1、小儿腺样体、扁桃体切除术（一）,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；,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 spec
2、ialist 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
3、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 1930sThe advent of antibiotics in the 1950s resulted in a dramatic decrease in the overall number of tonsillec
4、tomies. 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,The series published during the last 30 years show a clear shift in the indications of tonsillectomy. S
5、leep-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 indications for TA,
6、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 politiciansAs a consequence, the Austrian
7、 Pediatric and ENT Societies had to revise and tighten the guidelines for adenotonsillectomy,The 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
8、 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 ratherthan tonsillectomy is recommended. Furthermore, an overall hospital stay of 23 nights for inpatient surgery is su
9、ggested,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.,Bleeding episodes of grades A to B are named minor bleedings, grades C to E are severe bleedings,Postoperat
10、ive 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,Figure 2 indicates an increasing risk of haemorrhage with
11、rising age for tonsillectomy, the distribution of minor versus severe bleeding episodes is equal,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%).,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，
12、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）,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 d
13、ecrease 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 about the lack of standardized and nationwide monitori
14、ng of tonsil surgeries and their complications in order to improve the safety of such surgeries.,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
15、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,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 technology offers superior versatility because it is effective
16、 for performing a wide range of surgeries, including subcapsular tonsillectomy ( fig. 1 ), intracapsular tonsillectomy ( fig. 2 ) and adenoidectomy, all with the same device,Fig. 1. Subcapsular tonsillectomy, intraoperative view.,Fig. 2. Intracapsular tonsillectomy, intraoperative view,Intracapsular
17、 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,Long-term effects of intracap
18、sular 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, 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
19、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 ).,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 b
20、oth kinds of operations were compatible.,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
21、，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
22、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%,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
23、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,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
24、acute tonsillitis. 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（T145(Suppl 1):S115. ）,T&A治疗OSAHS的效果,6个美国、2个欧洲儿童睡眠中心对T182(5):67683.),Friedman等按循证医学的方法，研究了2008.7以前的英文文献，OSAHS的T140(6):800808）,T&A不能解除 OSAHS，说明在一些病例，肥
25、大的扁桃体、腺样体，不是造成OSAHS唯一的病理生理机制,如何选择有效手术目标？如何处理T&A失败和残余OSAHS病例？确定上气道功能性狭窄部位,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觉和肌肉的反射活动，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气道塌陷的真实情况，睡眠期的检查更值得关注,电影磁共振成像(Cine MRI):,国内外少数学者利用电影MRI 对OSAHS 儿童上气道进行了测量，并初步肯定了c MRI 在OSAHS 诊断中的作用设备、流程的复杂性以及高费用可能限制其推广,睡眠内镜检查(Sleep endoscopy
26、),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，诊断真实的阻塞部位，从而制定治疗计划应用睡眠内镜，对残余的 OSA进行检查，逐渐被重视，与cine MRI相比较，手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态，特别是喉的动态变化,Croft and Pringle于1991年首次用镇静药对OSA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“睡眠鼻内镜检查(sleep nasendoscopy)”Kezirian提议改名为药物诱导睡眠内镜检查(Drug-induced sleep endoscopy，DISE)，反映这项检查的特点：1，使用药
27、物；2，诱导出类似于自然睡眠状态下的上气道的状态；3，使用鼻咽喉纤维镜随后的20年里，一些研究证实了这项检查的可靠性，在成人研究较多，小儿研究较少,European position paper on drug-induced sedation endoscopy (DISE) Sleep Breath 22 April 2014,2013年在意大利召开的欧洲睡眠内镜专家会议达成的共识建议用名：drug-induced sedation endoscopy (DISE)DISE代表了打鼾和OSAHS应用最广泛的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,
28、符合循证医学标准的文献数目,2012年10月至2013年2月45例OSAHS患者，右美托咪定诱导睡眠内镜检查，男44例，女1例；年龄3360岁具体操作方法和观察内容：静脉给右美托咪定 1微克公斤加生理盐水至50ml，大于10 min泵完,Drug-induced sleep endoscopy: the VOTE classification,2000年，Myatt and Beckenham是最早的小儿睡眠内镜检查者，用氟烷诱导睡眠， 20例 AHI 30复杂病例的上气道发现,Myatt HM, Beckenham EJ. The use of diagnostic sleep nasend
29、oscopyin the management of children with complex upperairway obstruction. Clin Otolaryngol Allied Sci. 2000;25(3):200.,2012年Durr等用吸入七氟烷诱导，propofol (丙泊酚)静脉维持下，内镜检查了13例T&A残余OSAHS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 br
30、eathingafter adenotonsillectomy. Arch Otolaryngol Head Neck Surg.2012;138(7):63864.,同年美国斯坦福大学Lucile Packard儿童医院小儿耳鼻喉科报告80例睡眠内镜检查，分两组；一组内镜指导手术，39例，另一组T&A后仍有OSHA，41例。两组均说明睡眠内镜检查指导手术的作用,丙泊酚propofol (100 g/kg/min) and瑞芬太尼remi-fentanyl (100 ng/kg/min).Truong et al. Sleep endoscopy as a diagnostic tool in
31、 pediatric obstructive sleep apnea.International Journal of Pediatric Otorhinolaryngology 76 (2012) 722727,最近，美国Vanderbilt大学小儿耳鼻喉科报导连续的26例T&A后仍有OSHA的病例，年龄518岁，经睡眠内镜检查，确定为多平面阻塞，进行相应的手术,小儿上气道睡眠内镜检查评分系统,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 Surg. 2014;140(7):595-602,这只是一
32、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2利用现有条件，稳步开展3结合临床，进行前瞻性研究,
