传统及改良悬雍垂腭咽成形术对持续正压通气治疗的影响

目的　探讨传统悬雍垂腭咽成形术 (uvulopalatopharyngoplasty ,UPPP)及改良悬雍垂腭咽成形术后对阻塞性睡眠呼吸暂停低通气综合征 (obstructivesleepapnea hypopneasyndrome ,OSAHS)患者持续正压通气 (continuouspositiveairwaypressure,CPAP)治疗的影响。方法　选择传统UPPP及改良UPPP的OSAHS患者分别为 2 4例和 42例 ,术后随访 1 2个月以上 ,比较两种术式的疗效 ,并对其中的2 4例传统UPPP和 1 5例改良UPPP术后患者进行睡眠状态下CPAP治疗压力耐受性测试。结果　术后 1年两种术式治疗OSAHS的有效率分别为 58 3 %和 61 9% ,差异无显著性。 2 4例传统UPPP患者术后有 4例 (1 6 7% )患者在CPAP治疗时产生严重的口腔漏气 ,不能耐受CPAP治疗 ;1 5例改良UPPP术后患者的CPAP压力耐受性与未行手术者相似。结论　OSAHS患者手术时应尽量保留悬雍垂 ,保留咽腔基本解剖结构 ,为下一步的CPAP治疗提供良好的基础     

纤维内窥镜检查筛选UPPP病例

目的探讨筛选悬雍垂腭咽成形术 (UPPP)病例的简便方法,以期提高UPPP的疗效.方法58例阻塞性睡眠呼吸暂停综合征(OSAS)患者术前行纤维内窥镜下Muller's动作检查,确定阻塞平面.结果经筛选后,44例接受UPPP术,42例疗效满意,总有效率为95.45%.结论术前行纤维内窥镜下Muller's 动作检查,有助于筛选病例,提高UPPP的有效率.     

传统及改良悬雍垂腭咽成形术对持续正压通气治疗的影响

目的 探讨传统悬雍垂腭咽成形术(uvulopalatopharyngoplasty，UPPP)及改良悬雍垂腭咽成形术后对阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea—hypopnea syndrome，OSAHS)患者持续正压通气(continuous positive airway pressure，CPAP)治疗的影响。方法 选择传统UPPP及改良UPPP的OSAHS患者分别为24例和42例，术后随访12个月以上，比较两种术式的疗效，并对其中的24例传统UPPP和15例改良UPPP术后患者进行睡眠状态下CPAP治疗压力耐受性测试。结果 术后1年两种术式治疗OSAHS的有效率分别为58．3％和61．9％，差异无显著性。24例传统UPPP患者术后有4例(16．7％)患者在CPAP治疗时产生严重的口腔漏气，不能耐受CPAP治疗；15例改良UPPP术后患者的CPAP压力耐受性与未行手术者相似。结论 OSAHS患者手术时应尽量保留悬雍垂，保留咽腔基本解剖结构，为下一步的CPAP治疗提供良好的基础。     

阻塞性睡眠呼吸暂停综合征患者悬雍垂腭咽成形术后对嗓音影响的初步探讨

目的探讨阻塞性睡眠呼吸暂停综合征(OSAS)行悬雍垂腭咽成形术(UPPP)是否影响患者的嗓音质量和发音的难易程度。方法对15例无嗓音功能障碍的OSAS患者行UPPP术,对术前和术后的声学及空气动力学参数进行分析。结果 OSAS患者行UPPP术后发音质量和发音难易程度与术前相比并没有显著性差异(P0.05)。结论本文初步观察表明,UPPP对OSAS患者的嗓音质量无明显影响,值得进一步研究。     

悬雍垂腭咽成形术适应证选择

目的探讨悬雍垂腭咽成形术(uvulopalatopha-nyngoplasty,UPPP)的最佳手术适应证。方法经多导睡眠监测(polysomnography,PSG)确诊为阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)的216例中重度患者,根据年龄、体重指数、睡眠呼吸暂停低通气指数(apnea hypopneaindex,AHI)、血氧、最低血氧饱和度(LSaO2)、阻塞平面、阻塞类型等项检查中筛选出其中31例患者行UPPP手术治疗。结果本组近期有效率为93.5%,远期有效率为80.6%。结论UPPP手术疗效与手术前的适应证选择密切相关,提高UPPP疗效的关键在于选择合适病例。     

