小兒腺樣體、扁桃體切除術

小兒腺樣體、扁桃體切除術（一）為什么強調(diào)小兒？美國2011年版兒童扁桃體切除術臨床實踐指南該指南適用于1—18歲可能需行扁桃體切除術的患兒；Removalofthetonsilsandadenoidsisthoughttobethebreadandbutterofpediatricotolaryngology.Thecurrentcontroversialissueisfocusedonpediatrictonsillectomy,asurgicalprocedurethatislearnedearlyduringspecialisttrainingandperformedbyalmostallotolaryngologistsworldwide.Havingacloserlookatthehistoryoftonsillectomy,itbecomesquicklyclearthatbarelyanyotherENTsurgeryhasundergonesomanychangesregardingthefrequency,indicationandtechniqueastonsillectomydid.IndicationsofPediatricTonsillectomyAtthebeginningofthe20thcentury,recurrenttonsillitiswasthemainreasonforremovalofthetonsils.TArepresented30–50%ofallpediatricsurgeriesinthe1930sTheadventofantibioticsinthe1950sresultedinadramaticdecreaseintheoverallnumberoftonsillectomies.IntheUSA,thefrequencydroppedfrom1,400,000TAsperyearin1959to500,000in1979,IntheUK,200,000tonsillectomiesperyearin1930to50,000atthebeginningofthe21stcenturyTheseriespublishedduringthelast30yearsshowaclearshiftintheindicationsoftonsillectomy.Sleep-disorderedbreathingisnowthemainreasonforTAinchildren.Allstudiespublishedinthelastfewyearsshowthistrend,whichisevenmoreobviousinchildrenunder3yearsofage,whereOSASreaches90–100%ofindications.Inolderchildren,infectionsaremorefrequentindicationsforTATonsillectomy:ASimpleSurgicalProcedure?Austrianevents：Thedeathof5childreninAustriabelowtheageof6yearsduetoposttonsillectomyhaemorrhagein2006and2007showedhowquicklymedicalprocedurescanbediscussedanddebatedbythemediaandpoliticiansAsaconsequence,theAustrianPediatricandENTSocietieshadtoreviseandtightentheguidelinesforadenotonsillectomyThemainaimistorestricttonsillectomiestocaseswherethecompletetonsilhastobedissected.Thecriteriafortonsillectomyareformulatedvigorously:atleast7tonsilinfectionsin1yearor5tonsilinfectionsineachof2consecutiveyearshavetobedocumentedpriortotheremovalofthetonsils.Forchildrenyoungerthan6yearsofagewithtonsilhypertrophy,tonsillotomyratherthantonsillectomyisrecommended.Furthermore,anoverallhospitalstayof2–3nightsforinpatientsurgeryissuggestedDuringtheevaluationperiodfromOctober1,2009,toJune30,2010,allconsecutivetonsilandadenoidsurgeriesinAustria(n=9,405patients)andtheirriskfactorswereevaluated.BleedingepisodesofgradesAtoBarenamedminorbleedings,gradesCtoEareseverebleedingsPostoperativehaemorrhage,definedaseverybleedingepisodeafterextubation,wasreportedin12.3%aftertonsillectomy;onefourthofwhomexperiencedmultiplebleedings.Aftertonsillotomyonly2.2%patientsreportedapostoperativebleedingepisodeFigure2indicatesanincreasingriskofhaemorrhagewithrisingagefortonsillectomy,thedistributionofminorversusseverebleedingepisodesisequalFigure3showsalowrateofbleedingepisodesaftertonsillotomy(2.2%)withveryfewcasesrequiringsurgicaltreatmentundergeneralanaesthesia(0.7%).扁桃體切除術與扁桃體部分切除術，術后出血存在差異應用奧地利共識后，奧地利扁桃體切除術術后出血，需回手術處理的比率還是在文獻所報告的上限少量出血是嚴重出血的預兆統(tǒng)一術后出血觀察標準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（IntracapsularTonsillectomy、tonsillotomy）術后第一天需嚴密觀察，即使是小量出血TheeventsinAustriashowedthatlethalposttonsillectomyhaemorrhageisarealitywearefacedwithandthatstrictmonitoringofindicationsandcomplicationsmightdecreasetherateoflethaleventsinthefuture.Moreover,parentsbecamealertedtothepotentialrisksoftonsillectomiesthroughthemedia.Basedonourexperienceandgrowingmedicalization,weencouragecolleaguesinothercountriestothinkaboutthelackofstandardizedandnationwidemonitoringoftonsilsurgeriesandtheircomplicationsinordertoimprovethesafetyofsuchsurgeries.Tonsillectomy與IntracapsularTonsillectomy1930年Fowler提出removing“thetonsil,thewholetonsil,andnothingbutthetonsil,”措施是在咽肌與扁桃體被囊間anatomicaldissection，當時，扁桃體切除術針對的是慢性扁桃體炎囊內(nèi)扁桃體切除術，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)扁桃體切除術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Coblationcreatessignificantlylessepithelialdestructionandcollateraltissuedamagecomparedwithconventionalmonopolarelectrocautery.Additionally,Coblationtechnologyofferssuperiorversatilitybecauseitiseffectiveforperformingawiderangeofsurgeries,includingsubcapsulartonsillectomy(fig.1),intracapsulartonsillectomy(fig.2)andadenoidectomy,allwiththesamedeviceFig.1.Subcapsulartonsillectomy,intraoperativeview.Fig.2.Intracapsulartonsillectomy,intraoperativeviewIntracapsularPartialTonsillectomyforTonsillarHypertrophyinChildrenLaryngoscope112:August2002

