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上海耳鼻咽喉-头颈外科国际会议(汇编)  发帖心情 Post By:2004/4/17 18:41:00 [只看该作者]

2004’上海耳鼻咽喉-头颈外科学国际学术会议
暨2004’上海市耳鼻咽喉-头颈外科年会
2004’  Shanghai International Conference of Otorhinolaryngology
Head and Neck Surgery

论文汇编
Abstracts

中华医学会上海分会
上海市医学会耳鼻咽喉-头颈外科专业委员会
复旦大学附属眼耳鼻咽喉医院
2004年4月12日-14日
Chinese Medical Association Shanghai Branch
Shanghai Association of Otorhinolaryngology-Head and Neck Surgery
Eye.Ear.Nose and Throat Hospital , Fudan University
April 12-14, 2004

Greetings

Dear Colleagues and Friends,

On behalf of the organizing committee, I take great pleasure to welcome you to the 2004’ Shanghai International Conference of Otorhinolaryngology — Head & Neck Surgery.

In the last decade, great progress has been made in Otorhinolaryngology — Head & Neck Surgery. The 2004’ Shanghai International Conference of Otorhinolaryngology — Head & Neck Surgery will present a scientific program of up-to date quality covering all fields of Otorhinlaryngology on basic and clinical studies. We have invited world famous experts from United States, France, Canada, Belgium, Sweden, Japan, Singapore, Hong Kong and mainland China. Over the next few days, our guest speakers will deliver lectures and oral presentations. Meanwhile, panel discussion will be held for broad discussion on four topics. I am sure such broad international communications will be beneficial to every participants.  

I would like to thank all members of the organizing committee for their contributions to this conference.  Without their hard work, this conference would not have been possible.

As organizer, I sincerely hope that all the participants will have a fruitful and pleasant stay in Shanghai and hope you will have a memorable experience with valuable information in this wonderful occasion.

Lastly, I would like to express my best wishes for a successful conference and pleasant days for every participants!

Professor Liang ZHOU
Chairman
2004’ Shanghai International Conference of
Otorhinolaryngology — Head & Neck Surgery



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  发帖心情 Post By:2004/4/17 18:44:00 [只看该作者]

Guest Speakers

Professor Roger L. Crumley
Department of Otolaryngology - Head and Neck Surgery
University of California Medical Center
U.S.A

ProfessorP. Tran Ba Huy
Department of Otorhinolaryngology
Hopital Lariboisiere
Paris, France

Professor O. Sterkers
Department of Otorhinolaryngology
Hopital Beaujon
Paris, France

Professor J. Lacau St Guily
Department of Otolaryngology – Head and Neck Surgery    
Hopital Tenon
Paris, Fance

Professor JC. Pignat
Department of Otolaryngology – Head and Neck Surgery  
Hopital du Nord, Hopital de la Croix-Rousse
Lyon, France

Doctor D. Portmann
Institut Georges Portmann
Bordeaux, France

Professor T. Takasaka
Department of Otolaryngology
Sendai Hospital of Posts and Telecommunications
Sendai, Japan

ProfessorC. Bachert
Department of Otolaryngology
University of Ghent, Belgium
Professor J. Chen
Department of Otolaryngology
Sunnybrook & Women’s College Health Sciences Centre
University of Toronto,
Canada

Professor C.A. Hasselt
Department of Surgery, Division of Otolaryngology
Prince of Wales Hospital
Hong Kong

Doctor M. Tong
Department of Surgery, Division of Otolaryngology
Prince of Wales Hospital
Hong Kong

Doctor John K. S. Woo
Department of Surgery, Division of Otolaryngology
Prince of Wales Hospital
Hong Kong

Doctor K. Bergstrom
Implant Unit, Department of Otolaryngology
University of Goteborg
Sweden

Professor P.W. Yuen
Department of Surgery, Division of Otolaryngology
Queen Mary Hospital
University of Hong Kong
Hong Kong

Doctor Wang De-Yun
Department of Otolaryngology,
National University of Singapore, Singapore.

