ヘルペス脳炎後の嚥下障害に対し，喉頭蓋管形成術（Biller変法）を施行した1例

Epiglottoplasty for Dysphagia Associated Herpes Simplex Encephalitis

はじめに

　種々の神経疾患や口腔・咽頭癌術後においては，唾液誤嚥や食物誤嚥を抑制できず，誤嚥性肺炎を生じる症例が存在する．これらのうち，適切なリハビリテーション（以下，リハ）を一定期間行っても十分な効果が得られない症例には，外科的治療が考慮される．嚥下障害に対する外科的治療は，嚥下機能改善手術と誤嚥防止手術に分類される^1）が，誤嚥の防止を目的とする場合には後者が適応となる．誤嚥防止手術は確実に誤嚥を防止できる一方で発声機能の喪失によるquality of life（QOL）の低下をきたす．

　喉頭蓋管形成術は，Billerら^2）が舌癌に対し舌全摘出術を行った症例において誤嚥防止と術後の発声を可能にする方法として報告した．この手術は，喉頭蓋縁から披裂部を縦方向に管状に縫合し，その先端に発声のための小孔を作成するものである（図1）．本邦では，鹿野ら^3）がこれに改良を加えた方法を施行し，その有用性を報告している．しかし，他の誤嚥防止術と比べて，その認知度は高くなく，技術的にも難易度が高いと思われる．

　今回，われわれはヘルペス脳炎後の嚥下障害に対して，喉頭蓋管形成術を施行した症例を経験したので報告する．

Abstract : This report presents the case of a patient treated with epiglottoplasty (Biller's laryngoplasty technique) for the pseudobulbar type of dysphagia associated with herpes simplex encephalitis (HSE). A 67-year-old man developed acute HSE with disturbance of consciousness and intractable aspiration. Oral intake was tried, but resulted in aspiration pneumonia and was therefore canceled at the patient's former institution. At 12 months following onset, the patient consulted our hospital and we judged that aspiration could not be controlled, and that surgical management would be needed. In order to both prevent aspiration and preserve phonation, epiglot-toplasty was performed at 15 months following onset. Postoperatively, the patient was able to resume an unrestricted diet except for clear liquids. He also underwent voice rehabilitation with the support of his family and rehabilitation staff. These efforts finally enabled him to speak clearly. Epiglottoplasty is an effective treatment for intractable aspiration, but this procedure is not widely known to Japanese physiatrists. Careful patient screening and selection by the attending physiatrist is essential, as is providing adequate postoperative swallowing and voice rehabilitation.