小儿腺样体扁桃体切除术

小儿腺样体、扁桃体切除术（一）小儿腺样体扁桃体切除术1/65为何强调小儿？美国年版儿童扁桃体切除术临床实践指南该指南适合用于1—18岁可能需行扁桃体切除术患儿；小儿腺样体扁桃体切除术2/65小儿腺样体扁桃体切除术3/65Removalofthetonsilsandadenoidsisthoughttobethebreadandbutterofpediatricotolaryngology.Thecurrentcontroversialissueisfocusedonpediatrictonsillectomy,asurgicalprocedurethatislearnedearlyduringspecialisttrainingandperformedbyalmostallotolaryngologistsworldwide.小儿腺样体扁桃体切除术4/65Havingacloserlookatthehistoryoftonsillectomy,itbecomesquicklyclearthatbarelyanyotherENTsurgeryhasundergonesomanychangesregardingthefrequency,indicationandtechniqueastonsillectomydid.小儿腺样体扁桃体切除术5/65IndicationsofPediatricTonsillectomyAtthebeginningofthe20thcentury,recurrenttonsillitiswasthemainreasonforremovalofthetonsils.TArepresented30–50%ofallpediatricsurgeriesinthe1930sTheadventofantibioticsinthe1950sresultedinadramaticdecreaseintheoverallnumberoftonsillectomies.IntheUSA,thefrequencydroppedfrom1,400,000TAsperyearin1959to500,000in1979,IntheUK,200,000tonsillectomiesperyearin1930to50,000atthebeginningofthe21stcentury小儿腺样体扁桃体切除术6/65Theseriespublishedduringthelast30yearsshowaclearshiftintheindicationsoftonsillectomy.Sleep-disorderedbreathingisnowthemainreasonforTAinchildren.Allstudiespublishedinthelastfewyearsshowthistrend,whichisevenmoreobviousinchildrenunder3yearsofage,whereOSASreaches90–100%ofindications.Inolderchildren,infectionsaremorefrequentindicationsforTA小儿腺样体扁桃体切除术7/65Tonsillectomy:ASimpleSurgicalProcedure?Austrianevents：Thedeathof5childreninAustriabelowtheageof6yearsduetoposttonsillectomyhaemorrhageinandshowedhowquicklymedicalprocedurescanbediscussedanddebatedbythemediaandpoliticiansAsaconsequence,theAustrianPediatricandENTSocietieshadtoreviseandtightentheguidelinesforadenotonsillectomy小儿腺样体扁桃体切除术8/65Themainaimistorestricttonsillectomiestocaseswherethecompletetonsilhastobedissected.Thecriteriafortonsillectomyareformulatedvigorously:atleast7tonsilinfectionsin1yearor5tonsilinfectionsineachof2consecutiveyearshavetobedocumentedpriortotheremovalofthetonsils.Forchildrenyoungerthan6yearsofagewithtonsilhypertrophy,tonsillotomyratherthantonsillectomyisrecommended.Furthermore,anoverallhospitalstayof2–3nightsforinpatientsurgeryissuggested小儿腺样体扁桃体切除术9/65DuringtheevaluationperiodfromOctober1,,toJune30,,allconsecutivetonsilandadenoidsurgeriesinAustria(n=9,405patients)andtheirriskfactorswereevaluated.小儿腺样体扁桃体切除术10/65BleedingepisodesofgradesAtoBarenamedminorbleedings,gradesCtoEareseverebleedings小儿腺样体扁桃体切除术11/65小儿腺样体扁桃体切除术12/65Postoperativehaemorrhage,definedaseverybleedingepisodeafterextubation,wasreportedin12.3%aftertonsillectomy;onefourthofwhomexperiencedmultiplebleedings.Aftertonsillotomyonly2.2%patientsreportedapostoperativebleedingepisode小儿腺样体扁桃体切除术13/65Figure2indicatesanincreasingriskofhaemorrhagewithrisingagefortonsillectomy,thedistributionofminorversusseverebleedingepisodesisequal小儿腺样体扁桃体切除术14/65Figure3showsalowrateofbleedingepisodesaftertonsillotomy(2.2%)withveryfewcasesrequiringsurgicaltreatmentundergeneralanaesthesia(0.7%).小儿腺样体扁桃体切除术15/65小儿腺样体扁桃体切除术16/65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，需回手术处理比率还是在文件所汇报上限少许出血是严重出血预兆统一术后出血观察标准意义奥地利事件后，对6岁以下小儿，推荐扁桃体部分切除术（IntracapsularTonsillectomy、tonsillotomy）小儿腺样体扁桃体切除术17/65术后第一天需严密观察，即使是小量出血TheeventsinAustriashowedthatlethalposttonsillectomyhaemorrhageisarealitywearefacedwithandthatstrictmonitoringofindicationsandcomplicationsmightdecreasetherateoflethaleventsinthefuture.Moreover,parentsbecamealertedtothepotentialrisksoftonsillectomiesthroughthemedia.Basedonourexperienceandgrowingmedicalization,weencouragecolleaguesinothercountriestothinkaboutthelackofstandardizedandnationwidemonitoringoftonsilsurgeriesandtheircomplicationsinordertoimprovethesafetyofsuchsurgeries.小儿腺样体扁桃体切除术18/65Tonsillectomy与IntracapsularTonsillectomy1930年Fowler提出removing“thetonsil,thewholetonsil,andnothingbutthetonsil,”办法是在咽肌与扁桃体被囊间anatomicaldissection，当初，扁桃体切除术针正确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，所以，囊内扁桃体切除术是为慢性扁桃体切除禁忌症，不过对OSAS，是安全有效方法小儿腺样体扁桃体切除术19/65Coblation离子射频低温消融Coblationcreatessignificantlylessepithelialdestructionandcollateraltissuedamagecomparedwithconventionalmonopolarelectrocautery.Additionally,Coblationtechnologyofferssuperiorversatilitybecauseitiseffectiveforperformingawiderangeofsurgeries,includingsubcapsulartonsillectomy(fig.1),intracapsulartonsillectomy(fig.2)andadenoidectomy,allwiththesamedevice小儿腺样体扁桃体切除术20/65Fig.1.Subcapsulartonsillectomy,intraoperativeview.小儿腺样体扁桃体切除术21/65Fig.2.Intracapsulartonsillectomy,intraoperativeview小儿腺样体扁桃体切除术22/65IntracapsularPartialTonsillectomyforTonsillarHypertrophyinChildrenLaryngoscope112:August

