小兒腺樣體、扁桃體切除術(shù)共66張課件

1、小兒腺樣體、扁桃體切除術(shù)（一）為什么強(qiáng)調(diào)小兒？美國2019年版兒童扁桃體切除術(shù)臨床實(shí)踐指南該指南適用于118歲可能需行扁桃體切除術(shù)的患兒；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 special

2、ist 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.Indications of Pe

3、diatric TonsillectomyAt 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 1930sThe advent of antibiotics in the 1950s resulted in a dramatic decrease in the overall number of tonsillectomies

4、. 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 centuryThe series published during the last 30 years show a clear shift in the indications of tonsillectomy. Sleep-di

5、sordered 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 indications for TATonsille

6、ctomy: A Simple Surgical Procedure ?Austrian events：The death of 5 children in Austria below the age of 6 years due to posttonsillectomy haemorrhage in 2019 and 2019 showed how quickly medical procedures can be discussed and debated by the media and politiciansAs a consequence, the Austrian Pediatri

7、c and ENT Societies had to revise and tighten the guidelines for adenotonsillectomyThe main aim is to 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 infection

8、s 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 ratherthan tonsillectomy is recommended. Furthermore, an overall hospital stay of 23 nights for inpatient surgery is suggestedDur

9、ing the evaluation period from October 1, 2009, to June 30, 2019, all consecutive tonsil and adenoid surgeries in Austria (n = 9,405 patients) and their risk factors were evaluated.Bleeding episodes of grades A to B are named minor bleedings, grades C to E are severe bleedingsPostoperative haemorrha

10、ge, 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 episodeFigure 2 indicates an increasing risk of haemorrhage with rising age for

11、 tonsillectomy, the distribution of minor versus severe bleeding episodes is equalFigure 3 shows a low rate of bleeding episodes after tonsillotomy (2.2%) with very few cases requiring surgical treatment under general anaesthesia (0.7%).扁桃體切除術(shù)與扁桃體部分切除術(shù)，術(shù)后出血存在差異應(yīng)用奧地利共識后，奧地利扁桃體切除術(shù)術(shù)后出血，需回手術(shù)處理的比率還是在文獻(xiàn)所報(bào)

12、告的上限少量出血是嚴(yán)重出血的預(yù)兆統(tǒng)一術(shù)后出血觀察標(biāo)準(zhǔn)的意義奧地利事件后，對6歲以下小兒，推薦扁桃體部分切除術(shù)（Intracapsular Tonsillectomy、tonsillotomy）術(shù)后第一天需嚴(yán)密觀察，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

13、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 about the lack of standardized and nationwide monitoring of tonsil surg

14、eries and their complications in order to improve the safety of such surgeries.Tonsillectomy與Intracapsular Tonsillectomy1930年Fowler 提出removing “the tonsil, the whole tonsil, and nothing but the tonsil,” 措施是在咽肌與扁桃體被囊間anatomical dissection，當(dāng)時(shí)，扁桃體切除術(shù)針對的是慢性扁桃體炎囊內(nèi)扁桃體切除術(shù)，留下被囊，意味留下部分扁桃體組織，扁桃體再生長率增加，因此，囊內(nèi)扁桃

15、體切除術(shù)是為慢性扁桃體切除的禁忌癥，但是對OSAS，是安全有效的方法Coblation離子射頻低溫消融Coblation creates significantly less epithelial destruction and collateral tissue damage compared with conventional monopolar electrocautery. Additionally, Coblation technology offers superior versatility because it is effective for performing a wid

16、e range of surgeries, including subcapsular tonsillectomy ( fig. 1 ), intracapsular tonsillectomy ( fig. 2 ) and adenoidectomy, all with the same deviceFig. 1. Subcapsular tonsillectomy, intraoperative view.Fig. 2. Intracapsular tonsillectomy, intraoperative viewIntracapsular Partial Tonsillectomy f

17、or Tonsillar Hypertrophy in Children Laryngoscope 112: August 2019囊內(nèi)扁桃體切除術(shù)，保留了扁桃體包囊,以免暴露咽?。?50 例,與按標(biāo)準(zhǔn)術(shù)式進(jìn)行的例 比較，術(shù)后疼痛較輕，術(shù)中出血，二者相若，6例標(biāo)準(zhǔn)術(shù)式和1例囊內(nèi)扁桃體切除術(shù)續(xù)發(fā)性出血需再住院，5例標(biāo)準(zhǔn)術(shù)式和1例囊內(nèi)扁桃體切除術(shù)因失水需再住院，需再住院者，囊內(nèi)扁桃體切除術(shù)2例而標(biāo)準(zhǔn)術(shù)式11例結(jié)論：對OSAS，二者都有效，囊內(nèi)扁桃體切除術(shù)術(shù)后疼痛較輕，術(shù)后續(xù)發(fā)出血和失水餃少Long-term effects of intracapsular partial tonsillectom

