口腔颌面外科术后神经损伤的临床护理观察(4)
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【摘要】[18] ELMADAWY A,HEGAB A,ALAHMADY H,et and electromyographic assessment of facial nerve function after temporomandibular joint surgery[J].Int J Oral Maxillofac Surg,2015,44(10)::10.1016/
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口腔颌面部主要包括口腔和颌面部,位于面部下部,是消化系统的起点。口腔颌面部的骨骼包括上颌骨、下颌骨、颧骨、鼻骨等。因处于比较暴露的位置,所以在事故中受伤的可能性较大。受到损伤后不仅会对身体的组织器官造成不同程度的障碍,严重时还可能导致毁容甚至生命安全,影响患者的生活质量。交通事故是造成其伤害的主要因素,目前车祸已成为颌面部损伤的主要原因,其中最常见的部位是下颌骨。原因在于,下颌位于面部的前方和下部,是颌面部骨骼体积最大的部位,当受到外力冲击时,下颌骨首先接触地面或物体,因此最容易在事故中受损。临床上口腔颌面部疾病主要采取外科手术治疗。由于人体口腔解剖结构及生理功能特殊,口腔颌面外科术后容易出现多种并发症,特别是口腔颌面部的血管和神经组织较丰富,手术机械性刺激容易引起神经损伤,继而导致面部功能出现障碍[1-2]。口腔颌面外科手术一般涉及腮腺咬肌区、上下颌骨内、颈部等多个区域,术后容易造成颏神经、舌神经、面神经、下牙槽神经等损伤。相应损伤造成的功能障碍可对患者的生活质量产生严重影响。面神经是第七对脑神经,其解剖结构独特,解剖位置浅,容易受创伤、医源性和肿瘤等因素的损伤。面神经损伤后,面神经功能很难再生和恢复,大部分面神经受损容易导致水肿。血肿压迫引起的面瘫发生在受伤后1 d左右。面神经严重损伤时部分患者完全断裂,难以通过自发性轴突生长恢复。因血肿、粘连和神经鞘水肿造成的迟发性损伤多发生在损伤后2~5 d,因此,加强面神经损伤修复的研究具有重要的临床意义,必须采取科学的护理方式对神经损伤患者进行干预,以促使其面部功能的恢复。本研究进一步分析了口腔颌面外科术后神经损伤的临床特点及护理方法。1 资料和方法1.1一般资料选取2017-02—2019-06焦作煤业(集团)有限责任公司中央医院经口腔颌面外科手术治疗的患者76例,男40例,女36例;年龄18~67岁,平均34.6岁;致伤原因:交通事故伤43例,摔伤14例,砸伤8例,坠落伤6例,其他(工伤、划伤、斗殴)5例;颌面创伤部位:单纯颌面软组织创伤10例,颌面部骨折66例;其中19例患者存在合并伤,四肢损伤7例,颅脑损伤4例,眼部损伤4例,胸腹部损伤3例,颈椎损伤1例。所有患者术前无神经障碍症状,18例行内固定术治疗,58例行手术切开复位治疗,术后均出现神经受损症籽芯糠椒ǘ?6例口腔颌面外科手术患者的一般资料、损伤类型、治疗及护理方法等进行调查,汇总和统计手术治疗方式、手术切口类型、神经损伤类型等情况,同时采用焦虑自评量表(SAS)、抑郁自评量表(SDS)评估神经损伤患者的心理状况,面神经功能分级标准House-Brackmann(HB)评价面神经功能恢复情况。心理状况评估[2-4]:SAS、SDS量表评分20~80分,分值越低说明焦虑、抑郁程度越轻。面神经功能恢复评估[5-6]:初诊时及随访结束时(术后12个月)分别进行HB评价,评估患者治疗及护理后面神经功能的恢复情况。本组76例患者HB评价Ⅰ~Ⅳ级,无Ⅴ~Ⅵ级病例护理方法1.3.1 面肌功能训练:针对面肌瘫痪部位按照如下训练方法进行面部训练:抬眉,双手四指并拢,自眉中间向上交替施力协助完成抬眉动作;耸鼻,皱鼻;努嘴,吹口哨;闭眼,用力闭眼;蹙眉,做挤眉弄眼状;示齿,暴露上下牙龈;提口角,用手协助向上施力;鼓腮,将口闭紧做鼓腮状。每个动作重复4~5次,每天训练2~4次,每个动作以最大限度进行训练,力量较弱的肌肉可以用手协助完成各项训练,肌肉能够运动的情况下施以轻微拮抗力,进一步增强肌肉力量。