婴儿声门下血管瘤治疗初探

目的初步探讨婴儿声门下血管瘤的不同治疗方法及疗效。方法回顾性分析我院自2008～2011年收治的声门下血管瘤患儿13例,7例气管切开术后分次行平阳霉素瘤体内注射,4例口服普萘洛尔治疗,1例口服泼尼松片治疗,1例单纯行气管切开姑息治疗。结果 7例平阳霉素注射治疗,血管瘤完全消退,6例成功拔管,平均疗程7.5个月;4例口服普萘洛尔,3例血管瘤完全消退,1例大部分消退,平均疗程4.8个月;1例口服泼尼松片后8个月声门下肿块大部分消退,伴发库欣综合征;1例单纯气管切开患儿,于3年后血管瘤完全消退,拔除气管套管。结论平阳霉素瘤体内注射疗效是肯定的,但绝大多数患儿需行气管切开,且每次注药均需住院全麻下进行,疗程长。普萘洛尔可短时间内使瘤体缩小、改善呼吸道梗阻症状,避免了手术创伤性操作,且副作用小,可作为一线药物使用。     

低温等离子消融术治疗婴幼儿声门下血管瘤临床观察

目的:探讨低温等离子消融术治疗婴幼儿声门下血管瘤的疗效。方法:回顾性分析确诊为声门下血管瘤的5例婴幼儿的临床资料,其中2例患儿行气管切开术,全部患儿均于内镜下实施低温等离子消融术,术后给予口服普萘洛尔(心得安)辅助治疗,观察疗效。结果:所有患儿术后都获得较好的效果,血管瘤消失,未见复发。2例气管切开患儿术后顺利拔管。结论:对于体积较大的声门下血管瘤,采用气管切开后再用低温等离子消融治疗声门下血管瘤,能迅速缓解气道梗阻,缩短自然病程,无术后声门下狭窄等并发症,对于体积稍小的声门下血管瘤,直接于全身麻醉下行声门下血管瘤等离子消融术,可避免气管切开。普萘洛尔(心得安)辅助治疗亦可降低血管瘤复发。因此低温等离子消融术及普萘洛尔(心得安)辅助治疗婴幼儿声门下血管瘤具有安全、简单、微创及复发率低等优势,是治疗婴幼儿声门下血管瘤的一种有效方法。     

并发呼吸道梗阻的小儿脉管畸形的综合治疗

目的 总结并发呼吸道梗阻的小儿脉管畸形的临床特点,探讨该类疾病的治疗方法.方法 回顾性分析1985年6月至2007年12月间收治的47例并发不同程度呼吸道梗阻的小儿脉管畸形资料,其中男25例,女22例;年龄3个月～14岁,中位年龄2.3岁.静脉畸形27例,大囊型淋巴管畸形17例,微囊型淋巴管畸形3例.20例静脉畸形行无水乙醇病变内注射;7例广泛性静脉畸形中行无水乙醇注射+手术切除;17例大囊型淋巴管畸形行单纯平阳霉素病变内注射,3例微囊型淋巴管畸形行手术切除+平阳霉素注射.根据患者呼吸道梗阻程度和治疗需要,27例采用气管插管手术,3例术前紧急气管切开,2例术中预防性气管切开,1例拔管后气管切开.结果 30例治疗后留置气管插管24～48 h,除1例拔管后出现呼吸困难行气管切开,其余均顺利拔管;6例气管切开患儿分别于术后3周～4个月拔除气管套管.病变内注射治疗1次9例,重复注射2～5次38例.2例无水乙醇注射后出现局部黏膜坏死和1例轻度-过性血尿,5例平阳霉素注射后出现轻中度发热反应,经对症处理1 h～3周后恢复正常.全组随访1～23年,治愈38例,有效9例,没有无效患儿.结论 对合并呼吸道梗阻的小儿咽喉、纵隔部位的脉管畸形,推荐硬化疗法为主的治疗.静脉畸形可采用无水乙醇,淋巴管畸形可先用平阳霉素治疗,对多部位广泛性病变采用手术+硬化疗法的综合治疗可能缩短疗程和提高疗效.     