Doctor Jin Keat Siow
Department of Otolaryngology
Tan Tock Seng Hospital
Singapore


Doctor Low Wong Kein
Department of Otolaryngology
Singapore General Hospital
Singapore

Doctor Christopher Goh
Department of Otolaryngology
Singapore General Hospital
Singapore

Doctor Paul Mok
Department of Otolaryngology
Tan Tock Seng Hospital
Singapore

Doctor W. Qian
Institute of Cardiac-pulmonary Sleeping Disorder
Toronto General Hospital ,
Toronto University

杨伟炎教授
中国人民解放军总医院耳鼻咽喉头颈外科
北京

韩德民教授
北京同仁医院耳鼻咽喉头颈外科
北京

屠规益教授
中国医学科学院肿瘤医院头颈外科
北京

韩东一教授
中国人民解放军总医院耳鼻咽喉头颈外科
北京

李  源教授
中山大学第三附属医院耳鼻喉科
广州

许  庚教授
中山大学第一附属医院耳鼻喉科
广州

孔维佳教授
华中科技大学附属协和医院耳鼻喉科
武汉

李晓明教授
河北医科大学附属白求恩国际和平医院耳鼻喉科
石家庄

卜行宽教授
南京医科大学江苏省人民医院耳鼻喉科
南京

孙建军教授
中国人民解放军海军总医院耳鼻喉科
北京

邱建华教授
中国人民解放军第四军医大学西京医院耳鼻喉科
西安

杨蓓蓓教授
浙江大学附属第一医院耳鼻喉科
杭州



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  发帖心情 Post By:2004/4/17 18:46:00 [只看该作者]

A01. A Mastoid Approach to Relieve Hemifacial Spasm

Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital,
Fudan University, Shanghai China
Wang Zhengmin

There is a variety of approaches to relieve hemifacial spasms, although the exact etiology of the disease has not been known yet. One of these is microvascular decompression of the facial nerve at its exit of brainstem. This approach is widely accepted by neurologic and otoneurologic surgeon now.
Since 1998, surgical interference on the facial nerve via mastoid approach monitored with evoked electroneurograpy can relieve the muscular spasm with the minimal injury on the facial nerve along its mastoid segment. The surgical procedures include 4-8 pararalle longitudinal incisions on the nerve. The number of incisions, which is necessary to reach the total disappearance of the symptom, depends on the quantitative assessment of evoked potentials during the surgery.
In the treatment of 11 cases of hemifacial spasm, complete relieve from the symptom with normal facial movement appear in 6 cases, with mild facial paralysis in 5 cases. Follow up 3-5 years, no symptom occurs in 7 cases, slight facial twitch presents in 2 cases. Two cases remain slight facial paralysis with mild facial twitch.


A02.嗅神经母细胞瘤的治疗

解放军总医院耳鼻咽喉-头颈外科
杨伟炎


A03. Acoustic neuroma:diagnosis and therapy

Department of Otorhinolaryngology Hopital Beaujon, Paris, France
Olivier Sterkers

Summary:Although different morbidity rates have been reported for different approach types in vestibular schwannoma surgery, other influencing factors such as tumour size, and surgical experience may interfere with the outcome. In this study, we compared the postoperative functional results in different surgical approaches (translabyrinthine, middle cranial fossa, and retrosigmoid) performed by the same team for lesions of similar size. The results did not show any significant influence of the approach type on the functional outcome. The type of the approach should be adapted to the anatomical data obtained from the preoperative imaging.
Objectives: The aim of this study was to compare the results of different surgical approaches performed by the same team in vestibular schwannomas (VS) with similar size.
Study design: Between 1991 and 2002, 600 VS treated surgically were included in this retrospective study. The population was composed of 50 stage 1 (intracanalicular), 255 stage 2 (<15 ㎜ in cerebellopontine angle, CPA), 217 stage 3 (16-30 ㎜ in CPA), and 78 stage 4 (>30㎜ in CPA). The mean age was 51 years (range: 13 to 79). VS were removed through middle cranial fossa (MSF) in 58 cases (stages 1, and 2), through retrosigmoid route in 109 cases (stages 2, and 3), through translabyrinthine route in 338 cases (stages 1 to 4), and by transotic approach in 95 cases (intracochlear, and stage 4 lesions).
Results: A good facial function (grades 1, and 2 of House and Brackmann scale) in 79% of stage 1, 92% of stage 2, 59% of stage 3, and 43% of stage 4 lesions. Considering each tumour stage separately, no difference of facial function results was observed between approaches. In stages 1, and 2, MCF, and RS approaches gave a similar proportion of hearing preservation (Los Angeles hearing classes A, B, and C): 60% versus 50% (NS).Incomplete resection was reported in 5 stage 4 lesions. Neurological complications were reported in 1.7% of cases. No mortality was noted. CSF leaks necessitating surgical revision were reported in 9.5% cases.
Conclusion: A judicious choice of the approach type is based on the tumour location, and size, the preoperative assessment of the bony structures, and the hearing function.


