小兒腺樣體扁桃體切除術

小兒腺樣體、扁桃體切除術（一）小兒腺樣體扁桃體切除術1/65為何強調小兒？美國年版兒童扁桃體切除術臨床實踐指南該指南適合用于1—18歲可能需行扁桃體切除術患兒；小兒腺樣體扁桃體切除術2/65小兒腺樣體扁桃體切除術3/65Removalofthetonsilsandadenoidsisthoughttobethebreadandbutterofpediatricotolaryngology.Thecurrentcontroversialissueisfocusedonpediatrictonsillectomy,asurgicalprocedurethatislearnedearlyduringspecialisttrainingandperformedbyalmostallotolaryngologistsworldwide.小兒腺樣體扁桃體切除術4/65Havingacloserlookatthehistoryoftonsillectomy,itbecomesquicklyclearthatbarelyanyotherENTsurgeryhasundergonesomanychangesregardingthefrequency,indicationandtechniqueastonsillectomydid.小兒腺樣體扁桃體切除術5/65IndicationsofPediatricTonsillectomyAtthebeginningofthe20thcentury,recurrenttonsillitiswasthemainreasonforremovalofthetonsils.TArepresented30–50%ofallpediatricsurgeriesinthe1930sTheadventofantibioticsinthe1950sresultedinadramaticdecreaseintheoverallnumberoftonsillectomies.IntheUSA,thefrequencydroppedfrom1,400,000TAsperyearin1959to500,000in1979,IntheUK,200,000tonsillectomiesperyearin1930to50,000atthebeginningofthe21stcentury小兒腺樣體扁桃體切除術6/65Theseriespublishedduringthelast30yearsshowaclearshiftintheindicationsoftonsillectomy.Sleep-disorderedbreathingisnowthemainreasonforTAinchildren.Allstudiespublishedinthelastfewyearsshowthistrend,whichisevenmoreobviousinchildrenunder3yearsofage,whereOSASreaches90–100%ofindications.Inolderchildren,infectionsaremorefrequentindicationsforTA小兒腺樣體扁桃體切除術7/65Tonsillectomy:ASimpleSurgicalProcedure?Austrianevents：Thedeathof5childreninAustriabelowtheageof6yearsduetoposttonsillectomyhaemorrhageinandshowedhowquicklymedicalprocedurescanbediscussedanddebatedbythemediaandpoliticiansAsaconsequence,theAustrianPediatricandENTSocietieshadtoreviseandtightentheguidelinesforadenotonsillectomy小兒腺樣體扁桃體切除術8/65Themainaimistorestricttonsillectomiestocaseswherethecompletetonsilhastobedissected.Thecriteriafortonsillectomyareformulatedvigorously:atleast7tonsilinfectionsin1yearor5tonsilinfectionsineachof2consecutiveyearshavetobedocumentedpriortotheremovalofthetonsils.Forchildrenyoungerthan6yearsofagewithtonsilhypertrophy,tonsillotomyratherthantonsillectomyisrecommended.Furthermore,anoverallhospitalstayof2–3nightsforinpatientsurgeryissuggested小兒腺樣體扁桃體切除術9/65DuringtheevaluationperiodfromOctober1,,toJune30,,allconsecutivetonsilandadenoidsurgeriesinAustria(n=9,405patients)andtheirriskfactorswereevaluated.小兒腺樣體扁桃體切除術10/65BleedingepisodesofgradesAtoBarenamedminorbleedings,gradesCtoEareseverebleedings小兒腺樣體扁桃體切除術11/65小兒腺樣體扁桃體切除術12/65Postoperativehaemorrhage,definedaseverybleedingepisodeafterextubation,wasreportedin12.3%aftertonsillectomy;onefourthofwhomexperiencedmultiplebleedings.Aftertonsillotomyonly2.2%patientsreportedapostoperativebleedingepisode小兒腺樣體扁桃體切除術13/65Figure2indicatesanincreasingriskofhaemorrhagewithrisingagefortonsillectomy,thedistributionofminorversusseverebleedingepisodesisequal小兒腺樣體扁桃體切除術14/65Figure3showsalowrateofbleedingepisodesaftertonsillotomy(2.2%)withveryfewcasesrequiringsurgicaltreatmentundergeneralanaesthesia(0.7%).小兒腺樣體扁桃體切除術15/65小兒腺樣體扁桃體切除術16/65扁桃體切除術與扁桃體部分切除術，術后出血存在差異應用奧地利共識后，奧地利扁桃體切除術術后出血，需回手術處理比率還是在文件所匯報上限少許出血是嚴重出血預兆統(tǒng)一術后出血觀察標準意義奧地利事件后，對6歲以下小兒，推薦扁桃體部分切除術（IntracapsularTonsillectomy、tonsillotomy）小兒腺樣體扁桃體切除術17/65術后第一天需嚴密觀察，即使是小量出血TheeventsinAustriashowedthatlethalposttonsillectomyhaemorrhageisarealitywearefacedwithandthatstrictmonitoringofindicationsandcomplicationsmightdecreasetherateoflethaleventsinthefuture.Moreover,parentsbecamealertedtothepotentialrisksoftonsillectomiesthroughthemedia.Basedonourexperienceandgrowingmedicalization,weencouragecolleaguesinothercountriestothinkaboutthelackofstandardizedandnationwidemonitoringoftonsilsurgeriesandtheircomplicationsinordertoimprovethesafetyofsuchsurgeries.小兒腺樣體扁桃體切除術18/65Tonsillectomy與IntracapsularTonsillectomy1930年Fowler提出removing“thetonsil,thewholetonsil,andnothingbutthetonsil,”辦法是在咽肌與扁桃體被囊間anatomicaldissection，當初，扁桃體切除術針正確是慢性扁桃體炎囊內扁桃體切除術，留下被囊，意味留下部分扁桃體組織，扁桃體再生長率增加，所以，囊內扁桃體切除術是為慢性扁桃體切除禁忌癥，不過對OSAS，是安全有效方法小兒腺樣體扁桃體切除術19/65Coblation離子射頻低溫消融Coblationcreatessignificantlylessepithelialdestructionandcollateraltissuedamagecomparedwithconventionalmonopolarelectrocautery.Additionally,Coblationtechnologyofferssuperiorversatilitybecauseitiseffectiveforperformingawiderangeofsurgeries,includingsubcapsulartonsillectomy(fig.1),intracapsulartonsillectomy(fig.2)andadenoidectomy,allwiththesamedevice小兒腺樣體扁桃體切除術20/65Fig.1.Subcapsulartonsillectomy,intraoperativeview.小兒腺樣體扁桃體切除術21/65Fig.2.Intracapsulartonsillectomy,intraoperativeview小兒腺樣體扁桃體切除術22/65IntracapsularPartialTonsillectomyforTonsillarHypertrophyinChildrenLaryngoscope112:August

