悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停综合征60例报告

为探讨阻塞性睡眠呼吸暂停综合征的治疗方法，对６０例本病患者行悬雍垂腭咽成形术，其疗效分布是：显效５０％，进步３３．３％，无效１６．７％，总有效率为８３．３％。需要注意的关键是：①严格选择病例；②局麻下手术；③术中心电，血氧及血压监测；④重度ＯＳＡＳ患者术前行气管切开术；⑤术前吸氧，应用抗炎，止血药物，避免术后并发症发生。     

激光治疗阻塞性睡眠呼吸暂停低通气综合征疗效评价

目的：探讨Nd：YAG激光治疗阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的疗效。方法：对89例OSAHS患者行激光悬雍垂腭咽成形术(LAUP)．手术切除部分软腭及悬雍垂，在悬雍垂两侧向上楔形打开软腭。结果：术后6个月复查有76例行多导睡眠监测，治愈8例，显效36例，有效25例，无效7例，总有效率90．8％。结论：Nd：YAG激光具有止血凝固作用且穿透力强，手术视野清晰，并发症少，可缩短手术时间。LAUP治疗OSAHS效果良好。     

CO2激光悬雍垂软腭成形术

为安全，方便地治疗阻塞性睡眠呼吸暂停综合征，用多导仪对患者运用睡眠监测的方法进行论断分类和疗效判定，以ＯＣ２激光行悬凝垂软腭成形术。９８例ＯＳＡＳ患者经ＣＯ２激光行悬雍垂软腭成形术，术后睡眠多导仪监测者８９例，有铲者６７例，占７５．５％。术中有少量出血者６例，其他无出血及其他并发症。     

CO_2激光悬雍垂软腭成形术

为安全、方便地治疗阻塞性睡眠呼吸暂停综合征（Ｏｂｓｔｒｕｃｔｉｖｅｓｌｅｅｐａｐｎｅａｓｙｎｄｒｏｍｅ，ＯＳＡＳ），用多导仪对患者运用睡眠监测的方法进行诊断、分类和疗效判定，以ＣＯ２激光行悬雍垂软腭成形术。９８例ＯＳＡＳ患者经ＣＯ２激光行悬雍垂软腭成形术，术后睡眠多导仪监测者８９例，有效者６７例，占７５．５％。术中有少量出血者６例，其他无出血及其他并发症。此法是一种经济、简便的有效治疗方法     

阻塞性睡眠呼吸暂停低通气综合征围手术期并发症的预防及处理

目的 总结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 分析98例OSAHS患者的临床资料，术前高血压、糖尿病及心脏病者均对证治疗。81例选择全麻（82．7％），17例选择局麻（17．3％）。同期或术前1周行气管切开36例，占本组全麻患者的44．44％），其中体重指数超过正常上限29例，最低血氧饱和度〈50％29例，同时行鼻部手术者5例，心脏异常或伴高血压20例。结果 1例局麻下气管切开时出现心率、血氧下降，气管切开待病情稳定后再手术；1例全麻术后拔除气管插管后出现呼吸抑制，重新气管插管；术后创口出血1例，再次全麻止血；短期进食返呛23例（23．5％）。结论 重视OSAHS患者术前检查并对症治疗，以减少术中、术后心脑血管并发症；全麻患者应严格掌握拔管指征，待患者意识完全清醒后拔管；严重肥胖、重度OSAHS最低血氧饱和度〈50％或伴有较重的心血管合并症或同时行鼻部手术者，气管切开术可降低严重并发症的发生。     

阻塞性睡眠呼吸暂停综合征的诊断及预后评估

近数十年来，采用悬雍垂腭咽成形术治疗睡眠呼吸暂停综合征的疗效，各家结果极不一致（４５％～９５％）。皆因对方同的诊断、分型、手术文案、预后评价均无统一的标准。我们参照国外资料及本科临床工作，提出几项建议；包括初筛及诊断依据；阻塞部位确定、分型、手术方案；预后判定。目的是希望提高睡眠呼吸暂停综合征的诊治水平，有利于进一步研究。     

