多层螺旋CT多平面和三维重建技术诊断茎突过长症30例

目的 探讨多层螺旋CT（multi-slice computed tomography,MSCT）对茎突过长症的诊断价值.方法 对30例临床疑为茎突过长症但X线平片显示不清的患者,行茎突MSCT横断面螺旋方式扫描及多平面重建（multiplanar reformation,MPR）,并利用容积漫游技术（volume rendering technique,VRT）对茎突进行三维重建.结果 30例患者均得到确诊.通过MPR图像准确测得茎突长度,单侧过长23例,双侧过长7例.VRT图像可直观、立体的显示茎突的长度和角度,并可通过旋转多方位观察茎突的形态和解剖位置.结论 茎突MSCT轴位扫描结合MPR、VRT技术对茎突过长症诊断有重要价值.     

螺旋CT对气管支气管异物和狭窄的诊断价值

目的：探讨螺旋CT（MSCT）对气管、支气管异物和狭窄的诊断价值。方法：对18例可疑支气管异物的患儿进行MSCT检查。将获得的轴位扫描图像行Minp及MPR重建,并与支气管镜检查结果对照。结果：MSCT显示异物15例,21枚,其中1例异物CT值为278HU,其余14例CT值为-10．6～31．0HU;位于主支气管6例,叶支气管9例,其中并发段支气管异物4例。支气管炎性狭窄2例,异物取出后气道狭窄1例。异物及气管狭窄的显示以MPR和Minp图像最好。支气管镜所见与MSCT一致,但4例并发段支气管异物者未发现。MSCT所见不仅与支气管镜吻合,而且可准确显示段支气管以下的异物。结论：MSCT可准确显示气管、支气管异物与狭窄的直接和间接征象,并较准确地判定异物性质,对小儿支气管异物的诊断有重要参考价值。     

多层螺旋CT对先天性内耳发育畸形的诊断价值

目的探讨多层螺旋CT(multi-slice computed tomography，MSCT)对先天性内耳发育畸形的诊断价值。方法对44例先天性感音神经性聋患者做MSCT横断面螺旋方式扫描及多平面重建(multi-planar reformation，MPR)，必要时做单侧重叠放大重建，并利用容积漫游技术(volume rendering technique，VRT)对骨迷路进行三维重建。结果44例患者中25例CT表现正常，19例(36耳)表现为内耳发育畸形。畸形有以下几种：Michel型(1耳次)，共同腔畸形(3耳次)，不完全分隔Ⅰ型(3耳次)，不完全分隔Ⅱ型(Mondini型，5耳次)，前庭及半规管畸形(14耳次)，前庭导水管扩大(16耳次，其中6耳次伴随其他畸形)，内耳道畸形(8耳次均伴随其他畸形)。36耳畸形中33耳MSCT横断面图像和MPR图像、VRT图像均可以清晰的显示畸形的部位和程度，其中VRT图像可以直观、立体地显示畸形的空间形态结构；3耳水平半规管短小畸形患者VRT图像较断面图像更好的显示了畸形的部位和程度。结论MSCT提高了横断面图像以及MPR、VRT图像的空间分辨率。VRT图像直观、立体的显示了骨迷路畸形的空间形态结构，并且可以通过旋转多方位观察畸形的形态。MSCT扫描结合VRT可更加准确的对内耳骨迷路畸形的部位和程度做出诊断，加深了我们对各种畸形的理解，有助于人工耳蜗植入手术计划的制定。     

咽鼓管倾斜旁矢状位磁共振成像

目的 根据咽鼓管特殊的解剖结构进行咽鼓管倾斜旁矢状位磁共振成像.方法 选取3名志愿者(男2人,女1人)进行研究.应用3.0T超导型磁共振扫描仪,采用质子密度加权成像扫描(proton densityweighted imaging,PDWI)技术进行成像.首先获得头颅正中矢状位扫描图像,然后在此基础上沿双侧咽鼓管长轴所在平面进行咽鼓管倾斜轴位扫描,在获得图像上确定垂直于咽鼓管长轴的扫描线,进行平行于咽鼓管纵断面的倾斜旁矢状位扫描.将最终获得的原始数据通过多平面重建(multiplanar reconstruction,MPR),进一步修正扫描平面,并协助进行解剖结构识别.结果咽鼓管倾斜旁矢状位MRI图像显示咽鼓管软骨清晰,周围细小结构的软组织也能够辨认.结论 临床应用3.0T超导型磁共振扫描仪进行咽鼓管倾斜旁矢状位MR扫描,成像效果满意,操作简便易行,有助于咽鼓管相关疾病的诊断.     

