呼吸气囊辅助下紧急经皮气管切开术在呼吸道灼伤并发上呼吸道梗阻中的应用

上呼吸道梗阻是吸入性损伤早期严重并发症。部分患者伤后早期无明显梗阻迹象,但在水肿高峰期（8-24h）逐渐增重,并发严重上呼吸道梗阻,被迫行紧急气管切开,但此时行气管切开或气管插管并非易事。及时建立有效人工气道是抢救成功的关键。我院ICU于2008—09—2013—03对8例因火灾引起气道吸入性损伤并发严重上呼吸道梗阻患者,在气管插管失败的情况下,在呼吸气囊辅助下紧急实施了经皮气管切开术,效果良好,现报告如下。     

床旁多普勒超声引导下经皮气管切开术在重症脑出血患者中的应用

目的探讨床旁多普勒超声引导下经皮气管切开术（PDT）在重症脑出血患者中的应用价值。方法选取2014年1月—2019年4月南方医科大学附属小榄医院重症医学科监护治疗的重症脑出血患者126例，在ICU床旁采用超声引导下行PDT。术前采用超声进行检查，明确气管位置、周围组织及血管情况，确定穿刺部位及深度，指导术前气管导管退管。术中实时超声引导，确保手术安全。术后超声确认气管切开套管位置，筛查排除气胸等相关并发症。观察操作时间（从皮肤穿刺到成功置入气管套管时间）、一针穿刺成功率、置管成功率、气管插管意外脱管率；观察术中及术后并发症：出血量、血管/甲状腺损伤、气管后壁损伤、皮下气肿、气胸、低氧血症发生率等。结果126例患者手术均一次操作成功，一针穿刺成功率及置管成功率均为100%，未发生气管插管意外脱管。操作时间5~12 min，平均操作时间7.5 min。术中及术后未发生难以控制的大出血、严重低氧血症、血管/甲状腺损伤、气管后壁损伤、皮下气肿及气胸等并发症。结论对重症脑出血患者行床旁实时超声引导下行PDT，提高了手术的可视性、操作性和安全性，提高PDT成功率，降低相关并发症，具有良好的临床价值。     

半坐下肢抬高位在喉梗阻强迫体位气管切开术中的应用

目的　探讨半坐下肢抬高位（V形体位）在喉癌引起的喉梗阻患者强迫体位气管切开术中的应用优势。方法  收集2010年1月~2015年1月喉癌强迫体位喉梗阻在半坐位行气管切开术（半坐位组）患者20例，与2015年1月~2019年1月喉癌强迫体位喉梗阻在V形体位下行气管切开术（V形体位组）患者25例，进行临床对比分析。结果　两组患者手术均顺利完成，其中V形体位组4例出现术后并发症，半坐位组7例出现术后并发症，两组比较差异无统计学意义（χ2=2.172，P＞0.05）。V形体位组手术总时间及气管切开时间分别为（5.16±0.94）min、（3.44±0.77）min，半坐位组手术总时间及气管切开时间分别为（6.60±0.68）min、（5.00±0.79）min，两者相比差异有统计学意义（t 分别为6.67、5.94，P<0.05）。结论　不能平卧的喉癌伴强迫体位喉梗阻患者可考虑采取V形体位行紧急气管切开手术。     

声带息肉合并喉梗阻症状的治疗方法探讨

目的　研究喉显微镜支撑喉镜下CO2激光手术治疗声带息肉合并不同程度喉梗阻患者的疗效。方法　选取18例声带息肉伴有不同程度喉梗阻患者为研究对象，均采用纤维支气管镜引导下经鼻气管插管，实施喉显微镜支撑喉镜下CO2激光切除声带息肉手术，术后1个月复查电子喉镜，统计患者治疗总有效率及嗓音功能恢复、并发症以及术后复发等情况。结果　18例患者均一次性插管成功，无气管切开病例，除2例口咽侧壁擦伤外无其他并发症，术后呼吸困难症状改善明显，术后1个月嗓音功能恢复良好， 治愈14例（77.78%），好转4例（22.22%），随访半年，无复发病例。结论　纤维支气管镜引导下经鼻气管插管，CO2激光显微外科手术是治疗声带息肉合并喉梗阻患者安全、有效、微创的手术方法，值得临床推广应用。     

