肩胛舌骨肌综合征3例报道
Asian Case Reports in Surgery 亚洲外科手术病例研究, 2016, 5(4), 32-35 Published Online December 2016 in Hans.
A Report of Three Cases of Omohyoid Muscle Syndrome
Hanzhang Huang, Xiuling Wu, Feng Zhou, Shaoliang Han*
Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou Zhejiang
ththndReceived: Jan. 5, 2017; accepted: Jan. 19, 2017; published: Jan. 22, 2017
Copyright © 2016 by authors and Hans Publishers Inc. This work is licensed under the Creative Commons Attribution International License (CC BY).
Open Access
Abstract
Objective: To investigate the clinical characteristics of omohyoid muscle syndrome for the pur-pose of decreasing the rate of misdiagnosis and erroneous diagnosis. Methods: The clinical data of diagnosis and treatment in 3 patients with omohyoid muscle syndrome were summarized retros-pectively, and analyzed with the literatures reports. Results: The patients with omohyoid muscle syndrome included 2 males and 1 female; they clinically presented with evident bump of lower sternocleidomastoid muscle during swallowing. All 3 patients underwent surgery, including dis-section and lysis of the muscles, cut or resection of the lower belly of the omohyoid muscles. All patients were completely cured without recurrence. Conclusions: Omohyoid muscle syndrome is a rare clinical disease; the misdiagnosis and erroneous diagnosis may be reduced by high recogni-tion to this disease; and this disease can be cured by surgery. Keywords
Omohyoid Muscle Syndrome, Neck Mass, Operation
肩胛舌骨肌综合征3例报道
黄瀚章,吴秀玲,周 峰,韩少良*
温州医学院附属第一医院普外科,浙江 温州
*通讯作者。
文章引用: 黄瀚章, 吴秀玲, 周峰, 韩少良. 肩胛舌骨肌综合征3例报道[J]. 亚洲外科手术病例研究, 2016, 5(4): 32-35.
黄瀚章 等
收稿日期:2017年1月5日;录用日期:2017年1月19日;发布日期:2017年1月22日
摘 要
目的:探讨肩胛舌骨肌综合征的临床特点,减少误诊及漏诊。
:回顾性
3例肩胛舌骨肌综合征的诊治资料及文献报道。结果:3例肩胛舌骨肌综合征患者(男2例、女1例),临床上
现为吞咽时右侧颈部肿块2例及双侧颈部肿块1例。3例均采取手术治疗,即粘连肌肉松解、肩胛舌骨肌下腹切断或/和部分切除治疗方法,全部治愈、无复发。结论:肩胛舌骨肌综合征临床较少见,只要提高对此病的认识就会减少误诊、且手术效果良好。
关键词
肩胛舌骨肌综合征、颈部肿块、手术
1. 引言
