用来进行吞咽功能评估的仪器方法包括X线活动影像造影术（Videofluorography，VF）、电子内窥镜检查术（Videoendoscopy，VE）、核磁共振成像术（Magnatic Resonance Imaing，MRI）、计算机断层扫描术（ComputedTomography，CT）、超声波扫描术（Ultrasonography，US）和肌电图（Electromyography，EMG）等等，其中VF被认为是吞咽功能评估和吞咽困难诊断的金标准。不可否认，这些测量方法都有助于我们了解、认识吞咽这一复杂的生理活动，并为我们提供了重要的吞咽生理数据和临床参考价值。然而，上述仪器均存在着或多或少的缺点，如监测过程中的辐射性、仪器操作的复杂性、检查费用的昂贵性、对卧床病人的不便性等等，不同程度地限制了它们在临床中的广泛应用，给病患的疾病诊治带来麻烦的同时，也存在伦理学的争议。
事实上，口腔和咽部都参与了吞咽运动，其中许多重要结构的正常生理功能会受到口腔疾病的影响，从而造成吞咽功能异常。而且，口腔疾病的治愈不仅包含生理结构的恢复，更需要生理功能的恢复，这已经成为现代口腔医学发展的一个必然趋势。因此，作为医疗工作者的口腔医生，在口腔治疗过程中同样有责任、有义务参与到吞咽功能评估和针对因口腔疾患引起的吞咽困难早期诊治工作中来。在这种情况下，研发便于牙椅旁、病床边简单操作、无创定量评估吞咽相关结构生理运动和功能的仪器方法成为亟需解决的问题之一。
课题组早期已成功研发出舌压传感器，并通过测量多个舌-硬腭接触位点产生舌压有效地判断了吞咽口腔期的舌体运动。本实验拟在前期工作的基础上，将康复医学领域中用来记录人类某些精细动作的屈曲传感器应用到吞咽时舌骨-喉复合体运动的监测中，在确定受试者颈部合适的贴附位置以及所记录波形的标志时间点和特征后，同步应用VF来明确所得波形代表的舌骨运动生理意义，验证屈曲传感器在吞咽咽期喉运动监测中的有效性。在此基础上，利用舌压传感器和屈曲传感器同步监测吞咽过程中舌压变化和舌骨运动的生理协同性，为未来借助生物传感器系统无创、简单、定量、有效地评估吞咽口咽期功能提供理论基础和实践依据，同时也为椅旁、床边吞咽困难的早期诊治提供临床实验支撑。
本课题共分为两个部分，内容包括：
第一部分，屈曲传感器监测吞咽时喉运动的有效性验证。
首先，选取12名健康成年男性做为受试者，对屈曲传感器最佳贴附位置的确定进行研究。分别将屈曲传感器沿受试者颈前部中线贴附在3个位置上，嘱受试者在听到指令后一次性吞咽5ml水。通过对各个贴附位置所得波形的重复性以及波形最大震动幅值分析后可见，尽管屈曲传感器在3个不同贴附位置上记录到的喉运动相似波形出现频率无统计学差异，但当屈曲传感器顶端贴附在吞咽时甲状软骨最突点到达的最高位置时，吞咽过程中喉运动所产生的波形简单、清晰、便于后期分析，所产生的波形最大震动幅值也明显大于贴附在其它两个位置时的这一参数。这说明吞咽时甲状软骨最突点到达的最高位置为屈曲传感器测量吞咽时喉运动的合适贴附位置。在此基础上，对吞咽液体时所得喉运动波形的特征进行了描述，并通过微分法准确定位波形上7个标志时间点，为后期实验分析做准备。
随后，选取6名健康成年男性做为受试者，将屈曲传感器顶端贴附在吞咽时甲状软骨最突点到达的最高位置，并同步应用VF观察吞咽5ml液态钡餐过程中舌骨的生理运动。统计结果显示，屈曲传感器记录的喉运动波形某些标志时间点与VF记录的舌骨某些生理运动时间非常接近，它们之间具有明显的正相关性，从而证明波形各个标志时间点所代表的舌骨生理运动意义，比较后还发现屈曲传感器记录喉运动波形各时期与VF记录舌骨生理运动各时期的时间相似。
第二部分，利用生物传感器进行吞咽过程中舌压变化与舌骨运动生理协同作用的研究。
首先，选取14名健康成年男性做为受试者，用以观察正常吞咽过程中舌压的变化模式。将舌压传感器贴附在硬腭，测量受试者吞咽5ml水时5个舌-硬腭接触位点的舌压变化模式。结果显示，舌中线前部最先与硬腭接触，然后是舌边缘与硬腭接触，最后是舌中线后部与硬腭接触；所有测量位点的舌压快速达到峰值，然后缓慢降低直至消失。舌中线后部的舌压持续时间、峰值以及舌压积分值明显低于其它4个位点，而舌与硬腭两侧边缘接触的舌压没有统计学差异。这一实验结果表明，吞咽时舌与硬腭接触的顺序以及各个位点舌压的时间、峰值存在精确的协调性。、
然后，选取12名健康成年男性做为受试者，研究舌压传感器对屈曲传感器记录波形的影响。比较同一受试者在同时贴附屈曲传感器和舌压传感器或者仅贴附屈曲传感器而不贴附舌压传感器的情况下吞咽5ml水后屈曲传感器的记录参数变化。统计显示，无论贴附舌压传感器与否，屈曲传感器所记录波形的同一标志时间点之间的时间差非常微小，无统计差异，而且屈曲传感器记录的喉运动各时期持续时间也没有明显变化，表明舌压传感器的贴附对屈曲传感器吞咽过程中喉运动的波形记录不产生任何影响。
