小儿危重呼吸道阻塞的临床诊断和治疗

目的探讨小儿危重呼吸道阻塞的临床诊断及治疗方案。方法1995年1月至2005年1月汕头市中心医院耳鼻咽喉头颈外科收治73例小儿危重呼吸道阻塞，采用快速诊断和及时治疗的临床处理方法，分析应用该方法的效果。结果73例危重患者中炎症性疾病28例，占38．4％；异物33例，占45．2％，其他还有喉乳头状瘤8例，喉气管支气管痉挛3例，咽部畸胎瘤1例。采用气管插管和气管切开分别为39例次和27例次，占53．4％和37．0％，只采用内科治疗9例。72例患者均于12h内确诊并解除重度呼吸道阻塞，1例未治自动出院。发生严重并发症者23例，发生率为31．5％；手术并发症3例，发生率为4．1％。死亡4例，治愈68例，治愈率为93．2％。结论小儿危重呼吸道阻塞的病因复杂，病情凶险，快速诊断、及时解除呼吸道阻塞和采取有效的病因治疗方案，有利于提高治疗效果。     

喉气管成形术

新生儿和婴儿由于喉、气管病变造成的呼吸道阻塞,在诊断和治疗上还存在着许多问题,自开展喉部显微手术以来,已有几项新的手术用来解除喉及气管上部狭窄,设计的手术方案要尽量少影响喉的成长并保存其纤毛上皮层的功能。作者从1969至1974年五年间遇及喘鸣儿童427例,经直接喉镜检查,所见病因分析如下:     

喉内窥镜手术的并发症

喉内窥镜手术同气管内插管麻醉一样可并发喉损伤。本文对183例喉部据悉所施行204次喉内窥镜手术作了研究,计术后并发严重呼吸道梗阻12例,咽喉部粘膜水肿和血肿占31%,最常见为口咽部粘膜出血。气管内插管麻醉后喉水肿临床上已足以引起注意,插管麻醉后喉水肿或血肿其喉损伤发生率为1～6.3%,在颈部手术或手术时间超过1小时、使用较大口径气管导管的这类病人喉部并发症发生率较高。某些喉损伤可导致气道阻塞,喉水肿都发生在拔管后1小时内。本文12例术后有严重呼吸道     

喉、气管淋巴瘤所致的气道阻塞

淋巴瘤侵犯喉和气管较为少见。著者报告8例侵犯喉或气管的淋巴瘤病人,采用放疗、化疗、氦氧混合吸入、湿化和严密观察等处理,气道阻塞的解除取得满意效果,避免了气管切开。淋巴瘤是对放疗高度敏感的肿瘤,用放疗局部可以得到控制。用于解除呼吸道阻塞,初期量每日300～400Rad。联合化疗(cy-clophosphamide,doxorubicin,bleomycin,vineristine 等)对解除继发于淋巴瘤的压迫症     

降低小儿气管支气管异物并发症及病死率的诊断和治疗方案分析

目的　总结一套诊断和治疗方案 ,进一步降低小儿气管支气管异物的并发症率及病死率。方法　分析北京儿童医院 1987年 1月～ 2 0 0 3年 8月 72 6 0例小儿气管支气管异物患儿疗效 ,总结采用快速诊断方案 ,应用术前评估体系 ,建立围手术期治疗方案的效果。结果　应用快速诊断方案共实施气管镜检查术 76 18例 ,其中术后证实为气管异物的有 72 6 0例 ,诊断符合率达 95 3%。 72 6 0例小儿气管支气管异物病例中 ,2 4h内做出诊断并实施气管镜检的为 70 0 7例 ,占 96 4 %。无麻醉或表面麻醉 6 933例 ,全身麻醉及表面麻醉复合 32 7例 ,病史超过 1个月或为特殊类型的气管异物采用全身麻醉及表面分段麻醉相复合的麻醉方法 ,无麻醉并发症出现。 716 5例一次手术成功 ,占总手术98 7% ,95例实施二次或二次以上手术 ,16例转为纤维支气管镜取异物 ,12例由气管镜手术转至胸科开胸取出异物 ,其余 6 7例于二次气管镜手术时顺利取出异物。术后出现并发症 7例 ,占 0 1% ,其中 1996年以前 6例 ,1996年后对所有病例进行术前评估后再处理 ,手术并发症仅 1例。无死亡病例。结论　快速诊断 ,术前评估 ,实施适时有效的手术和围手术期治疗 ,可以有效降低小儿气管支气管异物的并发症率 ,降低死亡率。     