多层螺旋CT三维重建在诊断气管支气管异物中的应用

目的 评价多层螺旋CT(multilayer spiral computed tomography,MSCT)三维 重建对气管支气管异物诊断的价值。方法 对30例怀疑为气管支气管异物的患 者,实施肺螺旋CT平扫及三维重建,与硬性支气管镜下手术情况对比,分析各种重建方法对支气管异物的显示情况及诊断价值。结果 30例患者均获清晰图像,23例异物部位与术中所见一致,出现位移1例,假阴性1例,异物咳出后检查3例, 左主支气管狭窄1例,吸入性肺炎1例,均未见异物。各种重建方法均可清楚显示气管、支气管异物的位置、形状、大小及异物所致气管、支气管狭窄的部位、程度和外形改变。结论 螺旋CT及图像后处理技术在气管支气管异物诊断中具有重要的临床应用价值。     

多层螺旋CT对鼻区骨折的诊断和临床应用

外鼻是颜面中央最突出的部位,而且组成鼻区的各骨均较菲薄,故发生颌面部外伤时,鼻骨和临近诸骨常出现骨折.我们采用多层螺旋CT(multi-slice spiral CT,MSCT)轴位扫描结合冠状和矢状多平面重建技术(multi-planar reconstru ction,MPR)图像对鼻部外伤患者进行诊断,然后再参考MSCT所显示的骨折类型,制定合理的治疗方案.     

64排螺旋CT多平面重建和容积再现图像在面中部复杂骨折中的临床应用

目的：探讨64排螺旋CT多平面重建（MPR）及容积再现（VR）图像在面中部复杂骨折中的临床应用价值。方法：对46例面中部复杂骨折患者进行64排螺旋CT薄层扫描,容积数据传送到工作站进行MPR和VR三维成像。结果：46例面中部366处骨折,MPR图像对面中部各部位骨折的显示率为100％;VR图像对颧骨、颧弓、下颌骨骨折的显示率为100％,对上颌骨骨折的显示率为94．3％、眼眶骨折为93．2％、筛骨骨折为13．0％、蝶骨骨折为55．6%,平均显示率为86．3％。VR图像能够通过图像旋转、切割等功能从不同方向观察骨折的位置、范围、骨碎块的移位,了解骨折线的走行及外伤所致的畸形情况。结论：MPR结合VR成像对面中部骨折的诊断治疗具有很高的临床应用价值。64排螺旋CT图像能提高对深部纲微骨折的显示．     

多层螺旋CT在诊断颈部肿瘤中的应用

目的：探讨多层螺旋CT（MSCT）在颈部肿瘤病变中的应用价值。方法：应用Light Speed QX/i型MSCT检查32例颈部肿瘤患者（喉癌30例,颈段食管癌1例,甲状腺癌1例）,行三维重建及仿真内窥镜成像。结果：MSCT图像清晰,矢状面图像可显示会厌癌侵犯会厌前间隙,声带及声门下的情况以及有无侵犯甲状软骨达颈前软组织,冠状面图像可显示声门旁间隙、杓会厌皱襞及梨状窝受侵情况,并可显示甲状腺癌压迫并侵犯喉及气管情况,多平面重组配合增强扫描可显示转移淋巴结大小、数目与颈部血管关系等。结论：MSCT对术前明确肿瘤范围,行TNM分期及正确选择手术式有一定帮助。     

螺旋CT图像后处理技术在鼻腔鼻窦疾病诊断中的应用与评价

目的:探讨螺旋CT图像后处理技术对鼻腔鼻窦病变的显示能力和临床应用价值。方法:对健康志愿者10例及临床疑为鼻部病变者20例共56侧行鼻腔螺旋CT扫描后,经软件处理,进行多平面重建成像(MPR)和仿真内镜成像(CTVE),与鼻内镜检查和手术所见进行对比研究,利用Wilcoxon等级资料两样本秩和检验和χ2检验进行统计学分析。结果:螺旋CT MPR可从不同角度、各种层面、多方位地显示鼻腔、鼻窦及鼻咽部的解剖结构、病变部位和范围及气道、前中颅底的情况。CTVE可显示鼻腔正常解剖结构、病变位置和范围,与鼻内镜检查和手术所见类似,并可进入鼻内镜无法到达的腔道,如鼻窦内、狭窄的鼻道内以及梗阻病变的远端。结论:CT图像后处理技术对鼻腔鼻窦解剖和病变的显示提供了一种无创、全新、经济、安全的影像学方法,能弥补常规CT和鼻内镜的不足,合理使用CTVE、MPR等多种图像后处理技术,同时与水平位CT相互结合,可以增加诊断信息量,提高诊断正确率。     