最后，为了探讨吞咽过程中舌压变化与舌骨运动的生理协同性，选取14名健康男性做为受试者。将舌压传感器和屈曲传感器分别贴附在硬腭和颈前部同步记录吞咽5ml水时的舌压变化和喉运动。统计结果表明，舌压传感器记录的舌-硬腭接触各个位点舌压变化时程与前期实验结果一致；各个位点舌压产生时间接近舌骨上向运动的开始时间，舌压峰值出现时间略早于舌骨到达最上前位置的时间但无统计差异，而舌-硬腭接触消失与舌骨离开最上前位置开始回复运动几乎同时发生；吞咽过程中喉运动波形某些标志时间点与各位点舌压变化具有正相关性。
本课题的创新点：
1、首次将康复医学领域用来监测四肢精细运动的屈曲传感器应用到吞咽口咽期舌骨-喉复合体运动的无创监测中来；
2、第一次通过数学分析方法客观准确地定位了屈曲传感器记录波形上的标志时间点，避免了统计分析中实验人员的主观性误差；
3、实现了舌压传感器和屈曲传感器在吞咽监测中的同步化；
4、利用生物传感器系统无创、同步、定量地监测了吞咽过程中舌压变化和舌骨运动的生理协同性，为椅旁、床边吞咽口咽期功能评估和吞咽困难早期诊治提供了理论依据和实践支撑。
Swallowing refers to the entire act of placement of food in the mouth followed by theoral, pharyngeal and esophageal phases until the entrance of food into the stomach. As oneof the most complex physical behaviors requiring coordinated actions of several structures, it is modulated by the brainstem swallowing center, with the oral phase under voluntaryneuromuscular control and the latter two phases under involuntary neuromuscular control.First, the ingested food is processed to a bolus with adequate properties after masticationfollowed by the posterior propulsion with the help of tongue-hard palate contact (tonguepressure). Then, the swallowing is triggered with sensory input from receptors in thepharyngeal region as soon as the bolus reaches the pharynx, during which a continuum ofevents occurred in a well-defined tune, including vertical and anterior displacement of thehyolaryngeal complex, tilt and seal of the epiglottis, closure of the true and false vocalfolds, and opening of the upper esophageal sphincter (UES). Subsequently, the bolus istransferred down the throat into the esophagus safely, before peristaltic waves finally carryit from the esophagus to the stomach. Normal swallowing function plays a crucial role infood transportation, human nutrition, physical growth and even survival. Any disorderedactivities of the above structures and disrupted coordinated movements may result indysphagia which harms the health or even makes a threat to life.