A04.改良腭咽成形术进展

首都医科大学附属北京同仁医院
韩德民

腭咽成形术的创立及治疗OSAHS的理论基础  软腭平面气道是上气道最狭窄部位,也是上气道中唯一缺乏骨性支架的部位,因而在睡眠中最容易发生塌陷。多数研究表明70~90%的OSAS患者存在软腭平面阻塞(单独存在或与其它平面阻塞同时存在)。1982年Fujita等人首先应用悬雍垂腭咽成形术(Uvulopalatopharyngoplasty,UPPP)治疗本病,手术以切除部分肥厚软腭组织、多余的咽侧壁软组织及肥大的腭扁桃体、扩大咽腔、解除患者软腭平面阻塞为特征。该手术治疗OSAHS的基础旨在于扩大咽腔通气截面积及降低咽壁顺应性。
传统腭咽成形术存在的问题及改良的方向  有限的疗效及部分患者术后出现腭咽关闭不全,咽腔瘢痕狭窄及误咽等合并症,使手术的广泛应用受到限制。在软腭解剖学研究及OSAHS患者咽腔阻塞成因研究不断深入的基础上,腭咽成形术改良的方向主要集中在下述二方面,其一为加强某些在咽壁塌陷中起主要作用的结构切除,如腭帆间隙中脂肪组织的切除,咽后壁松弛黏膜的切除,腭咽肌的切除以提高手术疗效等;其二,为咽腔重要结构的保护,如保留悬雍垂及软腭重要肌肉等以减少手术合并症。
H-UPPP手术  1997年笔者提出H-UPPP手术,其特点是保留悬雍垂,解剖切除腭帆间隙脂肪组织,扩大软腭成型范围,尽可能保留咽腔基本结构,依靠术后悬雍垂肌、腭帆提肌、腭帆张肌的运动及双侧软腭愈合引起的向上向外的牵拉作用,悬雍垂可以逐步回缩至正常生理水平。不仅可有效地扩大咽腔,提高UPPP手术的疗效,并且避免了一些术后并发症。
外科手术治疗OSAHS发展方向  主要为准确判定阻塞平面及成因、制定合理手术方案软、硬气道同期手术治疗OSAHS、多平面联合手术治疗OSAHS、手术前后的综合治疗及生活保健指导。


A05. An update on allergic rhinitis – The importance of treating a major chronic respiratory disease

Department of OtolaryngologyUniversity of Ghent, Belgium
Claus Bachert

Allergic rhinitis is the most frequent allergic disease, currently affecting more than 20% of the population, and according to recent epidemiological data, with a still increasing prevalence. About the same prevalence also is reported for non-allergic rhinitis. The world health organization WHO recently addressed allergic rhinitis (AR) as a major chronic airway disease because of its frequency, impact on the quality of life and performance of the patients, and because of its role as risk factor for asthma. (ARIA 2001). The ARIA initiative also defined a new classification system for AR, differentiating intermittent from persistent disease according to the duration of symptoms. First studies with this new classification revealed that about two thirds of the patients suffer from intermittent rhinitis, although mostly moderate to severe, and one third suffers from persistent rhinitis. More than 60% of these patients use anti-allergic medication when needed. The ARIA initiative also developed guidelines for the treatment of AR, with antihistamines and topical corticosteroids as first line of treatment. Medications currently used should fulfill a number of criteria, including efficacy, anti-allergic properties, and safety. A topical antihistamine with a good efficacy profile, anti-allergic properties and a good tolerability such as azelastine nasal spray is very likely to meet most of these criteria.
AR today is understood as an inflammatory response, with an early phase dominated by histamine, and a late phase involving many mediators and cytokines, among those cys-leucotrienes. Whereas the early phase is clinically expressed as sneezing and rhinorrhea, the late phase mainly consists of rhinorrhea and nasal obstruction. Azelastine nasal spray has demonstrated not only a strong antihistamine effect, but also additional anti-allergic effects in vitro on cys-leucotrienes, ICAM-1 expression, interleukin-4, CD23, TNF, ECP, MPO, Substance P and many others. As a result of these anti-inflammatory activities, azelastine not only inhibits the early phase, but also reduces the late phase of AR, and effects on nasal obstruction were demonstrated in nasal allergen challenge tests and clinical practice.
Different from oral antihistamines or topical steroids, azelastine nasal spray relieves symptoms within 10 minutes after application, a true advantage in intermittent rhinitis, when patients use medications when needed. Furthermore, it has a favorable safety profile compared to those drug groups. Compared to levocabastine nasal spray, azelastine has been demonstrated to be more effective, and topical antihistamines are more efficacious than topical chromones.
In daily clinical practice, the differentiation between allergic and non-allergic rhinitis is not easy, and patients may have mixed forms of rhinitis, even with positive skin prick tests. Azelastine nasal spray is the only antihistamine indicated for non-allergic rhinitis in the US, and has been shown to significantly reduce all nasal symptoms including nasal obstruction, with good tolerability. Thus, it can be used even when the diagnosis of AR is not yet confirmed.
In summary, AR is a frequent, disabling allergic disease, which often is under-diagnosed and insufficiently treated. Antihistamines, including topical drugs, are first line treatment for AR, and azelastine also is effective in treating non-allergic rhinitis or mixed forms. Because of its rapid onset of action, azelastine increases compliance in patients taking medications when needed, as is the case in two thirds of AR patients, suffering from intermittent rhinitis.