多层螺旋CT在阻塞性睡眠呼吸暂停综合征诊断中的应用价值

目的:应用多层螺旋CT(multi-slice spiralcomputed tomography,MSCT)对确诊阻塞性睡眠呼吸暂停综合征(obstructive sleep apneasyndrome,OSAS)患者进行上气道成像,分析其形态特点。方法:确诊的OSAS患者28例,对照者14例,于深吸气末、深呼气末、平静呼吸、(Muller)动作时行上气道MSCT扫描,测量各咽部水平截面积及相应的矢、横径、软腭的长度、厚度,判断上气道的阻塞情况,计算气道塌陷度。结果:(1)OSAS组腭后区及舌后区截面积比对照组明显狭窄,且多发生在吸气时相。(2)OSAS组腭后区及舌后区的气道塌陷度较正常人高。(3)OSAS组软腭…     

闭合性喉气管外伤27例

目的 探讨闭合性喉气管外伤的特点,总结诊断及治疗方法。方法 27例患者中有严重软骨骨折和Ⅲ级以上吸入性呼吸困难的采用手术治疗,其余均保守治疗。结果 死亡1例,术后遗有喉狭窄1例,治疗效果较好25例。结论 闭合性喉气管外伤必须引起重视,对于手术治疗的方式以及术后管理还需要进一步探讨。     

严重颈部闭合性损伤致喉气管断裂的救治体会(附8例报告)

从1976年12月到1996年9月,我们救治了8例严重闭合性损伤致喉气管断裂的患者,男6例,女2例,年龄13～36岁,平均24岁。结果2例死亡,1例死于出血窒息,另1例尚未来得及手术而死亡;1例因救治不当发生喉气管狭窄而需进一步整复,其余5例恢复了喉的功能。强调在修复术中应最大限度地保留破碎的软骨膜、软骨和粘膜。本文重点讨论严重颈部闭合性损伤致喉气管断裂的发病机理、临床特点及急救原则。     

Pediatric laryngeal trauma: a case series at a tertiary children's hospital

Background

Pediatric blunt or sharp laryngotracheal injuries are infrequent because of the softer cartilages and the protection of the prominent mandible. These injuries usually occur secondary to striking furniture or via the “clothesline” injury.

Methods

We present five cases of pediatric laryngotracheal injury (thyroid cartilage, true vocal cords, cricoid cartilage, cricotracheal junction, and posterior tracheal wall).

Results

We examined the need for intubation, need for tracheostomy, length of intubation, length of hospital stay, interval until direct laryngoscopy, use of steroids, post-injury swallowing, and post-injury phonation.

Discussion

Three of the five patients were intubated either prior to arrival or upon arrival to the emergency department. Two of the patients underwent direct laryngoscopy on the day of arrival. Three patients received steroids. CT (computed tomography) was not helpful in diagnosis or decision regarding treatment. The patients with thyroid cartilage fracture, cricoid cartilage fracture, cricotracheal separation, and posterior tracheal wall tear required open repair. The tracheal wall injury, cricoid fracture, and cricotracheal separation were repaired with sutures and the thyroid cartilage fracture with a plate and screws. One tracheal stent was placed. Two open repairs were performed within 24 h of injury. The patient with posterior tracheal wall injury experienced persistent dysphagia and dysphonia, which may have been secondary to intraoperative dissection.

Conclusion

Dyspnea was not necessarily indicative of the severity of injury in our patients. CT added little information about the integrity of the larynx not already known by physical examination. Open repair was usually indicated for the blunt neck injuries in our series. Oral intubation proved less difficult than tracheostomy in our patient with cricoid cartilage fracture.     