肩胛舌骨肌综合征(omohyoid muscles syndrome)是1969年由Caswell和Zachary等首先报道的,特征性改变是当患者吞咽时具有X形侧方突出性颈部肿块[1] [2]。另外,绝大多数病人发病隐匿,且无外伤病史。国内由叶必远(1978年)首先报道,因其发病原因不明,且临床较少见,故易被误诊或漏诊[2] [3] [4]
[5]。我科曾收治肩胛舌骨肌综合征3例,现
如下。
2. 病例报告
病例1:患者、男性、22岁。吞咽时右颈前部隆起8 d,来我院就诊。检查:颈部无肿块,仅吞咽时右颈前部隆起约2 cm × 3 cm大小“包块”,吞咽动作完毕后,“包块”消失,颈部B超无肿块发现,诊断为“右肩胛舌骨肌综合征”收入住院。局麻 + 颈丛麻醉下以患侧肩肿舌骨肌隆起最高点作横形切口,长约5 cm,分离皮下组织,将胸锁乳突肌拉向外侧,暴露出突起的肩胛舌骨肌,同时分离该肌与周围筋膜的粘膜,分别挟持该肌膨隆的上下端中间切断,断端缝扎,嘱患作吞咽无隆起,术后4 d创口I期愈合,痊愈出院。
病例2:女、39岁。13年前患者吞咽时发现左颈部出现一肿块,吞咽动作结束肿块即消失。近半年来自觉肿块增大,伴有吞咽不适,曾到多家医院就诊,均不能确诊。否认外伤史及异物吞咽史。体检:吞咽时左侧胸锁乳突肌下段出现一肿块(图1),约5 cm × 3 cm × 2 cm,质中等,无压痛,边界不清,吞咽动作结束肿块即消失。颈部B超及纤维喉镜检查均未发现异常。临床诊断为肩胛舌骨肌综合征(左侧)。在局麻下行左侧肩胛舌骨肌切断术。于左侧锁骨上做低位横切口,长约4 cm,从胸锁乳突肌后缘入路,找到呈带状的肩胛舌骨肌,分离出肩胛舌骨肌下腹和中间腱部。嘱患者做吞咽动作,见该肌绷紧,将其前面的胸锁乳突肌顶起,形成肿块。探查周围无肿物后,切除中间腱部及部分下腹肌组织,长4 cm,结扎断端,再嘱患者做吞咽动作,肿块消失。术后病理组织学检查为横纹肌组织,肌纤维萎缩、变性,间质见少数脂肪浸润及纤维增生(图2)。术后5 d出院。
病例3:男、67岁。2年前患者吞咽时发现双侧颈前下方出现肿块,吞咽动作后肿块消失,无其他不适,未引起注意。近3个月来感吞咽时有阻挡感,曾在外院就诊,临床诊断为甲状腺肿,但甲状腺扫描、颈部B超及CT检查均未发现异常。体检:吞咽时双右胸锁乳突肌中、下段显著隆起,可触及肿块,约6 cm × 4 cm × 2 cm,质中等,边界不清,无压痛;吞咽动作结束,肿块随之消失,颈部恢复如常。
黄瀚章 等
Figure 1. Macroscopically, a protruding anterolateral neck
mass in the region of the left sternocleidomastoid muscle while
swallow, and disappear after swallow
图1. 吞咽时左侧胸锁乳突肌下段出现一肿块,吞咽动作结
束肿块即消失
Figure 2. The postoperative histopathological examination re-
vealed that was striated muscle with atrophy and degeneration,
and a few fatty infiltration and fibrous hyperplasia were also
found
图2. 术后病理组织学检查为横纹肌组织,肌纤维萎缩、变
性,间质见少数脂肪浸润及纤维增生
临床诊断为肩胛舌骨肌综合征(双侧)。在全麻下行双侧肩胛舌骨肌切断术。取颈前低位横切口,长约3.0 cm。从胸锁乳突肌后缘入路,显露双侧肩胛舌骨肌,嘱患者做吞咽动作,见肩胛舌骨肌向外顶起胸锁乳突肌,使该处隆起形成肿块,吞咽动作结束肿块消失。切除肩胛舌骨肌中间腱和部分下腹组织,长约5.0 cm,再观察患者,吞咽时肿块明显缩小。探查发现胸锁乳突肌锁骨头仍紧张,遂切断该肌外侧部分肌纤
维,再嘱患者作吞咽动作,肿块消失,吞咽时阻挡感也随之消失。术后病检:镜下见纤维组织轻度增生,
黄瀚章 等
灶性出血,肌纤维萎缩,轻度变性。病理诊断镜下见横纹肌部分萎缩、纤维化,呈透明变性(慢性间质性肌炎)。术后6 d出院、无复发。
3. 讨论
肩胛骨舌肌综合征临床少见,1969年由Caswell和Zachary等首先报道[1] [2],国内由叶必远(1978)首先报道,截止2011年全国仅报道123例[3] [4] [6] [7]。正常吞咽时,随着舌骨上下移动,肩胛舌骨肌随之伸缩;一旦此肌弹性减退,在吞咽时舌骨上移时而该肌不能相应伸长,向外顶起位于其浅面的胸锁乳突肌,使该处隆起形成肿块,吞咽动作结束后,舌骨下降后该肌回位,隆起的胸锁乳突肌亦随之恢复到原位,肿块消失。