179例气管切开患者并发症的分析

气管切开术系切开颈段气管，放入气管套管，以解除喉源性呼吸困难、呼吸机能失常或下呼吸道分泌物潴留所致呼吸困难的一种手术。由于手术时机的选择及手术条件的改善，可供选择的气管套管及套囊型号越来越合适，以及术后护理的改进，气管切开的并发症在逐渐下降。现对本院2007年7月～2008年7月179例气管切开患者出现的并发症进行分析总结。     

成人急性会厌炎呼吸困难程度的判断与处理

目的 :探讨成人急性会厌炎呼吸困难的判断方法及救治措施。方法 :报告 12 6例成人急性会厌炎患者的临床资料。结果 :行会厌切开术 30例 ,无一例发生窒息、炎症扩散和术中术后大出血等意外 ;行气管切开术8例均痊愈 ;行环甲膜切开术 1例死亡 ;保守治疗 87例中死亡 1例。结论 :成人急性会厌炎出现喉鸣、流涎、言语含糊不清是喉阻塞的重要体征 ,纤维喉镜检查是了解会厌肿胀程度最可靠的方法 ;救治的重点是保持呼吸道通畅 ,迅速消除会厌肿胀     

改良气管切开术在吸入性损伤抢救中的应用

目的探讨治疗重度吸入性损伤患者下呼吸道黏膜大面积坏死及清除脓血痂的有效方法.方法应用改良气管切开术抢救治疗重度吸入性损伤12例.常规气管切开暴露颈段气管3～5环,以颈4环为中心,上下弧形切除少许气管软骨,长度不超出2个气管环,分别缝合同侧的皮肤与气管切口1～2针,插入气管套管.结果改良气管切开术可随时取管,方便纤维支气管镜检查,及时清除下呼吸道阻塞物,预防发生再窒息,12例患者无1例因呼吸道阻塞而死亡.结论改良气管切开术不仅解除了喉梗阻,而且可观察下呼吸道病变及能有效、安全的清除阻塞物.     

侵犯喉气管支气管的复发性多软骨炎

目的　分析喉、气管和支气管受侵的复发性多软骨炎 (relapsingpolychondritis,RP)临床特点及预后。方法　回顾性分析 13例侵犯喉、气管和支气管的RP患者临床资料。结果　 1983年～1998年间我院收治 2 0例RP中 ,13例 (65 % )累及喉、气管和支气管 ,病变范围为弥漫性或局限性 ,病变部位 :喉 (46 % ) ,气管 (69% ) ,支气管 (69% )。治疗 :用皮质激素、免疫抑制剂和氨苯砜控制症状 ,4例因呼吸道梗阻行气管切开术 ,2例气管塌陷的患者用T型管或金属支架治疗。 13例中 2例治疗无效 ,死于呼吸道并发症 ,5年生存率 78 6 %。结论　呼吸道受累是RP病情严重的临床表现及主要死亡原因 ,经皮质激素、免疫抑制剂、氨苯砜治疗或气管切开术后可控制症状 ,但无法控制病程发展。     

颈部绞扼伤36例临床分析

目的:探讨颈部绞扼伤的临床抢救方法及疗效分析。方法:治疗原则把抢救生命放在首位,并尽可能恢复喉机能。气管切开是主要的治疗方法,凡病人入院后出现神志不清或声嘶、颈部气肿,不要过份强调呼吸困难的程度,应在48小时内行气管切开,同时采用人工冬眠、大剂量一次性地塞米松冲击治疗,及时修复喉软骨骨折及撕裂粘膜,并做好心理辅导。结果:36例病人,治愈18例,占50%;好转9例,占25%;有效2例,占5.6%;死亡7例,占19.4%,半年后随访,有3例恢复至全愈,1例有效恢复为好转。结论:纤维喉镜检查及CT扫描在评定损伤的范围,病情的危重起到关键性的作用,受伤后及时地转送医院,尽早地进行气管切开对疗效非常重要,并发现病人至医院的时间越短,疗效越好,入院后进行气管切开的时间越早,疗效越好。     

新生儿重度上呼吸道梗阻的病因分析

目的了解新生儿重度上呼吸道梗阻的原因。方法回顾性分析47例发生重度吸气性呼吸困难的新生儿的临床表现、直接喉镜、CT、上消化道造影等检查结果及治疗经过。结果47例中先天性疾病占87．2％（41／47）：先天性喉喘鸣15例，占31．9％，其中6例伴有胃食管反流；上呼吸道先天性囊肿14例（舌根囊肿10例，会厌囊肿3例，喉囊肿1例），占29．8％，其中有13例曾被误诊为先天性喉喘鸣；先天性总气管狭窄3例；先天性喉蹼2例；声带麻痹2例；皮耶-罗宾综合征3例；猫叫综合征2例。急性膜性喉气管支气管炎6例。47例中3例放弃治疗，44例经吸氧、药物治疗后呼吸困难缓解，其中曾行气管插管、吸痰37例次，行直接喉镜、支撑喉镜手术19例次。结论新生儿重度上呼吸道梗阻病因以先天性疾病为主，对这类患儿应及时进行相关检查，尽早明确病因，迅速解除梗阻，以降低新生儿死亡率和预防不良后遗症的发生。     