整个训练从神经损伤后15 d开始进行训练,每次训练15 min,每天训练3次,每个动作重复训练4~5次。患者根据制定的训练方案进行面肌功能训练,独自掌握训练方法之后,可在家属督促或协助下进行锻炼。必要时对面神经损伤部位予以肌肉按摩,指导患者对地仓、风池、迎香、阳白、听宫等穴位施加压力,顺健侧肌肉纹理走向及运动方向进行按揉,每次按摩3~5 min,每日进行3~4次 心理干预:口腔颌面外科术后神经损伤发病较突然,护理人员应及时针对患者的个人情况予以心理疏导,帮助患者克服困难,保持镇定,逐渐消除紧张、焦虑的负性情绪。护理干预期间给予患者足够的关怀,全面了解患者的心理状态,主动、耐心向患者解释神经损伤的发生原因,鼓励患者勇敢面对现实,进一步增强自身战胜疾病的信心,使其能够配合医务人员进行面肌功能训练。同时,引导家属与患者进行交流、沟通,给予更多关心和帮助,使患者能够处于最佳心理状态,积极面对疾病的治疗及康复训?健康教育:仔细、耐心向患者讲解口腔颌面外科术后神经损伤发生的具体情况,加深患者对神经损伤的了解,并告知患者坚持进行面肌功能训练,促使面肌功能尽快恢复。叮嘱患者戒烟,告知其香烟中的尼古丁有收缩血管作用,吸烟会进一步导致面神经缺血加重,可对康复造成严重影响。另外,由于面部神经损伤一定程度上影响患者的咀嚼功能,指导患者康复初期不宜食用粗硬食物,多食用富含蛋白质和热量的食物统计学方法应用统计学软件SPSS 23.0进行数据的处理,计量资料采用均数±标准差表示,行t检验,以P<0.05为差异有统计学意义。2 结果2.1口腔颌面外科手术切口的构成情况76例口腔颌面外科手术患者的手术切口主要包括颌面部原伤口切口、冠状切口、眼睑下切口、下颌下切口、口内切口,其中以口内切口、下颌下切口居多。见表1、涂谇或⒚嫱饪剖鹾笊窬鹕说姆植记榭?6例口腔颌面外科手术患者术后神经损伤涉及耳颞神经、舌下神经、颏神经、舌神经、副神经、面神经、下牙槽神经等,其中以下牙槽神经损伤、面神经损伤居多。见表2、涂谇或⒚嫱饪剖鹾笊窬鹕嘶颊逽AS、SDS评分对比口腔颌面外科术后神经损伤患者护理后SAS、SDS评分较护理前明显降低,差异均有统计学意义(P<0.05)。见表3。表1 口腔颌面外科手术切口的构成情况Table 1 The composition of incisions in oral andmaxillofacial surgery手术切口n构成比/%颌面部原伤口切口45.3冠状切口56.6眼睑下切口79.2下颌下切口2938.2口内切口3140.8表2 口腔颌面外科术后神经损伤的分布情况Table 2 Distribution of nerve injury after oral andmaxillofacial surgery损伤类型n构成比/%耳颞神经损伤22.6舌下神经损伤33.9颏神经损伤56.6舌神经损伤67.9副神经损伤79.2面神经损伤2431.6下牙槽神经损伤2938.2表3 口腔颌面外科术后神经损伤患者SAS、SDS评分对比(分,Table 3 Comparison of SAS and SDS scores of patients withnerveinjuryafteroralandmaxillofacial时间nSAS评分SDS评分护理前7655.护理后7637.值14..1893P值<0.05<0.05图1 口腔颌面外科手术切口的构成Figure 1 The composition of the incision in oral and maxillofacial surgery图2 口腔颌面外科术后神经损伤的分布Figure 2 Distribution of nerve injury after oral and maxillofacial 口腔颌面外科术后神经损伤初诊时及随访结束时的HB评价初诊时HB评价Ⅱ级以下的患者28例,随访结束时HB评价达到Ⅰ级25例(89.3%);初诊时HB评价Ⅲ级以上的患者48例,随访结束时HB评价达到Ⅰ级26例(54.2%)。见表4。3 讨论口腔颌面外科手术范围包括腮腺咬肌区、下颌下三角区、面侧深区、舌下区等头颈部重要解剖结构,术后神经损伤多见舌下神经、面神经、三叉神经及副神经损伤[7-9]。