Swallowing disorder is the consequences of various diseases, such as stroke,Parkinson’s disease, Alzheimer's disease, hemiplegia, myasthenia gravis and so on. It hasbecome a matter of increasing concern in the modern medicine. The specialists fromneurology department, E.N.T. department and rehabilitation department began to paymore and more attention to evaluate swallowing function and treat dysphagia. Also, in thedental practice, dentition defect, edentulous jaw, cleft lip and palate as well asmaxillofacial truama and tumors could result into reduced masticatory efficiency,velopharyngeal insufficiency, oral maxillofacial deformity or disorded motion of tongueand hyoid, which make lots of patients suffer from dysphagia. Therefore, it is ofimportance for dentist to take swallowing function evaluation into consideration before,during and after the diagnosis and treatment of common oral diseases, as this issue is vitalfor patients’ oral function rehabilitation. Thus, applying the appropriate appliances toevaluate the swallowing function and early diagnose dysphagia in dental work will notonly reduce the intensity of clinical work and improve the quality of health care, but alsobe helpful to reduce the patients’ sufferings and improve their quality of life.
Clinically, several methods have been adapted to measure swallowing function,including videofluorography (VF), videoendoscopy (VE), magnatic resonance imaing(MRI), computed tomography (CT), ultrasonography (US) and electromyography (EMG).Among them, VF is considered as the golden standard. There is no denying that all theabove methods have helped us to better understand swallowing physiology and providedus important reference data and clinical value. Nevertheless, their disadvantages also limittheir application widely because of the radiation exposure during observation, thecomplexity of the equipments operation, the high cost of physical examination or theinconvenience to medically unstable patients. The performances of them could trouble thedysphagic patients and give rise to ethical concerns sometimes.
Physically, dysphagia could attibute to the abnormal function of certain structures ororgans in the oral cavity and pharynx after some stomatology disease. Moreover, the cureof oral disease is not only limited to the recovery of physiological structure. Itscoincidence with the recovery of physiological function has become an inevitable trend ofthe modern oral and dental sciences. Consequently, it is the dentists’ duty to carry out theswallowing function evaluation during the treatment of oral diseases as well as earlydiagnosis and treatment of dysphagia arise from oral diseases. In these contexts, thedevelopment of a simple, non-invasive and quantitative method to assess theswallow-related organs is currently one of the most important issues.
Our previous research has successfully developed a sensor sheet for measuringtongue pressure produced by tongue-hard palate contact during swallowing. In thisresearch, we will introduce a bend sensor which is used for fine motor analysis of limb inthe rehabilitation field to observe the hyolaryngeal excursion during swallowing. Afterconfirmation of the best position to attach the bend sensor on the neck and thedetermination of several time points as well as the characters of the produced signalwaveform, the efficiency of bend sensor to detect laryngeal movement was verified byanalyzing the correlations and coordinations between time points on the signal waveformand hyoid activities acquired via VF. Then, tongue pressure sensor sheet and bend sensorwere applied simultaneously to determine the coordination of tongue pressure production and hyoid movement during swallowing in healthy subjects. It will benefit the evaluationof swallowing function non-invasively, simply, efficiently and quantitively. In addition,the bio-sensing system used in the present study provides the clinicians clinical trialsupport to diagnosis and treat dysphagic patients chair-side and bed-side.
The research is composed of two parts as listed below:
Part1, Validation of the efficiency of bend sensor to monitor laryngealmovement during swallowing.
First, twelve adult male subjects were recruited in this study for confirming the bestposition for attaching the bend sensor. Three positions on the front of the neck were testedto identify the best position to attach the bend sensor during swallowing5ml of water.Although the frequency of similar wave patterns among3positions differed little with nosignificant difference, the produced waveform was simple, clear and convenient for lateranalysis, and the maximum amplitude of the waveform was much larger when the tip ofthe sensor was fixed to the skin at the level of the prominence of the thyroid cartilagewhen it reaches highest position during swallowing. Consequently, the suitable positionfor placing the bend sensor was determined. In addition, the characters of the producedwaveform were described particularly based on7time points which were defined bydifferentiation.
