1、小兒腺樣體、扁桃體切除術(shù)（一）,1,為什么強(qiáng)調(diào)小兒？,美國(guó)2011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；,2,3,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 duri

2、ng specialist training and performed by almost all otolaryngologists worldwide.,4,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.,5,I

3、ndications 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 1930s The advent of antibiotics in the 1950s resulted in a dramatic decrease in the overall number

4、of tonsillectomies. 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,6,The series published during the last 30 years show a clear shift in the indications of to

5、nsillectomy. Sleep-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 indic

6、ations for TA,7,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 politicians As a conseque

7、nce, the Austrian Pediatric and ENT Societies had to revise and tighten the guidelines for adenotonsillectomy,8,The main aim is to restrict tonsillectomies to cases where the complete tonsil has to be dissected. The criteria for tonsillectomy are formulated vigorously: at least 7 tonsil infections i

8、n 1 year or 5 tonsil 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 rather than tonsillectomy is recommended. Furthermore, an overall hospital stay of 23 nights for in

9、patient surgery is suggested,9,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.,10,Bleeding episodes of grades A to B are named minor bleedings, grades C to E are s

10、evere bleedings,11,12,Postoperative 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,13,Figure 2 indicates an

11、increasing risk of haemorrhage with rising age for tonsillectomy, the distribution of minor versus severe bleeding episodes is equal,14,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%).,15,16,扁桃

12、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(shí)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)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(duì)6歲以下小兒，推薦扁桃體部分切除術(shù)（Intracapsular Tonsillectomy、tonsillotomy）,17,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 stric

13、t monitoring of indications and complications might decrease 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

14、about the lack of standardized and nationwide monitoring of tonsil surgeries and their complications in order to improve the safety of such surgeries.,18,Tonsillectomy與Intracapsular Tonsillectomy,1930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anatomic

15、al dissection，當(dāng)時(shí)，扁桃體切除術(shù)針對(duì)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(zhǎng)率增加，因此，囊內(nèi)扁桃體切除術(shù)是為慢性扁桃體切除的禁忌癥，但是對(duì)OSAS，是安全有效的方法,19,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 t

16、echnology offers superior versatility because it is effective for performing a wide range of surgeries, including subcapsular tonsillectomy ( fig. 1 ), intracapsular tonsillectomy ( fig. 2 ) and adenoidectomy, all with the same device,20,Fig. 1. Subcapsular tonsillectomy, intraoperative view.,21,Fig

17、. 2. Intracapsular tonsillectomy, intraoperative view,22,Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children Laryngoscope 112: August 2002,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

18、結(jié)論：對(duì)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,23,Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomyInternational Journal of Pediatric Otorhinolaryngology (2005) 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,

19、 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(guò) 通訊隨訪的10個(gè)問(wèn)題：關(guān)于General health, snoring, sleep apneas, eating difficulties，infections.,24,整體健康情況無(wú)差異,25,術(shù)后6月，無(wú)一例打鼾，1年后部分切除組有1例開(kāi)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 ).,26,術(shù)后1年，無(wú)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。

20、,27,26例術(shù)前存在吃飯困難，術(shù)后都解決 上感：,28,Conclusion：we found that the fundamental long-term results of both kinds of operations were compatible.,29,Tonsillar regrowth following partial tonsillectomy with radiofrequencyInternational Journal of Pediatric Otorhinolaryngology (2008) 72, 1922,前瞻性研究 20012006連續(xù)42 例射頻部

21、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 months). 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%),30,手術(shù)至再增生的時(shí)間1 to 18 months (mean, 9.3mo

22、nths). 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(duì)稱，且無(wú)癥狀，在隨訪中,31,32,扁桃體在扁桃體部分切除術(shù)后增生是一個(gè)重要的問(wèn)題，有的報(bào)告，如瑞典的兩組partial tonsillectomy with CO2 laser，只說(shuō)到無(wú)OSAS復(fù)發(fā)，但無(wú)增生記錄。美國(guó)microdebrider assisted intracapsular tonsillectomy 多中心研究，870例小兒，術(shù)后再增生率0.46%,33,有兩篇16 to 25 歲病人radiofreque

23、ncy tonsillotomy 后1年隨訪，無(wú)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(wú)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 tonsillotomy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,34,此外，50% 以上病例，增生前，有acute tonsillitis episode. 急性扁桃體炎對(duì)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