两种改良UPPP对重度OSAHS患者的疗效观察

目的比较不保留悬雍垂改良悬雍垂腭咽成形术(UPPP)和保留全部或部分悬雍垂改良UPPP对无下咽阻塞的重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者短期和长期的疗效.方法选择重度OSAHS患者27例,采用改良UPPP为主的综合治疗,全部病例术后随访6个月及2年,比较其疗效.结果不保留悬雍垂改良UPPP组15例,保留全部或部分悬雍垂改良UPPP组12例,术后6个月,后者总有效率为66.7%,前者总有效率为86.7%,但差异无显著性(P>0.05).术后2年,不保留悬雍垂改良UPPP组总有效率为73.3%,明显高于保留全部或部分悬雍垂改良UPPP组总有效率的33.3%,两组总有效率差异有显著性(P<0.05).结论根据不同的阻塞部位采用不同的改良UPPP术式是取得满意疗效的关键.     

悬雍垂腭咽成形术远期疗效观察

目的探讨悬雍垂腭咽成形术(uvulopalatophargngoplasty,UPPP)治疗阻塞性睡眠呼吸暂停低通气综合征(obstructivesleepapneahypopneasyndrome,OSAHS)的远期疗效。方法回顾性分析1996～2002年间行UPPP治疗的32例OSAHS患者的临床资料,疗效评定标准依据2002年中华医学会耳鼻咽喉科学分会(杭州)标准评定。结果22例白天嗜睡、缺氧状况改善,4例症状改善明显,6例症状无改善。结论单纯采用选择UPPP治疗OSAHS远期疗效较低。术前患者的选择和术式的选择尤其重要,不同的狭窄部位手术疗效亦有不同。     

阻塞性睡眠呼吸暂停低通气综合征患者术后血脂变化的研究

目的探讨阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OS-AHS)患者接受悬雍垂腭咽成形术(uvulopalatopharyngoplasty,UPPP)治疗前后血脂的变化。方法选取42例OSAHS患者组和40例正常对照组,均经多导睡眠监测(PSG)检查,并空腹抽取静脉血测定血脂水平。将两组血脂中的总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)、载脂蛋白-A(Apo-A)和载脂蛋白-B(Apo-B)进行比较。并对42例OSAHS患者行悬雍垂腭咽成形术(UPPP),术后6个月的相应检查指标与术前作比较。结果术前OSAHS组患者血中TG、TC、LDL、Apo-B高于对照组;Apo-A低于对照组,HDL有低于对照组趋势,但差异均无统计学意义,42例OSAHS患者经UPPP治疗6个月后,TG、TC、LDL、Apo-B及AHI与术前比较显著降低,Apo-A和HDL升高。结论OSAHS可引起脂代谢异常,行UPPP治疗有助于纠正OSAHS患者的脂代谢紊乱。     

阻塞性睡眠呼吸暂停低通气综合征患者腭咽成形术后并发症发生率对比分析

目的：评估悬雍垂腭咽成形术(UPPP)手术治疗OSAS患者术后出现咽部干燥、咽异物感等并发症发生率。方法：对经UPPP手术治疗后OSAS患者52例,进行术后随访评估。随访采用问卷方法,与正常人咽部干燥及咽异感症作对比。结果：随访5年中,OSAS组46例排除糖尿病的患者中,16例出现咽部干燥,对照组63例中12例出现,差异有统计学意义(P＜0.05);OSAS组22例出现咽异感症,对照组12例出现,差异有统计学意义（P＜0.01）。结论：OSAS患者UPPP术后咽异感症及咽部干燥患者较多,为创伤刺激及瘢痕愈合所致,应予重视。UPPP术后出现音色改变的可能性不大。     

阻塞性睡眠呼吸暂停综合征治疗模式的比较

目的 :分析比较阻塞性睡眠呼吸暂停综合征 (OSAS)不同治疗模式的疗效。方法 :将 5 2例患者分两组 :①单纯行悬雍垂腭咽成形术 (UPPP) (单纯UPPP组 ) 2 9例 ,②UPPP加经鼻持续正压通气 (CPAP)或口腔矫正器 (综合治疗组 ) 2 3例 ,进行治疗。结果 :两组近期疗效差异无显著性意义 (P >0 .0 5 ) ,但单纯UPPP组因术前未行CPAP治疗 ,故易出现手术并发症 ;两组远期疗效差异有极显著性意义 (P <0 .0 1)。结论 :OSAS采用多模式治疗是提高远期疗效的有效方法     

