60例改良腭咽成形术围手术期并发症处理

目的总结60例阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypop-nea syndrome,OSAHS）的麻醉、手术并发症及防治对策。方法 60例OSAHS患者均行改良腭咽成形术,其中6例同期行舌骨悬吊术。结果麻醉诱导致急性呼吸衰竭1例经抢救成功,原发性出血8例,继发性出血3例,术后短暂呼吸不畅1例,切口裂开10例,短期腭咽关闭不全5例,6例行舌骨悬吊术的患者有2例发生口底水肿,均经相应对症处理症状消失。结论规范的围手术期处理,术前气管切开或CPAP治疗,清醒状态下麻醉插管,重症患者术后延迟拔管等,可有效降低麻醉和手术意外的发生机会。     

阻塞性睡眠呼吸暂停低通气综合征行腭咽成形术围手术期的临床研究

目的探讨腭咽成形术(uvulopalatopharyngoplasty,UPPP)治疗中、重度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)围手术期的临床处理.方法对54例中、重度OSAHS患者实施了腭咽成形术,围手术期的处理包括(1)多道睡眠监测和心肺功能评估;(2)术前44例、术后29例行正压通气治疗;(3)静脉诱导吸入全身麻醉46例,局部浸润麻醉8例;(4)42例行保留悬雍垂的改良腭咽成形术.结果术前未接受CPAP治疗的局麻患者术中出现短暂呼吸困难2例,术后高血压危象、心动过速各1例,术后原发性出血2例.CPAP治疗组在麻醉清醒期及术后无急性上气道阻塞发生.全身麻醉5例插管困难,有高血压病史的19例术中血液动力学波动大.经典腭咽成形术后1周内腭咽关闭不全4例,行保留悬雍垂的改良腭咽成形术后咽部有异物感9例,但无其他并发症.结论充分认识UPPP 手术存在的潜在风险,认真进行围手术期的正确治疗有助于减少手术并发症,提高手术和麻醉的安全性.     

舌骨悬吊联合UPPP术治疗OSAHS患者普通病房围手术期的处理

目的探讨舌骨悬吊与悬雍垂腭咽成形术（UPPP）联合手术治疗阻塞性睡眠呼吸暂停低通气综合征（OSAHS）围手术期的观察、处理的必要性。 方法对78例患者术前均行多导睡眠呼吸监测，完善各系统的术前检查，并请相关科室会诊治疗相关疾病，根据情况行3～7d的正压通气治疗；术后自ICU病房转入普通病房后加强心电监护，密切观察呼吸、血压等变化，及时处理发生的问题等。 结果1例术后3d因咳嗽发生继发性出血，经二次手术止血出血停止; 2例颈部切口渗液，经处理后延迟愈合;6例开始进食时略有呛咳，经锻炼后在第3天消失。其余患者术后2～4d舌体运动略有受限，5～7d后舌体运动正常。 结论舌骨悬吊与UPPP的联合手术治疗OSAHS有一定的潜在危险，加强围手术期的处理能显著提高患者对手术的耐受性，降低手术风险，减少并发症的发生。     

阻塞性睡眠呼吸暂停低通气综合征的围手术期治疗

目的探讨阻塞性睡眠呼吸暂停低通气综合征(OSAHS) 围手术期的治疗措施和必要性。方法回顾性分析1030例OSAHS患者围手术期发生各种严重并发症的情况。1030例分为A组：2002年8月底以前未进行系统的围手术期治疗者396例;B组：2002年9月以后进行系统的围手术期治疗者634例,主要治疗包括手术前持续正压通气、术中熟练的技术操作并严格止血、术后监护等。结果A组术中因并发症死亡1例,术后发生原发性咽部出血10例、继发性出血15例、短期鼻咽返流35例、鼻咽闭锁1例。B组术后发生原发性咽部出血4例、继发性出血9例、短期鼻咽返流11例。与A组比较,B组并发症的发生率明显降低（P＜0.05）。两组均无其他严重心脑血管并发症出现。结论OSAHS患者手术有极大的潜在危险,加强围手术期的治疗能显著提高患者对手术及麻醉的耐受性, 降低手术风险, 减少并发症的发生。     

