小儿腺样体扁桃体切除术

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1—18岁可能需行扁桃体切除术的患儿；Removalofthetonsilsandadenoidsisthoughttobethebreadandbutterofpediatricotolaryngology.Thecurrentcontroversialissueisfocusedonpediatrictonsillectomy,asurgicalprocedurethatislearnedearlyduringspecialisttrainingandperformedbyalmostallotolaryngologistsworldwide.Havingacloserlookatthehistoryoftonsillectomy,itbecomesquicklyclearthatbarelyanyotherENTsurgeryhasundergonesomanychangesregardingthefrequency,indicationandtechniqueastonsillectomydid.Atthebeginningofthe20thcentury,recurrenttonsillitiswasthemainreasonforremovalofthetonsils.TArepresented30–50%ofallpediatricsurgeriesinthe1930sTheadventofantibioticsinthe1950sresultedinadramaticdecreaseintheoverallnumberoftonsillectomies.IntheUSA,thefrequencydroppedfrom1,400,000TAsperyearin1959to500,000in1979,IntheUK,200,000tonsillectomiesperyearin1930to50,000atthebeginningofthe21stcenturyTheseriespublishedduringthelast30yearsshowaclearshiftintheindicationsoftonsillectomy.Sleep-disorderedbreathingisnowthemainreasonforTAinchildren.Allstudiespublishedinthelastfewyearsshowthistrend,whichisevenmoreobviousinchildrenunder3yearsofage,whereOSASreaches90–100%ofindications.Inolderchildren,infectionsaremorefrequentindicationsforTAAustrianevents：Thedeathof5childreninAustriabelowtheageof6yearsduetoposttonsillectomyhaemorrhagein2006and2007showedhowquicklymedicalprocedurescanbediscussedanddebatedbythemediaandpoliticiansAsaconsequence,theAustrianPediatricandENTSocietieshadtoreviseandtightentheguidelinesforadenotonsillectomyThemainaimistorestricttonsillectomiestocaseswherethecompletetonsilhastobedissected.Thecriteriafortonsillectomyareformulatedvigorously:atleast7tonsilinfectionsin1yearor5tonsilinfectionsineachof2consecutiveyearshavetobedocumentedpriortotheremovalofthetonsils.Forchildrenyoungerthan6yearsofagewithtonsilhypertrophy,tonsillotomyratherthantonsillectomyisrecommended.Furthermore,anoverallhospitalstayof2–3nightsforinpatientsurgeryissuggestedDuringtheevaluationperiodfromOctober1,2009,toJune30,2010,allconsecutivetonsilandadenoidsurgeriesinAustria(n=9,405patients)andtheirriskfactorswereevaluated.BleedingepisodesofgradesAtoBarenamedminorbleedings,gradesCtoEareseverebleedingsPostoperativehaemorrhage,definedaseverybleedingepisodeafterextubation,wasreportedin12.3%aftertonsillectomy;onefourthofwhomexperiencedmultiplebleedings.Aftertonsillotomyonly2.2%patientsreportedapostoperativebleedingepisodeFigure2indicatesanincreasingriskofhaemorrhagewithrisingagefortonsillectomy,thedistributionofminorversusseverebleedingepisodesisequalFigure3showsalowrateofbleedingepisodesaftertonsillotomy(2.2%)withveryfewcasesrequiringsurgicaltreatmentundergeneralanaesthesia(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，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）术后第一天需严密观察，即使是小量出血TheeventsinAustriashowedthatlethalposttonsillectomyhaemorrhageisarealitywearefacedwithandthatstrictmonitoringofindicationsandcomplicationsmightdecreasetherateoflethaleventsinthefuture.Moreover,parentsbecamealertedtothepotentialrisksoftonsillectomiesthroughthemedia.Basedonourexperienceandgrowingmedicalization,weencouragecolleaguesinothercountriestothinkaboutthelackofstandardizedandnationwidemonitoringoftonsilsurgeriesandtheircomplicationsinordertoimprovethesafetyofsuchsurgeries.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Coblation离子射频低温消融Coblationcreatessignificantlylessepithelialdestructionandcollateraltissuedamagecomparedwithconventionalmonopolarelectrocautery.Additionally,Coblationtechnologyofferssuperiorversatilitybecauseitiseffectiveforperformingawiderangeofsurgeries,includingsubcapsulartonsillectomy(fig.1),intracapsulartonsillectomy(fig.2)andadenoidectomy,allwiththesamedeviceFig.1.Subcapsulartonsillectomy,intraoperativeview.Fig.2.Intracapsulartonsillectomy,intraoperativeview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比较CO2-lasertonsillotomy与conventionaltonsillectomies术后6年的结果6年前的41OSAS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通讯随访的10个问题：关于Generalhealth,snoring,sleepapneas,eatingdifficulties，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：wefoundthatthefundamentallong-termresultsofbothkindsofoperationswerecompatible.前瞻性研究2001－2006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%)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