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小儿腺样体扁桃体切除术23/65Long-termeffectsofintracapsularpartialtonsillectomy(tonsillotomy)comparedwithfulltonsillectomy

InternationalJournalofPediatricOtorhinolaryngology()69,463—469比较CO2-lasertonsillotomy与conventionaltonsillectomies术后6年结果6年前41OSAS小儿,9－15岁，进行CO2-laser(n=21)或conventional(n=20).此次随访全部病例曾在术后6个月和1年随访过通讯随访10个问题：关于Generalhealth,snoring,sleepapneas,eatingdifficulties，infections.小儿腺样体扁桃体切除术24/65整体健康情况无差异小儿腺样体扁桃体切除术25/65术后6月，无一例打鼾，1年后部分切除组有1例开始打鼾，6年后部分切除组8例、常规切除组4例打鼾，但比术前轻，(部分切除11例、常规切除14例不打鼾).小儿腺样体扁桃体切除术26/65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。小儿腺样体扁桃体切除术27/6526例术前存在吃饭困难，术后都处理上感：小儿腺样体扁桃体切除术28/65Conclusion：wefoundthatthefundamentallong-termresultsofbothkindsofoperationswerecompatible.小儿腺样体扁桃体切除术29/65Tonsillarregrowthfollowingpartialtonsillectomywithradiofrequency

