医学小儿腺样体扁桃体切除术培训课件.ppt

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1、小儿腺样体扁桃体切小儿腺样体扁桃体切除术除术美国2011年版儿童扁桃体切除术临床实践指南该指南适用于118岁可能需行扁桃体切除术的患儿;Removal of the tonsils and adenoids is thought to be the bread and butter of pediatric otolaryngology.The current controversial issue is focused on pediatric tonsillectomy,a surgical procedure that is learned early during specialist

2、 training and performed by almost all otolaryngologists worldwide.Having a closer look at the history of tonsillectomy,it becomes quickly clear that barely any other ENT surgery has undergone so many changes regarding the frequency,indication and technique as tonsillectomy did.At the beginning of th

3、e 20th century,recurrent tonsillitis was the main reason for removal of the tonsils.TA represented 3050%of all pediatric surgeries in the 1930sThe advent of antibiotics in the 1950s resulted in a dramatic decrease in the overall number of tonsillectomies.In the USA,the frequency dropped from 1,400,0

4、00 TAs per year in 1959 to 500,000 in 1979,In the UK,200,000 tonsillectomies per year in 1930 to 50,000 at the beginning of the 21st centuryThe series published during the last 30 years show a clear shift in the indications of tonsillectomy.Sleep-disordered breathing is now the main reason for TA in

5、 children.All studies published in the last few years show this trend,which is even more obvious in children under 3 years of age,where OSAS reaches 90100%of indications.In older children,infections are more frequent indications for TAAustrian events:The death of 5 children in Austria below the age

6、of 6 years due to posttonsillectomy haemorrhage in 2006 and 2007 showed how quickly medical procedures can be discussed and debated by the media and politiciansAs a consequence,the Austrian Pediatric and ENT Societies had to revise and tighten the guidelines for adenotonsillectomyThe main aim is to

7、restrict tonsillectomies to cases where the complete tonsil has to be dissected.The criteriafor tonsillectomy are formulated vigorously:at least 7 tonsil infections in 1 year or 5 tonsil infections in each of 2 consecutive years have to be documented prior to the removal of the tonsils.For children

8、younger than 6 years of age with tonsil hypertrophy,tonsillotomy ratherthan tonsillectomy is recommended.Furthermore,an overall hospital stay of 23 nights for inpatient surgery is suggestedDuring the evaluation period from October 1,2009,to June 30,2010,all consecutive tonsil and adenoid surgeries i

9、n Austria(n=9,405 patients)and their risk factors were evaluated.Bleeding episodes of grades A to B are named Bleeding episodes of grades A to B are named minor bleedings,grades C to E are severe bleedingsminor bleedings,grades C to E are severe bleedingsPostoperative haemorrhage,defined as every bl

10、eeding episode after extubation,was reported in 12.3%after tonsillectomy;one fourth of whom experienced multiple bleedings.After tonsillotomy only 2.2%patients reported a postoperative bleeding episodeFigure 2 indicates an increasing risk of haemorrhage with rising age for Figure 2 indicates an incr

11、easing risk of haemorrhage with rising age for tonsillectomy,the distribution of minor versus severe bleeding episodes is equaltonsillectomy,the distribution of minor versus severe bleeding episodes is equalFigure 3 shows a low rate of bleeding episodes after tonsillotomy(2.2%)with Figure 3 shows a

12、low rate of bleeding episodes after tonsillotomy(2.2%)with very few cases requiring surgical treatment under general anaesthesia(0.7%).very few cases requiring surgical treatment under general anaesthesia(0.7%).扁桃体切除术与扁桃体部分切除术,术后出血存在差异应用奥地利共识后,奥地利扁桃体切除术术后出血,需回手术处理的比率还是在文献所报告的上限少量出血是严重出血的预兆统一术后出血观察标准

13、的意义奥地利事件后,对6岁以下小儿,推荐扁桃体部分切除术(Intracapsular Tonsillectomy、tonsillotomy)术后第一天需严密观察,即使是小量出血The events in Austria showed that lethal posttonsillectomy haemorrhage is a reality we are faced with and that strict monitoring of indications and complications might decrease the rate of lethal events in the fu

14、ture.Moreover,parents became alerted to the potential risks of tonsillectomies through the media.Based on our experience and growing medicalization,we encourage colleagues in other countries to think about the lack of standardized and nationwide monitoring of tonsil surgeries and their complications

