医学小儿腺样体扁桃体切除术培训课件.ppt
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1、小儿腺样体扁桃体切小儿腺样体扁桃体切除术除术美国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 specialist
2、 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.At the beginning of th
3、e 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 tonsillectomies.In the USA,the frequency dropped from 1,400,0
4、00 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 centuryThe series published during the last 30 years show a clear shift in the indications of tonsillectomy.Sleep-disordered breathing is now the main reason for TA in
5、 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 TAAustrian events:The death of 5 children in Austria below the age
6、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 Pediatric and ENT Societies had to revise and tighten the guidelines for adenotonsillectomyThe main aim is to
7、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 infections in each of 2 consecutive years have to be documented prior to the removal of the tonsils.For children
8、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 suggestedDuring the evaluation period from October 1,2009,to June 30,2010,all consecutive tonsil and adenoid surgeries i
9、n Austria(n=9,405 patients)and their risk factors were evaluated.Bleeding episodes of grades A to B are named Bleeding episodes of grades A to B are named minor bleedings,grades C to E are severe bleedingsminor bleedings,grades C to E are severe bleedingsPostoperative haemorrhage,defined as every bl
10、eeding 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 episodeFigure 2 indicates an increasing risk of haemorrhage with rising age for Figure 2 indicates an incr
11、easing risk of haemorrhage with rising age for tonsillectomy,the distribution of minor versus severe bleeding episodes is equaltonsillectomy,the distribution of minor versus severe bleeding episodes is equalFigure 3 shows a low rate of bleeding episodes after tonsillotomy(2.2%)with Figure 3 shows a
12、low rate of bleeding episodes after tonsillotomy(2.2%)with very few cases requiring surgical treatment under general anaesthesia(0.7%).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,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
13、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 decrease the rate of lethal events in the fu
14、ture.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 monitoring of tonsil surgeries and their complications
15、 in order to improve the safety of such surgeries.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Fig.1.Subcapsular tonsillectomy,intraope
16、rative view.Fig.2.Intracapsular tonsillectomy,intraoperative view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-laser tonsillotomy 与conventional tonsillectomies 术
17、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术后6 6月,无一月,无一例打鼾,例打鼾,1 1年后年后部分切除组有部分切除组有1 1例开始打鼾,例开始打鼾,6 6年后部分切除组年后部分切除组8 8例、常规切除例、常规切除组组4 4例打鼾,但例打鼾,但比术前轻,比术前轻,(部部分切除分切除1
18、111例、常例、常规切除规切除1414例不打例不打鼾鼾 ).).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 both kinds of operations were compatible.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
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