经支撑喉镜平阳霉素注射治疗喉咽巨大血管瘤12例临床研究

目的：探讨经支撑喉镜平阳霉素注射治疗下咽及喉部巨大血管瘤的方法及疗效。方法：12例下咽及喉部巨大血管瘤患者术前行多导睡眠监测,在全身麻醉下常规行气管切开术,经口插入支撑喉镜进入咽喉部声门区,经长管针行血管瘤体内注射平阳霉素（每3周注射1次,总剂量〈50mg）。结果：治愈10例,显效2例。术后经多导睡眠监测显示患者缺氧较术前明显改善。经1年以上的随访,未见复发。结论：该方法治疗下咽及喉部巨大血管瘤风险小、安全性高、喉功能保存好、治疗彻底,能改善患者缺氧,提高其生活质量,是治疗咽喉巨大血管瘤的一种理想方法。     

普萘洛尔治疗婴儿声门下血管瘤临床分析

目的总结普萘洛尔治疗婴儿声门下血管瘤（subglottic hemangioma, SGH）的疗效及副作用。方法25例患儿经电子喉镜或纤维支气管镜检查诊断为声门下血管瘤,年龄1～7个月,其中5例Ⅲ度呼吸困难患儿气管插管。所有患儿以口服普萘洛尔治疗。定期复诊随访。结果20例在普通病房住院患儿口服普萘洛尔24～48 h后喉鸣、呼吸困难等临床症状明显改善,安静状态下无呼吸困难表现。5例气管插管后在PICU病房的患儿,3 d后拔出气管插管,患儿喉鸣及呼吸困难明显好转。随诊期间复查电子喉镜提示21例患儿血管瘤均完全消失,4例患儿声门下血管瘤大部分消退。所有患儿喉鸣及呼吸困难症状消失。停药后患儿随诊未发现病情反复者。25例患儿未做气管切开或行外科手术治疗。结论普萘洛尔治疗婴儿声门下血管瘤疗效确定、副作用小、创伤小,可作为婴儿声门下血管瘤治疗的主要方法,同时也要注意普萘洛尔应用的禁忌症。     

先天性婴儿声门下血管瘤长期误诊一例

婴儿声门下血管瘤国内报告甚少。我们遇1例长期误诊者,现报告如下: 患儿,女,3岁。出生后50天因不明原因咳嗽,呼吸困难收入儿科。诊断为“喘息性支气管炎,急性喉-气管炎”。经抗生素、激素治疗无效且呼吸困难逐渐加重。入院后第6天出现Ⅲ～Ⅳ度喉梗阻,经耳鼻喉科行紧急气管切开,术后呼吸困难缓解。直接喉镜检查不满意,因拔管困难遂带管出院。1月后又入院要求拔管,检查患儿带管呼吸     

避免气管切开的喉裂开术

避免气管切开的喉裂开术周晓红１杨森１喉裂开术是治疗喉部疾病的一种手术进路，一般用于病变范围小的喉内病变，通常该手术是先行气管切开后做喉裂开术，以防术后发生呼吸道梗阻。我院曾遇４例病变范围小的患者在局麻下行喉裂开术，未行气管切开，术后无１例发生喉梗阻...     

