先天性第四鳃裂畸形的诊断和治疗

目的 探讨先天性第四鳃裂畸形(congenital fourth branchial anomaly,CFBA)的解剖学特点、临床表现、诊断和外科处理原则.方法 回顾性分析8例CFBA患者的临床资料,年龄27～300个月(中位年龄114个月);男4例,女4例;初治3例,复发5例;病变均位于左颈,其中囊肿型1例,窦道型3例(均为内瘘口),瘘管型4例;3例表现为急性甲状腺炎,4例表现为颈深部脓肿,1例表现为颈部肿块.结果 术前检查包括食管吞钡8例次、直接喉镜4例次、CT 5例次、MRI 5例次.急性期患者采取充分引流、控制感染;静止期患者行病灶完整切除+喉返神经解剖+甲状腺腺叶部分切除,对复发病例采用择区性颈清扫术根除瘢痕、炎性肉芽和病变组织.术后1例患者切口局部感染,经换药后愈合;1例患者出现暂时性声带麻痹,1个月后完全恢复.患者随访13～42个月,中位随访时间21个月,未见复发.结论 CFBA走行与喉返神经和甲状腺关系密切.食管吞钡、直接喉镜检查最具诊断价值,CT和MRI有助于明确诊断.治疗原则为感染静止期行喉返神经解剖和甲状腺腺叶部分切除,必要时切除部分甲状软骨翼板以减少并发症和预防复发,复发病例可采用择区性颈清扫术治疗.     

先天性第一鳃裂畸形的走行探讨和治疗经验

目的对先天性第一鳃裂畸形的走行进行探讨并总结治疗经验。方法回顾性分析2011年6月至2016年6月收治的10例第一鳃裂畸形患者的临床资料,对第一鳃裂畸形的走行及其手术方式进行分析。结果 2例患者瘘管经腮腺浅面至耳屏处外耳道。5例与面神经总干有密切关系:3例瘘管经总干外侧终于外耳道软骨部,2例瘘管经总干内侧终于外耳道软骨部。2例与颞面干关系密切:1例经颞面干外侧终于外耳道,1例经颞面干内侧终于外耳道。1例与颈面干内侧终于外耳道。本组患者术后随访3~63个月,中位随访时间24个月,8例无复发,1例复发,1例失访。结论本组病例与腮腺及面神经关系密切,需解剖面神经,处理腮腺浅叶。第一腮裂畸形患者术后均应进行长期随访。     

鳃裂畸形的诊治

鳃裂畸形属先天性疾病,是胚胎发育过程中鳃沟与咽囊发生异常穿破或未完全闭合而形成,可表现为颈侧部的囊肿、瘘管或窦道。临床上较少见,容易误诊,治疗不当易复发。我们近期收治2例鳃裂畸形患者,通过复习相关文献,分析总结如下。1临床资料病例1。患者,女性,8岁,因"出生后发现     

甲状腺微小乳头状癌右侧喉返神经后方淋巴结转移相关危险因素Meta分析

目的:通过Meta分析探讨甲状腺微小乳头状癌(PTMC)右侧喉返神经后方(Ⅵb区)淋巴结转移的危险因素.方法:检索国内外文献数据库中PTMC喉返神经后方淋巴结转移相关的文献,检索截止时间是2020年6月,由两名研究者筛选文献、提取数据后,采用Revman5.3软件进行Meta分析.结果:共纳入5篇文章,共计1884例研...     

择区性颈清扫术治疗复发性鳃裂畸形

目的:探讨择区性颈清扫术治疗复发性鳃裂畸形的疗效.方法:回顾性分析18例复发性鳃裂畸形病例资料.根据鳃裂畸形的胚胎学和解剖学特点,选择不同类型的择区性颈清扫术式治疗.手术解剖、保护重要的血管神经,应用整块切除原则根除病变组织、瘢痕、炎性肉芽.结果:18例患者中,16例切口Ⅰ期愈合,2例术后切口局部感染,经换药后愈合.1例复发性第一鳃裂瘘管术后出现暂时性面瘫, 术后2个月完全恢复.1例复发性第四鳃裂瘘管,术后出现暂时性声带麻痹,1个月后恢复.随访12～78个月,平均35个月,所有病例未见复发.结论:择区性颈清扫术治疗复发性鳃裂畸形,安全、有效.     