A06. Acoustic neuroma:
indications and surgical techniques

Department of Otorhinolaryngology Hopital Lariboisiere Paris, France
P.Tran Ba Huy


A07. Multifocal Laryngeal Carcinoma:
A Clinical and Pathological Analysis

1 Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital of Fudan University,
2 Department of Pathology, Eye, Ear, Nose and Throat Hospital of Fudan University,
Zhou Liang, 1  Ding Peng, 1  Wang Shu-yi, 2  Wang Wei1

Objective: To study the carcinogenesis and the possible risk factors of multifocal laryngeal carcinomas. Methods: The histological type, pathological grading, T staging, tumor size, tumor location and history of 12 cases of multifocal laryngeal carcinomas operated between 1991 and 1999 were retrospectively reviewed and analyzed. Results: The incidence of multifocal laryngeal carcinomas was 1.4%(12/861). All of them were squamous cell carcinomas. The histological type and pathological grading of different focuses in each patient were the same. The rate of two-focus cancer was 91.7%(11/12), and only one case was a three-focus tumor. 75% (9/12 ) of the tumors located in vocal cords. Three patients (25.0%) had a history of radiotherapy, and one had several biopsies for dysplasia of vocal cords. Conclusion: The different focuses of multifocal laryngeal carcinomas might arise from one tumor cell clone. The intralaryngeal implantation by the vibration or contact of two vocal cords might be the cause of multifocal laryngeal carcinoma. The radiotherapy and repeated medical stimulation to the larynx might be the induced factors.
Key words: multifocal cancer,  larynx,  carcinogenesis,


A08. An Update on Screening and Management
of Nasopharyngael Carcinoma

Division of Otorhinolaryngology, Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong SAR, PRC.
C Andrew van Hasselt, Michael C F Tong, John K S Woo

Nasopharyngeal carcinoma (NPC) is the commonest cancer before the age of 45 in males in Hong Kong.  The age-standardized incidence for all ages and ***es is around 23 per 100,000.  Aetiology of NPC have been linked to dietary and non-dietary environmental factors, genetic factors and Epstein-Barr virus infection.  Based on findings from our Centre, a tumorigenesis model incorporating these factors has been proposed.  Despite the increase in understanding of the tumour biology in recent years, there has not been any change in the mode of presentation and the delay in diagnosis.  Nearly half of our patients still presented late with cervical metastases.  The reasons for this late presentation include the relatively minor nature of common nasal symptoms perceived by the patients and the inability of most non-specialists to visualized the nasopharynx and diagnose the disease.  Over recent years we have experience in employing the techniques of endoscopy, serology, cytology and imaging for diagnosis and screening but each method has its drawbacks.  We believe that genetic screening employing one or more of the markers both serologically and cytologically promise the greatest potential. It is hoped that early detection of NPC together with advances in management will significantly reduce the overall morbidity and mortality in our patients.