儿童声门下区肿物诊治方法的探讨

目的:探讨儿童声门下区肿物的诊断及治疗方法。方法:我科以呼吸困难为主诉收治的声门下区肿物患儿35例,所有患者均先行电子喉镜初步判断肿物性质,再行颈部B超及颈部增强CT检查以明确诊断。对于声门下血管瘤的患儿采用口服普萘洛尔、声门下平阳霉素注射治疗,其他类型肿物均行支撑喉镜下CO2激光肿物切除术。结果:经确诊为声门下血管瘤31例,声门下囊肿2例,声门下纤维瘤1例,声门下肉芽肿1例。术后随访1个月~3年,31例血管瘤患儿治疗后25例治愈,6例好转;非血管源性肿物患儿术后均治愈。结论:儿童声门下区肿物中血管源性肿物发生率较高,建议采用电子喉镜、颈部CT及B超等阶梯性诊断方式。口服普萘洛尔治疗声门下血管瘤是一种安全可靠的治疗方法;支撑喉镜下肿物切除术是声门下非血管源性肿瘤的首选治疗方式。     

内镜支撑喉镜下低温等离子射频治疗声门下狭窄

目的:探讨内镜支撑喉镜下低温等离子射频治疗声门下狭窄的可行性及疗效。方法:回顾分析我院收治的6例声门下狭窄患者,继发于气管切开者1例,气管内插管后致狭窄者3例,声门下B细胞淋巴瘤1例,Wegener肉芽肿1例。6例均采用内镜支撑喉镜声门下狭窄低温等离子射频切除术。结果:术后1周内均成功拔管出院。随访3～21个月,声门下B细胞淋巴瘤及Wegener肉芽肿2例在术后3个月再次出现呼吸困难,并再次行低温等离子手术,目前拔管随访中。结论:内镜支撑喉镜下低温等离子射频治疗声门下狭窄是一种安全、微创的手术方式,对于再次狭窄的患者,可以再次手术。     

喉气管重建术治疗儿童声门下狭窄的临床分析

目的 通过对5例行喉气管重建术治疗的儿童声门下狭窄病例的临床分析,探讨该术式的适应证选择、术中与术后处理及其风险.方法 报道2008年9月至2010年2月收治的5例声门下狭窄患儿,女4例,男1例;年龄4～6岁;先天性狭窄2例,获得性狭窄3例;Cotton-Myer分级:轻Ⅲ度狭窄1例,重Ⅲ度3例,Ⅳ度1例.全部采用喉气管重建术,其中1例轻Ⅲ度狭窄患儿未行气管切开造口术,另外4例入院时已行气管切开造口术.结果 5例患儿术后肋软骨移植物成活与生长良好,术后喉气管镜见声门下管腔扩大,4例Ⅲ度狭窄改善至Ⅰ度狭窄,1例Ⅳ度狭窄改善至Ⅱ度狭窄,呼吸困难消失.4例术前有气管切开患儿半年内均成功拔管,其中1例声带前连合损伤引起声音嘶哑,2年后明显改善.所有患儿术后随访2年均未出现再狭窄.结论 喉气管重建术是治疗中-重度儿童声门下狭窄的有效方法,术前全面的检查评估与合适的手术方式选择是成功的关键.     

Controlled risk of stenosis after surgical excision of laryngeal hemangioma

OBJECTIVE: To evaluate the risk of subglottic stenosis after surgical excision of congenital subglottic hemangioma. DESIGN: Retrospective analysis and case series. SETTING: Tertiary care teaching hospital. PATIENTS: A total of 13 pediatric patients diagnosed with subglottic hemangioma with unilateral, bilateral, or circular lesions and more than 50% airway obstruction between 1992 and 2001. INTERVENTION: Open surgical excision was performed as a single-stage procedure either as primary or secondary intention. The cricoid cartilage was left open at the end of the procedure. Postoperative intubation was carried out in a pediatric intensive care unit. MAIN OUTCOME MEASURE: An adequate airway after surgical excision. RESULTS: All patients were successfully extubated. No recurrence was noted. Three patients developed subglottic stenosis, two grade 1 and one grade 2. All 3 showed a favorable outcome and did not require reintubation. One needed endoscopic management of the stenosis. Of these 3 cases, 2 occurred after carbon dioxide laser treatment (out of 3) and 1 after circumferential dissection (out of 3). CONCLUSIONS: Extubation after surgery was successful in all cases of subglottic hemangioma. Risk of subglottic stenosis was limited and occurred only after circumferential dissection, especially if associated with prior traumatic laser damage of the hemangioma.     