本病病因不明,目前认为,本病系因先天局部筋膜发育薄弱、劳损或撕裂导致中间腱鞘松弛所致,其主要病理改变是肩胛舌骨肌横纹肌细胞变性、肌纤维萎缩、弹性减退。肩胛舌骨肌综合征的病因目前尚无定论,插胃管、激烈呕吐及咳嗽可能是其诱因。目前认为有以下几种病因:① 先天性中间腱膜发育不良使肩胛骨舌骨肌失去约束,长期处于低张力状态,逐渐发生肌肉萎缩,久之肌肉变性,以致弹性丧失;② 局部粘连:肩胛舌骨肌与周围的粘连,可使其收缩受限,吞咽动作时舌骨上升,肩胛舌骨肌因周围粘连而受到牵引力增大,久之使肌萎缩[2] [3] [4] [5]。
主要临床特征是吞咽时颈部出现包块,同时伴有吞咽不适、或吞咽困难。吞咽动作完成后,颈部包块随之消失,局部触诊及颈部B超、CT检查及食管造影等检查均无阳性发现。只要掌握本病的这些临床特征,诊断并不困难,但应与颈部囊状水瘤、颈侧鳃裂囊肿、颈内静脉扩张症、颈淋巴结肿大、甲状腺肿及胸骨舌骨肌综合征(Sternohyoid muscle syndrome)等疾病相鉴别,以免误诊[3]-[6] [8] [9]。
本病治疗主要是手术切除与胸锁乳突肌相交叉部分的肩胛舌骨肌,且在手术台上即见效果。入路、后缘入路、胸骨头和锁骨头之间入路三种。大多数患者只需切断肩胛舌骨肌中间腱和下腹即可治愈,但少数患者需要分离切断与周围肌肉筋膜间的粘连,才能取得满意的效果[3] [4] [5] [8] [9]。近年来,也有作者报道采用微创方法成功实施腔镜下肩胛舌骨肌离断术[7]。
参考文献 (References)
[1] Caswell Jr., H.T. (1969) The Omohyoid Syndrome. Lancet, 2, 319.
[2] Zachary, R.B., Young, A. and Hammond, J.D. (1969) The Omohyoid Syndrome. Lancet, 2, 104-105.
[3] Ye, B.Y. (1980) Omohyoid Muscle Syndrome: Report of a Case. Chinese Medical Journal, 93, 65-68.
[4] 高广文. 肩胛舌骨肌综合征17例手术治疗体会. 中华普通外科杂志, 1997, 12(6): 342.
[5] Matsumura, H., Watanabe, Y., Kawamoto, K., et al. (2008) Omohyoid Muscle Syndrome in a Patient with Parkinson’s
Disease. Rinsho Shinkeigaku, 48, 347-350.
[6] Kim, J.S., Hong, K.H., Hong, Y.T., et al. (2015) Sternohyoid Muscle Syndrome. American Journal of Otolaryngology,
36, 190-194.
[7] Sun, Z.P., Zhu, Y.B. and Zhang, N.W. (2016) Laparoscopic Omohyoid Muscle Transection Surgery: A Novel
Procedure against Omohyoid Muscle Syndrome. Chinese Medical Journal (English Edition), 129, 604-605.
[8] Lee, A.D., Yu, A., Young, S.B., et al. (2015) Omohyoid Muscle Syndrome in a Mixed Martial Arts Athlete: A Case
Report. Sports Health, 7, 458-462.
[9] Zhang, H., Zhao, C. and Wang, D. (1995) False Dysphagia Caused by Omohyoid Muscle Syndrome: 50 Cases of Au-
topsy and 2 Cases of Clinical Reports. Chinese Journal of Surgery, 33, 362-363.
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