Laryngoscopies in the obese: predicting problems and optimizing visualization

OBJECTIVES: This pilot study was designed to 1) identify predictors of difficult laryngeal exposure in obese patients, 2) develop strategies for efficient intubation and intraoperative visualization of the glottis, and 3) devise perioperative protocols for difficult laryngoscopies. METHODS: We undertook a retrospective study over a 1-year period of 14 consecutive patients with a body mass index of more than 30 kg/M2 who underwent elective direct laryngoscopy under general anesthesia. Measurements of height, weight, neck circumference, Mallampati score, and Cormack-Lehane classification of the airway were recorded. Problems encountered during anesthesia induction and emergence were also noted. The laryngologist recorded on a visual analog scale the degree of difficulty encountered in obtaining a binocular stereoscopic view and magnification, illumination, and suspension. RESULTS: Anatomic challenges during difficult laryngoscopy included decreased neck extension, redundant folds of tissue in the oropharynx and hypopharynx, and upper airway collapsibility. Overall, there was an association between the incidence of difficult laryngeal exposure and the Cormack-Lehane score (r = .57; p = .03), but the Mallampati score was of limited utility to the laryngologist. Neck size in female patients correlated with the Cormack-Lehane score (p = .02). Neither weight nor body mass index were predictive of a difficult laryngeal exposure. Straight blade laryngoscopes with a distal flange allowed greater depth of insertion and provided the best visualization of the glottis. CONCLUSIONS: An appropriate clinical examination may help predict a difficult airway. However, further studies are warranted to fully characterize the anatomic predictors of a difficult laryngeal exposure.     

可视喉镜在先天性舌根囊肿患儿手术麻醉中的应用

目的 探讨可视喉镜与传统喉镜在先天性舌根囊肿患儿麻醉气管插管中的临床效果和安全性.方法 选择拟于气管插管全麻下行舌根囊肿切除术的患儿(Ⅰ～Ⅱ度呼吸困难)72例,随机分为传统喉镜组(M组)与可视喉镜组(G组).记录两组患儿气管插管时间、一次插管成功率、插管失败率、声门显露程度、插管前与插管时SpO2、HR及MAP的变化及...     

低温等离子治疗喉损伤性肉芽肿9例

目的 研究提高喉损伤性肉芽肿手术治疗效果的新方法。方法 9例喉损伤性肉芽肿患者中男2例,女7例;22～65岁,平均45岁; 9例患者就诊前1～3个月均有气管内插管史;经抗炎、禁声、雾化吸入治疗1～2月后无好转。2例尚有呼吸困难。在支撑喉镜下导入显微镜调整焦距,充分显露喉腔病变,开启流量泵和低温等离子射频消融系统,连接喉用7.0刀头,用脚踏板控制刀头,将等离子刀头置于肉芽肿表面,从上至下消融肉芽肿,直至肉芽肿基底,尽可能避免损伤周围黏膜。术后应用地塞米松及庆大霉素雾化吸入1周。结果 9例患者均一次手术成功,手术后肉芽肿复发1例,复发部位为对侧,经再次手术,未再复发。8例随访3个月～2年,未见复发,1例失访。病理检查证实,切取的肉芽组织表现为鳞状上皮黏膜慢性炎性反应,并有少量炎性细胞浸润。结论 低温等离子射频消融术治疗喉损伤性肉芽肿,为喉损伤性肉芽肿提供了一种安全、有效、微创的理想治疗术式,可避免术后复发。     