18、y (tonsillotomy) compared with full tonsillectomyInternational Journal of Pediatric Otorhinolaryngology (2019) 69, 463469比較CO2-laser tonsillotomy 與conventional tonsillectomies 術(shù)后6年的結(jié)果6年前的41 OSAS 小兒, 9 15 歲，進(jìn)行CO2-laser (n = 21)或conventional (n = 20). 此次隨訪的全部病例曾在術(shù)后6個(gè)月和1年隨訪過通訊隨訪的10個(gè)問題：關(guān)于General health,

19、 snoring, sleep apneas, eating difficulties，infections.整體健康情況無差異術(shù)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(shù)前輕， (部分切除11例、常規(guī)切除14例不打鼾 ). 術(shù)后1年，無1例呼吸暫停，術(shù)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(shù)前輕。26例術(shù)前存在吃飯困難，術(shù)后都解決上感：Conclusion：we found that the fundamental long-term results of both kinds of operations were co

20、mpatible.Tonsillar regrowth following partial tonsillectomy with radiofrequencyInternational Journal of Pediatric Otorhinolaryngology (2019) 72, 1922前瞻性研究 20192019連續(xù)42 例射頻部分扁桃體切除術(shù)的OSAS小兒，22 girls and 20 boys ，年齡 1 to10 years (mean, 4.7 years). 術(shù)后隨訪：第一個(gè)月為2周一次，以后每13月一次，隨訪了6 to 32months (mean, 14.3 mon

21、ths).35/42 術(shù)前癥狀消失，扁桃體大小與術(shù)后第一日一樣，此35例中的23例年齡在4歲以下 (65.7%). 7/42扁桃體再增生(16.6%)，年齡 2.4 to 6 years (mean, 3.9 years)，其中5例年齡在4歲以下 (71.4%)手術(shù)至再增生的時(shí)間1 to 18 months (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(shù)前癥狀復(fù)發(fā)檢查扁桃體明顯增大，有的兩側(cè)扁桃體接觸，只能再作扁桃體剝離術(shù)另2例兩側(cè)增生不對稱，且無癥狀，在隨訪中扁桃體在扁桃體部分切除術(shù)后增生是一個(gè)重要的問題，有的報(bào)告，如瑞典的兩組part

22、ial tonsillectomy with CO2 laser，只說到無OSAS復(fù)發(fā)，但無增生記錄。美國microdebrider assisted intracapsular tonsillectomy 多中心研究，870例小兒，術(shù)后再增生率0.46%有兩篇16 to 25 歲病人radiofrequency tonsillotomy 后1年隨訪，無扁桃體增生。本組病例，年齡較小，術(shù)后增生率16.6%. 增生率高，年齡可能是個(gè)重要因素，無增生的病例中，66% 小于4歲，有增生的病例中，71.4%小于4歲，提示年齡小可能是radiofrequency-assisted tonsillotom

23、y術(shù)后增生的危險(xiǎn)因素. 作者經(jīng)驗(yàn)，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. 急性扁桃體炎對扁桃體增生的影響不清楚。在 radiofrequency-assisted tonsillotomy中，破壞了tonsillar capsule 可能是急性扁桃體炎促使增生的因素Tonsillar capsule may be barrier limiting tonsillar regrowth in acute tonsillitis. Therefore, preserv

24、ation of the tonsillar capsule as much as possible may be an important issue in tonsillotomy surgeries. 腺樣體和扁桃體切除術(shù)（T&A）在治療小兒阻塞性睡眠呼吸暫停低通氣綜合征(OSAHS)中，有重要地位強(qiáng)調(diào)術(shù)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，但不能鑒定阻塞平面和優(yōu)選手術(shù)目標(biāo)（Clinical practice guideline: Polysomnography for sleep-disordered breathing pri

25、or to tonsillectomy in children. Otolaryngol Head Neck Surg. 2019;145(Suppl 1):S115. ）T&A治療OSAHS的效果6個(gè)美國、2個(gè)歐洲兒童睡眠中心對T&A治療OSAHS的效果的評價(jià)：最終完全解決的只有 27.2 %的病例(Bhattacharjee R, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Res

