小儿腺样体扁桃体切除术PPT课件

1、小儿腺样体、扁桃体切除术（一）,1,为什么强调小儿？,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；,2,3,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 duri

2、ng specialist training and performed by almost all otolaryngologists worldwide.,4,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.,5,I

3、ndications of Pediatric Tonsillectomy,At the beginning of the 20th century, recurrent tonsillitis was the main reason for removal of the tonsils. TA represented 3050% of all pediatric surgeries in the 1930s The advent of antibiotics in the 1950s resulted in a dramatic decrease in the overall number

4、of tonsillectomies. In the USA, the frequency dropped from 1,400,000 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 century,6,The series published during the last 30 years show a clear shift in the indications of to

5、nsillectomy. Sleep-disordered breathing is now the main reason for TA in 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 indic

6、ations for TA,7,Tonsillectomy: A Simple Surgical Procedure ?,Austrian events：The death of 5 children in Austria below the age 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 politicians As a conseque

7、nce, the Austrian Pediatric and ENT Societies had to revise and tighten the guidelines for adenotonsillectomy,8,The main aim is to restrict tonsillectomies to cases where the complete tonsil has to be dissected. The criteria for tonsillectomy are formulated vigorously: at least 7 tonsil infections i

8、n 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 younger than 6 years of age with tonsil hypertrophy, tonsillotomy rather than tonsillectomy is recommended. Furthermore, an overall hospital stay of 23 nights for in

9、patient surgery is suggested,9,During the evaluation period from October 1, 2009, to June 30, 2010, all consecutive tonsil and adenoid surgeries in Austria (n = 9,405 patients) and their risk factors were evaluated.,10,Bleeding episodes of grades A to B are named minor bleedings, grades C to E are s

10、evere bleedings,11,12,Postoperative haemorrhage, defined as every bleeding 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 episode,13,Figure 2 indicates an

11、increasing risk of haemorrhage with rising age for tonsillectomy, the distribution of minor versus severe bleeding episodes is equal,14,Figure 3 shows a low rate of bleeding episodes after tonsillotomy (2.2%) with very few cases requiring surgical treatment under general anaesthesia (0.7%).,15,16,扁桃

12、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）,17,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 stric

13、t monitoring of indications and complications might decrease the rate of lethal events in the future. 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

14、about the lack of standardized and nationwide monitoring of tonsil surgeries and their complications in order to improve the safety of such surgeries.,18,Tonsillectomy与Intracapsular Tonsillectomy,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anatomic

15、al 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,19,Coblation离子射频低温消融,Coblation creates significantly less epithelial destruction and collateral tissue damage compared with conventional monopolar electrocautery. Additionally, Coblation t

16、echnology offers superior versatility because it is effective for performing a wide range of surgeries, including subcapsular tonsillectomy ( fig. 1 ), intracapsular tonsillectomy ( fig. 2 ) and adenoidectomy, all with the same device,20,Fig. 1. Subcapsular tonsillectomy, intraoperative view.,21,Fig

17、. 2. Intracapsular tonsillectomy, intraoperative view,22,Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children Laryngoscope 112: August 2002,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

18、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,23,Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomyInternational Journal of Pediatric Otorhinolaryngology (2005) 69, 463469,比较CO2-laser tonsillotomy 与conventional tonsillectomies 术后6年的结果 6年前的41 OSAS 小儿,

19、 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.,24,整体健康情况无差异,25,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 ).,26,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。

20、,27,26例术前存在吃饭困难，术后都解决 上感：,28,Conclusion：we found that the fundamental long-term results of both kinds of operations were compatible.,29,Tonsillar regrowth following partial tonsillectomy with radiofrequencyInternational Journal of Pediatric Otorhinolaryngology (2008) 72, 1922,前瞻性研究 20012006连续42 例射频部

21、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%),30,手术至再增生的时间1 to 18 months (mean, 9.3mo

22、nths). 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,31,32,扁桃体在扁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%,33,有两篇16 to 25 岁病人radiofreque

23、ncy 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radiofrequency-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,34,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