A09.鼻内镜、鼻眼、鼻颅底手术

中山大学第一附属医院耳鼻咽喉科
许庚


A10. Treatment in ear agenesis

Institut Georges Portmann , Bordeaux, France
Didier Portmann


A11. Paraganglioma Jugulare:
angiography and surgery

Department of Otorhinolaryngology,Hopital Lariboisiere,Paris, France
P. Tran Ba Huy


A12. Treatment of laryngeal papillomatosis
by local Cidofovir

Department of Otolaryngology – Head and Neck Surgery, Hopital Tenon,Paris,  Fance
J. Lacau St  Guilly


A13. Advances in laryngeal reinnervation surgery

Department of Otolaryngology - Head and Neck Surgery ,
University of California Medical Center , U.S.A
Roger Crumley


A14. Management Options of Facial Nerve Schwannomas

Department of Otolaryngology, Sunnybrook & Women’s College ,
Health Sciences Centre, University of Toronto
Canada Joe Chen

This talk will focus on the behavior and clinical presentation of FNS, therapeutic options in its management and surgical outcome.  The attendees will learn about current issues related to diagnosis and radiologic techniques.  Controversies regarding expectant management and the timing of surgery to reduce operative morbidity will be emphasized.



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  发帖心情 Post By:2004/4/17 18:47:00 [只看该作者]

A15.循证医学与头颈肿瘤学

中国医学科学院  中国协和医科大学  肿瘤医院头颈外科
屠规益

近十余年来医学界有一个新名词-循证医学(实证医学)-从实质上说,这并不是一个新概念。临床医学是一门应用科学,本来就要求医师用有效的、可靠的医疗方案去治疗患者。由于在长年的实际中,在医学发展的过程中,不可避免的参杂了非科学的、人为的因素。有些无用、甚而有害的治疗混杂被应用,危害患者。因而,提出了实证医学的观点,以加强医学应用的科学性要求,避免“人云亦云”的治疗对患者带来的损害。
实证医学要求:在为患者作出治疗决定时,要利用现有的、被科学证实的、最有效的治疗方案。实证医学要求医师充分应用医学实验科研结果,尊重患者自主权,结合医师个人经验来进行治疗。
贯彻实证医学的步骤: 1.确定临床实践中的问题: 2.检索有关医学文献;3.学习并严格评价文献;4.应用最佳证据,指导临床决策;5.通过经验和实践,提高临床学术水平和医疗质量。
l头颈肿瘤学中非实证医学举例: 20世纪的教训
1.口腔癌下颌骨半切除的例子
2.上颌骨癌眶内容切除术
l实证医学在头颈肿瘤学的应用
1.头颈肿瘤学与耳鼻咽喉科学
-(多学科综合治疗与单纯外科)
《美国头颈外科(外科医师)学会》到《美国头颈学会》
2.N0患者的选择性颈全清扫术(Elective Neck Dissection)
-50年争论尘埃落定
分区性(择区性)颈清扫术 (Selective Neck Dissection)
-一个尚未被充分认识的手术
3.头颈部肿瘤功能保全性治疗-50年历史,尚未被普遍接受
4.鼻咽癌(低分化癌)以手术为主的治疗
-违背肿瘤治疗原则
5.甲状腺全切除术(适用于甲状腺癌,结节性甲状腺肿,甲亢)
-器官全切除术――“疾病根治的捷径?!”
6.化疗在头颈鳞癌的作用-20世纪末20年世界性实验的失败
-文献的误导-“学而不思则罔”
7.肿瘤临床中的少数与全体
-肿瘤患者治疗后,几乎没有例外的都有严重后遗症或致残性。肿瘤患者为了保全生命要付出代价。但肿瘤医师不应该片面强调肿瘤的根治性,将少数患者的临床特点(30%治疗需要)应用在全体患者的治疗上(70%无辜牺牲)。
实证医学应用上的问题
1.继续教育和医师执照问题  -我国尚未形成制度
2.临床科研-前瞻性随机分组研究(Prospective Randomized Clinical Trial,or RCT, Randomized Controlled Trial)贯彻的困难