Anterior and posterior cartilage graft dimensions in successful laryngotracheal reconstruction

OBJECTIVE: To describe the dimensions of cartilage grafts used for successful laryngotracheal reconstruction, with the goal of establishing appropriate sizes for "off-the-shelf" tissue-engineered cartilage grafts. DESIGN: A retrospective review of prospectively maintained operative illustrations of a single surgeon's experience. SETTING: Two tertiary children's hospitals. PATIENTS: A consecutive sample of 54 patients (tracheotomized or intubated) with a diagnosis of subglottic stenosis. INTERVENTIONS: Each patient underwent anterior (n = 30), posterior (n = 3), or anterior and posterior (n = 22) laryngotracheal reconstruction. Rib cartilage was used in 51 patients and thyroid cartilage was used in 3 patients. MAIN OUTCOME MEASURE: Successful or failed extubation. RESULTS: Of the 54 patients, 48 (89%) were successfully decannulated. The mean +/- SEM length of the anterior graft was 20.7 +/- 10.3 mm, and the mean width of the anterior graft was 7.7 +/- 2.5 mm. The mean length of the posterior graft was 13.9 +/- 2.9 mm, and the mean width of the posterior graft was 4.2 +/- 0.9 mm. CONCLUSIONS: With the prospect of tissue-engineered cartilage implants becoming available for laryngotracheal reconstruction, the most appropriate templates for designing these implants should be based on the geometric dimensions of grafts carved from native tissues in cases that have been successfully decannulated. Based on our analysis, the use of 2-mm increments for the posterior grafts suggests a set of molds that are 2, 4, and 6 mm wide and 22 mm long. Using 2 x 2-mm increments for the anterior grafts indicates that 36 mold sizes will be sufficient for 90% of predicted cases.     

Airway salvation after failed anterior graft in a child with long segment stenosis

Objectives

1-Recognize difficulties and review techniques in long-segment laryngotracheal stenosis repair. 2-Contribute to increasing clinical and surgical skills in pediatric airway reconstruction through reporting our experience with a novel reconstruction technique involving use of a failed anterior graft and prolonged postoperative stenting.

Methods

Case report: 10 year old male with history of burn injury who required a tracheostomy due to prolonged intubation/inhalational injury in 2005. Subglottic/tracheal stenosis was identified and he subsequently underwent anterior costal cartilage grafting involving the thyroid cartilage, cricoid cartilage, and trachea. He remained tracheostomy dependent for six years due to failed graft and postoperative complications despite several attempts to improve the airway with CO2 laser and balloon dilation. In 2011, preoperative CT with 3D reconstruction revealed a 32 mm long segment of complete stenosis. The patient underwent suprahyoid release and single stage reconstruction with cricotracheal resection and partial preservation of the anterior costal cartilage graft found in the luminal scar tissue.

Results

Postoperatively the patient was stented with a nasal endotracheal tube for 2 weeks. Bronchoscopy showed mild tracheal collapse inferior to the site of anastamosis and granulation tissue at the site of anastomosis. Granulation tissue was removed and the subglottic anastomosis site was stented with a 2 cm Dumon stent for 6 months.

Conclusion

The problem of long segment stenosis after failed cartilage graft reconstruction of the airway is evaluated and a novel technique of laryngotracheal reconstruction involving a pre-existing failed anterior graft and short segment stenting is described.     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的 探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因，提高喉气管狭窄成形术技术。方法 回顾分析第四军医大学唐都医院1983－2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情衣治疗效果，研究其成败原因及解决方法。结果 36例中29例（80．5％）一次成形术成功治愈，拔除气管切开大管，恢复正常呼吸，经1－10年随访，疗效巩固。7例失败未愈。失败原因：局部皮肤血管循环差（大剂量放射治疗后，反复多次手术局部瘢痕重），伤口感染软骨坏死排出，T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质。结论 用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单，带T形管时间短，疗效好。缺点是增加一个手术切口，游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法。选择好适应证，术后加强护理，正确应用支撑器可以提高疗效。     

Composite hyoid-sternohyoid interposition graft in the surgical treatment of laryngotracheal stenosis