悬雍垂腭咽成形术和鼻部手术治疗阻塞性睡眠呼吸暂停低通气综合征

目的对合并鼻部和口咽部阻塞的阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome，OSAHS）患者进行鼻部手术和改良悬雍垂腭咽成形术（uvulopalatopharyngoplasty，UPPP），探讨不同手术及不同顺序联合手术对疗效的影响。方法OSAHS诊断和评估手术疗效采用多道睡眠监测（polysomnography，PSG）、Epworth嗜睡量表（Epwoahsleepscore，ESS）评分、体重指数（bodymassindex，BMI）和主观症状。患者按照单、双日的半随机方法分为A、B两组，A组46例先行鼻手术，B组42例先行改良UPPP。术后2个月评估，A、B两组中无效者分别再行UPPP和鼻部手术。两组患者均在最后手术后随访1年以上。结果A组单纯鼻部手术后有效率23．9％（11／46），轻度患者有效率44．0％（11／25），随访1年无复发；其余疗效差的轻度和中度患者共35例均行UPPP，1年后随访检测PSG有效率85．7％（30／35）。B组单纯UPPP有效率47．6％（20／42），轻度者有效率63．6％（14／22），中度有效率30．0％（6／20），1年后随访检测PSG复发4例；其余疗效差的22例再行鼻部手术，1年后有效率86．4％（19／22）。两组总体疗效差异无统计学意义（89．1％和83．3％，P〉0．05）。A、B两组联合手术者与单纯行鼻部手术或UPPP术的有效率差异有统计学意义（P〈0．05）。A、B两组联合手术者有效率差异无统计学意义（85．7％和86．4％，P〉0．05）。结论合并鼻部和口阻塞的OSAHS患者，轻度者可先行单纯鼻部手术，无效或效果差时再行UPPP；中度患者改良UPPP联合鼻部手术可提高有效率。     

阻塞性睡眠呼吸暂停综合征的诊断及预后评估

近数十年来，采用悬雍垂腭咽成形术治疗睡眠呼吸暂停综合征的疗效，各家结果极不一致（45％～95％）。皆因对该病的诊断、分型、手术方案、预后评价均无统一的标准。我们参照国外资料及本科临床工作，提出几项建议：包括初筛及诊断依据；阻塞部位确定、分型、手术方案；预后判定。目的是希望提高睡眠呼吸暂停综合征的诊治水平，有利于进一步研究。     

舌根悬吊术后舌后气道形态学改变

对患有阻塞性睡眠呼吸暂停综合症（ob-structive sleep apnea syndrome，OSAS）的28例男性患，行舌根悬吊术。分别于手术前、术后行多导睡眠呼吸监测（PSG），观察呼吸紊乱指数等指标变化；行喉咽侧位片，测量舌后气道矢状径大小。术后行纤维内窥镜检查，观察舌后气道外部形态；术后发放问卷调查表，对白日嗜睡等作出评估。     

鼻通气手术治疗阻塞性睡眠呼吸暂停低通气综合征的疗效

目的：探讨鼻通气手术治疗阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的疗效。方法：71例OSAHS患者经多道睡眠图(PSG)监测确诊，同时应用纤维鼻咽喉镜及电视摄像系统检查确定存在鼻阻塞性病变并行鼻通气手术，分析术后Epworth 嗜睡(ESS)评分及PSG主要监测指标的变化。结果：ESS评分由术前的14.8±5.2下降为9.7±4.6（t=6.19, P=0.00）,差异有统计学意义。术后PSG监测显示，显效8例，有效29例，无效34例。睡眠结构分析表明，鼻通气手术后觉醒时间明显减少，浅睡眠〔非快速眼动睡眠(NREM)1期〕明显减少，中度睡眠（NREM 2期）明显增多， 快速眼动睡眠(REM)睡眠明显增多（P＜0.01）；深度睡眠（NREM 3+4期）差异无统计学意义（P＞0.05）。PSG主要指标呼吸暂停指数(AI)、低通气指数(HI)、最低血氧饱和度(LSaO2)、微觉醒指数和鼾声指数术后均明显好转，差异有统计学意义（P＜0.01），而呼吸暂停低通气指数(AHI)和体重指数(BMI)手术前后差异无统计学意义（P＞0.05）。结论：鼻通气手术对存在鼻阻塞性病变的OSAHS患者有一定的治疗作用，应纳入整个OSAHS治疗计划中；OSAHS患者行鼻部手术后再行PSG监测对选择腭咽部术式有指导意义。     

The frequency-modulation following response in young and aged human subjects

The frequency-modulation following response (FMFR) is a steady-state evoked response which may be a neural correlate of frequency discrimination. Aged subjects with normal hearing have abnormal frequency discrimination for low carrier frequencies and thus it might be predicted that aged individuals would have reduced FMFR amplitudes compared to young subjects. In this study, FMFR amplitudes were measured for frequency-modulated sinusoids with a carrier frequency of 0.5 kHz (80 dB SPL). In Experiment 1, the modulation depth was held constant (80%) and the modulation rate was varied (4-38 Hz), whereas in Experiment 2 the modulation rate was held constant (38 Hz) and the modulation depth was varied (0-80%). Aged subjects had significantly larger FMFR amplitudes than young subjects for certain stimulus parameters, although individual variability was large. Such results would not be predicted given previous data regarding frequency discrimination, but are consistent with several reports of larger-than-normal amplitudes of middle latency and late responses in aged subjects.     