选择性颈清扫术在复发性第二三鳃裂瘘管术中的应用

由于鳃裂瘘管与颈部重要神经、血管关系密切,手术切除不彻底,易造成反复感染.对于复发者,常规手术方法更难治愈.我们采用选择性颈清扫术,整块切除病变组织,保留颈内动静脉、神经、胸锁乳突肌, 治疗8例复发性第二、三鳃器瘘管患者,术后随访2～10年,无一例复发,总结如下.     

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目的　探讨甲状腺乳头状癌（papillary thyroid carcinoma,PTC）右喉返神经后方淋巴结（LN-prRLN,右颈VI-2亚区）清扫的临床价值。方法　选取2014～2015年收治的右侧或双侧PTC患者408例,采用单因素分析及多因素Logistic回归分析研究LN-prRLN转移与患者各项临床病理特征的关系,ROC曲线分析其预测价值。结果　408例PTC右颈VI区淋巴结转移率为49.02%,其中右VI-1亚区（右颈中央浅层）为46.32%,右VI-2亚区为16.67%。单因素分析右VI-2转移与性别、年龄、右侧癌灶大小及数目、被膜侵犯、右VI-1转移及转移灶大小、右颈侧区淋巴结转移有关（P 均＜0.05）。多因素分析显示,右VI-2转移与右侧癌灶大小、被膜侵犯、右颈VI-1转移、右颈侧区淋巴结转移相关（P 均<0.05）。ROC显示：年龄＜35.5岁、右侧癌灶>0.85 cm、右颈VI-1亚区转移淋巴结＞1.5个、右颈VI-1亚区淋巴结转移灶>0.45 cm、右颈侧区转移淋巴结＞0.5个来预测LN-prRLN转移的AUC值分别为0.585、0.787、0.788、0.725、0.719。结论　当患者是男性、年龄＜35.5岁、右侧癌灶＞0.85 cm、被膜侵犯、右颈VI-1亚区转移淋巴结＞1.5个、右颈VI-1亚区淋巴结转移灶＞0.45 cm、右颈侧区转移淋巴结＞0.5个时,需常规行LN-prRLN清扫。     

喉癌颈淋巴结处理原则的制定与应用

喉癌术后颈淋巴结转移癌复发是影响喉癌预后的重要因素之一 ,降低颈淋巴结转移癌的复发率是提高喉癌治疗水平的重要条件。我科在 1 995年对既往诊治的喉癌患者的颈淋巴结转移及转移癌复发的临床资料进行了回顾性分析〔1〕,并对行功能性颈清扫术和根治性颈清扫术的两组条件相近的本病患者的颈淋巴结转移癌复发情况进行对比研究〔2〕,同时根据由此而获得的资料 ,制定了喉癌颈淋巴结处理原则。 1 995年以后我们将处理原则应用于临床实践 ,获得了较好的效果。现将按处理原则治疗喉癌患者的情况总结如下。1　资料与方法1 .1　处理原则的制定1 995…     

功能性颈清扫术在复发性鳃裂畸形治疗中的应用

目的:探讨功能性颈清扫术在复发性鳃裂畸形治疗中的应用。方法:回顾性分析我科采用功能性颈清扫术治疗复发性鳃裂畸形(瘘管和囊肿)患者15例的资料。结果:13例切口一期愈合,2例二期愈合,1例术后饮水呛咳,1个月后自行恢复,1例术后遗留Horner综合征。随访2个月～6年,除2例失访外,无一例复发。结论:功能性颈清扫术对于多次复发的第二、第三鳃裂畸形(瘘管和囊肿)是一种安全有效的治疗手段。     

