小儿腺样体扁桃体切除术ppt课件

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,Removalofthetonsilsandadenoidsisthoughttobethebreadandbutterofpediatricotolaryngology.Thecurrentcontroversialissueisfocusedonpediatrictonsillectomy,asurgicalprocedurethatislearnedearlyduringspecialisttrainingandperformedbyalmostallotolaryngologistsworldwide.,4,Havingacloserlookatthehistoryoftonsillectomy,itbecomesquicklyclearthatbarelyanyotherENTsurgeryhasundergonesomanychangesregardingthefrequency,indicationandtechniqueastonsillectomydid.,5,IndicationsofPediatricTonsillectomy,Atthebeginningofthe20thcentury,recurrenttonsillitiswasthemainreasonforremovalofthetonsils.TArepresented3050%ofallpediatricsurgeriesinthe1930sTheadventofantibioticsinthe1950sresultedinadramaticdecreaseintheoverallnumberoftonsillectomies.IntheUSA,thefrequencydroppedfrom1,400,000TAsperyearin1959to500,000in1979,IntheUK,200,000tonsillectomiesperyearin1930to50,000atthebeginningofthe21stcentury,6,Theseriespublishedduringthelast30yearsshowaclearshiftintheindicationsoftonsillectomy.Sleep-disorderedbreathingisnowthemainreasonforTAinchildren.Allstudiespublishedinthelastfewyearsshowthistrend,whichisevenmoreobviousinchildrenunder3yearsofage,whereOSASreaches90100%ofindications.Inolderchildren,infectionsaremorefrequentindicationsforTA,7,Tonsillectomy:ASimpleSurgicalProcedure?,Austrianevents：Thedeathof5childreninAustriabelowtheageof6yearsduetoposttonsillectomyhaemorrhagein2006and2007showedhowquicklymedicalprocedurescanbediscussedanddebatedbythemediaandpoliticiansAsaconsequence,theAustrianPediatricandENTSocietieshadtoreviseandtightentheguidelinesforadenotonsillectomy,8,Themainaimistorestricttonsillectomiestocaseswherethecompletetonsilhastobedissected.Thecriteriafortonsillectomyareformulatedvigorously:atleast7tonsilinfectionsin1yearor5tonsilinfectionsineachof2consecutiveyearshavetobedocumentedpriortotheremovalofthetonsils.Forchildrenyoungerthan6yearsofagewithtonsilhypertrophy,tonsillotomyratherthantonsillectomyisrecommended.Furthermore,anoverallhospitalstayof23nightsforinpatientsurgeryissuggested,9,DuringtheevaluationperiodfromOctober1,2009,toJune30,2010,allconsecutivetonsilandadenoidsurgeriesinAustria(n=9,405patients)andtheirriskfactorswereevaluated.,10,BleedingepisodesofgradesAtoBarenamedminorbleedings,gradesCtoEareseverebleedings,11,12,Postoperativehaemorrhage,definedaseverybleedingepisodeafterextubation,wasreportedin12.3%aftertonsillectomy;onefourthofwhomexperiencedmultiplebleedings.Aftertonsillotomyonly2.2%patientsreportedapostoperativebleedingepisode,13,Figure2indicatesanincreasingriskofhaemorrhagewithrisingagefortonsillectomy,thedistributionofminorversusseverebleedingepisodesisequal,14,Figure3showsalowrateofbleedingepisodesaftertonsillotomy(2.2%)withveryfewcasesrequiringsurgicaltreatmentundergeneralanaesthesia(0.7%).,15,16,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（IntracapsularTonsillectomy、tonsillotomy）,17,术后第一天需严密观察，即使是小量出血TheeventsinAustriashowedthatlethalposttonsillectomyhaemorrhageisarealitywearefacedwithandthatstrictmonitoringofindicationsandcomplicationsmightdecreasetherateoflethaleventsinthefuture.Moreover,parentsbecamealertedtothepotentialrisksoftonsillectomiesthroughthemedia.Basedonourexperienceandgrowingmedicalization,weencouragecolleaguesinothercountriestothinkaboutthelackofstandardizedandnationwidemonitoringoftonsilsurgeriesandtheircomplicationsinordertoimprovethesafetyofsuchsurgeries.,18,Tonsillectomy与IntracapsularTonsillectomy,1930年Fowler提出removing“thetonsil,thewholetonsil,andnothingbutthetonsil,”措施是在咽肌与扁桃体被囊间anatomicaldissection，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,Coblationcreatessignificantlylessepithelialdestructionandcollateraltissuedamagecomparedwithconventionalmonopolarelectrocautery.Additionally,Coblationtechnologyofferssuperiorversatilitybecauseitiseffectiveforperformingawiderangeofsurgeries,includingsubcapsulartonsillectomy(fig.1),intracapsulartonsillectomy(fig.2)andadenoidectomy,allwiththesamedevice,20,Fig.1.Subcapsulartonsillectomy,intraoperativeview.,21,Fig.2.Intracapsulartonsillectomy,intraoperativeview,22,IntracapsularPartialTonsillectomyforTonsillarHypertrophyinChildrenLaryngoscope112:August2002,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,23,Long-termeffectsofintracapsularpartialtonsillectomy(tonsillotomy)comparedwithfulltonsillectomyInternationalJournalofPediatricOtorhinolaryngology(2005)69,463469,比较CO2-lasertonsillotomy与conventionaltonsillectomies术后6年的结果6年前的41OSAS小儿,915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Generalhealth,snoring,sleepapneas,eatingdifficulties，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。,27,26例术前存在吃饭困难，术后都解决上感：,28,Conclusion：wefoundthatthefundamentallong-termresultsofbothkindsofoperationswerecompatible.,29,TonsillarregrowthfollowingpartialtonsillectomywithradiofrequencyInternationalJournalofPediatricOtorhinolaryngology(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，22girlsand20boys，年龄1to10years(mean,4.7years).术后随访：第一个月为2周一次，以后每13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2.4to6years(mean,3.9years)，其中5例年龄在4岁以下(71.4%),30,手术至再增生的时间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partialtonsillectomywithCO2laser，只说到无OSAS复发，但无增生记录。美国microdebriderassistedintracapsulartonsillectomy多中心研究，870例小儿，术后再增生率0.46%,33,有两篇16to25岁病人radiofrequencytonsillotomy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-assistedtonsillotomy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acutetonsillitisepisode.急性扁桃体炎对扁桃体增生的影响不清楚。在radiofrequency-assistedtonsillotomy中，破坏了tonsillarcapsule可能是急性扁桃体炎促使增生的因素Ton