A16.喉部疾病的微创治疗

上海长海医院耳鼻咽喉科  
周水淼 郑宏良 温武 孙广滨

一、微创外科的概念: “微创”一直是外科学追求的境界。但什么才是微创外科?出现于上世纪末的“微创”概念,在新世纪将有什么新作为? “微创外科新概念”:中国科学院院士裘法祖教授认为,凡是能减少组织的手术损伤、有利于机体功能恢复的治疗措施都应属于微创外科的范围,包括腔镜外科、内镜外科、介入放射外科、定向引导外科、远程医学,甚至还应包括显微外科和基因治疗等。黄志强院士认为: 21世纪外科微创化的新概念应是促进外科、创伤、感染整体效应的微创化。二、喉部疾病微创治疗: 利用先进的医疗设备,如电子喉镜、纤维喉镜、激光等,进行喉部某些疾病的治疗,具有痛苦小、创伤轻、费用少、疗效好、喉功能保留好等特点。三、喉部疾病微创治疗的工具:①电子喉镜;②纤维喉镜;③激光;④支撑喉镜;⑤电视支撑喉镜;⑥手术显微镜。四、微创无止境,尽可能做到微创、再微创:痛苦小、创伤轻;费用少、疗效好;是我们理想的目标。五、目前已开展的几种喉部疾病的微创治疗: 1、喉癌; 2、喉及下咽血管瘤; 3、双侧声带麻痹行杓状软骨切除术; 4、会厌囊肿;5、声门闭合不全及单侧声带麻痹;6、声带息肉、小结。六、喉癌是喉部常见的恶性肿瘤,随着医疗技术的不断进步,早期喉癌病人的百分比逐年增加。传统的部分喉切除或放疗都会给病人带来较大的创伤和痛苦。手术还会给发音功能带来较大损害。因此,喉癌的微创治疗是非常有价值的。七、早期喉癌的激光治疗已逐渐为学术界公认,在第五版全国通用教材书中已将其写入,列为喉癌的治疗方法中第一条。八、激光治疗早期喉癌是近年来喉癌微创手术的一个重要进展,CO2激光支撑喉镜下治疗早期喉癌国外已广泛展开,国内少数医院也在不断开展,CO2激光治疗早期声带癌具有以下优点:①损伤小,无需颈部切口;②出血少,易止血,术野清晰;③准确率高;④愈合快,瘢痕小,感染少;⑤组织肿胀轻,有可能避免气管切开;⑥手术时间短,病人痛苦小;⑦喉软骨保持完整,喉功能保全好;⑧术后恢复时间短,且并发症少;⑨住院时间短,病人心理负担轻,社会花费低等。但其仍有一定的局限性:①靠近声带前端、近前联合处的某些肿瘤,支撑喉镜下不能暴露或不能完全暴露时,CO2激光不能进行有效的治疗;②国外有人甚至将侵犯至前联合的喉癌病人列为CO2激光手术禁忌症;③某些心肺功能差,不能耐受全麻者,也不能进行CO2激光治疗。九、改良方法(微创、再微创):1.全麻支撑喉镜下纤维喉镜导入激光光纤,消除盲区。(动态)2.局麻纤维喉镜下导入激光光纤,解决不能耐受全麻的体弱患者。(动态)十、喉及下咽血管瘤:这是比较棘手的问题,手术有三个困难:(1)不易彻底切除;(2)术中止血困难;(3)喉功能容易被损害。十一、目前治疗方法:经皮穿刺注射平阳霉素(照片);进一步发展方向:经电子喉镜倒入注射针,微创治疗法。十二、双侧声带麻痹:1.经喉裂开行杓状软骨切除;2.颈外进路杓状软骨切除;3.经口全麻支撑喉镜下激光杓状软骨切除术。十三、经口全麻支撑喉镜下激光杓状软骨切除术:可保持发音不受大的影响,声门面积达到    ,即可保证正常呼吸而拔管。十四、会厌囊肿激光治疗:以往采用全麻支撑喉镜下或局麻间接喉镜下手术,现可局麻纤维喉镜下激光手术,具有创伤小,恢复快,效果好。十五、声门闭全不全、单侧声带麻痹的脂肪注射术:电子喉镜引导下微创手术。十六、声带息肉、小结的切除:六十年代前,直接喉镜下切除或间接喉镜下切除;七十年代,国外开展全麻支撑喉镜下喉显微手术;八十年代,我国也开展全麻支撑喉镜下喉显微手术,部分医院开展表麻纤维喉镜下声带息肉和小结的切除术;九十年代末以来,电子喉镜下声带息肉和小结的切除逐步推广普及。十七、小的息肉可在表麻电子喉镜下切除,大的息肉能在表麻电子喉镜下切除吗?答案:有可能,如一次切除不全,可分次切除,附照片。十八、随着时代、科技的进步,喉部微创技术必将更加蓬勃发展,进入更新的境界。


A17. Advance in the research on allergic rhinitis

Department of Otolaryngology, National University of Singapore, Singapore.
De-Yun WANG

