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研究生:汪昇勳
論文名稱:喉咽逆流對於喉頭組織結構與嗓音變化特性的影響
指導教授:鄭靜宜鄭靜宜引用關係
學位類別:碩士
校院名稱:國立高雄師範大學
系所名稱:聽力學與語言治療研究所
學門:醫藥衛生學門
學類:復健醫學學類
論文種類:學術論文
論文出版年:2012
畢業學年度:100
語文別:中文
中文關鍵詞:喉咽逆流喉頭鏡檢查發現評分嗓音聽知覺評估嗓音聲學分析
外文關鍵詞:laryngopharyngeal refluxreflux finding scorevoice perceptual assessmentvoice acoustic analysis
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摘要

本研究主要目的在探討喉咽逆流患者之喉頭組織結構變化與「嗓音聽知覺評估」和「嗓音聲學分析參數」的關係。研究的對象有31位喉咽逆流患者,另有31位正常「對照組」。由兩位耳鼻喉科專科醫師做「喉咽逆流喉頭鏡檢查發現評分」;由兩位語言治療師做「GRBAS嗓音聽知覺評估」評分;並使用「多向度嗓音分析軟體」(MDVP)對嗓音作聲學參數的分析。結果發現,喉咽逆流患者喉頭組織結構變化,以「喉室閉塞」(31/31)、「喉頭紅斑或充血」(31/31)、「瀰漫性喉頭水腫」(31/31)及「聲帶後聯結處肥厚」(31/31)四個向度出現頻率最高,主要表現在聲帶以上及喉頭後部。在「GRBAS嗓音聽知覺評估」方面,喉逆流組在「GRBAS嗓音聽知覺評估」五個向度的分數都比對照組高,且嗓音障礙程度大多屬於輕中度。在「嗓音聲學分析」方面,在延長母音/a/的測驗中,兩組在「相對的頻率擾動度」(Jitt)、「相對平均擾動度」(RAP)、「音高擾動度商數」(PPQ)、「絕對振幅擾動度」(ShdB)、「相對的振幅擾動度」(Shim)、「振幅擾動度商數」APQ、「尖峰振幅的變異」(vAm)與「嗓音擾動度指標」(VTI)等八個聲學參數有顯著差異。「喉咽逆流喉頭鏡檢查發現評分」與「GRBAS嗓音聽知覺評估」的相關分析顯示「喉咽逆流喉頭鏡檢查發現評分」總分與「整體不良音質」、「粗嗓度」、「氣息聲」具高度相關,和「無力度」、「緊困度」則有中度相關。「喉咽逆流喉頭鏡檢查發現評分」與「嗓音聲學分析參數」的相關分析顯示兩者各向度間相關並不顯著。在「GRBAS嗓音聽知覺評估」與「嗓音聲學分析參數」的相關分析顯示「GRBAS嗓音聽知覺評估」的各向度與「嗓音聲學分析參數」都只具有中度以下的相關。使用逐步區別分析來預測喉逆流組或對照組,發現若同時使用「嗓音聲學分析參數」及「GRBAS嗓音聽知覺評估」的變項,則具最佳區別模型的變項是「平均音高週期」(To)、「整體不良音質」、和「緊困度」。



關鍵字: 喉咽逆流、喉頭鏡檢查發現評分、嗓音聽知覺評估、嗓音聲學分析


The influence of laryngopharyngeal reflux on
the laryngeal structures and voice characteristics changes
Wang, Sheng Hsun

Abstract
The purpose of this research focused mainly on the relationships among the laryngoscopic findings, perceptual assessments, and the acoustic analysis parameters of larygopharygeal reflux disease (LPRD). The study subjects were 31 LPR patients and 31 normal people served as the control group. Two otolaryngologists conducted larygoscopic examination, while two speech therapists evaluated voice perceptual assessment (GRBAS). Multi-Dimensional Voice Program (MDVP) was used to analyze voice acoustic parameters. The laryngeal changes were mainly above the vocal cord and the posterior portion of larynx on the laryngoscopic findings of LPR. For voice perceptual assessment, LPR patients scored statistically significant higher than the control group on the five-dimentional voice quality scales, and the severity was almost at mild-moderate level. There was a significant difference between two group on eight acoustic analysis parameters of Jitt、RAP、PPQ、ShdB、Shim、APQ、vAm and VTI. Between the correlation of reflux finding scores and voice perceptual assessment (GRBAS), the total reflux finding score was highly correlated with grade(G), rough(R), and breathiness(B). The correlations between the reflux finding score and the voice acoustic analysis parameters were not significant. Between the correlations of voice perceptual assessment and voice acoustic parameters, every dimention of voice perceptual assessment was only moderately or lowly correlated with voice acoustic analysis parameters. Stepwise discriminant analysis was used to predict LPR group and control group, and it is found that while voice acoustic analysis parameters and voice perceptual assessment are used at the same time, the best discriminate variables were average pitch period (To), grade(G), and strained(S).