26、pir Crit Care Med. 2019;182(5):67683.)Friedman等按循證醫(yī)學(xué)的方法，研究了2019.7以前的英文文獻(xiàn)，OSAHS的T&A治療，1079例病人，平均年齡6.5歲，T&A治療成功率66.3%（AHI 15），以AHI 1為標(biāo)準(zhǔn)，成功率59.8%如果以術(shù)前AHI 20以上、年齡3歲或肥胖癥定為“complicated children”，那么，complicated 病人治療成功率38.7%，而uncomplicated 病人治療成功率73.8%（Friedman M, et al. Updated systematic review of tonsill

27、ectomy and adenoidectomy for treatment of pediatric obstrutive sleep apnea/hypopnea syndrome. Otolaryngol,Head Neck Surg. 2009;140(6):800808） T&A不能解除 OSAHS，說明在一些病例，肥大的扁桃體、腺樣體，不是造成OSAHS唯一的病理生理機(jī)制如何選擇有效手術(shù)目標(biāo)？如何處理T&A失敗和殘余OSAHS病例？確定上氣道功能性狹窄部位確定上氣道狹窄部位的方法上氣道正常形態(tài)的保持需要依賴感覺和肌肉的反射活動，入睡后咽肌和舌肌緊張性下降造成咽壁肌張力下降和舌后墜致

28、氣道塌陷清醒期的檢查不能反映睡眠期的上氣道塌陷的真實(shí)情況，睡眠期的檢查更值得關(guān)注電影磁共振成像(Cine MRI): 國內(nèi)外少數(shù)學(xué)者利用電影MRI 對OSAHS 兒童上氣道進(jìn)行了測量，并初步肯定了c MRI 在OSAHS 診斷中的作用設(shè)備、流程的復(fù)雜性以及高費(fèi)用可能限制其推廣睡眠內(nèi)鏡檢查(Sleep endoscopy)某些藥物可以產(chǎn)生接近正常的睡眠狀態(tài)，在此條件下進(jìn)行纖維鏡檢查，診斷真實(shí)的阻塞部位，從而制定治療計(jì)劃應(yīng)用睡眠內(nèi)鏡，對殘余的 OSA進(jìn)行檢查，逐漸被重視，與cine MRI相比較，手術(shù)醫(yī)生可以直接檢查氣道，可以看清睡眠時(shí)鼻咽、口咽、舌位以及喉的異常狀態(tài)，特別是喉的動態(tài)變化Croft

29、 and Pringle于1991年首次用鎮(zhèn)靜藥對OSA患者進(jìn)行纖維鼻咽喉鏡檢查，以了解上氣道塌陷情況，命名為“睡眠鼻內(nèi)鏡檢查(sleep nasendoscopy)”Kezirian提議改名為藥物誘導(dǎo)睡眠內(nèi)鏡檢查(Drug-induced sleep endoscopy，DISE)，反映這項(xiàng)檢查的特點(diǎn)：1，使用藥物；2，誘導(dǎo)出類似于自然睡眠狀態(tài)下的上氣道的狀態(tài)；3，使用鼻咽喉纖維鏡隨后的20年里，一些研究證實(shí)了這項(xiàng)檢查的可靠性，在成人研究較多，小兒研究較少European position paper on drug-induced sedation endoscopy (DISE) Sle

30、ep Breath 22 April 20192019年在意大利召開的歐洲睡眠內(nèi)鏡專家會議達(dá)成的共識建議用名：drug-induced sedation endoscopy (DISE)DISE代表了打鼾和OSAHS應(yīng)用最廣泛的上氣道內(nèi)鏡評價(jià)方法，但在執(zhí)行中，鎮(zhèn)靜藥及其劑量、適應(yīng)癥等存在爭論，規(guī)范化了一些問題符合循證醫(yī)學(xué)標(biāo)準(zhǔn)的文獻(xiàn)數(shù)目2019年10月至2019年2月45例OSAHS患者，右美托咪定誘導(dǎo)睡眠內(nèi)鏡檢查，男44例，女1例；年齡3360歲具體操作方法和觀察內(nèi)容：靜脈給右美托咪定 1微克公斤加生理鹽水至50ml，大于10 min泵完Drug-induced sleep endoscopy

31、: the VOTE classification2000年，Myatt and Beckenham是最早的小兒睡眠內(nèi)鏡檢查者，用氟烷誘導(dǎo)睡眠， 20例 AHI 30復(fù)雜病例的上氣道發(fā)現(xiàn)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):200.2019年Durr等用吸入七氟烷誘導(dǎo)，propofol (丙泊酚)靜脈維持下，內(nèi)鏡檢查了13例T&A殘余OSAHS病例，發(fā)現(xiàn)多平面阻塞Durr ML