胸大肌肌皮瓣在鼻咽癌放疗后颈部挽救性手术中的应用

目的总结胸大肌肌皮瓣在修复鼻咽癌放疗后颈部转移灶残留或复发根治术后缺损中的应用。方法回顾性分析27例鼻咽癌颈部转移灶残留或复发的病人,行根治性颈清扫术,对颈部皮肤缺损用胸大肌肌皮瓣修复。结果1例病人术后3 h死亡,26例病人均一期修复成功。1例术后发生乳糜漏,3例远端吻合口处有感染,5例肌皮瓣远端部分坏死,8例延迟愈合。3年生存率为52.4%。结论鼻咽癌放疗后颈部转移灶残留或复发的挽救性手术应选择根治性颈清扫术;胸大肌肌皮瓣血供丰富,易成活,可取瓣面积大,能满足修复术后缺损的需要。     

胸大肌肌皮瓣在鼻咽癌放疗后颈部残留或复发手术中的应用

目的 总结胸大肌肌皮瓣在修复鼻咽癌放疗后颈部转移灶残留或复发术后缺损中的应用。方法 回顾性分析27例鼻咽癌颈部转移灶残留或复发的患者，行根治性颈清扫术，对颈部皮肤缺损用胸大肌肌皮瓣修复。结果 1例患者术后3h死亡，1例术后发生乳糜漏，3例远端吻合口处有感染，5例肌皮瓣远端部分坏死，共有8例延迟愈合。26例患者均一期修复成功。3年生存率为52．4％。结论 鼻咽癌放疗后颈部转移灶残留或复发的挽救性手术应选择根治性颈清扫术；胸大肌肌皮瓣血供丰富，易成活，可取瓣面积大，能满足修复术后缺损的需要；术后患者颈部紧缩感明显减轻，颈部活动度较前改善。     

头颈部恶性肿瘤治疗后大出血成功救治体会

目的 探讨不同头颈部恶性肿瘤治疗后大出血有效的急救方法 .方法 对18例成功抢救的不同头颈部恶性肿瘤手术和(或)放射治疗后大出血的病例进行回顾性分析.9例鼻咽部大出血病例中,1例大出血引起窒息进行紧急手术抢救,6例颌内动脉破裂行数字减影血管造影术(DSA)栓塞颌内动脉止血,2例鼻咽部溃疡者行溃疡切除,采用帽状腱膜鼻咽缺损修复止血.9例颈部大出血中,皆先行指压暂时止血,或立即在床旁用三角针、7号或10号丝线经皮行颈动脉破裂口上下结扎,再到手术室行规范的手术.结果 1例由鼻咽癌放疗后引起的颅底颈内动脉破裂出血行颈总动脉结扎术;6例鼻咽大出血病例行CT和DSA检查证实颌内动脉破裂引起,行DSA介入栓塞颌内动脉止血成功;2例鼻咽部深部溃疡出血帽状腱膜修复缺损止血成功.3例鼻咽癌、3例喉癌和1例下咽癌颈动脉破裂口结扎止血后,颈部溃疡用胸大肌皮瓣修复6例,下斜方肌修复1例.6例肌皮瓣修复成功,1例喉癌修复颈部创而的胸大肌肌皮瓣部分坏死,颈动脉再次破裂出血后成功止血.1例甲状腺癌多次手术放疗后无法修复缺损创面;1例颈部淋巴瘤全身状况极差,未修复缺损创面.所有患者出血抢救后无偏瘫,1例鼻咽癌放疗后出血行颈总动脉结扎术后部分脑梗死,6个月后死于肺部感染;2例鼻咽癌出血抢救成功后在11个月后死于局部复发;其余病例在12～36个月内死于再复发(7例)、远处转移或(和)全身衰竭(8例).结论 针对不同头颈部恶性肿瘤治疗后大出血时的具体情况选择不同的治疗方法 ,DSA介入栓塞治疗和指压止血经皮颈动脉结扎分别是鼻咽癌放疗后鼻咽大出血和颈动脉破裂出血救治的有效方法 .     

颈部复发癌的外科治疗

作者报告9例(10次)手术的经验,所有病例均系颈淋巴清扫及放疗后颈部复发者,病灶固定并侵及颈动脉。手术方式:切除颈部病灶及颈动脉,即刻行动脉重建。血管移植物采用自体大隐静脉5例(6次),人造血管(Gere-Tex)3例,另1例因颈动脉切除不多,直接吻合。血管吻合所选择的动脉:锁骨下动脉5例,腋动脉1例,颈总动脉近心端3例。此外,5例同时行胸大肌皮瓣修复皮肤或咽部粘膜缺损。结果:1例偏瘫,1例暂时性偏瘫,无手术死亡,亦无感染及咽     