Then, in order to evaluate the physiological significance of the waveform producedby the bend sensor during swallowing, six adult male subjects were recruited, and the tipof the bend sensor was fixed to the skin at the level of the prominence of the thyroidcartilage when it reaches highest position during swallowing5ml of liquid barium bolus.In addition, VF was used to observe the hyoid motion simultaneously. The results showedus that the time lags between certain time points of the obtained waveform from bendsensor and certain hyoid activities observed by VF were negligible with positivecorrelations indicating that we could presume some important hyoid activities by certaintime points of the waveform from bend sensor during swallowing. Furthermore, therewere no obvious significances after comparing each phase on the signal waveform and the VF events.
Part2, Application of the biosensor in the study of the coordination of tonguepressure production and hyoid movement during swallowing.
Fourteen adult male subjects were recruited in this study to observe the pattern oftongue pressure (TP) during swallowing. The pattern of TP produced in five contactsbetween the tongue and hard palate during swallowing5ml of water was recorded by atongue pressure sensor sheet. TP was generated initially by close contact with theanteriomedian part of the hard palate, then with the circumferential part, and finally withthe posteriomedian part. TP reached a peak quickly, then decreased gradually beforedisappearing almost simultaneously at each measured part of the hard palate. Duration,magnitude and integrated value of TP were significantly smaller in the posteriomedian partcompared to the other four parts measured. No laterality was found in TP produced at thecircumferential parts of the hard palate. Our findings indicate that the order of tonguecontact against each part of the hard palate as well as duration and magnitude of TP arecoordinated precisely during swallowing.
Then, twelve adult male subjects were recruited for investigating the influence ofusage of tongue pressure sensor sheet on the signal waveform produced by bend sensorduring swallowing. The data recorded by bend sensor was obtained with attaching tonguepressure sensor sheet simultaneously or not during swallowing5ml of water. There wereno obvious significances for the time lags between the same time point or for the matchedphases on the signal waveform produced by bend sensor whether concurrently attachingtongue pressure sensor sheet or not, suggesting us that the usage of tongue pressure sensorsheet exerted no influences on the waveform of the laryngeal movement produced by bendsensor during swallowing.
At last, fourteen adult male subjects were recruited to measure the coordinationtongue pressure and hyoid movement with sensors during swallowing. In this study, weapplied a tongue pressure sensor sheet on the hard palate to record TP and a bend sensoron the frontal neck to monitor the laryngeal movement which was synchronized withhyoid motion during swallowing5ml of water. The pattern of TP on hard palate in this study was consistent with the previous results in part2. The TP was produced closely tothe hyoid elevation, then reached maximal value a little earlier than the hyoid began stablein the most superior-anterior position but without significance, and ceased concurrentlywith the onset of hyoid descending. Significant positive correlations were found betweencertain time points on the laryngeal signal waveform and the recorded TP.
The innovations of this research:
1. We firstly introduced the bend sensor which was used to monitor the limb finemotor in the rehabilitation field to non-invasively monitor the hyolaryngeal excursionduring oropharyngeal swallowing.
2. This is the first time to read the signal waveform of hyolaryngeal movement frombend sensor objectively by mathematical analysis. This guarantees that the analysis is notaffected by the raters’ subjective judgments.
3. We achieved the simultaneous application of tongue pressure sensor sheet andbend sensor during swallowing.
4、These results firstly showed the coordination between TP production and hyoidmotion by using bio-sensing system non-invasively, simultaneously, quantitatively. Itcould be beneficial for clinicians to evaluate oral and pharyngeal phases of swallowing aswell as early diagnosis and treatment of dysphagia chair-side and bed-side.