囊內扁桃體切除術，保留了扁桃體包囊,以免暴露咽??；150例,與按標準術式進行例

比較，術后疼痛較輕，術中出血，二者相若，6例標準術式和1例囊內扁桃體切除術續(xù)發(fā)性出血需再住院，5例標準術式和1例囊內扁桃體切除術因失水需再住院，需再住院者，囊內扁桃體切除術2例而標準術式11例結論：對OSAS，二者都有效，囊內扁桃體切除術術后疼痛較輕，術后續(xù)發(fā)出血和失水餃少小兒腺樣體扁桃體切除術23/65Long-termeffectsofintracapsularpartialtonsillectomy(tonsillotomy)comparedwithfulltonsillectomy

InternationalJournalofPediatricOtorhinolaryngology()69,463—469比較CO2-lasertonsillotomy與conventionaltonsillectomies術后6年結果6年前41OSAS小兒,9－15歲，進行CO2-laser(n=21)或conventional(n=20).此次隨訪全部病例曾在術后6個月和1年隨訪過通訊隨訪10個問題：關于Generalhealth,snoring,sleepapneas,eatingdifficulties，infections.小兒腺樣體扁桃體切除術24/65整體健康情況無差異小兒腺樣體扁桃體切除術25/65術后6月，無一例打鼾，1年后部分切除組有1例開始打鼾，6年后部分切除組8例、常規(guī)切除組4例打鼾，但比術前輕，(部分切除11例、常規(guī)切除14例不打鼾).小兒腺樣體扁桃體切除術26/65術后1年，無1例呼吸暫停，術后6年，部分切除組3例常規(guī)切除組4例有呼吸暫停，但較術前輕。小兒腺樣體扁桃體切除術27/6526例術前存在吃飯困難，術后都處理上感：小兒腺樣體扁桃體切除術28/65Conclusion：wefoundthatthefundamentallong-termresultsofbothkindsofoperationswerecompatible.小兒腺樣體扁桃體切除術29/65Tonsillarregrowthfollowingpartialtonsillectomywithradiofrequency