晚期扁桃体癌放疗后复发的手术治疗

目的　探讨晚期扁桃体癌放疗后复发的手术治疗方法。方法　对我科 1 993年 6月～ 2 0 0 0年 8月诊治的 2 3例晚期扁桃体癌根治性放疗后复发的病例 ,采取颈 下颌骨正中切开外旋入路切除扁桃体复发肿瘤 ,带蒂的胸大肌皮瓣I期修复缺损 ,并行颈淋巴结清扫术。结果　全部病例随访 3～ 1 0年 ,3年生存率 2 6 .1 %(6 / 2 3) ,3年无瘤生存率 1 7.4 %(4/ 2 3) ,3年内局部再复发 1 9例 ,其中死亡 1 6例 ,失访 1例。皮瓣下、颈部局部感染 5例 ,皮瓣远端部分坏死 2例 ,呼吸困难 1例 ,误咽 2例。结论　晚期扁桃体癌放疗后复发的预后差。对适合病例作下颌骨正中切开外旋入路切除肿瘤 ,带蒂胸大肌皮瓣I期修复缺损 ,并行颈淋巴结清扫术 ,可延长病人生命 ,减少痛苦 ,提高生存质量。     

肿瘤累及颈动脉的外科治疗

目的 探讨颈部肿瘤累及大血管的手术中血管处理方法及注意事项.方法 分析8例颈部肿瘤累及颈动脉患者一期整块切除肿瘤及颈动脉以及颈动脉重建手术的方法、效果和术后并发症.结果 患者均在颈动脉转流(颈总动脉-颈内动脉)下切断颈总动脉及颈内动脉,行颈部清扫手术或肿瘤切除术.2例患者采用膨体聚四氟乙烯(expanded polytetrafluoroethylene,ePTFE)人造血管移植,6例患者采用自体大隐静脉移植.全组患者无缺血性脑卒中发生.2例患者术后发生伤口感染,再次手术探查发现均有咽瘘发生.结论 采用术中转流、肿瘤连同受累颈动脉整块切除、颈动脉重建的方法治疗累及颈动脉的颈部进展期肿瘤安全有效并可明显改善患者生活质量.移植血管首选自体静脉.应特别注意防止术后感染.对于手术后局部组织广泛切除,移植血管床无软组织填充、血液供应及侧支循环差或已经暴露咽腔者,应采用转移肌皮瓣覆盖.     

鼻咽癌放疗后颈转移手术的病理学基础

鼻咽癌首诊颈转移率高达70yo，故放疗常规包括颈部照射，但放疗后仍有颈淋巴结肿瘤的残留或复发，对这些病人是否行根治性颈清扫仍有分歧，为制订最适外科治疗，该作者研究了颈淋巴结转移性肿瘤的病理学表现。43例病人均为鼻咽癌放疗后颈淋巴结肿瘤残留或复发，男34人，女9人，年龄二3一71岁，平均sl岁，其中13例为残留，30例为复发，且所有病人均在一侧颈部。术前颈部作临床检查，并详细记录颈部淋巴结的数目、大小、活动度及位置，鼻咽作纤维内窥镜检查及活检证实局部病灶在控制中。所有病人作经典的根治性颈清扫术，包括胸锁乳突肌、预内…     

经舌骨入路口咽前壁癌的综合治疗

目的 探讨对口咽前壁癌患者施行以经舌骨入路切除为主的综合治疗效果.方法 回顾性分析2005年5月至2010年10月24例口咽前壁即舌根会厌区癌患者的临床资料.24例患者中T27例,T3 2例,T4 15例;N0 7例,N1 4例,N2 12例,N3 1例.均经舌骨入路,行全舌根和(或)半舌切除+喉部分切除9例,舌部分切除+喉全切除7例,舌全切除+喉部分切除7例,舌部分切除(全舌根+半舌)1例.胸大肌岛状肌皮瓣修复全舌(7例)或部分舌(9例)及咽侧壁缺损(16例),修复颈部皮肤缺损1例;游离前臂皮瓣+胸骨舌骨肌瓣修复半舌、咽侧及部分咽后缺损1例;胸骨舌骨肌瓣修复舌根2例;直接拉拢缝合4例.20例行双侧颈清扫术,4例行单侧颈清扫术.术前放疗5例,术后放疗16例.结果 24例患者原发灶切缘均阴性,17例(70.8％)患者淋巴转移阳性.术后咽瘘3例,其中2例舌部分切除+喉全切除胸大肌皮瓣一期修复术后4d出现咽瘘者,经清创换药后拉拢缝合;1例舌根全切除+喉部分切除术后放疗后咽瘘者以胸大肌皮瓣修复.17例保留喉功能患者中16例于术后1～6个月内拔管,恢复正常饮食,构音尚可,另1例发音、吞咽尚好,但堵管后通气不足,未能拔管.随访3年以上21例,Kaplan-Meier法计算3年总生存率72.6％.结论 经舌骨入路口咽前壁癌切除是较为理想的术式之一,手术缺损较大,多需一期修复,综合治疗尚能取得较满意结果.     