15、 in order to improve the safety of such surgeries.1930年Fowler 提出removing“the tonsil,the whole tonsil,and nothing but the tonsil,”措施是在咽肌与扁桃体被囊间anatomical dissection,当时,扁桃体切除术针对的是慢性扁桃体炎囊内扁桃体切除术,留下被囊,意味留下部分扁桃体组织,扁桃体再生长率增加,因此,囊内扁桃体切除术是为慢性扁桃体切除的禁忌症,但是对OSAS,是安全有效的方法Fig.1.Subcapsular tonsillectomy,intraope

16、rative view.Fig.2.Intracapsular tonsillectomy,intraoperative view囊内扁桃体切除术,保留了扁桃体包囊,以免暴露咽肌;150 例,与按标准术式进行的例 比较,术后疼痛较轻,术中出血,二者相若,6例标准术式和1例囊内扁桃体切除术续发性出血需再住院,5例标准术式和1例囊内扁桃体切除术因失水需再住院,需再住院者,囊内扁桃体切除术2例而标准术式11例结论:对OSAS,二者都有效,囊内扁桃体切除术术后疼痛较轻,术后续发出血和失水饺少比较CO2-laser tonsillotomy 与conventional tonsillectomies 术

17、后6年的结果6年前的41 OSAS 小儿,9 15 岁,进行CO2-laser(n=21)或conventional(n=20).此次随访的全部病例曾在术后6个月和1年随访过通讯随访的10个问题:关于General health,snoring,sleep apneas,eating difficulties,infections.整体健康情况无差异术后术后6 6月,无一月,无一例打鼾,例打鼾,1 1年后年后部分切除组有部分切除组有1 1例开始打鼾,例开始打鼾,6 6年后部分切除组年后部分切除组8 8例、常规切除例、常规切除组组4 4例打鼾,但例打鼾,但比术前轻,比术前轻,(部部分切除分切除1

18、111例、常例、常规切除规切除1414例不打例不打鼾鼾 ).).术后1年,无1例呼吸暂停,术后6年,部分切除组3例常规切除组4例有呼吸暂停,但较术前轻。26例术前存在吃饭困难,术后都解决上感:Conclusion:we found that the fundamental long-term results of both kinds of operations were compatible.前瞻性研究 20012006连续42 例射频部分扁桃体切除术的OSAS小儿,22 girls and 20 boys,年龄 1 to10 years(mean,4.7 years).术后随访:第一个月为

19、2周一次,以后每13月一次,随访了6 to 32months(mean,14.3 months).35/42 术前症状消失,扁桃体大小与术后第一日一样,此35例中的23例年龄在4岁以下(65.7%).7/42扁桃体再增生(16.6%),年龄 2.4 to 6 years(mean,3.9 years),其中5例年龄在4岁以下(71.4%)手术至再增生的时间1 to 18 months(mean,9.3months).4/7(57.1%)在增生前有急性扁桃体炎发作,5/7 有术前症状复发检查扁桃体明显增大,有的两侧扁桃体接触,只能再作扁桃体剥离术另2例两侧增生不对称,且无症状,在随访中扁桃体在扁

20、桃体部分切除术后增生是一个重要的问题,有的报告,如瑞典的两组partial tonsillectomy with CO2 laser,只说到无OSAS复发,但无增生记录。美国microdebrider assisted intracapsular tonsillectomy 多中心研究,870例小儿,术后再增生率0.46%有两篇16 to 25 岁病人radiofrequency tonsillotomy 后1年随访,无扁桃体增生。本组病例,年龄较小,术后增生率16.6%.增生率高,年龄可能是个重要因素,无增生的病例中,66%小于4岁,有增生的病例中,71.4%小于4岁,提示年龄小可能是rad

21、iofrequency-assisted tonsillotomy术后增生的危险因素.作者经验,用其他方法消融,未遇增生病例,因此,radiofrequency可能也是增生的原因此外,50%以上病例,增生前,有acute tonsillitis episode.急性扁桃体炎对扁桃体增生的影响不清楚。在 radiofrequency-assisted tonsillotomy中,破坏了tonsillar capsule 可能是急性扁桃体炎促使增生的因素Tonsillar capsule may be barrier limiting tonsillar regrowth in acute ton

22、sillitis.Therefore,preservation of the tonsillar capsule as much as possible may be an important issue in tonsillotomy surgeries.腺样体和扁桃体切除术(腺样体和扁桃体切除术(T&A)在)在治疗小儿阻塞性睡眠呼吸暂停低通治疗小儿阻塞性睡眠呼吸暂停低通气综合征气综合征(OSAHS)中,有重要地位中,有重要地位强调术前多道睡眠仪强调术前多道睡眠仪(polysomnography,PSG)监测,定监测,定量分析睡眠及量分析睡眠及/或气体交换异常情况,或气体交换异常情况,但不能

