腺样体肥大一定需要手术治疗吗?

儿童腺样体肥大在临床上很常见,很多家长很担心它引起的副作用,对是否需要手术以及手术的并发症等相关情况顾虑重重,现就腺样体相关解剖、生理、腺样体肥大的手术治疗相关情况简要介绍如下:

一、腺样体的解剖:

腺样体又称增殖体或咽扁桃体,是位于鼻咽顶壁与后壁交界处的淋巴组织,是咽淋巴环重要组成部分,正常生理情况下,儿童2-6岁时增生最显著,10-12岁左右逐渐萎缩,15岁前后萎缩至成人程度,成人基本消失。若腺样体增生,并引起相应症状者称为腺样体肥大。

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二、腺样体肥大的诊断方法:

临床检查腺样体肥大的方法较多,如前鼻镜检查、鼻咽部指诊、间接鼻咽镜检查、电子鼻咽镜或鼻内镜检查等,在影像学方面有鼻咽侧位X 线平片、计算机摄影、数字化摄影、计算机层析成像和磁共振成像。具体如下:

1.鼻内窥镜检查:鼻内窥镜检查能够直接反映腺样体的大小、颜色、形态、是否压迫咽鼓管咽口及堵塞后鼻孔的面积,此检查安全性及诊断准确性较高。

  1. 影像学检查:包括鼻咽部侧位X线片检查及鼻咽部CT检查,能够测量鼻咽气道阻塞程度,观察邻近骨质,易于鉴别诊断。

3.睡眠检查:

①多导睡眠监测( Polysomnography,PSG) ,包括监测患儿夜间的眼动电、脑电、心电、肌电、呼吸气流、胸腹运动、氧饱和度、体位、鼾声、经皮/呼气末二氧化碳分压等。虽然PSG在儿童中的应用有一定局限性和不足,但是对于腺样体肥大患儿,在条件允许的情况下应首先建议进行标准PSG监测,以便明确睡眠呼吸暂停的严重程度、夜间缺氧状况、睡眠质量等。

② 家庭式便携式睡眠监测,其导联较少,且不被限定在实验室,患儿及家长更容易接受。对于不便开展睡眠实验室监测的一些科室或基层医院,可建议腺样体肥大患儿进行便携式睡眠监测,以初步评估其睡眠呼吸障碍。此外动态氧饱和度监测也可作为检测儿童睡眠呼吸障碍性疾病的一个初筛手段。

  1. 儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS) 疾病特异性生活质量调查( OSA-18) 量表:评估腺样体肥大患儿生活质量,以期了解OSA-18 量表是否可作为临床评估腺样体肥大患儿生活质量状况的指标。对手术治疗前后儿童阻塞性睡眠呼吸障碍( obstructive sleep disordered breathing ,OSDB) 患者的生活质量进行评估。( OSA-18) 量表中包括睡眠障碍、身体症状、情绪不佳、白天影响、对患儿监护人的影响程度等5 个维度; 每个维度又分为3-4 个条目,共18项条目。以7点顺序评分记录症状出现的频繁程度,依次为1-7分。评分越高,提示疾病对生活质量的影响越严重。

三、腺样体肥大的诊断标准:

  1. 鼻内窥镜检查: Ⅰ度阻塞: 腺样体阻塞后鼻孔25% 以下; Ⅱ度阻塞: 腺样体阻塞后鼻孔26%~50%; Ⅲ度阻塞: 腺样体阻塞后鼻孔51%~75%; Ⅳ度阻塞: 腺样体阻塞后鼻孔76%~100%; Ⅲ度以上伴有临床症状为腺样体肥大。
  2. 影像学检查: 以腺样体最突出点至颅底骨面的垂直距离为腺样体的厚度A,硬腭后端至翼板与颅底交点间的距离为鼻咽通气道的宽度N。A/N≤0.60 属正常范围; A/N 在0.61 ~0.70 之间属中度肥大; A/N≥0.71 即为病理性肥大。但是需排除急性上呼吸道感染期、鼻咽部肿瘤、鼻息肉等病变患者。

四、腺样体肥大的病因

腺样体肥大是生理现象,也有病理和继发性因素,多发人群为儿童,病因未明,可能与炎症反应有关,目前研究证实,机体免疫功能低下,当鼻咽部等受到反复炎性刺激或有腺样体自身炎性反应时,可逐渐引起腺样体的增生性肥大。另外空气污染、遗传因素、相关邻近器官炎症(鼻腔、副鼻窦、扁桃体炎症)、上呼吸道感染、不良生活习惯、变态反应、营养不良、内分泌等也是继发腺样体肥大的诱因。

五、腺样体肥大的临床表现及危害。

腺样体肥大在儿童中为常见病或多发病之一,其发病率约为10% ~ 30%。主要引起患儿的鼻咽部狭窄,进而导致阻塞型睡眠呼吸暂停低通气综合征、听力障碍和颌面部发育障碍等,严重时可影响到神经系统、内分泌系统、心血管系统等损害。