Subglottic hemangioma

Subglottic hemangioma is a rare condition that can be potentially life threatening because of airway obstruction. It is common for subglottic hemangioma to be misdiagnosed as croup initially. Infants with a subglottic hemangioma and cutaneous facial hemangiomas in a "beard" distribution should be evaluated for PHACE syndrome. Endoscopic laser resection is effective for subglottic hemangioma but carries a chance of subglottic stenosis, up to 25%. Open excision of subglottic hemangioma is an excellent option, particularly in patients with bilateral or circumferential subglottic hemangioma. It is a more extensive surgery when compared with endoscopic laser resection. Surgeons who do not have access to a pediatric intensive care unit staffed by experienced pediatric intensivists should not use this procedure.     

Use of potassium titanyl phosphate (KTP) laser in management of subglottic hemangiomas

OBJECTIVE: to study the role of KTP laser in management of subglottic hemangioma. DESIGN: retrospective analysis of patients with subglottic hemangioma treated by the senior authors. Setting: tertiary care teaching hospital. PATIENTS: twelve patients with subglottic hemangiomas. INTERVENTION: patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases). MAIN OUTCOME MEASURE: resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation. RESULTS: All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated. CONCLUSION: subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications.     

The application of the potassium-titanyl-phosphate (KTP) laser in the management of subglottic hemangioma

BACKGROUND: Subglottic hemangioma is the most common neoplasm of the infant airway. Most lesions involute spontaneously; however, some may grow to cause life-threatening respiratory tract distress. The standards of treatment have been tracheotomy, corticosteroids, and laser vaporization. However, use of the carbon dioxide laser has been associated with increased risk of damage to adjacent mucosa and an increased risk for the development of subglottic stenosis postoperatively. OBJECTIVE: To review our experience with the use of the potassium-titanyl-phosphate laser in the treatment of subglottic hemangioma. PATIENTS AND METHODS: A retrospective review of 6 patients with subglottic hemangioma treated with the potassium-titanyl-phosphate laser was carried out at a tertiary care children's hospital. Patients' medical charts were evaluated for factors such as age, sex, degree of airway obstruction, location of hemangioma, number of laser procedures performed, and postoperative results, including short- and long-term complications. RESULTS: All 6 patients had significant relief of airway obstruction after use of the potassium-titanyl-phosphate laser. Five of the patients had localized disease, and one had circumferential subglottic involvement. The average number of procedures was 1.7. There were no intraoperative complications. One patient had prolonged intubation following surgery, and only one developed grade 1 subglottic stenosis requiring dilation. Long-term results have been promising in that all patients are asymptomatic and follow-up laryngoscopy and bronchoscopy have shown complete resolution of the hemangioma. CONCLUSION: The potassium-titanyl-phosphate laser can be used to provide significant clinical relief of airway obstruction due to grade 1 and 2 subglottic hemangioma, with minimal complications.     

Subglottic hemangioma in infants

A series of seven cases of subglottic hemangioma in infants ranging in age from three weeks to 18 months is being presented. These cases were treated between 1958 and 1972. There was no sexual preponderance, four cases being male and three female. All cases presented with severe upper respiratory obstruction requiring immediate tracheoscopy and tracheotomy. Two cases presented with simultaneous cutaneous hemangiomata of the back. Careful post-tracheotomy observation is stressed to insure adequate pulmonary ventilation. Repeat bronchoscopy for aspiration of retained secretions and removal of a polyp at the tracheostomy was necessary in one case. Blood gas analysis for PCO2 and Po2 to determine extent of chronic hypoxia is recommended; also chest X-rays may reveal evidence of cardio-megaly, especially of the right ventricle as seen in chronic pulmonary hypertension secondary to alveolar hypoventilation. Gradual involution of the hemangioma after 12 months of age is to be expected. In those cases with associated cutaneous lesions, the resolution of the skin lesion may be used as a guide to determine the extent of resolution of the tracheal lesions. Lateral X-rays of the trachea and barium studies of the upper esophagus are helpful to demonstrate the extent of the subglottic mass and also the degree of involvement of the party wall between the esophagus and trachea. One dose of radiotherapy was administered in only one case. Careful repeat tracheoscopy is recommended prior to decannulation to insure an adequate airway. Cortico-steroids and cryotherapy were not used in these cases. All infants survived, and two of the more recent cases have not been de-cannulated to date.     