InternationalJournalofPediatricOtorhinolaryngology()72,19—22前瞻性研究－連續(xù)42例射頻部分扁桃體切除術OSAS小兒，22girlsand20boys，年紀1to10years(mean,4.7years).術后隨訪：第一個月為2周一次，以后每1－3月一次，隨訪了6to32months(mean,14.3months).35/42術前癥狀消失，扁桃體大小與術后第一日一樣，此35例中23例年紀在4歲以下(65.7%).7/42扁桃體再增生(16.6%)，年紀2.4to6years(mean,3.9years)，其中5例年紀在4歲以下(71.4%)小兒腺樣體扁桃體切除術30/65手術至再增生時間1to18months(mean,9.3months).4/7(57.1%)在增生前有急性扁桃體炎發(fā)作，5/7有術前癥狀復發(fā)檢驗扁桃體顯著增大，有兩側扁桃體接觸，只能再作扁桃體剝離術另2例兩側增生不對稱，且無癥狀，在隨訪中小兒腺樣體扁桃體切除術31/65小兒腺樣體扁桃體切除術32/65扁桃體在扁桃體部分切除術后增生是一個主要問題，有匯報，如瑞典兩組partialtonsillectomywithCO2laser，只說到無OSAS復發(fā)，但無增生統(tǒng)計。美國microdebriderassistedintracapsulartonsillectomy多中心研究，870例小兒，術后再增生率0.46%小兒腺樣體扁桃體切除術33/65有兩篇16to25歲病人radiofrequencytonsillotomy后1年隨訪，無扁桃體增生。本組病例，年紀較小，術后增生率16.6%.增生率高，年紀可能是個主要原因，無增生病例中，66%小于4歲，有增生病例中，71.4%小于4歲，提醒年紀小可能是radiofrequency-assistedtonsillotomy術后增生危險原因.作者經驗，用其它方法消融，未遇增生病例，所以，radiofrequency可能也是增生原因小兒腺樣體扁桃體切除術34/65另外，50%以上病例，增生前，有acutetonsillitisepisode.急性扁桃體炎對扁桃體增生影響不清楚。在radiofrequency-assistedtonsillotomy中，破壞了tonsillarcapsule可能是急性扁桃體炎促使增生原因Tonsillarcapsulemaybebarrierlimitingtonsillarregrowthinacutetonsillitis.Therefore,preservationofthetonsillarcapsuleasmuchaspossiblemaybeanimportantissueintonsillotomysurgeries.小兒腺樣體扁桃體切除術35/65腺樣體和扁桃體切除術（T&A）在治療小兒阻塞性睡眠呼吸暫停低通氣綜合征(OSAHS)中，有主要地位強調術前多道睡眠儀(polysomnography，PSG)監(jiān)測，定量分析睡眠及/或氣體交換異常情況，但不能判定阻塞平面和優(yōu)選手術目標（Clinicalpracticeguideline:Polysomnographyforsleep-disorderedbreathingpriortotonsillectomyinchildren.OtolaryngolHeadNeckSurg.;145(Suppl1):S1–15.）小兒腺樣體扁桃體切除術36/65T&A治療OSAHS效果6個美國、2個歐洲兒童睡眠中心對T&A治療OSAHS效果評價：最終完全處理只有27.2%病例(BhattacharjeeR,etal.Adenotonsillectomyoutcomesintreatmentofobstructivesleepapneainchildren:amulticenterretrospectivestudy.AmJRespirCritCareMed.;182(5):676–83.)小兒腺樣體扁桃體切除術37/65Friedman等按循證醫(yī)學方法，研究了.7以前英文文件，OSAHST&A治療，1079例病人，平均年紀6.5歲，T&A治療成功率66.3%（AHI＜1~5），以AHI＜1為標準，成功率59.8%假如以術前AHI＞20以上、年紀＜3歲或肥胖癥定為“complicatedchildren”，那么，complicated病人治療成功率38.7%，而uncomplicated病人治療成功率73.8%（FriedmanM,etal.Updatedsystematicreviewoftonsillectomyandadenoidectomyfortreatmentofpediatricobstrutivesleepapnea/hypopneasyndrome.Otolaryngol,HeadNeckSurg.;140(6):800–808）小兒腺樣體扁桃體切除術38/65T&A不能解除OSAHS，說明在一些病例，肥大扁桃體、腺樣體，不是造成OSAHS唯一病理生理機制小兒腺樣體扁桃體切除術39/65↓怎樣選擇有效手術目標？怎樣處理T&A失敗和殘余OSAHS病例？確定上氣道功效性狹窄部位小兒腺樣體扁桃體切除術40/65確定上氣道狹窄部位方法上氣道正常形態(tài)保持需要依賴感覺和肌肉反射活動，入睡后咽肌和舌肌擔心性下降造成咽壁肌張力下降和舌后墜致氣道塌陷清醒期檢驗不能反應睡眠期上氣道塌陷真實情況，睡眠期檢驗更值得關注小兒腺樣體扁桃體切除術41/65電影磁共振成像(CineMRI):