在临床中，中风、帕金森病、阿尔茨海默症、偏瘫、重症肌无力等疾病导致的吞咽障碍已成为现代医学日益关注的问题之一，许多神经内科、耳鼻喉、康复医学等专业的专科医生开始将越来越多的精力放在吞咽功能评估以及各种疾病引起的吞咽困难诊治工作中来。在口腔医学中，牙列缺损患者、牙列缺失患者、唇腭裂患者以及口颌面部创伤、肿瘤术后患者，由于咀嚼功能的降低、腭咽闭合不全、口腔颌面部畸形或者舌和舌骨等生理器官运动功能障碍等原因，同样饱受吞咽困难的困扰。因此，口腔医生在针对口腔常见疾患进行义齿修复、正畸治疗、头颈部创伤或肿瘤手术及愈后康复训练的同时，也要考虑患者在疾病诊断前、治疗中以及医治后的吞咽功能，这一点对于患者口腔机能的康复至关重要。如果在口腔临床工作中能够借助简便、有效的仪器方法进行吞咽功能评估以及吞咽困难早期诊治，不仅可以降低医生临床工作强度、提高医疗质量，而且也有助于减轻病患疾苦，提高病人生活质量。
目前临床上被用来进行吞咽功能评估的仪器方法包括X线活动影像造影术（Videofluorography，VF）、电子内窥镜检查术（Videoendoscopy，VE）、核磁共振成像术（Magnatic Resonance Imaing，MRI）、计算机断层扫描术（ComputedTomography，CT）、超声波扫描术（Ultrasonography，US）和肌电图（Electromyography，EMG）等等，其中VF被认为是吞咽功能评估和吞咽困难诊断的金标准。不可否认，这些测量方法都有助于我们了解、认识吞咽这一复杂的生理活动，并为我们提供了重要的吞咽生理数据和临床参考价值。然而，上述仪器均存在着或多或少的缺点，如监测过程中的辐射性、仪器操作的复杂性、检查费用的昂贵性、对卧床病人的不便性等等，不同程度地限制了它们在临床中的广泛应用，给病患的疾病诊治带来麻烦的同时，也存在伦理学的争议。
事实上，口腔和咽部都参与了吞咽运动，其中许多重要结构的正常生理功能会受到口腔疾病的影响，从而造成吞咽功能异常。而且，口腔疾病的治愈不仅包含生理结构的恢复，更需要生理功能的恢复，这已经成为现代口腔医学发展的一个必然趋势。因此，作为医疗工作者的口腔医生，在口腔治疗过程中同样有责任、有义务参与到吞咽功能评估和针对因口腔疾患引起的吞咽困难早期诊治工作中来。在这种情况下，研发便于牙椅旁、病床边简单操作、无创定量评估吞咽相关结构生理运动和功能的仪器方法成为亟需解决的问题之一。
课题组早期已成功研发出舌压传感器，并通过测量多个舌-硬腭接触位点产生舌压有效地判断了吞咽口腔期的舌体运动。本实验拟在前期工作的基础上，将康复医学领域中用来记录人类某些精细动作的屈曲传感器应用到吞咽时舌骨-喉复合体运动的监测中，在确定受试者颈部合适的贴附位置以及所记录波形的标志时间点和特征后，同步应用VF来明确所得波形代表的舌骨运动生理意义，验证屈曲传感器在吞咽咽期喉运动监测中的有效性。在此基础上，利用舌压传感器和屈曲传感器同步监测吞咽过程中舌压变化和舌骨运动的生理协同性，为未来借助生物传感器系统无创、简单、定量、有效地评估吞咽口咽期功能提供理论基础和实践依据，同时也为椅旁、床边吞咽困难的早期诊治提供临床实验支撑。
本课题共分为两个部分，内容包括：
第一部分，屈曲传感器监测吞咽时喉运动的有效性验证。
首先，选取12名健康成年男性做为受试者，对屈曲传感器最佳贴附位置的确定进行研究。分别将屈曲传感器沿受试者颈前部中线贴附在3个位置上，嘱受试者在听到指令后一次性吞咽5ml水。通过对各个贴附位置所得波形的重复性以及波形最大震动幅值分析后可见，尽管屈曲传感器在3个不同贴附位置上记录到的喉运动相似波形出现频率无统计学差异，但当屈曲传感器顶端贴附在吞咽时甲状软骨最突点到达的最高位置时，吞咽过程中喉运动所产生的波形简单、清晰、便于后期分析，所产生的波形最大震动幅值也明显大于贴附在其它两个位置时的这一参数。这说明吞咽时甲状软骨最突点到达的最高位置为屈曲传感器测量吞咽时喉运动的合适贴附位置。在此基础上，对吞咽液体时所得喉运动波形的特征进行了描述，并通过微分法准确定位波形上7个标志时间点，为后期实验分析做准备。
随后，选取6名健康成年男性做为受试者，将屈曲传感器顶端贴附在吞咽时甲状软骨最突点到达的最高位置，并同步应用VF观察吞咽5ml液态钡餐过程中舌骨的生理运动。统计结果显示，屈曲传感器记录的喉运动波形某些标志时间点与VF记录的舌骨某些生理运动时间非常接近，它们之间具有明显的正相关性，从而证明波形各个标志时间点所代表的舌骨生理运动意义，比较后还发现屈曲传感器记录喉运动波形各时期与VF记录舌骨生理运动各时期的时间相似。
第二部分，利用生物传感器进行吞咽过程中舌压变化与舌骨运动生理协同作用的研究。
首先，选取14名健康成年男性做为受试者，用以观察正常吞咽过程中舌压的变化模式。将舌压传感器贴附在硬腭，测量受试者吞咽5ml水时5个舌-硬腭接触位点的舌压变化模式。结果显示，舌中线前部最先与硬腭接触，然后是舌边缘与硬腭接触，最后是舌中线后部与硬腭接触；所有测量位点的舌压快速达到峰值，然后缓慢降低直至消失。舌中线后部的舌压持续时间、峰值以及舌压积分值明显低于其它4个位点，而舌与硬腭两侧边缘接触的舌压没有统计学差异。这一实验结果表明，吞咽时舌与硬腭接触的顺序以及各个位点舌压的时间、峰值存在精确的协调性。、