Transversal resection of trachea as the method of treatment of postintubational stenosis

We present an experience with transversal tracheal resection with end-to-end anastomosis in 3 patients with extensive subglottic stenosis because of prolonged intubation. All the patients were treated chirurgically based on the Pearson's method. In order to attein the fixation of tracheal stumbs, poroplastic splint was applied into the lumen of the trachea and patency of airways was protected by tracheotomy.There were no major complications during treatment and time of the treatment was significally shortening.     

Cricotracheal resection for pediatric subglottic stenosis

Until recently, cricotracheal resection (CTR) has not been commonly accepted as a treatment modality for severe subglottic stenosis in the pediatric age group. The reasons have included the risk of a possible dehiscence at the site of the anastomosis, the likelihood of injury to the recurrent laryngeal nerves, and the interference with normal growth of the larynx. Thirty-eight infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary thyrotracheal anastomosis. Thirty-three patients were tracheotomy-dependent at the time of surgery and 34 were referred cases; 27 were classified as grade III, and 10 as grade IV stenoses according to new Cotton's classification. Nineteen patients were younger than 3 years of age at the time of surgery. The tracheotomy was resected during the surgical procedure in 21 cases. Decannulation was achieved in 36/38 cases after an open procedure. There is one complete restenosis and one good result awaiting decannulation after further surgery for a Pierre Robin syndrome. The authors experienced no lesion of the recurrent laryngeal nerves and no fatality. Thirty-one patients show no exertional dyspnea, three a slight stridor while exercising, and two patients are not decannulated. The postoperative follow-up in longer than 10 years in eight cases. All patients show a normal growth of the larynx and trachea. Compared to laryngotracheoplasties, CTR gives better results for severe subglottic stenosis. This operation should become the treatment of choice for severe (grade III and IV) subglottic stenosis in infants and children.     

Partial cricoid resection with primary tracheal anastomosis for subglottic stenosis in infants and children

Fifteen infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary tracheal anastomosis. The etiology of the stenosis was congenital in 3 cases and was acquired after prolonged intubation in 12. Fourteen patients were tracheotomy dependent at the time of surgery, and 13 (87%) of the 15 were classified grade III (7 cases) and IV (6 cases) according to Cotton. The resection included the cricoid only in 5 cases and the cricoid and a segment of trachea (1 to 4 rings) in 10 cases. Decannulation was achieved after a single open procedure in 14 (93%) of the cases. The authors encountered no lesion of the recurrent laryngeal nerves and no fatalities. There was, however, 1 restenosis. Twelve cases were decannulated within 6 months, most of them at 2 months. The postoperative voice is normal in 10 cases, and a slight dysphonia is present in 4 cases. Twelve patients show no exertional dyspnea, and 2 exhibit a slight stridor while practicing sports. Ten of 14 cases have been followed for more than 5 years, with the longest follow-up now being 14 years. In all cases, the laryngotracheal development is normal. The results of this small series compare favorably with those of laryngotracheoplasty procedures usually performed for subglottic stenosis in infants and children. In the future, partial cricoid resection with primary tracheal anastomosis should be considered as an important treatment option for severe subglottic stenoses in infants and children.