颈部肿块和瘢痕病变致颈动脉窦过敏综合征(附2例报告)

报告1例鼻咽癌颈淋巴结转移致颈动脉窦过敏综合征和1例全喉切除加颈淋巴结清扫术术后瘢痕形成出现颈动脉窦过敏综合征.对耳鼻咽喉科相关疾病引起的颈部肿块和瘢痕病变压迫颈动脉窦所致颈动脉窦过敏综合征的致病原因、临床表现及诊断、治疗原则进行了讨论.此类患者在临床上少见,易误诊,应引起重视.     

气管套管损伤致颈部大动脉破裂

作者们于1975～1982年间施行了680例上呼吸道及上消化道肿瘤手术,发生颈部大动脉出血者18例,其中4例(22％)是由于气管套管损伤。1例为喉咽癌行全喉切除,一侧根治性颈清扫,对侧功能性颈清扫术后病人,1例为放疗后一年复发而行全喉切除术,1例为放疗后13个月复发而行全喉和甲状腺切除术,另1例为全喉切除并双侧颈清扫后放疗的病人。由于气管所处位置的关系,控制大量出血,保护正常呼吸道殆不可能。因此4例病人全都死于呼吸道无力控制。通常创口未完全愈合形成瘘管是引起出血的主要原因;肿瘤局部溃疡、放疗后皮肤坏死亦可     

Trends in blunt laryngotracheal trauma in children

Objective

To examine the presentation, mechanisms, and management of blunt laryngotracheal trauma in a pediatric population, emphasizing the rise in severity.

Design

Retrospective analysis of laryngotracheal trauma evaluated from 1995 to 2008. The presentation, mechanism, management and outcomes data are detailed.

Setting

Tertiary medical center.

Patients

Thirty-five patients were identified with major laryngotracheal trauma.

Main outcome measures

Surgical results, airway patency, voicing, swallowing and other residual disabilities are tabulated.

Results

Average age was 10.8 years, with boys outnumbering girls 22-13. In cases of major trauma, mechanisms were related to motor vehicle accidents (MVAs) in seven patients. Five of 11 major trauma victims were unconscious at presentation. Definitive airway reconstruction involved laryngotracheoplasty and tracheal resection/reanastomosis. Ten of 11 remain decannulated.

Conclusions

In an increasingly mobile society, major laryngotracheal trauma is occurring in a younger population. Victims of major laryngotracheal trauma may be unconscious or have other injuries that obscure airway injury, highlighting the need for vigilance. Once the airway is secured and the patient stabilized, airway reconstruction is undertaken, achieving decannulation in most patients. Hoarseness is often a lasting morbidity.     

HLA associations in otosclerosis in Japanese patients

Otosclerosis is a disease of the otic capsule that is caused by abnormal resorption and redeposition of bony tissue. Sixty-two unrelated Japanese patients exhibiting clinical otosclerosis were typed for HLA-A, -B,-C antigens. Twenty-one of the patients were also typed for DR antigens. The frequency of HLA-Aw33 was significantly higher in otosclerosis patients than in the control group (24.2% vs 9.5%). This finding suggests that the presence of HLA-Aw33 antigens may be related to an increased susceptibility to otosclerosis or to its clinical outcome.     

Changes in immunologic response in tonsillectomized children. I Immunosuppression in recurrent tonsillitis

The possible immunoregulatory role of the tonsils was studied by determining immunoglobulins IgG, A, M, E and factors C'3, C'4 and PFB of the complement system before and after tonsillectomy. The synthesis in vitro of IgG and IgM by lymphocytes stimulated with pokeweed mitogen was also measured. There were statistically significant differences between pre and post-operative levels of serum IgG, IgA and IgM, which decreased after surgery. Practically no change in the mean values of IgE and no significant differences in the levels of serum C'3, C'4, and PFB, were found. The in-vitro synthesis of both immunoglobulins (IgG, IgM) by lymphocytes increased significantly after tonsillectomy. Our results suggest that not only does tonsillectomy have no counterproductive effect on the immune system, but that, on the contrary, it seems to improve the immune response, since it appears to unblock the suppression to which the immune system was subject.     

Immunotype findings in macrophages in aural cholesteatomas

Summary Since a heavy cellular infiltrate is seen in the stroma of most aural cholesteatomas, we attempted to characterize this cell population in more detail using monocyte/macrophage-specific monoclonal antibodies. KiM1+ (specific for CD 11c antigen, the 150kDa -chain of a leukocyte integrin), and KiM6+ phagocytes were present in two- or fourfold higher numbers in the stroma of the six excised cholesteatomas than in the control tissues. Since the stroma of the cholesteatoma is devoid of microvessles, the typical perivascular localization of dermal macrophages was not seen in the cholesteatomas studied. The density of the macrophages in the normal ear skin was much higher in the upper dermis than in the lower dermis. In the cholesteatomatous specimens, the phagocytes were evenly scattered within the connective tissue and the cellular infiltrate. In contrast to diseased skin, no Mac 387+ macrophages were detected in the cholesteatomas. A great number of phagocytic cells closely resembling dermal macrophages was found in the stroma of the cholesteatomas and probably contributes to an active autoimmune process. Offprint requests to: B. Negri