呼吸道硬结病致瘢痕性喉狭窄的手术治疗

目的：探讨呼吸道硬结病致瘢痕性喉狭窄的临床特点和治疗方法。方法：回顾性分析7例导致瘢痕性喉狭窄的呼吸道硬结病的临床资料和治疗方法。结果：对4例单纯喉瘢痕性喉狭窄者,行喉裂开成形术,术后随访7-14年,无复发;喉及颈段气管瘢痕性狭窄2例,行喉气管成形腔内扩张术和舌骨肌瓣成形术各1例,术后分别随访6年和8年,均无复发;1例声门下狭窄患者术后声门下腔宽敞,但术后3个月复查时,肉芽肿病变增生致声门下闭锁,手术失败。结论：瘢痕性喉狭窄应根据不同的病变部位采取相应的手术方式,术中须避免过多的粘膜损伤,以防再度狭窄;对严重的喉气管狭窄者应用粘膜瓣、骨肌瓣等组织充分增加狭窄部的管壁以解除狭窄。     

电子喉镜在喉部疾病诊治中的应用

目的 :探讨电子喉镜在喉部疾病诊断中的价值及其在喉部疾病治疗中的作用。方法 :采用 PentaxVNL- 15 30型和 Olym pus BF- 2 40型电子喉镜对 3 6 2 8例有喉部症状的患者行喉部检查 ,对 12 2 1例声带息肉、声带小结等喉部疾病患者行电子喉镜下的各种治疗。结果 :3 6 2 8例患者顺利接受了检查 ,并得到诊断。 76 8例声带息肉和 2 49例声带小结患者在电子喉镜下作了息肉或小结的切除 ,113例下咽和喉部的异物患者在电子喉镜下取出异物 ,91例其他喉部疾病患者接受了电子喉镜下的相应治疗。结论 :电子喉镜是喉部疾病诊断和治疗的一种新的有用工具。     

支撑喉内镜下咽喉部微创手术的临床应用

目的：探讨支撑喉内镜系统手术治疗咽喉部疾病的临床应用价值，进一步改进咽喉部微创手术方式。方法：全麻下采用支撑喉内镜系统微创手术治疗34例咽喉疾病患者，术中微波等处理残灶及出血区；恶性肿瘤术后行40Gy放疗。结果：本组34例患者均一次手术成功，随访1～16个月．未见严重手术并发症；术前已发生声嘶的26例良性病变者术后1个月内发声恢复正常；2例早期声带癌术中保留喉结构和功能，随诊6～12个月未见肿瘤复发，声嘶明显好转。结论：支撑喉内镜微创手术治疗咽喉部良性病变、早期声带癌及癌前期病变具有重要价值，该项技术具有视野大、清晰度高、照明度好、切除病变彻底、保留结构功能好等优点．值得临床推广应用。     

Airway obstruction: a rare complication of benign vocal fold polyps

OBJECTIVES: Benign laryngeal polyps usually present with hoarseness and dysphonia. There have been a few reported cases, however, of polyps that caused airway obstruction. Herein we present our series of obstructing laryngeal polyps. METHODS: A retrospective review was performed of all patients with benign laryngeal lesions treated by the senior author (A.M.S.S.) between 1997 and 2006. Patients who presented with airway obstruction were identified. Detailed information was recorded on the demographics, presenting signs and symptoms, and surgical procedures. Preoperative and postoperative laryngoscopies were reviewed. RESULTS: Ten patients were identified. There were 7 women and 3 men. The mean age was 49 years (range, 34 to 64 years). All had a history of vocal abuse and smoking, with a mean of 35.2 pack-years (range, 7.5 to 112.5 pack-years). All underwent microlaryngoscopy with excision of the lesions. Jet ventilation or a small endotracheal tube was used to secure the airway. The mean follow-up of 9 patients was 71.2 days (range, 25 to 208 days); 1 patient was lost to followup. An excellent airway and improved voice was achieved in all. Forty-four percent (4 of 9) had persistent dysphonia and a decreased mucosal wave after the operation. CONCLUSIONS: Benign laryngeal polyps may present with airway obstruction and thus should be included in the differential diagnosis of stridor. Endoscopic treatment can result in an excellent airway, but dysphonia may persist in some cases.     