囊內(nèi)扁桃體切除術，保留了扁桃體包囊,以免暴露咽肌；150例,與按標準術式進行的例

比較，術后疼痛較輕，術中出血，二者相若，6例標準術式和1例囊內(nèi)扁桃體切除術續(xù)發(fā)性出血需再住院，5例標準術式和1例囊內(nèi)扁桃體切除術因失水需再住院，需再住院者，囊內(nèi)扁桃體切除術2例而標準術式11例結(jié)論：對OSAS，二者都有效，囊內(nèi)扁桃體切除術術后疼痛較輕，術后續(xù)發(fā)出血和失水餃少Long-termeffectsofintracapsularpartialtonsillectomy(tonsillotomy)comparedwithfulltonsillectomy

InternationalJournalofPediatricOtorhinolaryngology(2005)69,463—469比較CO2-lasertonsillotomy與conventionaltonsillectomies術后6年的結(jié)果6年前的41OSAS小兒,9－15歲，進行CO2-laser(n=21)或conventional(n=20).此次隨訪的全部病例曾在術后6個月和1年隨訪過通訊隨訪的10個問題：關于Generalhealth,snoring,sleepapneas,eatingdifficulties，infections.整體健康情況無差異術后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，但比術前輕，(部分切除11例、常規(guī)切除14例不打鼾).術后1年，無1例呼吸暫停，術后6年，部分切除組3例常規(guī)切除組4例有呼吸暫停，但較術前輕。26例術前存在吃飯困難，術后都解決上感：Conclusion：wefoundthatthefundamentallong-termresultsofbothkindsofoperationswerecompatible.Tonsillarregrowthfollowingpartialtonsillectomywithradiofrequency

InternationalJournalofPediatricOtorhinolaryngology(2008)72,19—22前瞻性研究2001－2006連續(xù)42例射頻部分扁桃體切除術的OSAS小兒，22girlsand20boys，年齡1to10years(mean,4.7years).術后隨訪：第一個月為2周一次，以后每1－3月一次，隨訪了6to32months(mean,14.3months).35/42術前癥狀消失，扁桃體大小與術后第一日一樣，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2.4to6years(mean,3.9years)，其中5例年齡在4歲以下(71.4%)手術至再增生的時間1to18months(mean,9.3months).4/7(57.1%)在增生前有急性扁桃體炎發(fā)作，5/7有術前癥狀復發(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后增生是一個重要的問題，有的報告，如瑞典的兩組partialtonsillectomywithCO2laser，只說到無OSAS復發(fā)，但無增生記錄。美國microdebriderassistedintracapsulartonsillectomy多中心研究，870例小兒，術后再增生率0.46%有兩篇16to25歲病人radiofrequencytonsillotomy后1年隨訪，無扁桃體增生。本組病例，年齡較小，術后增生率16.6%.增生率高，年齡可能是個重要因素，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-assistedtonsillotomy術后增生的危險因素.作者經(jīng)驗，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acutetonsillitisepisode.急性扁桃體炎對扁桃體增生的影響不清楚。在radiofrequency-assistedtonsillotomy中，破壞了tonsillarcapsule可能是急性扁桃體炎促使增生的因素Tonsillarcapsulemaybebarrierlimitingtonsillarregrowthinacutetonsillitis.Therefore,preservationofthetonsillarcapsuleasmuchaspossiblemaybeanimportantissueintonsillotomysurgeries.腺樣體和扁桃體切除術（T&A）在治療小兒阻塞性睡眠呼吸暫停低通氣綜合征(OSAHS)中，有重要地位強調(diào)術前多道睡眠儀(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)選手術目標（Clinicalpracticeguideline:Polysomnographyforsleep-disorderedbreathingpriortotonsillectomyinchildren.OtolaryngolHeadNeckSurg.2011;145(Suppl1):S1–15.）T&A治療OSAHS的效果6個美國、2個歐洲兒童睡眠中心對T&A治療OSAHS的效果的評價：最終完全解決的只有27.2%的病例(BhattacharjeeR,etal.Adenotonsillectomyoutcomesintreatmentofobstructivesleepapneainchildren:amulticenterretrospectivestudy.AmJRespirCritCareMed.2010;182(5):676–83.)Friedman等按循證醫(yī)學的方法，研究了2008.7以前的英文文獻，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＜1~5），以AHI＜1為標準，成功率59.8%如果以術前AHI＞20以上、年齡＜3歲或肥胖癥定為“complicatedchildren”，那么，complicated病人治療成功率38.7%，而uncomplicated病人治療成功率73.8%（FriedmanM,etal.Updatedsystematicreviewofto