茎突综合征诱发的慢性咳嗽25例

目的探讨茎突综合征诱发的慢性咳嗽及其可能机制。方法对25例慢性咳嗽伴茎突综合征患者进行茎突切除术,以评价其临床效果。结果16例(64%)完全解除咳嗽症状,6例(24%)明显好转。总显效率88%(22/25)。茎突综合征诱发的咳嗽,可能与刺激舌咽神经、咽丛和迷走神经的联系反射有关。切除茎突能减少其对神经的刺激,并割断部分感觉神经末梢,减少刺激反射,提高治疗效果。结论茎突综合征可能是引起慢性咳嗽的一个原因,手术切除茎突是有效的治疗方法。     

表现为脓样耳漏的耳真菌感染的诊治体会

目的 :探讨表现为脓样耳漏的耳真菌感染原因及治疗方法。方法 :对 1998～ 2 0 0 0年诊治的 45例“难治性”脓性耳漏患者 (除外肿瘤 ,胆脂瘤 ,经常规抗炎、抗过敏等治疗 1月以上无效的 )进行耳分泌涂片或培养查真菌 ,并采用不同的治疗方法。结果 :有 43例 (95 .5 6 % )为真菌感染 ,行抗真菌治疗后均痊愈。结论 :在遇到脓样耳漏时 ,尤其是“难治性”的 ,临床医生要考虑到真菌感染的可能 ,以免误诊 ,治疗上要根据不同病情选择相应的方法综合治疗     

Assessment of secondary haemorrhage rates following adult tonsillectomy--a telephone survey and literature review

Many previous studies have considered patient re-admission rates alone as the true rate of secondary haemorrhage following adult tonsillectomy. We aimed to determine the true rate of secondary haemorrhage following tonsillectomy in adults by performing a telephone interview with 60 consecutive patients. Whilst 40% (n = 24) of our patients reported a significant episode of bleeding (blood actively flowing from their mouth for more than 1 min) following discharge, only 8% (n = 5) were re-admitted and only 3% (n = 2) required return to theatre. Review of the current literature suggests that return-to-theatre rates are more consistent than hospital re-admission rates in large studies. We would suggest that although secondary haemorrhage can occasionally be very serious, the majority is minor, and it would therefore be more useful when comparing different techniques for tonsillectomy to consider numbers of patients returning to theatre rather than re-admission rates.     

Management of suspected foreign body aspiration in children1

We aimed to establish prevailing consultant opinion on the management of children with a history suggestive of foreign body (FB) aspiration but no clinical or radiological findings. FB aspiration is a common problem in children. Most agree that bronchoscopy should be performed if a child has clinical or radiological signs. With suggestive history but no such signs, the decision is more difficult; both bronchoscopy and neglected FBs have the potential for serious consequences. A postal questionnaire was sent to all British Association of Otolaryngologists and Head and Neck Surgeon (BAO‐HNS) consultants. The 563 questionnaires sent elicited a 63% reply rate. With suspected organic FBs, 52% would bronchoscope immediately, 38% would observe, and 10% would discharge. With suspected inorganic FBs, 35% would bronchoscope, 42% would observe, and 23% would discharge. Thus, the majority suggest admission, showing a preference for bronchoscopy with a history of organic FB, and observation if inorganic. Unless justified, it may be unacceptable to discharge these patients.     

Management of suspected foreign body aspiration in children

We aimed to establish prevailing consultant opinion on the management of children with a history suggestive of foreign body (FB) aspiration but no clinical or radiological findings. FB aspiration is a common problem in children. Most agree that bronchoscopy should be performed if a child has clinical or radiological signs. With suggestive history but no such signs, the decision is more difficult; both bronchoscopy and neglected FBs have the potential for serious consequences. A postal questionnaire was sent to all British Association of Otolaryngologists and Head and Neck Surgeon (BAO-HNS) consultants. The 563 questionnaires sent elicited a 63% reply rate. With suspected organic FBs, 52% would bronchoscope immediately, 38% would observe, and 10% would discharge. With suspected inorganic FBs, 35% would bronchoscope, 42% would observe, and 23% would discharge. Thus, the majority suggest admission, showing a preference for bronchoscopy with a history of organic FB, and observation if inorganic. Unless justified, it may be unacceptable to discharge these patients.     

Resolved effusion on myringotomy: A study of dry tap without general anesthesia

Objectives

Finding a resolution of middle ear effusion using myringotomy, or dry tap (DT), is relatively common, but its clinical outcome is confounded by general anesthesia (GA). The confounding effect of GA and a time delay can be removed because laser myringotomy can be completed under topical anesthesia, which is a routine procedure for otitis media with effusion (OME) before GA in our clinic. DT without GA would clarify the clinical outcome, and the percentage of recurrence for OME after DT would be clinically relevant. The objectives of the present study are (1) to clarify the clinical nature of DT without including the confounding effect of GA and a time delay and (2) to determine if OME recurs when a ventilation tube (VT) is not used for DT.