鼻咽癌放疗后颈淋巴结复发和残留的外科治疗

目的 分析鼻咽癌放疗后颈淋巴结残留和复发者的4种清扫方式的疗效，希望能为临床提供更多手术方式的选择。方法 回顾性分析88例鼻咽癌患者资料，分析总体疗效：生存率、复发率、远处转移率和手术并发症；比较全颈清扫、改良性、择区性颈清扫术和颈淋巴结切除术4种手术方式的生存率、复发率；比较术后颈部放疗与否者的生存率、复发率。结果 采用生命表法统计88例鼻咽癌患者5年累积生存率42.8％，颈淋巴结复发率为22．7％。Ⅱ期、Ⅲ期、Ⅳ期患者的5年生存率(生命表法)分别为56.7％、36．1％、32.4％。全颈清扫术、改良性颈清扫术、择区性颈清扫术和颈淋巴结切除术组5年累积生存率(Kaplan-Meier法)分别为39．8％、60．0％、37．9％和44．1％，差异无统计学意义(Log Rank统计值=1．0，P=0.8011)，颈淋巴结复发率差异也无统计学意义(χ^2=0．470，P=0．493)。颈清扫术后颈部给予与未给予术后放疗者的5年累积生存率(Kaplan-Meier法)分别为39．1％和45．3％，差异无统计学意义(Log Rank统计值=0．06，P=0．8138)，颈淋巴结复发率差异也无统计学意义(χ^2=0．593，P=0．441)。结论 只要合理选择病例，配合必要的术后局部和浅表的放疗，4种清扫方式都能有效和安全地控制肿瘤。     

先天性梨状窝瘘管的诊断与治疗

目的 探讨先天性梨状窝瘘管(congenital pyriform sinus fistula,CPSF)的临床表现和治疗原则。方法 对2007年1月至2011年1月经手术确认连接梨状窝与甲状腺叶瘘管的7例CPSF患者资料进行分析。患者均表现为复发性左侧颈部低位脓肿或急性化脓性甲状腺炎,所有患者均有误诊病史,病程3 ～11年,均曾数次行切开引流或外科探查。急性感染期患者脓肿切开引流,炎性反应消退后进行检查和根治性手术。结果 炎性反应静止期CT检查,均可见左侧甲状腺叶深面及其周围间隙瘢痕组织增生;6例患者行X线钡餐检查,5例可见源于梨状窝的瘘管。4例患者术前行直达喉镜检查,3例可见位于梨状窝尖部附近的瘘口。手术切除瘘管及左侧部分甲状腺叶,保护喉返神经。术后恢复顺利,未出现永久性喉返神经麻痹或甲状腺功能低下等并发症。随访5～40个月,未见复发。结论 对于有反复发作下颈部脓肿病史的患者,尤其位于左侧者,应高度怀疑CPSF的存在,X线钡餐和CT检查是有效的诊断方法,完整切除瘘管及受累甲状腺叶可治愈CPSF。     

Resection of recurrent branchial cleft deformity using selective neck dissection technique

ObjectivesThis study explores application of selective neck dissection technique in recurrent second, third, and fourth branchial cleft deformities.MethodsA total of 19 cases of recurrent second, third, and fourth branchial cleft deformities were treated using the selective neck dissection technique, during which the sternocleidomastoid muscle, cervical anterior muscle, and carotid sheath were contoured. The lesion above the prevertebral fascia was then resected en bloc. Finally, the opening of the internal fistula was ligated and sutured using the purse-string approach.ResultsPatients in this study had no injures to their internal carotid artery, jugular vein, vagus nerve, accessory nerve, hypoglossal nerve, or recurrent laryngeal nerve. There were also no complications such as poor wound healing. The patients were monitored for 7–73 months and showed no recurrences.ConclusionsUsing selective neck dissection to treat second, third, and fourth branchial cleft deformities resulted in en bloc lesion resections and reduced the chance of recurrence. Contouring the sternocleidomastoid muscle, strap muscle, and carotid sheath is key to the surgical procedure, as it leads to en bloc lesion resection while retaining the recurrent laryngeal nerve and carotid sheath.     

Intraoperative fistulograms in the management of branchial apparatus abnormalities in children

OBJECTIVE: We sought to evaluate the role and efficacy of intraoperative fistulograms in visualizing branchial apparatus (fistula/sinus) abnormalities in the pediatric age group (3 months-12 years). METHODS: This was a retrospective analysis of 20 pediatric patients who underwent fistula and/or sinus excision during a period of 18 years (1988-2006). RESULTS: The male:female ratio was 11:9. Eighteen of the 20 patients presented with unilateral abnormalities, 2 with bilateral abnormalities. An intraoperative fistulogram was utilized in every instance. The fistulogram clearly differentiated the sinus tracts from complete fistulas in all cases. It was also highly useful in delineating the exact length and course of the sinus/fistula tracts. CONCLUSIONS: Intraoperative fistulograms are easy to do in the operating room on the day of the scheduled surgery. They are a very useful tool in the management of branchial apparatus abnormalities.     