InternationalJournalofPediatricOtorhinolaryngology()72,19—22前瞻性研究－连续42例射频部分扁桃体切除术OSAS小儿，22girlsand20boys，年纪1to10years(mean,4.7years).术后随访：第一个月为2周一次，以后每1－3月一次，随访了6to32months(mean,14.3months).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23例年纪在4岁以下(65.7%).7/42扁桃体再增生(16.6%)，年纪2.4to6years(mean,3.9years)，其中5例年纪在4岁以下(71.4%)小儿腺样体扁桃体切除术30/65手术至再增生时间1to18months(mean,9.3months).4/7(57.1%)在增生前有急性扁桃体炎发作，5/7有术前症状复发检验扁桃体显著增大，有两侧扁桃体接触，只能再作扁桃体剥离术另2例两侧增生不对称，且无症状，在随访中小儿腺样体扁桃体切除术31/65小儿腺样体扁桃体切除术32/65扁桃体在扁桃体部分切除术后增生是一个主要问题，有汇报，如瑞典两组partialtonsillectomywithCO2laser，只说到无OSAS复发，但无增生统计。美国microdebriderassistedintracapsulartonsillectomy多中心研究，870例小儿，术后再增生率0.46%小儿腺样体扁桃体切除术33/65有两篇16to25岁病人radiofrequencytonsillotomy后1年随访，无扁桃体增生。本组病例，年纪较小，术后增生率16.6%.增生率高，年纪可能是个主要原因，无增生病例中，66%小于4岁，有增生病例中，71.4%小于4岁，提醒年纪小可能是radiofrequency-assistedtonsillotomy术后增生危险原因.作者经验，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儿腺样体扁桃体切除术34/65另外，50%以上病例，增生前，有acutetonsillitisepisode.急性扁桃体炎对扁桃体增生影响不清楚。在radiofrequency-assistedtonsillotomy中，破坏了tonsillarcapsule可能是急性扁桃体炎促使增生原因Tonsillarcapsulemaybebarrierlimitingtonsillarregrowthinacutetonsillitis.Therefore,preservationofthetonsillarcapsuleasmuchaspossiblemaybeanimportantissueintonsillotomysurgeries.小儿腺样体扁桃体切除术35/65腺样体和扁桃体切除术（T&A）在治疗小儿阻塞性睡眠呼吸暂停低通气综合征(OSAHS)中，有主要地位强调术前多道睡眠仪(polysomnography，PSG)监测，定量分析睡眠及/或气体交换异常情况，但不能判定阻塞平面和优选手术目标（Clinicalpracticeguideline:Polysomnographyforsleep-disorderedbreathingpriortotonsillectomyinchildren.OtolaryngolHeadNeckSurg.;145(Suppl1):S1–15.）小儿腺样体扁桃体切除术36/65T&A治疗OSAHS效果6个美国、2个欧洲儿童睡眠中心对T&A治疗OSAHS效果评价：最终完全处理只有27.2%病例(BhattacharjeeR,etal.Adenotonsillectomyoutcomesintreatmentofobstructivesleepapneainchildren:amulticenterretrospectivestudy.AmJRespirCritCareMed.;182(5):676–83.)小儿腺样体扁桃体切除术37/65Friedman等按循证医学方法，研究了.7以前英文文件，OSAHST&A治疗，1079例病人，平均年纪6.5岁，T&A治疗成功率66.3%（AHI＜1~5），以AHI＜1为标准，成功率59.8%假如以术前AHI＞20以上、年纪＜3岁或肥胖症定为“complicatedchildren”，那么，complicated病人治疗成功率38.7%，而uncomplicated病人治疗成功率73.8%（FriedmanM,etal.Updatedsystematicreviewoftonsillectomyandadenoidectomyfortreatmentofpediatricobstrutivesleepapnea/hypopneasyndrome.Otolaryngol,HeadNeckSurg.;140(6):800–808）小儿腺样体扁桃体切除术38/65T&A不能解除OSAHS，说明在一些病例，肥大扁桃体、腺样体，不是造成OSAHS唯一病理生理机制小儿腺样体扁桃体切除术39/65↓怎样选择有效手术目标？怎样处理T&A失败和残余OSAHS病例？确定上气道功效性狭窄部位小儿腺样体扁桃体切除术40/65确定上气道狭窄部位方法上气道正常形态保持需要依赖感觉和肌肉反射活动，入睡后咽肌和舌肌担心性下降造成咽壁肌张力下降和舌后坠致气道塌陷清醒期检验不能反应睡眠期上气道塌陷真实情况，睡眠期检验更值得关注小儿腺样体扁桃体切除术41/65电影磁共振成像(CineMRI):

