【作者】 韩英；

【导师】 徐伟；

【作者基本信息】 山东大学 ， 耳鼻咽喉科学， 2020， 硕士

【摘要】 研究目的:先天性梨状窝瘘管包括传统概念的第三鳃裂瘘管和第四鳃裂瘘管,大部分患者在儿童期发病,多数患者以反复发作的甲状腺化脓性炎症或颈部红肿、脓性包块形成而就医。以前最早的治疗方式是以颈清扫的方式切除颈动脉鞘内的全部瘢痕、肉芽组织及同侧甲状腺,并延甲状软骨板侧缘探查至内瘘口,一并结扎。往往手术后颈部损伤严重,术后遗留并发症不少,颈部形成不同程度的瘢痕,影响美观,尤其因为影响发育,不适用于儿童期的梨状窝瘘患者。目前国际国内均开展内镜下通过烧灼内瘘口的方式治疗梨状窝瘘,减轻颈部创伤,更有利于治愈儿童期的病人。但是这些烧灼手术的首次治疗失败率较高,病人往往需要多次手术才能彻底治愈本病。本研究探讨以支撑喉镜下通过内瘘口的化学烧灼加缝合术、并同期颈部切开引流为主要术式治疗梨状窝瘘的疗效。研究方法:我们对自2012年3月至2020年1月我们耳鼻喉头颈外科采用内瘘口化学烧灼加缝合术同期行颈部脓肿切开引流术治疗的75例梨状窝瘘的病人的临床资料进行分析与综合。患者一般情况:男40例,女35例,年龄1-67岁(≤8岁者32例,>8岁者43例),梨状窝瘘位于左侧颈部者64例、右侧7例、双侧4例。8例病人是以前在外院行颈部开放性瘘管切除,手术术后复发的,2例病人是在外院支撑喉镜下行内瘘口的CO2激光烧灼术后又复发的,2例为外院甲状腺切除术后咽瘘、电子喉镜检查发现内瘘口,剩余63例患者单纯给予多次的颈部炎症切开引流,没有行内镜下微创手术或颈部的有创性手术治疗。所有患者都有过反复发作的甲状腺化脓性炎症或颈部红肿、脓性包块形成,入院时97.33%(73/75)的患者表现为颈部感染急性期。5例因颈部感染导致内瘘口周围的梨状窝粘膜炎症反应者,先行颈部切开引流,待内瘘口周围炎症反应消退后,再行内瘘口的化学烧灼外加缝合术;2例患者就诊时颈部处于炎症静止期,仅给予内瘘口的封闭术,而颈部炎症未给予切开引流;其余68例患者均同期行内瘘口化学烧灼+缝合术并颈部脓肿切开引流。所有患者在内瘘口封闭术后鼻饲流质饮食7-10天,颈部脓腔每日清创、换药。研究结果:73例(75侧)内瘘口经支撑喉镜下化学烧灼外加缝合术后一期闭合,手术一期成功率97.33%;7-10天后拔出胃管经口进食。2例内瘘口术后未能一期闭合的患者,分别于术后8个月和17个月再次行支撑喉镜下内瘘口化学烧灼加缝合术,术后痊愈。2例就诊时处于颈部感染静止期的女性幼儿患者,未同期行颈部切开引流,虽然术后内瘘口闭合好,但是患者分别于术后第1个月和第10个月出现颈部感染复发,随给予颈部感染进行切开处理,彻底搔刮清理其内炎性病变组织,置碘仿纱条,使病变组织得以引流,每日给予换药,使颈部形成新的瘢痕组织后没有再复发。术后随访半年到8年,已封闭的内瘘口瘢痕愈合好、颈部感染无复发。所有患者均无声带麻痹、吞咽障碍等严重并发症出现。结论:梨状窝瘘是导致颈部脓肿和化脓性甲状腺炎反复发作的最常见原因,支撑喉镜下内瘘口化学烧灼外加缝合术能够有效治愈梨状窝瘘,长期效果可靠;对于合并颈部感染急性期的患者,同期给予内瘘口的烧灼封闭术和颈部炎症给予切开引流术,内瘘口的愈合不会受到影响。我们采用的内瘘口先烧灼在缝合,同期行颈部炎症切开引流的手术方式,手术复发率几乎没有、对患者颈部损伤轻、手术后病人愈合时间短、并发症的发生率低,可以作为治疗梨状窝瘘的首选术式,尤其适用于儿童患者。更多还原

【Abstract】 ObjectivePyriform sinus fistula(PSF)is a rare condition which is due to embryological persistence or incomplete developmental anomalies.These patients usually present with repeated cervical infections and recurrences.Management options included traditional open-neck surgery,endoscopy-assisted open-neck surgery,and endoscopic obliteration of the sinus tract.Open neck surgery has widely been accepted as a definitive treatment for PSF,and endoscopic surgery has been reported in recent years However,both approaches are not satisfactory because of high recurrence rates and postoperative complications.The aim of this study was to evaluate the long-term effectiveness of the internal opening obliteration via endoscopic chemocauterization and suture as definitive treatment for pyriform sinus fistulae.MethodsA retrospective review of 75 cases of PSF treated at our department from 2012 to 2020.32 cases younger than 8 years old,43 patients older than 8 years old.Most of PSF presented as recurrent suppurative thyroiditis and neck infection mainly on the left side.All of them were treated with obliteration of the internal opening via endoscopic chemocauterization and suture.The patients presenting with acute neck abscess was performed with simultaneously neck external incision and drainage.The patients were fed through nasal feeding and performed neck debridement daily after endoscopic surgery.ResultsOf 75 patients,97.33%(73/75)of all internal opening recovered and experienced no recurrence after their first endoscopic surgery.Recurrence was developed in 2 patients in the follow-up period,they were treated with recauterization and suture 8 or 17 months after the first treatment,and then recovered.All of them treated with endoscopic surgery showed no recurrence with a follow-up period of 6-96 months.There were no complications occurred.ConclusionEndoscopic obliteration of the internal opening via chemocauterization and suture combined with simultaneously neck external incision and drainage is a safe and effective management option for pyriform sinus fistulae.Endoscopic surgery in infected state isn’t a negative influence for optimal patient outcomes.We advocate using this minimally invasive technique as first line of treatment for pyriform sinus fistula.更多还原