一般来说,面部神经损伤的发生与口腔表4 口腔颌面外科术后神经损伤初诊时及随访结束时的HB评价Table 4 HB evaluation of nerve injury after oral andmaxillofacial surgery at the initial diagnosis andat the end of follow-up初诊时HB评价n随访结束时HB评价Ⅰ级Ⅱ级Ⅲ级Ⅳ级Ⅰ级Ⅱ级Ⅲ级Ⅳ级颌面部疾病有关,而口腔颌面外科术后出现的神经损伤则主要是术中电刀止血操作导致的,属于一种医源性损伤[10-14]。临床常用的面神经功能分级标准为House-Brackmann分级,它将面神经功能分为6级:1级代表正常,2级代表轻度异常,3级代表中度异常,4级代表中重度异常,5级代表重度异常,6级代表完全性面瘫[15]。面神经损伤的并发症包括暴露性角膜炎、流口水、发音困难、进食困难等。在动物模型中眨眼反射、触手的方向及其自主活动经常被用作行为观察的指标,面神经损伤会导致神经电生理改变[16-20]。口腔颌面部血供丰富,创伤时出血较多,如果是闭合性损伤,容易形成血肿,组织水肿反应又快又重。如口底、舌根或颌下损伤,可因水肿或血肿而影响呼吸道通畅,甚至造成窒息。口腔颌面部损伤往往伴牙齿损伤,牙齿会因损伤的冲击而折断脱位,这些受损的牙齿或牙齿碎片会飞入邻近组织,造成“继发性弹片损伤”[21-23],并将牙石和细菌带入深层组织,造成伤口感染。面部畸形影响饮食和口腔卫生,口腔是消化道的入口,损伤后会影响咀嚼和吞咽功能,阻碍正常进食,创伤后往往会有不同程度的畸形或其他解剖结构损伤,如腮腺损伤可并发涎瘘,面神经损伤可发生面瘫,三叉神经损伤可出现其分布区麻木[24-28]。本组患者术后神经损伤以下牙槽神经损伤、面神经损伤居多,其中下牙槽神经损伤后患者容易出现患侧下唇及牙齿感觉异常,面神经损伤会导致其支配的表情肌运动功能异常,从而出现额纹消失、闭眼不全、口角歪斜等现象[10,29-30]。对于接受口腔颌面外科手术的患者而言,手术治疗本身就是对患者造成的二次创伤,手术过程中出现各种类型的神经损伤情况是不可避免的[11,31-32]。本研究中76例患者的手术切口以口内切口居多,主要是因口内切口为临床常用的手术切口。由于面部神经损伤不仅损害面肌功能,引起面肌萎缩,更有甚者导致面部畸形,这都会给患者的日常生活及身心健康造成负担。研究表明[12,33-34]面部神经损伤后应尽早采取措施予以修复,若延期修复会影响最终的功能康复,所以早期对口腔颌面外科术后神经损伤患者进行护理干预,对其面神经功能康复具有重要意义。在护理方面,心理干预和健康教育是确保患者面部功能恢复的重要前提[13-14]。因口腔颌面外科术后神经损伤的发生较突然,患者容易产生抑郁、焦虑等心理负担,而保持良好心态是保证患者积极面对疾病护理及康复的基础,开展心理干预消除患者的心理负担,能够帮助患者增强救治的信心,也为其日后面肌功能训练的顺利进行奠定了基础。健康教育的实施是提升患者对疾病认识的一个重要手段,同时也是帮助患者正确对待病情,纠正不良生活习惯的指导原则。在心理干预和健康教育的基础上,指导患者进行面肌功能训练,能够进一步促进损伤神经的有效恢复。另外还要积极预防感染,对于伤口感染,及时清创治疗,用过氧化氢、0.9%生理盐水清洗伤口,清除坏死组织,术后及时使用足量抗生素,并严格按照疗程进行。加强饮食护理,根据患者的损伤情况给予流质或半流质、高维生素、高热量、高蛋白的饮食,让患者充分认识到正常的口腔进食不仅可以刺激唾液分泌,还可加速神经损伤恢复,锻炼并恢复咬合和咀嚼功能。本研究中患者护理后SAS、SDS评分较护理前明显降低(P<0.05);随访结束时,初诊时HB评价Ⅱ级以下的患者达到Ⅰ级恢复占89.3%,初诊时HB评价Ⅲ级以上的患者达到Ⅰ级恢复占54.2%,与相关研究报道结果相近[15],说明早期有效的临床护理对口腔颌面外科术后神经损伤患者的康复进程大有裨益。口腔颌面外科术后神经损伤患者应尽早采取护理措施进行干预,通过面肌功能训练促进其面神经损伤的修复,从而提升术后面部神经损伤患者的生活质量。4 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