23、鉴定阻塞平面和优选手术目但不能鉴定阻塞平面和优选手术目标标(Clinical practice guideline:Polysomnography for sleep-disordered breathing prior to tonsillectomy in children.Otolaryngol Head Neck Surg.2011;145(Suppl 1):S115.)T&A治疗治疗OSAHS的效果的效果6个美国、个美国、2个欧洲儿童睡眠个欧洲儿童睡眠中心对中心对T&A治疗治疗OSAHS的效的效果的评价:最终完全解决的果的评价:最终完全解决的只有只有 27.2%的病例的病例(Bhat

24、tacharjee R,et al.Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children:a multicenter retrospective study.Am J Respir Crit Care Med.2010;182(5):67683.)Friedman等按循证医学的方法,研究了等按循证医学的方法,研究了2008.7以前的英文文献,以前的英文文献,OSAHS的的T&A治疗,治疗,1079例病人,平均年龄例病人,平均年龄6.5岁,岁,T&A治疗成功率治疗成功率66.3%(AHI 1

25、5),),以以AHI 1为标准,成功率为标准,成功率59.8%如果以术前如果以术前AHI 20以上、年龄以上、年龄3岁或岁或肥胖症定为肥胖症定为“complicated children”,那么,那么,complicated 病人治疗成功率病人治疗成功率38.7%,而而uncomplicated 病人治疗成功率病人治疗成功率73.8%(Friedman M,et al.Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstrutive sleep apnea/hyp

26、opnea syndrome.Otolaryngol,Head Neck Surg.2009;140(6):800808)T&A不能解除不能解除 OSAHS,说明,说明在一些病例,肥大的扁桃体、在一些病例,肥大的扁桃体、腺样体,不是造成腺样体,不是造成OSAHS唯一唯一的病理生理机制的病理生理机制如何选择有效手术目标?如何选择有效手术目标?如何处理如何处理T&A失败和残余失败和残余OSAHS病病例?例?确定上气道功能性狭窄确定上气道功能性狭窄部位部位确定上气道狭窄部位的方法确定上气道狭窄部位的方法上气道正常形态的保持需要依赖感上气道正常形态的保持需要依赖感觉和肌肉的反射活动,入睡后咽肌觉和肌肉

27、的反射活动,入睡后咽肌和舌肌紧张性下降造成咽壁肌张力和舌肌紧张性下降造成咽壁肌张力下降和舌后坠致气道塌陷下降和舌后坠致气道塌陷清醒期的检查不能反映睡眠期的上清醒期的检查不能反映睡眠期的上气道塌陷的真实情况,睡眠期的检气道塌陷的真实情况,睡眠期的检查更值得关注查更值得关注电影磁共振成像电影磁共振成像(Cine MRI):国内外少数学者利用电影国内外少数学者利用电影MRI 对对OSAHS 儿童上气道进行了测量儿童上气道进行了测量,并初步肯定了,并初步肯定了c MRI 在在OSAHS 诊断中的作用诊断中的作用设备、流程的复杂性以及高费用设备、流程的复杂性以及高费用可能限制其推广可能限制其推广睡眠内镜

28、检查睡眠内镜检查(Sleep endoscopy)某些药物可以产生接近正常的睡眠状态某些药物可以产生接近正常的睡眠状态,在此条件下进行纤维镜检查,诊断真,在此条件下进行纤维镜检查,诊断真实的阻塞部位,从而制定治疗计划实的阻塞部位,从而制定治疗计划应用睡眠内镜,对残余的应用睡眠内镜,对残余的 OSA进行检查进行检查,逐渐被重视,与,逐渐被重视,与cine MRI相比较,手相比较,手术医生可以直接检查气道,可以看清睡术医生可以直接检查气道,可以看清睡眠时鼻咽、口咽、舌位以及喉的异常状眠时鼻咽、口咽、舌位以及喉的异常状态,特别是喉的动态变化态,特别是喉的动态变化Croft and Pringle于于

29、1991年首次用镇静药年首次用镇静药对对OSA患者进行纤维鼻咽喉镜检查,以患者进行纤维鼻咽喉镜检查,以了解上气道塌陷情况,命名为了解上气道塌陷情况,命名为“睡眠鼻内睡眠鼻内镜检查镜检查(sleep nasendoscopy)”Kezirian提议改名为药物诱导睡眠内镜检提议改名为药物诱导睡眠内镜检查查(Drug-induced sleep endoscopy,DISE),反映这项检查的特点:,反映这项检查的特点:1,使用,使用药物;药物;2,诱导出类似于自然睡眠状态下,诱导出类似于自然睡眠状态下的上气道的状态;的上气道的状态;3,使用鼻咽喉纤维镜,使用鼻咽喉纤维镜随后的随后的20年里,一些研究