1.鼻部症状:阻塞后鼻道,影响上颌窦、前组筛窦和额窦引流形成阻塞性炎症。主要表现为鼻塞、流涕、闭塞性鼻音等。

  1. 鼻后滴漏综合征(postnasal drip syndrome,PNDs):咽部分泌物增多,引起咽痛,咳嗽,咳痰,易发生支气管炎,还可引起厌食、呕吐、消化不良等消化系统症状。

3.影响儿童颅颌面骨骼发育:腺样体肥大儿童因长期的呼吸道阻塞和张口呼吸,引起神经肌肉的异常活动,可能导致儿童颅颌面骨骼发育异常,如上颌骨变长,硬腭高拱,牙列不齐,唇肌松弛、开唇露齿、唇外翻,上唇短厚翘起,下颌骨下垂,面部缺乏表情,呈迟钝或茫然面容,即所谓的“腺样体面容”。

4.耳部症状:腺样体肥大对咽鼓管咽口造成堵塞或长期压迫,就很有可能发生中耳炎,导致耳痛、耳闷胀感、耳鸣、听力下降。一般认为,腺样体肥大引起的分泌性中耳炎的原因包括:①腺样体内部是容易滋生引发分泌性中耳炎病毒的场所;②咽鼓管出现反流; ③腺样体的免疫功能出现异常; ④咽鼓管出现机械性障碍或者功能障碍等。

  1. 儿童阻塞性睡眠呼吸暂停综合征:腺样体肥大最主要的危害是可导致儿童阻塞性睡眠呼吸暂停综合征( Obstructive Sleep Apnea Syndrome,OSA),反复发作的低氧血症和高碳酸血症,导致大脑的慢性缺氧,由此导致神经体液的一系列改变。如: 神经调节功能失衡,儿茶酚胺、肾素-血管紧张素、内皮素分泌增加,微血管收缩,内分泌功能紊乱,血流动力学改变,微循环异常等。可影响到神经系统、内分泌系统、心血管系统等多系统并发症,特别是对心、肺、脑血管损害。主要表现为:遗尿、表情迟钝、记忆力下降、生长发育迟缓、注意力不集中、学习困难、智力减退、厌食、消化不良、多动障碍、焦虑,抑郁、胸闷不安、肺扩张不好,日久导致鸡胸或扁平胸等。

六、腺样体肥大的治疗方法:

1.一般治疗与预防: 预防感冒、避免接触过敏原、合理饮食,如减少甜食及油腻食物的摄入、减少或尽量避免二手烟的吸入。锻炼身体、控制体重等也可能对腺样体肥大及睡眠呼吸障碍有改善作用。轻度腺样体肥大患儿,若未引起明显局部症状及睡眠呼吸紊乱,早期应重视生活调整,并密切关注疾病进展及症状表现。

2.药物治疗:

采用鼻用激素、大环内酯类抗生素及黏液促排剂,对伴有分泌性中耳炎、鼻窦炎等需要同时治疗。

3.传统医学疗法: ①中医中药内服疗法: 辨证施治,专病专方。②外治法: 针刺法、艾灸法、拔罐法、耳穴压丸法、熏鼻法、刺络法等。

4.鼻腔冲洗

鼻腔冲洗作为鼻窦炎及鼻腔鼻窦术后重要的治疗手段之一, 具有清理鼻腔鼻窦及鼻咽部的脓性分泌物、清除局部炎性介质、改善局部黏膜环境、促进局部炎性反应好转的作用, 能改善由于胃食管反流、变态反应上气道炎性反应等导致的鼻咽部黏膜病变。如:予高渗海盐水200 mL (清诺, 内含3% 高渗盐水) 喷鼻腔, 3 次/日, 连续使用4 -8周。

5.手术治疗

①鼻内镜下低温射频消融切除术

鼻内镜下低温射频消融切除术治疗儿童腺样体肥大。因低温等离子射频刀在切割时具有止血作用,且治疗温度低,因而不易造成周围正常组织的损伤。

② 鼻内镜下电动吸切器法切除术

鼻内镜下电动吸切器法切除腺样体,术中腺样体可直视、清晰、无残留、止血彻底、并发症少。

③传统腺样体刮除术

术中凭经验切除腺样体,不易掌握深度,易出血及出现咽鼓管损伤等

鼻内镜下低温等离子及电动吸切器治疗腺样体,视野清楚、操作简单、微创、出血少、痛苦小,明显优于传统腺样体刮除术。临床上适合手术治疗的腺样体肥大患者,可首选鼻内镜下低温等离子或电动吸切器切除腺样体。

七、腺样体手术切除的适应症:

1.腺样体肥大引起张口呼吸、打鼾或有闭塞性鼻音。

2.腺样体肥大可堵塞咽鼓管咽口引起分泌性中耳炎出现听力下降者或导致化脓性中耳炎反复发作久治不愈者。

3.已形成“腺样体面容”并有消瘦、发育障碍者。

4.腺样体肥大伴鼻腔、鼻窦炎症反复发作或上呼吸道感染频发者。

鉴于研究表明高渗海水( 希诺宁或清诺等) 联合联合鼻用激素鼻腔局部用药,以及孟鲁司特联合鼻用激素、鼻用激素联合克拉霉素等治疗儿童腺样体肥大,对症状改善及腺样体体积缩小有明显的作用,所以建议在常规腺样体手术前通过药物治疗1-2个月筛查患儿,可明显降低手术率。

七、腺样体切除术后对身体的影响。

1.明显改善儿童阻塞性睡眠呼吸暂停综合症。

儿童阻塞性睡眠呼吸暂停的主要病因是扁桃体及腺样体肥大,手术切除扁桃体及腺样体效果十分肯定。手术治疗对患者健康相关的生活质量改善有意义。

2.对身体免疫功能的影响。

腺样体因自身含有各个发育阶段的T 淋巴细胞、B 淋巴细胞、浆细胞及树状细胞等具有参与中央及外周淋巴器官相似的免疫调节机制作用,各种变应原均能产生T 淋巴细胞和细胞免疫作用。小儿生长过程中腺样体利用其腺体组织中具有免疫活性的淋巴细胞、上皮细胞、巨噬细胞和其他辅助细胞参与免疫活动,使IgA、IgG 等高亲和性抗体显著增加,发挥抗感染作用。作为机体第一道防线的IgA、IgG、IgM,其检测有助于了解机体抵抗感染能力。

术后随诊发现反复呼吸道感染的发生次数虽有减少,但却比术前的感染程度加重,支气管炎、支气管肺炎发生率增加,其原因可能与低龄儿童在全身免疫系统尚未发育完善,局部免疫组织起主导作用的时期去除腺样体这一重要器官,造成患儿暂时性免疫缺陷有关。

研究表明,腺样体切除术后1个月时,IgG、IgA 、IgM 及CD3 、CD4 、CD8 均较术前下降,但差异无统计学意义(P>0.05),但不低于小儿体液免疫的正常范围,术后3-4个月上述免疫功能指标均恢复至术前水平

由此可知,腺样体切除治疗OSAHS 疗效显著,短期免疫指标虽然有所下降,但长期免疫参数均可恢复至正常水平,不会对患儿术后免疫功能产生严重影响。

3.手术早期出血和感染

随着手术方式的改进,及有效抗生素的使用,在鼻内镜下低温等离子及电动吸切器治疗腺样体,具有视野清楚、微创、极少出现出血和感染。

八、腺样体肥大患儿治疗方案的选择:

  1. 腺样体肥大患儿需要考虑患儿的免疫功能发育,且麻醉手术风险较大,不建议在患儿免疫系统发育前进行切除,所以排除3岁以下的患儿;

2.腺样体肥大患儿,特别是合并有鼻窦炎、扁桃体肥大的患儿,首先进行需进行1-2个月的规范治疗,同时注重评估腺样体体积的变化。有部分患儿治疗后对症状改善及腺样体体积缩小有明显的作用,能达到症状和体征改善的目的,继续保守治疗。常规腺样体手术前通过药物保守治疗1-2个月筛查患儿,治疗无效者建议手术治疗,可明显降低手术率。

3.严重听力受损和生长发育障碍的患儿,都应尽早进行切除治疗,以防病情的进一步恶化等。

4.如果儿童晚上睡眠很差,有憋气,而且时间已经很长( 超过6 周) ,或反复出现这种情况,鼻内窥镜检查和CT 检查提示腺样体肥大明显,经保守治疗无效,即使小于3 岁以下也考虑手术。

5.如果伴有鼻炎、鼻窦炎、中耳炎等并发症,经过治疗无明显好转,特别是中耳炎伴有听力下降的,即使腺样体肥大不重,也考虑尽早切除

6.腺样体肥大的3 岁以下小儿如果出现以下症状建议手术: 身材矮小,体重偏低,腺样体面容,鸡胸或平胸,遗尿,夜间盗汗,精神萎靡或嗜睡,多动症,反应迟钝或性情暴躁等建议手术。

7.如腺样体肥大引发儿童阻塞性睡眠呼吸暂停综合征( Obstructive Sleep Apnea Syndrome,OSA) 的患儿已出现神经系统、内分泌系统或心血管系统并发症,应考虑手术治疗。

总之,腺样体肥大患儿,首先药物保守治疗,对药物治疗无效者要果断行手术治疗。腺样体有一定免疫功能,腺样体肥大手术原则上3周岁以上手术,但是腺样体肥大出现明显并发症,影响患者生长发育者,经保守治疗无效者,即使小于3周岁也应该及时手术治疗。手术出院后还需针对病因进行治疗,积极治疗鼻炎、鼻窦炎和分泌性中耳炎,直至完全恢复,营养不良患儿加强营养,锻炼身体,尽快使生长发育恢复正常。

 

 

 

腺样体肥大一定需要手术治疗吗?》上有3,853条评论

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