然后，选取12名健康成年男性做为受试者，研究舌压传感器对屈曲传感器记录波形的影响。比较同一受试者在同时贴附屈曲传感器和舌压传感器或者仅贴附屈曲传感器而不贴附舌压传感器的情况下吞咽5ml水后屈曲传感器的记录参数变化。统计显示，无论贴附舌压传感器与否，屈曲传感器所记录波形的同一标志时间点之间的时间差非常微小，无统计差异，而且屈曲传感器记录的喉运动各时期持续时间也没有明显变化，表明舌压传感器的贴附对屈曲传感器吞咽过程中喉运动的波形记录不产生任何影响。
最后，为了探讨吞咽过程中舌压变化与舌骨运动的生理协同性，选取14名健康男性做为受试者。将舌压传感器和屈曲传感器分别贴附在硬腭和颈前部同步记录吞咽5ml水时的舌压变化和喉运动。统计结果表明，舌压传感器记录的舌-硬腭接触各个位点舌压变化时程与前期实验结果一致；各个位点舌压产生时间接近舌骨上向运动的开始时间，舌压峰值出现时间略早于舌骨到达最上前位置的时间但无统计差异，而舌-硬腭接触消失与舌骨离开最上前位置开始回复运动几乎同时发生；吞咽过程中喉运动波形某些标志时间点与各位点舌压变化具有正相关性。
本课题的创新点：
1、首次将康复医学领域用来监测四肢精细运动的屈曲传感器应用到吞咽口咽期舌骨-喉复合体运动的无创监测中来；
2、第一次通过数学分析方法客观准确地定位了屈曲传感器记录波形上的标志时间点，避免了统计分析中实验人员的主观性误差；
3、实现了舌压传感器和屈曲传感器在吞咽监测中的同步化；
4、利用生物传感器系统无创、同步、定量地监测了吞咽过程中舌压变化和舌骨运动的生理协同性，为椅旁、床边吞咽口咽期功能评估和吞咽困难早期诊治提供了理论依据和实践支撑。
Swallowing refers to the entire act of placement of food in the mouth followed by theoral, pharyngeal and esophageal phases until the entrance of food into the stomach. As oneof the most complex physical behaviors requiring coordinated actions of several structures, it is modulated by the brainstem swallowing center, with the oral phase under voluntaryneuromuscular control and the latter two phases under involuntary neuromuscular control.First, the ingested food is processed to a bolus with adequate properties after masticationfollowed by the posterior propulsion with the help of tongue-hard palate contact (tonguepressure). Then, the swallowing is triggered with sensory input from receptors in thepharyngeal region as soon as the bolus reaches the pharynx, during which a continuum ofevents occurred in a well-defined tune, including vertical and anterior displacement of thehyolaryngeal complex, tilt and seal of the epiglottis, closure of the true and false vocalfolds, and opening of the upper esophageal sphincter (UES). Subsequently, the bolus istransferred down the throat into the esophagus safely, before peristaltic waves finally carryit from the esophagus to the stomach. Normal swallowing function plays a crucial role infood transportation, human nutrition, physical growth and even survival. Any disorderedactivities of the above structures and disrupted coordinated movements may result indysphagia which harms the health or even makes a threat to life.