This article reports six patients with severe laryngotracheal stenosis. The causes of stenosis were tracheotomy (two cases); prolonged endotracheal intubation (one case); laryngeal trauma (two cases); and surgery with postoperative chemo- and radiotherapy, addressing a thyroid gland follicular adenocarcinoma (one case). Two patients were already tracheotomized. The main postoperative complication was necrosis of the graft in a female patient who had previously undergone treatment for thyroid follicular adenocarcinoma. All patients were decannulated 6 months postoperatively. Five patients were then regularly followed up, but we lost contact with one patient. Comparison between pre- and postoperative pulmonary function testing revealed an increased maximum inspiratory flow (V _i max₅₀) in five cases between 0.57 l/s and 2.18 l/s. A helical scan with 3-dimensional reconstruction of the cervical area in four patients confirmed the presence and preservation of the hyoid bone graft. Four patients remained satisfied with their postoperative voice quality, one patient was dissatisfied, and one patient was not followed up. This technique is effective in adults with severe laryngotracheal stenosis, restricted to the first tracheal rings, providing one takes into consideration the main contraindications of the procedure: past history of radiotherapy and thyroid surgery. Received: 25 February 2000 / Accepted: 5 September 2000     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因,提高喉气管狭窄成形术技术.方法回顾分析第四军医大学唐都医院1983～2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情及治疗结果,研究其成败原因及解决方法.结果 36例中29例(80.5%)一次成形术成功治愈,拔除气管切开套管,恢复正常呼吸,经1～10年随访,疗效巩固.7例失败未愈.失败原因局部皮肤血循环差(大剂量放射治疗后,反复多次手术局部瘢痕重),伤口感染软骨坏死排出,T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质.结论用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单,带T形管时间短,疗效好.缺点是增加一个手术切口,游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法.选择好适应证,术后加强护理,正确应用支撑器可以提高疗效.     

Prefabricated composite free flaps for tracheal reconstruction: a new technique

OBJECTIVES: Successful laryngotracheal reconstruction requires both structurally supported tissue that withstands airway pressure changes and well-vascularized epithelial lining to prevent granulation and stricture formation. For circumferential defects, end-to-end anastomosis achieves favorable results, but for long-segment or large noncircumferential defects, no proven methods have emerged. Several animal studies describe prefabricated soft tissue flaps wrapped around synthetic materials or cartilage. However, prefabricated flaps have had very little use in human airway reconstruction. We present a patient with laryngeal stenosis and tracheostomy dependence following chemoradiotherapy for hypopharyngeal carcinoma. METHODS: In an attempt to widen the patient's laryngeal airway, a thyrotracheal autograft procedure, previously described by our institution, was performed. We transferred a segment of hemitrachea cephalad using the thyroid gland as a "vascular carrier," thus creating an 8-cm-long trough inferiorly that involved a 40% defect of the anterior tracheal circumference. Severe radiation damage to the cervical skin precluded use of traditional tracheoplasty methods. We used a technique whereby costal cartilage strips were implanted into a radial forearm free flap, designed to replicate the anterior tracheal wall. RESULTS: Four weeks later, we harvested the prefabricated composite flap and placed it into the defect, using forearm skin as tracheal lining. The cervical skin defect was closed with an island deltopectoral flap. A soft stent was kept in the neotrachea for 3 weeks, and a tracheostomy tube was left beneath it. The tracheostomy was subsequently closed with local advancement flaps, and the patient currently maintains an excellent airway. CONCLUSIONS: Prefabricated composite free flaps are an attractive option for certain challenging cases of airway reconstruction.     

Laryngotracheoplasty in early childhood

Because of increased risk of surgery in infancy and because surgery at this age may affect laryngotracheal growth it is preferable to postpone open surgical correction of congenital or acquired laryngotracheal stenoses until pre-school or even school age. However, early intervention by one of the surgical methods available today appears to be justified if a child with a tracheostomy has unsatisfactory home surroundings, if the tracheostomy impedes a rehabilitation programme or if the laryngeal stenosis does not allow voice production. Of 42 children with congenital (14) or acquired (28) laryngotracheal stenosis, 13 were operated between the ages of 3 months and 6 years. The following surgical methods were used, depending on the type and degree of stenosis: (1) submucosal scar resection (5 cases); (2) "stepped incision" as described by Evans and Todd (2 cases); (3) widening of the anterior wall by an autogenous cartilage graft as described by Cotton (2 cases); (4) laminotomy with interposition of an autogenous cartilage graft as described by Rethi (3 cases); (5) multiple-staged laryngotracheal reconstruction with regional skin flaps and repeated cartilage grafting (1 case). The soft silicon Montgomery T tube was preferred in all cases for stenting the reconstructed laryngotracheal lumen, because it seems to be the most convenient and safest method. The importance of painstaking postoperative intensive care is emphasized. Up to now 11 patients have been extubated, but 4 of them show a mild restenosis. The history of one child who has not yet been decannulated is reported in detail to demonstrate the limits of laryngotracheoplasty in early childhood.