减少悬雍垂腭咽成形术并发症的围手术期处理

目的总结阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome，OSAHS）患者行悬雍垂腭咽成形术（uvulopalatopharyngoplasty，UPPP）的围手术期处理经验和教训，分析手术后气管切开病例原因，提出避免行气管切开术的对策。方法回顾性分析2002—2005年258例行改良UPPP手术的OSAHS患者围手术期处理、麻醉药物选择、术中及术后呼吸道管理。根据是否进行系统的围手术期处理分为A组（32例无系统处理）及B组（226例接受系统处理）。术前均给予2～3d常规抗生素治疗，手术在全麻下进行，术前均未行气管切开术。B组中对多道睡眠呼吸监测（polysomnography，PSG）为“双50”（即呼吸暂停低通气指数〉50次／h且最低血氧饱和度〈0．50）的68例患者术前行持续正压通气（continuous positive airway pressure，CPAP）呼吸机治疗1～3周，麻醉中选用分解代谢快的麻醉药，手术应用改良的压舌板。结果A组术后3例（9．4％）行气管切开，其中2例由于术后出血，1例因术后喉水肿；B组术后无气管切开病例；两组比较，X^2=21．35，P〈0．001，差异有统计学意义。A组患者术后原发性出血3例（9．4％），B组患者无术后原发性出血。两组比较，X^2=21．35，P〈0．001，差异有统计学意义。A组患者术后继发性出血5例（15．6％），B组患者术后继发性出血26例（11．5％），两组比较，X^2=0．15，P〉0．05，差异无统计学意义。两组患者伤口裂开及反流发生率相似，差异无统计学意义。结论经过有效的围手术期处理及合适的麻醉药物使用、彻底的术中止血，可有效降低UPPP手术并发症的发生率。     

阻塞性睡眠呼吸暂停低通气综合征围手术期监护体系

目的 探讨建立围手术期监护体系在阻塞性睡眠呼吸低通气综合征(OSAHS)治疗中的意义。方法 回顾性分析100例OSAHS患者围手术期发生各种严重并发症的情况，分为两组来对比研究，未进行系统的围手术期治疗者50例作为A组；建立围手术期监护者 50例作为B组。建立围手术期监护体系主要包括从手术前的系列查体，到各个专业的会诊治疗，从局部的影像定位和PSG监测，到3～7d的正压通气治疗，必要时的气管切开手术，从手术的麻醉护理的精深麻醉和配合，到手术后的ICU监护，而后到普通病房的特殊护理，到出院后的健康教育。 结果 A组术中因并发症死亡1例,术后发生原发性咽部出血10例、继发性出血10例、气管阻塞2例、气管切开2例。B 组患者术中、术后均未发生咽部出血、气管阻塞、气管切开的情况。B组较A组并发症的发生率明显降低(P<0. 05)，两组均无其他严重心脑血管并发症出现。结论 OSAHS患者手术有极大的潜在危险性,建立OSAHS围手术期监护体系，加强围手术期的治疗能显著提高患者对手术及麻醉的耐受性,降低手术风险,减少各种术中、术后并发症的发生。     

阻塞性睡眠呼吸暂停低通气综合征合并高血糖患者的围手术期血糖管理

目的 探讨血糖管理在控制阻塞性睡眠呼吸暂停低通气综合征(OSAHS)合并高血糖患者围手术期并发症的作用和效果。 方法 选取进行手术治疗的OSAHS合并高血糖患者30例作为研究对象,为所有患者提供全面的术前心理护理、控制血糖、活动与饮食及术后并发症观察、血糖监测、疼痛控制等血糖管理,观察患者手术并发症情况。 结果 30例OSAHS合并高血糖患者围手术期血糖控制良好,2例出现术后并发症包括出血1例、低血糖1例,给予及时治疗处理。30例均治愈出院,无糖尿病酮症酸中毒发生。 结论 围手术期血糖管理可有效控制OSAHS合并高血糖患者手术并发症,保证治愈率。     

阻塞性睡眠呼吸暂停低通气综合征患者围手术期并发症的处理

目的：探讨阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者围手术期并发症的预防及处理方法。方法：回顾分析110例阻塞性睡眠呼吸暂停综合征患者行悬雍垂腭咽成形术（UPPP）围手术期的临床资料。结果：UPPP术后原发性出血6例，呼吸困难5例，发热4例，无1例发生饮食呛咳和口咽狭窄。结论：OSAHS为全身疾病，行UPPP术必须严格掌握手术适应证，加强和重视围手术期处理及结合个体制定手术方案，以避免发生严重并发症。     