Swallowing disorder is the consequences of various diseases, such as stroke,Parkinson’s disease, Alzheimer's disease, hemiplegia, myasthenia gravis and so on. It hasbecome a matter of increasing concern in the modern medicine. The specialists fromneurology department, E.N.T. department and rehabilitation department began to paymore and more attention to evaluate swallowing function and treat dysphagia. Also, in thedental practice, dentition defect, edentulous jaw, cleft lip and palate as well asmaxillofacial truama and tumors could result into reduced masticatory efficiency,velopharyngeal insufficiency, oral maxillofacial deformity or disorded motion of tongueand hyoid, which make lots of patients suffer from dysphagia. Therefore, it is ofimportance for dentist to take swallowing function evaluation into consideration before,during and after the diagnosis and treatment of common oral diseases, as this issue is vitalfor patients’ oral function rehabilitation. Thus, applying the appropriate appliances toevaluate the swallowing function and early diagnose dysphagia in dental work will notonly reduce the intensity of clinical work and improve the quality of health care, but alsobe helpful to reduce the patients’ sufferings and improve their quality of life.
Clinically, several methods have been adapted to measure swallowing function,including videofluorography (VF), videoendoscopy (VE), magnatic resonance imaing(MRI), computed tomography (CT), ultrasonography (US) and electromyography (EMG).Among them, VF is considered as the golden standard. There is no denying that all theabove methods have helped us to better understand swallowing physiology and providedus important reference data and clinical value. Nevertheless, their disadvantages also limittheir application widely because of the radiation exposure during observation, thecomplexity of the equipments operation, the high cost of physical examination or theinconvenience to medically unstable patients. The performances of them could trouble thedysphagic patients and give rise to ethical concerns sometimes.
Physically, dysphagia could attibute to the abnormal function of certain structures ororgans in the oral cavity and pharynx after some stomatology disease. Moreover, the cureof oral disease is not only limited to the recovery of physiological structure. Itscoincidence with the recovery of physiological function has become an inevitable trend ofthe modern oral and dental sciences. Consequently, it is the dentists’ duty to carry out theswallowing function evaluation during the treatment of oral diseases as well as earlydiagnosis and treatment of dysphagia arise from oral diseases. In these contexts, thedevelopment of a simple, non-invasive and quantitative method to assess theswallow-related organs is currently one of the most important issues.
Our previous research has successfully developed a sensor sheet for measuringtongue pressure produced by tongue-hard palate contact during swallowing. In thisresearch, we will introduce a bend sensor which is used for fine motor analysis of limb inthe rehabilitation field to observe the hyolaryngeal excursion during swallowing. Afterconfirmation of the best position to attach the bend sensor on the neck and thedetermination of several time points as well as the characters of the produced signalwaveform, the efficiency of bend sensor to detect laryngeal movement was verified byanalyzing the correlations and coordinations between time points on the signal waveformand hyoid activities acquired via VF. Then, tongue pressure sensor sheet and bend sensorwere applied simultaneously to determine the coordination of tongue pressure production and hyoid movement during swallowing in healthy subjects. It will benefit the evaluationof swallowing function non-invasively, simply, efficiently and quantitively. In addition,the bio-sensing system used in the present study provides the clinicians clinical trialsupport to diagnosis and treat dysphagic patients chair-side and bed-side.
The research is composed of two parts as listed below:
Part1, Validation of the efficiency of bend sensor to monitor laryngealmovement during swallowing.