国内外少数学者利用电影MRI对OSAHS儿童上气道进行了测量，并初步必定了cMRI在OSAHS诊疗中作用设备、流程复杂性以及高费用可能限制其推广小儿腺样体扁桃体切除术42/65小儿腺样体扁桃体切除术43/65睡眠内镜检验(Sleependoscopy)

一些药品能够产生靠近正常睡眠状态，在此条件下进行纤维镜检验，诊疗真实阻塞部位，从而制订治疗计划应用睡眠内镜，对残余OSA进行检验，逐步被重视，与cineMRI相比较，手术医生能够直接检验气道，能够看清睡眠时鼻咽、口咽、舌位以及喉异常状态，尤其是喉动态改变小儿腺样体扁桃体切除术44/65CroftandPringle于1991年首次用镇静药对OSA患者进行纤维鼻咽喉镜检验，以了解上气道塌陷情况，命名为“睡眠鼻内镜检验(sleepnasendoscopy)”．Kezirian提议更名为药品诱导睡眠内镜检验(Drug-inducedsleependoscopy，DISE)，反应这项检验特点：1，使用药品；2，诱导出类似于自然睡眠状态下上气道状态；3，使用鼻咽喉纤维镜随即20年里，一些研究证实了这项检验可靠性，在成人研究较多，小儿研究较少小儿腺样体扁桃体切除术45/65Europeanpositionpaperondrug-inducedsedationendoscopy(DISE)

SleepBreath22April年在意大利召开欧洲睡眠内镜教授会议达成共识提议用名：drug-inducedsedationendoscopy(DISE)DISE代表了打鼾和OSAHS应用最广泛上气道内镜评价方法，但在执行中，镇静药及其剂量、适应症等存在争论，规范化了一些问题小儿腺样体扁桃体切除术46/65符合循证医学标准文件数目小儿腺样体扁桃体切除术47/65年10月至年2月45例OSAHS患者，右美托咪定诱导睡眠内镜检验，男44例，女1例；年纪33～60岁详细操作方法和观察内容：静脉给右美托咪定1微克／千克加生理盐水至50ml，大于10min泵完小儿腺样体扁桃体切除术48/65Drug-inducedsleependoscopy:theVOTEclassification小儿腺样体扁桃体切除术49/65年，MyattandBeckenham是最早小儿睡眠内镜检验者，用氟烷诱导睡眠，20例AHI＞30复杂病例上气道发觉MyattHM,BeckenhamEJ.Theuseofdiagnosticsleepnasendoscopyinthemanagementofchildrenwithcomplexupperairwayobstruction.ClinOtolaryngolAlliedSci.;25(3):200.小儿腺样体扁桃体切除术50/65年Durr等用吸入七氟烷诱导，propofol(丙泊酚)静脉维持下，内镜检验了13例T&A残余OSAHS病例，发觉多平面阻塞DurrML,MeyerAK,KezirianEJ,RosbeKW.Drug-inducedsleependoscopyinpersistentpediatricsleep-disorderedbreathingafteradenotonsillectomy.ArchOtolar