阻塞性睡眠呼吸暂停低通气综合征患者围手术期的综合治疗

阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者围手术期风险较大,睡眠片段化及低氧血症是其中两个主要因素。OSAHS是麻醉期并发症及死亡率高发的危险因素,围手术期并发症约为10%～20%左右,在上气道手术中尤为明显,围手术期须予以高度重视,将风险降至最小范围,及早发现并处理隐患有利于防止并发症发生。本文就OSAHS手术相关的潜在并发症及规避方法进行综述分析。     

阻塞性睡眠呼吸暂停低通气综合征手术治疗的警示

目的 探讨行悬雍垂腭咽成形术（uvulopalatopharyngoplasty,UPPP）围手术期易出现的严重并发症的预防和处理。方法 在180例行UPPP及1例行探查止血的阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS)患者中，报告并总结了10例严重并发症的临床资料。结果 UPPP术中发生心绞痛和心肌梗塞各1例；术后发生口咽狭窄3例，继发性出血3例，吞咽反流和开放性鼻音及分泌性中耳炎1例；鼻部探查止血手术中诱导麻醉插管时窒息死亡1例。结论 OSAHS为全身性代谢性疾病，行UPPP手术及其他全身麻醉手术时必须严格掌握手术适应证，加强围手术期治疗并结合个体情况制定手术方案，避免严重并发症。     

A Decrease in Maxillary Sinus Pressure,as Seen in Upper Airway Allergy or Infection,Results in an Increase in Upper Airway Nitric Oxide Levels

The paranasal sinuses are connected to the nasal cavity via small osties. Ostial occlusion, caused by mucosal swelling, will result in a slowly increasing negative pressure inside the sinus cavity. In parallel, the oxygen content in the sinus will decrease, resulting in the development of relative hypoxia. Hypoxia is a powerful inducer of nitric oxide (NO) synthase, and inducible NO synthase has been shown to be present in considerable amounts in the upper airways, including the sinuses. The present study was designed to investigate whether a reduction in sinus pressure would affect upper airway NO production. Thirteen healthy volunteers were investigated. A pressure chamber was used to lower the ambient pressure to-4.9 kPa. NO was sampled from one nostril or via a drainage tube inserted into the maxillary sinus before, during and after the hypobaric exposure. When the pressure was decreased, NO levels increased from 256 &#45 15 to 316 &#45 19 ppb ( n =13, p <0.001). The NO levels remained elevated (282 &#45 21 ppb; p <0.05) when measurements were repeated 20 min after leaving the chamber. The nasal airway resistance (V2 tot ) also increased as a result of the chamber session (from 16 &#45 2° before to 21 &#45 3° after; p <0.05). An increase in NO levels was also found when the experiments were repeated with NO sampled directly from the maxillary sinus (225 &#45 6 before and 265 &#45 9 ppb after; n =6, p <0.001). For control purposes the nasal analyses were repeated again, this time under hyperbaric conditions (+4.9 kPa). This resulted in a slight decrease in the NO levels (from 273 &#45 22 to 241 &#45 17 ppb; n =10, p <0.001), but there was no change in the nasal airway resistance. We conclude that a reduction in sinus pressure, as seen in upper airway allergy or infection, may result in an increase in upper airway NO production.     

A simple objective evaluation and grading for facial paralysis outcomes

Matrix metalloproteinase (MMP)-2 and -9 degrade type IV collagen, which is one of the major components of the basement membrane in normal tissue and expressed in the surroundings of the cancer nest in squamous cell carinoma. The degeneration of type IV collagen is an essential step in the metastasis to lymph nodes and distant organs. In this study, we examined MMP-2 and -9 levels of cancer tissue and serum obtained from patients with head and neck squamous cell carcinoma (HNSCC) in order to evaluate the relationship between the clinicopathologic features and MMPs. We examined the production of MMP-2 and -9 in cancer tissue homogenates of 73 patients who had HNSCC and the serum MMP levels of 16 patients with HNSCC and 8 healthy volunteers. We also studied the localization of MMP-2 in the carcinoma using an immunohistochemical approach. The concentrations of MMP-2 and -9 in the tissue homogenates and serum were measured by means of a sandwich enzyme immunoassay using a monoclonal antibody. Immunohistochemical analyses were performed with monoclonal antibody to MMP-2. The concentration of MMP-2 in the tumor tissue homogenates was unrelated to tumor size, but that in patients with lymph node metastases was significantly higher than in those without lymph node metastases. The concentration of MMP-9 was unrelated to lymph node metastasis and tumor size. The levels of both MMP-2 and -9 in serum were unrelated to lymph node metastasis. Immunohistochemistry indicated that MMP-2 was mainly expressed in cancer cells. Because MMP-2 degrades type IV collagen, the level of MMP-2 in carcinomas may be a useful indicator of the degree of invasion and metastasis.     