喉癌术中和术后的气道并发症及处理

目的 对喉癌术中和术后的气道并发症进行总结。方法 回顾我科近10年所做的875例喉癌术中和术后气道并发症，进行归纳、分析，并提出预防方法。结果 共发生各种呼吸困难并发症42例，其中严重并发症8例。经归纳共有6种不同并发症发生。结论 喉癌手术结束时，将气管造口两侧皮肤与气管壁两侧各缝合一针是很好的预防方法；认真细致的气管切开护理；对术后病人细心的传授、耐心指导，可有效减少术后的气道并发症。     

Quincke's edema: diagnosis and management of 102 patients with sudden upper airway obstruction

BACKGROUND: Hereditary angioedema (HAE) is extremely rare and clinically characterized by recurrent and self-limiting skin, intestinal and life threatening laryngeal edema. Because of the danger of asphyxiation, it is vital that acute attacks of laryngeal edema be interrupted immediately. The aim of this study is to provide information on the incidence, diagnosis and treatment of laryngeal edema with upper airway obstruction in general and due to HAE. METHODS: 102 patients with swelling of the larynx and difficulty in breathing (stridor) and 21 patients with a manifest HAE were surveyed at the Department of Otorhinolaryngology, Head and Neck Surgery of the Ludwig-Maximilians-University of Munich from 2001 to 2004. RESULTS: 63% of the laryngeal swellings with airway obstruction were due to radiotherapy in cancer and the intake of ACE-Inhibitors. Just 22% were due to allergic reactions. Only one patient (< 1%) suffered from HAE. All patients were treated with intravenous steroids and anti-histamines successfully, except the HAE patient. After emergency coniotomy the patient was treated with purified C1 inhibitor concentrate (C1-INH). CONCLUSIONS: According to our experience almost all patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids and anti-histamines. In contrast these drugs have no effect on HAE. Replacement therapy with C1-INH has proved to be effective. The challenge is to realize whether an airway obstruction is due to HAE or not. In this case, careful observation, the right medication and an appropriate airway management are lifesaving. The possibility of sudden airway obstruction and asphyxiation must be discussed with these patients and their relatives.     

喉显微外科技术在严重新生儿上气道梗阻中的应用

目的 探讨严重新生儿上气道梗阻病因、临床特征及喉显微外科手术疗效,以提高新生儿阻塞性呼吸困难的诊治水平。 方法 采用观察性研究,分析16例咽喉相关的严重上气道梗阻新生儿临床资料。 结果 共纳入患儿16例(男9例、女7例),出生后7~28 d出现临床症状,包括吸气性呼吸困难、喉喘鸣、三凹征等。其中先天性喉软化症6例、下咽及舌根囊肿3例、喉部血管瘤2例、喉入口畸胎瘤1例、先天性喉蹼1例、双声带麻痹1例、继发性声门下狭窄1例、插管后喉粘连1例。16例患儿均给予相应显微外科治疗,手术顺利。顺利拔管患儿15例,仅1例喉软化症患儿拔管后仍有明显呼吸困难,行气管切开。 结论 严重新生儿上气道梗阻多与咽喉病变相关,需早期行局部及全身检查明确病因及诊断,对有手术指征者积极采取微创手术治疗,可挽救患儿生命,取得满意疗效。     

Endoscopic CO2 Laser Management of Laryngocele

Objective To report on the management of laryngoceles by CO₂ laser‐assisted endoscopic excision. Study Design A 15‐year retrospective study of 12 adult patients (7 men and 5 women) who presented with a laryngocele. Nine patients had an internal laryngocele, one patient had an external laryngocele, and two patients had combined internal‐external components. Two laryngoceles were right‐sided, six were left‐sided, and four were bilateral. Methods An endoscopic examination of the laryngocele was carried out for both diagnostic and therapeutic purposes. Once identified the air‐ or mucus‐filled cyst (extending from the laryngeal ventricle into the paraglottic space and beyond the thyrohyoid membrane in some cases), the laryngocele was excised in toto, with its surrounding capsule, via endoscopic approach using the CO₂ laser. Results The main presenting symptom was dysphonia in seven patients, visible or palpable mass in the neck in three, and upper airway obstruction in the remaining two. All laryngoceles were treated with endoscopic laser excision of the internal and external components when required. The average postoperative stay in hospital was 1.8 days. Only two of the patients treated had a tracheotomy; both cases presented elsewhere with an emergency airway obstruction, which necessitated tracheotomy. In these two cases, decannulation was subsequently performed. There were no significant complications. The follow‐up ranged from 6 months to 5 years. Conclusion CO₂ laser‐assisted endoscopic excision of a laryngocele is a quick, precise, and safe alternative to an external approach excision (lateral thyroidotomy, laryngofissure) with fewer complications than its external counterparts, resulting in speedier rehabilitation of both the patient and his or her voice.