Allergic rhinitis is characterized by IgE-mediated inflammation of the nasal mucosa, involving an intricate network between inflammatory cells and different types of soluble factors such as mediators, cytokines, chemokines and adhesion molecules. Mediators released by activated cells during allergic reactions are the major effectors in provoking the specific symptoms and non-specific hyperreactivity of allergic rhinitis. Many studies have demonstrated the occurrence of nasal symptoms (sneezing, nasal obstruction and rhinorrhea) within minutes after experimental and natural allergen exposure. This response has been described as the early phase reaction that is associated with a significant increase in mediators such as histamine, tryptase, prostaglandin D2 (PGD2), leukotriene C4 (LTC4) and kinins. The infiltration and activation of eosinophils are predominant condition during the late-phase reaction, which is mainly characterized by unilateral and/or bilateral nasal obstruction with little sneezing and rhinorrhea. The latter condition is found to be very common in the pathophysiology of patients with ongoing allergic rhinitis. During the last decades, there has been a significant increase in the worldwide prevalence of allergic rhinitis and asthma. A number of epidemiological theories have been proposed to account for these findings, while “hygiene hypothesis” is one with particularly attractive. It was shown that the proinflammatory cytokines are produced in particularly by a subtype of T helper cells known as Th2. The other T helper subtype, Th1, tends to antagonize the allergic response. Several epidemiologic studies were able to show that Th1 responses induced by microbial stimulation can counterbalance allergen-induced Th2 response. Contrary, one could predict a weaker Th1 response and higher prevalence of allergy in the absence of microbial stimulation. Regulation and control of Th1 and Th2 response is a complex interplay between genetic and environmental factors, but the exact mechanisms underlying this pathological condition are not yet fully understood. Understanding of the cellular and molecular mechanisms of allergic rhinitis appears to be an exciting field of medicine with regard to both basic and clinical research. New knowledge on the pathophysiological mechanisms underlying allergic inflammation of the nasal mucosa will undoubtedly aid new therapeutic strategies and pharmacological agents for treatment of allergic rhinitis.


A18.UPPP联合GAHM治疗重度OSAHS

上海交通大学附属第六人民医院   耳鼻喉科、睡眠呼吸障碍(鼾症)诊治中心
殷善开 易红良 关建  鲁文莺  于栋贞 黄艳艳

目的 评估UPPP联合颏舌肌前移舌骨悬吊术(GAHM,genioglossus advancement hyoid myotomy)治疗重度OSAHS患者的疗效。方法 18例经PSG确诊为重度OSAHS(AHI>40)的患者,并经电子鼻咽喉镜检查结合Müller试验和头影测量分析确定为存在多平面阻塞。所有患者于术前先行CPAP治疗1~2周,然后同期行UPPP联合GAHM手术。术后至少6个月再行PSG检查,呼吸暂停低通气指数(AHI,apnea hypopnea index)<5,SaO2 >90%为治愈;AHI <20为显效;AHI降低≥25%为有效;AHI降低<25%为无效。结果 平均AHI从65.4±20.5下降到30.5±15.5, 平均最低血氧饱和度从63±16%上升至85±7%。治愈率6%,显效率67%,有效率83%,无效率17%。结论 UPPP联合GAHM不失为目前治疗存在多平面阻塞的重度OSAHS患者的一种有效的手术方案。


A19.经耳蜗进路切除侵犯岩斜区的桥小脑角肿瘤

上海第二医科大学附属新华医院耳鼻咽喉-头颈外科
吴  皓  曹荣萍  陈向平

目的  探讨通过耳蜗进路切除侵犯岩尖、斜坡区域的桥小脑角肿瘤的手术方法和手术效果。方法  耳蜗进路的要点是,在迷路进路的基础上,将面神经完全轮廓化,切除鼓室内容物,完全磨去耳蜗和面神经骨管,面神经保留在原位或从骨管中游离出来并向后移位改道,使在颅底形成一个直达岩尖、斜坡区域的三角形的窗。肿瘤切除后,回复硬脑膜,取腹部脂肪填充于硬脑膜缺损处和乳突切除后的空腔,并覆盖面神经。术中均使用面神经监护仪,术后均复查CT和MRI。结果  12例桥小脑角病变,其中听神经瘤6例、脑膜瘤3例、先天性胆脂瘤2例、三*神经鞘膜瘤1例,10例肿瘤全切,2例次全切除,脑组织无明显损伤,无术后脑脊液漏及颅内感染;术后1周面神经功能1~2级2例(17%), 3~4级9例(75%),1例面神经中断行改道吻合;术后6~48月随访面神经功能1~2级8例(67%), 3~4级4例(33%)。结论  经耳蜗进路能使侵犯岩尖、斜坡区域的桥小脑角病灶得到良好的显露,而不用任何牵拉,值得应用于术前听力较差的这些部位肿瘤患者。