國內外少數(shù)學者利用電影MRI對OSAHS兒童上氣道進行了測量，并初步必定了cMRI在OSAHS診療中作用設備、流程復雜性以及高費用可能限制其推廣小兒腺樣體扁桃體切除術42/65小兒腺樣體扁桃體切除術43/65睡眠內鏡檢驗(Sleependoscopy)

一些藥品能夠產生靠近正常睡眠狀態(tài)，在此條件下進行纖維鏡檢驗，診療真實阻塞部位，從而制訂治療計劃應用睡眠內鏡，對殘余OSA進行檢驗，逐步被重視，與cineMRI相比較，手術醫(yī)生能夠直接檢驗氣道，能夠看清睡眠時鼻咽、口咽、舌位以及喉異常狀態(tài)，尤其是喉動態(tài)改變小兒腺樣體扁桃體切除術44/65CroftandPringle于1991年首次用鎮(zhèn)靜藥對OSA患者進行纖維鼻咽喉鏡檢驗，以了解上氣道塌陷情況，命名為“睡眠鼻內鏡檢驗(sleepnasendoscopy)”．Kezirian提議更名為藥品誘導睡眠內鏡檢驗(Drug-inducedsleependoscopy，DISE)，反應這項檢驗特點：1，使用藥品；2，誘導出類似于自然睡眠狀態(tài)下上氣道狀態(tài)；3，使用鼻咽喉纖維鏡隨即20年里，一些研究證實了這項檢驗可靠性，在成人研究較多，小兒研究較少小兒腺樣體扁桃體切除術45/65Europeanpositionpaperondrug-inducedsedationendoscopy(DISE)

SleepBreath22April年在意大利召開歐洲睡眠內鏡教授會議達成共識提議用名：drug-inducedsedationendoscopy(DISE)DISE代表了打鼾和OSAHS應用最廣泛上氣道內鏡評價方法，但在執(zhí)行中，鎮(zhèn)靜藥及其劑量、適應癥等存在爭論，規(guī)范化了一些問題小兒腺樣體扁桃體切除術46/65符合循證醫(yī)學標準文件數(shù)目小兒腺樣體扁桃體切除術47/65年10月至年2月45例OSAHS患者，右美托咪定誘導睡眠內鏡檢驗，男44例，女1例；年紀33～60歲詳細操作方法和觀察內容：靜脈給右美托咪定1微克／千克加生理鹽水至50ml，大于10min泵完小兒腺樣體扁桃體切除術48/65Drug-inducedsleependoscopy:theVOTEclassification小兒腺樣體扁桃體切除術49/65年，MyattandBeckenham是最早小兒睡眠內鏡檢驗者，用氟烷誘導睡眠，20例AHI＞30復雜病例上氣道發(fā)覺MyattHM,BeckenhamEJ.Theuseofdiagnosticsleepnasendoscopyinthemanagementofchildrenwithcomplexupperairwayobstruction.ClinOtolaryngolAlliedSci.;25(3):200.小兒腺樣體扁桃體切除術50/65年Durr等用吸入七氟烷誘導，propofol(丙泊酚)靜脈維持下，內鏡檢驗了13例T&A殘余OSAHS病例，發(fā)覺多平面阻塞DurrML,MeyerAK,KezirianEJ,RosbeKW.Drug-inducedsleependoscopyinpersistentpediatricsleep-disorderedbreathingafteradenotonsillectomy.ArchOtolar