First, twelve adult male subjects were recruited in this study for confirming the bestposition for attaching the bend sensor. Three positions on the front of the neck were testedto identify the best position to attach the bend sensor during swallowing5ml of water.Although the frequency of similar wave patterns among3positions differed little with nosignificant difference, the produced waveform was simple, clear and convenient for lateranalysis, and the maximum amplitude of the waveform was much larger when the tip ofthe sensor was fixed to the skin at the level of the prominence of the thyroid cartilagewhen it reaches highest position during swallowing. Consequently, the suitable positionfor placing the bend sensor was determined. In addition, the characters of the producedwaveform were described particularly based on7time points which were defined bydifferentiation.
Then, in order to evaluate the physiological significance of the waveform producedby the bend sensor during swallowing, six adult male subjects were recruited, and the tipof the bend sensor was fixed to the skin at the level of the prominence of the thyroidcartilage when it reaches highest position during swallowing5ml of liquid barium bolus.In addition, VF was used to observe the hyoid motion simultaneously. The results showedus that the time lags between certain time points of the obtained waveform from bendsensor and certain hyoid activities observed by VF were negligible with positivecorrelations indicating that we could presume some important hyoid activities by certaintime points of the waveform from bend sensor during swallowing. Furthermore, therewere no obvious significances after comparing each phase on the signal waveform and the VF events.
Part2, Application of the biosensor in the study of the coordination of tonguepressure production and hyoid movement during swallowing.
Fourteen adult male subjects were recruited in this study to observe the pattern oftongue pressure (TP) during swallowing. The pattern of TP produced in five contactsbetween the tongue and hard palate during swallowing5ml of water was recorded by atongue pressure sensor sheet. TP was generated initially by close contact with theanteriomedian part of the hard palate, then with the circumferential part, and finally withthe posteriomedian part. TP reached a peak quickly, then decreased gradually beforedisappearing almost simultaneously at each measured part of the hard palate. Duration,magnitude and integrated value of TP were significantly smaller in the posteriomedian partcompared to the other four parts measured. No laterality was found in TP produced at thecircumferential parts of the hard palate. Our findings indicate that the order of tonguecontact against each part of the hard palate as well as duration and magnitude of TP arecoordinated precisely during swallowing.
Then, twelve adult male subjects were recruited for investigating the influence ofusage of tongue pressure sensor sheet on the signal waveform produced by bend sensorduring swallowing. The data recorded by bend sensor was obtained with attaching tonguepressure sensor sheet simultaneously or not during swallowing5ml of water. There wereno obvious significances for the time lags between the same time point or for the matchedphases on the signal waveform produced by bend sensor whether concurrently attachingtongue pressure sensor sheet or not, suggesting us that the usage of tongue pressure sensorsheet exerted no influences on the waveform of the laryngeal movement produced by bendsensor during swallowing.
At last, fourteen adult male subjects were recruited to measure the coordinationtongue pressure and hyoid movement with sensors during swallowing. In this study, weapplied a tongue pressure sensor sheet on the hard palate to record TP and a bend sensoron the frontal neck to monitor the laryngeal movement which was synchronized withhyoid motion during swallowing5ml of water. The pattern of TP on hard palate in this study was consistent with the previous results in part2. The TP was produced closely tothe hyoid elevation, then reached maximal value a little earlier than the hyoid began stablein the most superior-anterior position but without significance, and ceased concurrentlywith the onset of hyoid descending. Significant positive correlations were found betweencertain time points on the laryngeal signal waveform and the recorded TP.
The innovations of this research:
1. We firstly introduced the bend sensor which was used to monitor the limb finemotor in the rehabilitation field to non-invasively monitor the hyolaryngeal excursionduring oropharyngeal swallowing.
2. This is the first time to read the signal waveform of hyolaryngeal movement frombend sensor objectively by mathematical analysis. This guarantees that the analysis is notaffected by the raters’ subjective judgments.
3. We achieved the simultaneous application of tongue pressure sensor sheet andbend sensor during swallowing.
4、These results firstly showed the coordination between TP production and hyoidmotion by using bio-sensing system non-invasively, simultaneously, quantitatively. Itcould be beneficial for clinicians to evaluate oral and pharyngeal phases of swallowing aswell as early diagnosis and treatment of dysphagia chair-side and bed-side.
引文
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