Key words: laryngopharyngeal reflux, reflux finding score, voice perceptual assessment, voice acoustic analysis


目次
中文摘要………………………………………………………………...................... .I
英文摘要………………………………………………………………...................... II
目次……………………………………………………………………..................... III
表次……………………………………………………………………......................IV
圖次…………………………………………………………………….......................V
附錄次…………………………………………………………………......................VI
第一章 緒論……………………………………………………………………..........1
第一節 研究背景與動機…………………………………………………………..1
第二節 研究目的與待答問題……………………………………………………..5
第三節 名詞解釋……………………………………………………………..........7
第二章 文獻探討……………………………………………………………..............9
第一節 喉咽逆流病患的臨床表現………………………………………………..9
第二節 喉咽逆流之喉頭組織變化………………………………………………21
第三節 喉咽逆流與聽知覺評估……………………............................................29
第四節 嗓音聲學分析與聽知覺評估的關係........................................................36
第三章 研究方法……………………………………………………………............45
第一節 研究設計與工具…………………………………………………............45
第二節 研究對象與程序…………………………………………………............47
第三節 資料分析…………………………………………………........................52
第四章 結果與討論…………………………………………………………............55
第一節「喉咽逆流喉頭鏡檢查發現評分」的測量………………..………............55
第二節「嗓音聽知覺估」的測量…………………………………………............61
第三節 「嗓音聲學分析」的測量…………………………………........................63
第四節「喉咽逆流喉頭鏡檢查發現評分」與嗓音的關係............. .......... ..........74
第五節「嗓音聽知覺評估」與「嗓音聲學分析」的關係...................................78第六節 區別分析………………………………………………….........................82
第五章 結果與討論………………………………………………………….............87
第一節 主要發現………………………………………………………….............87
第二節 綜合討論………………………………………………….........................89
第三節 研究限制………………………………………………………….............94
第四節 建議……………………………………………………………….............96
參考文獻…………………………………………………...........................................99
附錄………………………………………………….................................................106


表次

表2-1 、喉咽逆流(LPR)與胃食道逆流(GERD)臨床之症狀差異………………… ….11
表2-2 、常見「喉咽逆流」患者症狀………………………………………………….13
表2-3 、逆流症狀指標(RSI) ………………………………………………………….. .15
表2-4 、「喉咽逆流喉頭鏡檢查發現評分」表(RFS) …………………………..........25
表2-5 、二元性聽知覺評分等級表( perceptual rating scales) …………………........... 32
表2-6 、MDVP聲學參數之類別…………………………………………………….....36
表2-7 、粗嗓度(rough)或刺耳聲(harshness)與部分聲學測量之相關數據……….….. 40
表2-8 、氣息聲(breathy)與部分聲學測量之相關數據…………………………............40
表3-1 、喉逆流組與對照組年齡分佈…………………………………………………..47
表4-1 、喉逆流組之「喉頭鏡檢查發現評分」之平均數、標準差與相關係數…………58
表4-2 、「嗓音聽知覺評估」重測信度……………………………………………….....61
表4-3 、喉逆流組和對照組「嗓音聽知覺評估」分數平均數、標準差與t檢定表……62
表4-4 、喉逆流組之嗓音聽知覺評估各向度分數之皮爾森相關係數 ……………….62
表4-5 、對照組之嗓音聽知覺評估各向度分數之皮爾森相關係數 ………………….63
表4-6 、喉逆流組之作業一與作業二聲學參數之平均數、標準差、t檢定與相關係數 …..69
表4-7 、對照組之作業一與作業二聲學參數之平均數、標準差、t檢定與相關係數 …….70
表4-8 、喉逆流組與對照組兩作業間之聲學參數比較 ………………………………..73
表4-9 、「喉頭鏡檢查發現評分」與「音聽知覺評估」之Kendall等級相關係數….....75
表4-10、喉逆流組的「喉頭鏡檢查發現評分」與作業一之嗓音聲學分析」參數之
相關性(Kendall等級相關係數) ………………………………...………………77
表4-11、「嗓音聽知覺評估」各向度分數與作業一之「嗓音聲學分析」各參數之
相關性(Kendall等級相關係數)………………………………………………....80
表4-12、粗嗓度和氣息聲與部分聲學測量之相關(皮爾森相關係數)………………81
表4-13、三個區別模型之變量與係數 ………………………………………………….82
表4-14、區別分析之受測者(對照組)……………………………..………………….84
表4-15、區別分析之受測者(喉逆流組)…………………………..………………….85
表4-16、區別分析分類效果表…………………………..……………………………….86

圖次

圖2-1、喉頭冠狀剖面示意圖…………………………………………………………..24
圖2-1、喉頭內視鏡橫剖面圖…………………………………………………………..24
圖4-1、聲門下水腫……………………………………………………………..……....58
圖4-2、喉頭肉芽組織…………………………………………………………..………58
圖4-3、聲帶後聯結處肥厚、瀰漫性喉頭水腫………………………………..………59
圖4-4、聲帶後聯結處肥厚、瀰漫性喉頭水腫、湧泉之分泌物於梨形窩處..………59
圖4-5、 聲帶後聯結處肥厚、聲門下水腫、喉室閉塞…………………………..…..59
圖4-6、黏稠的喉頭內黏液……………………………………………………………..59
圖4-7、喉頭紅斑/充血………………………………………………………………..60
圖4-8、喉頭紅斑/充血、聲帶水腫…………………………………………………..60
圖4-9、黏稠的喉頭內黏液、喉室閉塞(完全)、偽聲帶溝、聲帶後聯結處肥厚…60
圖4-10喉頭紅斑/充血、喉室閉塞(部分)………………………………………...60


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