30、证实了这项检年里,一些研究证实了这项检查的可靠性,在成人研究较多,小儿研查的可靠性,在成人研究较多,小儿研究较少究较少European position paper on drug-induced sedation endoscopy(DISE)Sleep Breath 22 April 20142013年在意大利召开的欧洲睡眠内年在意大利召开的欧洲睡眠内镜专家会议达成的共识镜专家会议达成的共识建议用名:建议用名:drug-induced sedation endoscopy(DISE)DISE代表了打鼾和代表了打鼾和OSAHS应用最广应用最广泛的上气道内镜评价方法,但在执泛的上气道内镜评价方

31、法,但在执行中,镇静药及其剂量、适应症等行中,镇静药及其剂量、适应症等存在争论,规范化了一些问题存在争论,规范化了一些问题符合循证医学标准的文献数目符合循证医学标准的文献数目2012年年10月至月至2013年年2月月45例例OSAHS患者,患者,右美托咪定诱导睡眠右美托咪定诱导睡眠内镜检查内镜检查,男,男44例,女例,女1例;年龄例;年龄3360岁岁具体操作方法和观察内容:静脉给具体操作方法和观察内容:静脉给右美托咪定右美托咪定 1微克公斤加生理盐微克公斤加生理盐水至水至50ml,大于,大于10 min泵完泵完Drug-induced sleep endoscopy:the VOTE clas

32、sification2000年,年,Myatt and Beckenham是最早的小是最早的小儿睡眠内镜检查者,用氟烷诱导睡眠儿睡眠内镜检查者,用氟烷诱导睡眠,20例例 AHI 30复杂病例的上气道发现复杂病例的上气道发现Myatt HM,Beckenham EJ.The use of diagnostic sleep nasendoscopyin the management of children with complex upperairway obstruction.Clin Otolaryngol Allied Sci.2000;25(3):200.2012年年Durr等用吸入七氟烷

33、诱导,等用吸入七氟烷诱导,propofol(丙泊酚丙泊酚)静脉维持下静脉维持下,内镜检查了,内镜检查了13例例T&A残余残余OSAHS病例,发现多平面阻塞病例,发现多平面阻塞Durr ML,Meyer AK,Kezirian EJ,Rosbe KW.Drug-inducedsleep endoscopy in persistent pediatric sleep-disordered breathingafter adenotonsillectomy.Arch Otolaryngol Head Neck Surg.2012;138(7):63864.同年美国斯坦福大学同年美国斯坦福大学Luci

34、le Packard儿儿童医院小儿耳鼻喉科报告童医院小儿耳鼻喉科报告80例睡眠内镜检例睡眠内镜检查,分两组;一组内镜指导手术,查,分两组;一组内镜指导手术,39例,例,另一组另一组T&A后仍有后仍有OSHA,41例。两组均说例。两组均说明睡眠内镜检查指导手术的作用明睡眠内镜检查指导手术的作用丙泊酚丙泊酚propofol(100 g/kg/min)and瑞芬太尼瑞芬太尼remi-fentanyl(100 ng/kg/min).Truong et al.Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea

35、.International Journal of Pediatric Otorhinolaryngology 76(2012)722727最近,美国最近,美国Vanderbilt大学小儿耳鼻大学小儿耳鼻喉科报导连续的喉科报导连续的26例例T&A后仍有后仍有OSHA的病例,年龄的病例,年龄518岁,经睡岁,经睡眠内镜检查,确定为多平面阻塞,眠内镜检查,确定为多平面阻塞,进行相应的手术进行相应的手术小儿上气道睡眠内镜检查评分系小儿上气道睡眠内镜检查评分系统统2014年Chan,D K 为小儿上气道DISE评分系统,以规范DISE的检查报告JAMA Otolaryngol Head Neck Su

36、rg.2014;140(7):595-602这只是一种动态或者进展,正如这只是一种动态或者进展,正如.To date,the use of DISE to detect mechanisms and sites of upper airway obstruction in children with OSA has not been systematically studiedSeckin O,et al.Drug-Induced Sleep Endoscopy for Upper Airway Evaluation in Children With Obstructive Sleep Apnea Laryngoscope,123:292297,2013我们的应对1了解发展趋势,增加知识了解发展趋势,增加知识2利用现有条件,稳步开展利用现有条件,稳步开展3结合临床,进行前瞻性研究结合临床,进行前瞻性研究

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