A case of cortical deafness and anarthria

The nasal epithelium protects the underlying tissue from damage. Epithelial cell growth is controlled by epidermal growth factor (EGF) and is possibly affected by toxic proteins, e.g. eosinophil cationic protein (ECP). The aims of this study were to examine nasal fluid epithelial cell counts and their relations to EGF, eosinophils and ECP in 23 patients with seasonal allergic rhinitis and 20 healthy controls. Nasal fluid epithelial cell counts were lower in patients than in controls. EGF levels did not differ between patients and controls, and correlated with epithelial cell counts in controls but not in patients. Eosinophils and ECP were higher in patients than in controls, but did not correlate with epithelial cell counts. The role of growth factors, such as EGF, in regulating epithelial cells merits further study.     

Bilateral versus unilateral cochlear implantation in young children

Objectives

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

Material and methods

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

Results

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p < 0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

Conclusions

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.     

Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis

Objective

To systematically evaluate the diagnosis of eosinophilic esophagitis (EE).

Methods

A retrospective review of 657 patients seen at the EE center of a tertiary care children's hospital between 1994 and 2007 was performed. Charts were reviewed for the 144 patients who were also seen by the otolaryngology service.

Results

One hundred forty-four patients received 193 otolaryngology-related diagnoses. Eustachian tube dysfunction (27.5%) and sleep disordered breathing (24.9%) were the most common, followed by dysphagia (13.0%), rhinosinusitis/nasal congestion (9.3%) and airway stenosis (5.2%). Seventy-nine patients (54.9%) had a pre-existing diagnosis of EE at the time of their otolaryngology consultation. Twenty-one patients (14.6%) were referred to the gastroenterology service for evaluation for EE. Forty-four patients (30.5%) remained undiagnosed. Twenty-five of these patients presented with dysphagia, 16 of whom were not previously diagnosed with EE; only 4 of these 16 patients were referred for evaluation for EE. In one case, a child with moderate sized tonsils underwent adenotonsillectomy for dysphagia and failure to thrive; this patient was diagnosed with EE 1 month post-operatively.

Conclusions

Twenty percent of patients with EE may require care by an otolaryngologist for a myriad of complaints. Even experienced pediatric otolaryngologists may not recognize this condition. Otolaryngologists should consider EE in patients presenting with dysphagia. A careful gastroenterology review of symptoms may also allow otolaryngologists to identify EE in patients with allergy mediated nasal complaints, or laryngeal/airway disorders.     

Correction of the Glosso-Larynx and Resultant Positional Changes of the Hyoid Bone and Cranium

In ankyloglossia with deviation of the epiglottis and larynx (ADEL) the tongue is located forward and as a result the epiglottis is elevated and leans towards the mouth. The larynx is also raised and curves ventrally. Various symptoms have been observed as a result of this condition. Correction of the glosso-larynx (CGL) is the operation performed to treat ADEL. The CGL procedure and the results obtained with it are reported in this paper. In addition, we studied the following six parameters using head and neck X-rays before and after CGL (the changes in these parameters as a result of CGL are shown in parentheses): ( i ) the shortest vertical length between the hyoid bone and mandible (+10.3 mm); ( ii ) the vertical length between the hyoid bone and the tangent line of C2-4 (+4.6 mm); ( iii ) the shortest length between the hyoid bone and the chin (+2.9 mm); ( iv ) the angle between the hyoid bone and the tangent line of C2-4 (+3.3°); ( v ) the length of H-M, where H is the intersection of a tangent line of C2-4 and a vertical line from the hyoid bone and M is the intersection of a tangent line of C2-4 and the mandible (+7.4 mm); and ( vi ) the width of the narrowest part of the hypopharynx (+3.0 mm). The changes in all the measured parameters after CGL were significantly different ( p <0.05).     