Methods

The control group consisted of 308 children who received an unilateral myringotomy due to a natural resolution in the contralateral ear. The experimental group consisted of 296 children who had a bilateral myringotomy, and a ventilation tube was not inserted for DTs after laser myringotomy under topical anesthesia. The rate of DT and the recurrence rate of OME without tube insertion was the main outcome measure.

Results

In the control group, which showed a natural resolution, the rate of DT was 16.9% (52/308) of patients, and DT was more common in non-B tympanometry, which only had a recurrence rate of 17.3% (9/52). In the study group, 3.7% of patients showed unilateral DT (UDT) with contralateral positive effusion, and 5.4% of patients showed bilateral DTs (BDTs). BDT showed a non-B tympanometry pattern and a low rate of recurrence (25.0%), which was similar to the control group. UDT showed a B-type tympanometry in 81.8% of the patients, and the recurrence rate was significantly higher (68.2%; 15/22) than the BDT and control patients. BDT or DT with signs of natural resolution showed a low rate of OME recurrence regardless of tympanometry, and thus, patients do not need a VT.

Conclusions

DT was not rare even without GA and the associated time delay, and DT was more common in the children that showed a natural resolution. However, microscopy and tympanometry was imperfect to predict dry tap, and thus, the surgeon needs to be prepared for individualized management of DT. UDT with B-type tympanometry and contralateral persistent effusion frequently recurred without tubes, and thus, VT for UDT appeared to be necessary.     

Population study of the ability to benefit from amplification and the provision of a hearing aid in 55-74-year-old first-time hearing aid users

About 40% of 55-74-year-olds have an impairment in at least one ear of 25+ dB HL, and 27% have bilateral impairment at this level, with 11% being impaired bilaterally at 35+ dB HL. Only 6% currently use a hearing aid. The performance of a random sample of participants aged 55-74 years on speech-in-noise tasks shows that significant statistical benefit was obtained from bilateral amplification in over 20% of the population who do not currently use a hearing aid. The offer of a hearing aid to all those who exceeded a 25 dB HL criterion in the worse car was accepted and taken up by 40%, with 16% declining and the remainder being excluded for pathological and logistic reasons (e.g. hearing loss profile not suitable for aid). This is a very high rate of 71% acceptance. One in four fitted with the hearing aid showed a statistical advantage for hearing speech in noise in freefield (noise and speech from in front) with the hearing aid. Thus at least 10% of the population who do not currently use an aid would benefit substantially from a hearing aid in a quiet speech-in-noise environment. Those with poorer cognitive function show greater benefit overall and less disadvantage in very bad signal-to-noise environments. The overall pattern of results support screening and providing hearing aids to those who do not currently have an aid(s), and suggests that there would be considerable population benefit. At least two main questions for further research remain: (1) would bilateral aiding strategies give greater benefit; and (2) would different hearing aids and fitting strategies be more appropriate for people with differing 'cognitive task' loadings on phonological memory and lexical decision factors?     

Fascia and perichondrium atrophy in tympanoplasty and recurrent middle ear atelectasis.

Fascia and perichondrium grafts to replace and reinforce thin, atrophic tympanic membranes (TMs) are recommended by several authors to correct middle ear atelectasis by forming a fibrous, collapse-resistant TM. This study reviewed the status of connective tissue grafts performed over the 10-year period from 1979 to 1988 to determine if these grafts would maintain sufficient strength and fibrous character to resist recurrent atelectasis. The author used fascia or perichondrium to repair 89 TM defects, and 63 ears were available for follow-up: 54 had cholesteatomas and 9 had perforations. Graft atrophy was judged by microscopic otoscopy and Kodachrome otophotography. Fascia TM grafts atrophied in 35 of 43 ears (80%), and perichondrium atrophied in 8 of 20 ears (40%). Grafts maintained their relatively thick and fibrous character in only 20 of 63 ears (32%). If fascia and perichondrium used to correct atelectasis were to atrophy at the same rate as the grafts in this series, atelectasis would recur after attempts to reinforce atrophic TMs. Atelectasis-prone middle ears require intubation despite surgery.     

腮腺良性肿瘤手术中面神经的损伤

目的 探讨腮腺良性肿瘤术中面神经损伤与手术方式的关系.方法 对我院1999～2006年住院治疗病理证实为腮腺良性肿瘤的患者116例进行回顾性分析.结果 腮腺全切除术后面神经重要分支功能损伤发生率(66.7%)明显高于腮腺浅叶摘除术(39.2%)和腮腺部分切除术(12.5%);下颌缘支功能损伤的几率(31.9%)高于颊支(9.2%)和颧支(2.9%).结论 面神经主要分支功能损伤与手术方式密切相关,选择适当手术方式和手术范围,可减少面神经损伤的发生,提高患者术后生活质量.