气管科学

158 气管切开术的临床应用王勋贵州医药(5):28,1983 本世纪四十年代以前,气管切开的主要适应症为喉梗阻,其后逐步扩大到内、外、儿、神经和传染等科的有关病例。本文135例气管切开病例中,因上呼吸道梗阻切开者73例,因下呼吸道分泌物滞留及气体交换不足而切开的有62例。共有28例次发生各种手术并发症,为解除喉梗阻作切开的并发症出现率是33.3％,其他原因手术的并发症为11.5％。喉梗阻愈严重,产生并发症的机会愈多,患几年龄愈小,也容易发生并发症。为了减少手术并发症的发生,应采取以下措施:1.把紧急气管切开转化为常规切开,即对有严重喉梗阻病人先作气管内插管,再按常规步骤切开气管。2.最好在良     

气管食管科学

气管食管科学2001 1444插管引导小儿气管切开术/杜晓东…//山东医大基础医学院学报一20()l,15(l)一50~51 目的:研究安全易行的小儿气管切开方法。方法:对34例有气管切开指征的患儿.分组行常规气管切开术、麻醉插管或小JL支气管镜引导的气管切开术。结果:插管引导的小儿气管切开术组,术者易判断气管,手术时间短;插管后经吸痰、给氧.改善了缺氧状况,利于术者从容操作且‘降低了并发症。结论:插管引导的小儿气管切开术较常规气管切开术安全易行.减少了手术并发症。参5(原提要)2001 1445硬气管镜下取小儿支气管异物失败原因分析/孙慧茹…,们高…     

气管插管喉部并发症

气管插管被用于解除上呼吸道梗阻、呼吸衰竭时的辅助通气、呼吸道管理和手术麻醉需要，但同时气管插管也可以引起多种喉部并发症，特别是长期插管的患者。本文对气管插管所致喉部并发症的类型、相关因素及防治方法进行综述。     

气管切开术在治疗头面颈部烧伤中的临床意义

目的 探讨头面颈部烧伤病人行气管切开术的适应证、手术时机及有关注意事项。方法 对36例头面颈部烧伤行气管切开术的病人进行同颐性总结。结果 36例病人均在伤后12～72小时内行气管切开术，解除了上呼吸道梗阻，清除了下呼吸道分泌物，改善了缺氧状况，提高了严重烧伤病人的治愈率。本组治愈3l例(86．1％)，死亡5例(139％)。结论 对头面颈部烧伤尤其是吸入性损伤病人，应尽早行气管切开术，时间选择在伤后12小时内为宜，拔管选择在手术后2周左右为宜。     

吸入性损伤与预防性气管切开术

大面积烧伤合并面颈部烧伤的病例90%在伤后6～16h内发生严重呼吸困难,73%为中重度粘膜损伤,均于气管切开后呼吸困难解除.热力引起的吸入性损伤,上呼吸道的粘膜伤重于下呼吸道,且以喉部受损伤最重.因此,在评估吸入性损伤程度时,应结合粘膜伤全面考虑,因患者早期易发生上呼吸道梗阻,故应采取预防性气管切开术.     

经皮气管切开术在重症患者二次气管切开中的临床应用

目的探讨经皮气管切开术在重症患者二次气管切开中的临床应用及意义。方法回顾分析南方医科大学附属小榄医院ICU采用经皮气管切开术完成二次气管切开的45例重症患者的临床资料，根据患者具体情况选择手术部位，观察其操作时间、术中及术后并发症情况。结果45例患者全部在床旁顺利完成经皮气管切开手术，平均操作时间5 min，术中未发生大出血、气管损伤、窒息等并发症。手术中出血5～20 ml，未发生术后出血、切口感染、气胸等并发症。结论重症患者二次气管切开术的难度增加，把握好指征和方式、选择好手术部位、严密监护下实施经皮气管切开术，具有较好的安全性。     

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.