舌骨悬吊手术的并发症

目的探讨对重度阻塞性呼吸暂停低通气综合征（OSAHS）患者行悬雍垂腭咽成形术（UPPP）联合舌骨悬吊术时引起的并发症。方法对重度OSAHS患者行UPPP联合舌骨悬吊术109例,每例患者术前均行清醒状态纤维喉镜下Muller检查、上气道的X线片或上气道CT测量,术前确定阻塞平面为腭-咽及舌-咽平面,但以舌-咽平面为主,均行UPPP联合舌骨悬吊术,术后均于ICU保留气管插管监护1～2d。结果1例患者术中下颌骨下缘打孔过于偏下,穿线打结后丝线将下颌骨打孔处下缘撕裂;6例患者术后颈部切口出现脂肪液化;3例患者颏部切口反复红肿,考虑缝线局部刺激;2例患者术后出现颈部切口出血。所有患者在开始进食时有咽部、舌部不适,手术2～4d后舌体运动略有受限,一般在5～7d后舌体运动感觉正常。结论舌骨悬吊术的并发症较少,解除重度OSAHS患者的舌-咽平面的狭窄不失为一种简单、安全、有效的方法。     

阻塞性睡眠呼吸暂停低通气综合症手术的麻醉期处理

目的探讨阻塞性睡眠呼吸暂停低通气综合征（OSAHS）手术的麻醉期处理,减少手术麻醉风险。 方法对145例OSAHS患者根据咽部暴露程度进行Mallampati分级。快速气管插管组114例（Ⅰ～Ⅱ级）,清醒气管插管组25例（Ⅲ～Ⅳ级）,气管切开组6例（清醒气管插管组中体重大于100kg、短颈者）。快速气管插管组术毕待患者完全清醒后拔除气管导管、送监护病房。清醒气管插管组和气管切开组术后送重症监护室监护。 结果快速气管插管组和气管切开组均顺利插入导管,清醒气管插管组7例出现呼吸抑制,面罩辅助呼吸后插入导管。三组均未发生上呼吸道梗阻。快速气管插管组6例拔管时出现恶心、呕吐,8例出现呼吸抑制。 结论降低阻塞性睡眠呼吸暂停低通气综合征手术的围术期风险须重视术前访视,正确选择麻醉诱导方法,加强术中管理、合理选择用药,严格掌握拔管指证,加强术后监护。     

OSAHS患者手术麻醉中应用纤维喉镜引导经鼻行气管插管

目的 探讨在纤维喉镜引导下经鼻气管插管应用于阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者手术麻醉中的效果。 方法 选取OSAHS患者70例,将其分为纤维喉镜组和麻醉视频喉镜组,每组35例,观察2个组于纤维喉镜或麻醉视频喉镜引导下经鼻气管插管一次插管成功的例数、插管所用时间以及咽部损伤出血、咽后壁损伤、术中鼻腔活动性出血、术后鼻腔粘连、鼻塞等不良反应发生率。 结果 纤维喉镜组全部气管导管一次插管成功,平均所用时间(32.34±6.13)s,位置正确,麻醉全程无需调整。麻醉视频喉镜组5例患者有不同原因需要重新插管,均2次成功,平均所用时间(56.54±23.75)s,失败率14%(5/35)。纤维喉镜组插管所用时间明显优于麻醉视频喉镜组(P<0.05)。纤维喉镜组无1例出现鼻腔、咽喉黏膜损伤,术后患者插管侧鼻腔无鼻塞加重症状出现。麻醉视频喉镜组插管后鼻腔活动性出血3例,术后鼻腔粘连3例,咽后壁损伤3例。 结论 纤维喉镜引导气管插管可作为OSAHS患者困难气管插管首选,方式安全高效。     

喉非特异性肉芽肿治疗方法的优先选择

目的 探讨喉非特异性肉芽肿的综合治疗方式的优先选择及治疗效果。方法 确诊为喉非特异性肉芽肿的患者20例,对8例有气管插管史者,未经任何保守治疗即行支撑喉镜下手术治疗,术后吸入类固醇2周;12例无气管插管史者,给予制酸药为主,支撑喉镜下手术、吸入类固醇、语音疗法为辅的治疗。结果 所有患者治疗疗程结束后随访6个月,有气管插管史患者出现复发1例,经再次手术、术后吸入类固醇治疗后治愈;无气管插管史患者,10例仅经制酸治疗后症状完全消失,2例经同时配合予支撑喉镜下手术、吸入类固醇及语音疗法后治愈。结论 喉非特异性肉芽肿病因复杂,治疗方法多样,对于有气管插管史者,优先选择手术及术后吸入类固醇治疗可缩短治疗时间,疗效显著;对于无气管插管史者,优先选择以制酸治疗为主的综合治疗,疗效显著。     