A right-sided fourth branchial cleft cyst: a case report

Branchial anomalies are a consequence of abnormal development of the branchial apparatus during embryogenesis. Here, a pediatric case with a right-sided fourth branchial cyst that was discovered on fetal ultrasound scanning (US) is presented. The embryological basis for the occurrence of this cyst and definitive surgical management are discussed.     

Parapharyngeal second branchial cyst: A case report

Branchial cleft cysts extending to the lateral wall of the pharynx are rare. An eight year old female child presented with a cystic swelling in the left parotid region. A bluish cyst was seen anterior to the anterior pillar of left tonsil. CT scan showed the cyst extending into left parapharyngeal space. External part of the cyst was excised via a transcervical approach and the internal part was marsupalised per orally     

Neck management in patients undergoing postradiotherapy salvage laryngeal surgery for recurrent/persistent laryngeal cancer

OBJECTIVE: To determine a plan for the management of cervical lymph nodes in patients undergoing salvage laryngeal surgery (SLS) for recurrent/persistent laryngeal cancer after primary radiotherapy (RT). STUDY DESIGN:: Retrospective chart review. METHODS: Charts of 51 consecutive patients who had salvage total or supracricoid laryngectomy with or without neck dissection for recurrent/persistent laryngeal squamous cell carcinoma after primary RT from 1988 to 2005 in our institution were reviewed. No patients received concomitant or neo-adjuvant chemotherapy. Thirty-four patients underwent SLS along with unilateral or bilateral neck dissection, whereas 17 patients underwent the SLS without neck dissection. Reports of preRT and preSLS staging of the primary tumor and the neck, recorded using the TNM system, were reviewed. Reports of the final histopathologic examination for the excised laryngeal cancer and cervical lymph nodes were reviewed. RESULTS: Thirty-four patients underwent SLS with unilateral or bilateral neck dissection. The preRT staging of the primary tumor for those 34 patients showed that 32 (94%) were staged T-1 (14) and T-2 (18), whereas the preSLS staging of the primary tumor for those 34 patients showed that 29 (85%) were staged T-3 and T-4. The postSLS final histopathologic examination of the excised lymph nodes in those 34 patients demonstrated that 30 (88%) did not have any evidence of nodal metastasis. On comparing patients with and without nodal metastasis (on their postSLS final histopathology), we found that the preSLS neck staging, based on computed tomographic (CT) scanning of the neck, was significantly associated with the negative/positive postSLS status of nodal metastasis (P = .006). Of 29 patients staged preSLS as N-0, 28 (97%) patients did not have nodal metastasis on their postSLS final pathology (negative predictive value = 97%, confidence interval, 82.2-99.9). PreRT neck staging, preRT and preSLS staging of the primary tumor, along with laryngeal subsite involvement (supraglottis, glottis, subglottis) did not significantly correlate with the status of neck metastasis on final postSLS histopathology (P = .68, 0.78, 0.49, and 0.42, respectively). None of the 34 patients had any neck tumor recurrence in the postSLS follow-up period (median, 3 yr). In addition, all 17 patients who underwent SLS without neck dissection were staged N-0 both before RT as well as preSLS, and none developed neck disease in the postSLS follow-up period (median, 2.5 yr). CONCLUSION: Management of the neck in patients undergoing salvage total or supracricoid laryngectomy for laryngeal cancer recurrence/persistence after primary RT should be based on the preSLS CT staging of the neck. Patients staged N-0 preSLS are not likely to harbor occult nodal metastasis and therefore may not require elective neck dissection.     

Recurrent neck infection with branchial arch fistula in children

Objective

Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side.

Methods

A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases.

Results

The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence.

Conclusion

Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.     

31例鳃裂发育畸形临床诊治分析

目的探讨鳃裂发育畸形的临床诊治。方法回顾性分析31例鳃裂瘘管、窦道及囊肿诊治情况,其中第一鳃裂瘘管7例,第二鳃裂瘘管6例、鳃裂窦道及囊肿12例,第三鳃裂瘘管6例。初次手术者16例,复发再次手术者15例。结果经合理用药,术中熟悉瘘管行走途径,精细解剖,彻底切除瘘管、窦道及囊肿,1例出现面神经下颌缘支不全麻痹;1例出现咽瘘,经换药后痊愈。其中27例随访1年以上,截止目前无1例再次复发。结论熟悉各型鳃裂畸形的发病机制及颈部解剖,合理选择手术时机是治愈该种疾病的关键。