Autoimmunity in Sudden Sensorineural Hearing Loss: Possible Role of Anti-endothelial Cell Autoantibodies

In order to verify whether anti-endothelial cell autoantibodies (AECAs) can be used as serological markers of inner ear vasculitis in sudden sensorineural hearing loss (SSHL), 32 patients affected by idiopathic SSHL were investigated. All patients underwent a routine general physical examination and extensive audiovestibular, microbiological and immunological investigations. Fourteen normal subjects without a history of HL, autoimmune or metabolic disease served as controls. Detection of AECAs was performed using an indirect immunofluorescence technique. AECA-positive patients were treated with methylprednisone, while AECA-negative patients were treated with a combined regimen of steroids, plasma expander and aspirin. The average hearing recovery for 5 frequencies (0.25-4 kHz) was analyzed in each subject 1 month after treatment and every 3 months thereafter; median follow-up was 12 months (range 9-18 months). A total of 15/32 patients (46.8%; 11/19 females, 4/13 males) were AECA-positive and thus differed significantly from the normal population in whom only 2/14 tested cases were positive ( p =0.03). Severe hearing loss was associated with being AECA-positive in 8/11 cases. During follow-up, 25/32 patients improved their hearing and 17 of these patients were AECA-negative. The seven cases without hearing improvement were all AECA-positive. In patients with SSHL, immune-mediated vascular damage may have a pathogenetic role and AECAs may represent a serological marker of vasculitis even if they are not inner ear-specific and even if they represent an epi-phenomenon rather than the only cause of SSHL.     

Carcinoma of the Nasopharynx: Analysis of Treatment Results in 91 Patients

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan -Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% ( n ¾ 3) for Stage I; 100% ( n ¾ 2) for Stage IIA; 90.9% ( n ¾ 11) for Stage IIB; 78.8% ( n ¾ 25) for Stage III; 53.0% ( n ¾ 29) for Stage IVA; 37.5% ( n ¾ 16) for Stage IVB; and 20.0% ( n ¾ 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% ( n ¾ 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% ( n ¾ 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% ( n ¾ 19). These results showed a statistically significant difference ( p ¾ 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit.     

Treatment Effects in Patients with Squamous Cell Carcinoma of the Oral Cavity

A total of 221 patients (155 males, 66 females; stage I, n ¾ 55; stage II, n ¾ 58; stage III, n ¾ 57; stage IV, n ¾ 51) with squamous cell carcinoma of the oral cavity were studied. Tumor localization was as follows: cancer of the tongue, n ¾ 161; cancer of the oral floor, n =28; cancer of the hard palate, n ¾ 12; cancer of the buccal mucosa, n ¾ 11; and cancer of the gingiva, n ¾ 9. In order to compare the effect of different treatments, three major treatment groups were defined, namely a surgery group, a radiotherapy group and a combination treatment group. Five-year cumulative survival rates showed significant differences between stage classifications (stage I=91%, stage II=73%, stage III=63%, stage IV=47%; p <0.01) but not between tumor sites. The 5-year cumulative survival rate was highest for oral floor cancer (80%). In the early-cancer group, the 5-year cumulative survival rate for the surgery group (92%) was significantly higher ( p <0.05) than those for both the radiation (69%) and combination (71%) groups. In the advanced-cancer group, the 5-year cumulative survival rate for the surgery group (74%) was significantly higher ( p <0.05) than those for both the radiation (37%) and combination (51%) groups. No significant difference in regional control rates was observed between the treatment groups. Five-year regional control rates were 86% for cervical untreated patients with T1N0 tumors and 60% for cervical untreated patients with T2N0 tumors. Fourteen N0 cases were treated with neck dissection. Cervical metastasis was found pathologically in 2/14 (14%) of these cases. The 5-year survival rate for patients with cervical recurrences after primary tumor resection was 70% ( n ¾ 15). In contrast, the 5-year survival rate for patients with both primary tumor resection and neck dissection was 74% ( n ¾ 14) but no significant difference was observed between these 2 groups.rate .     

One‐stop neck lump clinic: phase 2 of audit. How are we doing?

One‐stop neck lump clinic: phase 2 of audit. How are we doing? Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one‐stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.