Evaluación de la vía aérea mediante laringoscopia indirecta en pacientes con hipertrofia de la amígdala lingual

Introduction and objectivesPrevalence of the lingual tonsillar hypertrophy is unknown but it is believed that its presence is associated with the difficult airway. To investigate this, indirect laryngoscopy was performed on patients in the preoperative evaluation and this pathology was diagnosed. The relationship with difficulty of viewing the larynx, intubation and ventilation, under general anaesthesia and using direct laryngoscopy, was then studied.MethodsWe performed the demographic variable checks and tests for predicting difficult intubation (mouth opening, thyromental distance, cervical flexion-extension, neck thickness and Mallampati test), in the preoperative step on 300 patients who were going to be submitted to general anaesthesia. We then performed indirect laryngoscopy on them using a 70° rigid laryngoscope to ascertain the frequency of appearance of lingual tonsillar hypertrophy. Next, under general anaesthesia, we carried out direct laryngoscopy to verify whether there was difficulty in viewing the larynx and intubation and ventilation. We then investigated the association of demographic predictors of difficult intubation, including indirect laryngoscopy, with the presence of this condition.ResultsPrevalence of lingual tonsillar hypertrophy was 2%. No relationship between the appearance of this entity and the difficulty of viewing the larynx, intubation and ventilation was found. Only indirect laryngoscopy was linked to the appearance of this pathology.ConclusionsLingual tonsillar hypertrophy is a relatively frequent disorder, whose presence is not usually associated with difficult airway.     

Prediction of difficult laryngeal exposure in patients undergoing microlaryngosurgery

OBJECTIVES: Although difficult laryngeal exposure (DLE) is a common problem encountered during microlaryngosurgery, reliable predictors of DLE and grading systems of laryngeal exposure have been scarcely suggested in the field of laryngology. We propose a new classification of laryngeal exposure focusing on the extent of glottic visualization. METHODS: We investigated physical parameters that could predict DLE; 73 patients underwent a physical examination including 15 parameters. During endotracheal intubation and suspension laryngoscopy, Cormack-Lehane and laryngeal exposure scores were obtained for each patient and compared with the parameters. RESULTS: The patients' ages ranged from 23 to 77 years. The laryngeal exposure score was correlated with the Cormack-Lehane score (p < .001, r = 0.469). Of all parameters, body mass index, neck circumference, thyroid-mental distance, and horizontal thyroid-mental distance showed significant correlation with the laryngeal exposure score (p < .05). From analysis of the candidate parameters in 13 patients with DLE and the non-DLE group, we found that the cutoff values for predicting DLE were a body mass index of > 25.0 kg/m2, a neck circumference of > 39.5 cm, a thyroid-mental distance of < 5.5 cm, and a horizontal thyroid-mental distance of < 4.0 cm. CONCLUSIONS: According to the proposed classification of laryngeal exposure, patients with obesity, a muscular neck, or retrognathia are likely to present DLE, and preoperative measurement of the predictors may be useful in preparing for microlaryngosurgery.     

支撑喉镜下喉显微手术患者的体位改进

目的 探讨嗅物位对支撑喉镜下喉显微手术术野暴露的优势。 方法 选择拟行支撑喉镜下喉显微手术的嗓音疾病患者60例,随机分为嗅物位组(A组)及去枕仰卧位组(B组)2组,每组30例。A组患者予以枕下垫自制头枕,肩背部紧贴于手术台面,再将其头部伸展于寰枕关节;B组患者摆放去枕仰卧位。评价声门暴露情况,根据声带病变范围及性质行喉显微手术。 结果 (1)暴露声门耗时:A组(2.42±1.04)min明显短于B组(3.20±0.95)min,两组比较差异具有统计学意义(P<0.05);(2)手术并发症:A组术后喉部疼痛VAS评分低于B组,两组比较差异具有统计学意义(P<0.05);A组术后咽喉部黏膜损伤发生率(6.7%)明显低于B组(30.0%),术后舌部麻木及术中术后牙齿损伤情况基本无发生,与B组比较,术后恢复良好、手术并发症少。 结论 嗅物位较去枕仰卧位更有利于支撑喉镜下的声门暴露,耗时更短、手术并发症更少。