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A20.慢性侵袭性真菌性鼻-鼻窦炎的概念、
早期诊断及治疗

中山大学附属第三医院  
李  源

我们对一组48例真菌性鼻-鼻窦炎(fungal rhinosinusitis,FRS)的诊断和治疗进行了前瞻性研究,并根据研究结果结合文献,提出我们对慢性侵袭性真菌性鼻-鼻窦炎(chronic invasive fungal rhinosinusitis,CIFRS)的概念、早期诊断及治疗的意见。摘要如下:
CIFRS的由来和概念:
尽管对侵袭型真菌病的认识始于1965年Hora的首例报告[1],但对CIFRS的首例报告则是在距离32年后的1997年。当时,de Shazo等发现其临床表现既不同于NIFRS,也不同于暴发型,提出慢性侵袭性真菌性鼻-鼻窦炎(CIFRS)这一新的临床类型[1]。2000年,Stringer等[2]根据自己的1组病例,并总结其他报告的病例,首次全面叙述了CIFRS的概念:临床表现为缓慢进行性组织侵犯,病程在4周以上,易复发,预后较差,多发生在长期全身应用皮质类固醇激素、糖尿病或白血病的个体,最终诊断是依据组织病理学证实真菌细胞侵入组织和骨质。
CIFRS的早期诊断
以组织病理学(Gomori六胺银染色)[3]结果为最终诊断依据,48例FRS 中,CIFRS为18例,NIFRS(非侵袭性真菌性鼻-鼻窦炎)为30例。对2组病程、临床症状、鼻内镜检查、真菌种类方面的比较表明,CIFRS除有少数病例表现血性涕外,与NIFRS没有特异性差别。鼻窦CT特征上,CIFRS除了多窦受累和骨质破坏较NIFRS多见和略严重外,其他特征亦无特异性差异。由此我们认为,由于CIFRS进展缓慢,且影像技术进步和临床应用日益广泛,使CIFRS在早期被发现的机会大大增加,但在发病早期、即尚未进展到发生明显的周围结构破坏时,若以临床症状和鼻窦CT特征作为诊断依据不甚可靠。然对2组窦内病变、窦黏膜特征的观察表明CIFRS病变表现远比NIFRS严重: CIFRS窦内病变多为泥石样物,且窦内有多量稠脓,该特征与最终病理结果的符合率为88.9%(16/18),NIFRS窦内病变则多为干酪样块,且脓性物少。CIFRS窦黏膜多表现为暗红色、水肿、肥厚、质脆、易出血、表面颗粒样增生或色黑、脱落和坏死性改变,此特征与最终病理结果的符合率为83.3%(15/18)。NIFRS窦黏膜则多表现为轻度充血、表面光滑或水肿、苍白和稍增厚。由此我们认为,术中所见窦内病变和窦黏膜特征可作为CIFRS早期诊断依据。
为此我们提出,对术前诊断为NIFRS者,术中应重点观察窦内病变和窦黏膜特征,若具备上述特征者应怀疑早期CIFRS。若临床症状同时有血性涕或较严重头痛、鼻窦CT表现多窦受累或骨质破坏则应高度怀疑。病程较长是区别急性侵袭型的依据。是否合并糖尿病和白血病,或是否长期全身应用皮质类固醇激素是参考因素。组织病理学证实真菌侵犯窦黏膜是诊断的金标准。
我们的研究提示,常规HE染色对窦内病变的真菌检出率为64.2%,对侵入黏膜组织内的真菌检出率更低(仅3.8%)。而六胺银染色对窦内病变和侵入黏膜组织内的真菌检出率分别为90.6%(48/53)和34.0%(18/53)。因此,我们建议对FRS病理学检查应行真菌特异性银染色(Gomori六胺银染色),这对于诊断早期CIFRS尤为重要。
CIFRS的治疗:
我们对最终病理证实为CIFRS的18例中,行窦内病变清除术者无一治愈(0/7),需再次行鼻窦清创术;然行鼻窦清创术后加抗真菌药物治疗者治愈率达81.8%(9/11)。对NIFRS行单纯鼻窦内病变清除术绝大多数可获得良好疗效(93.1%,27/29)。关于抗真菌药物的应用目前仍无规范的模式,国外文献报告对侵袭型者抗真菌药物应用不得少于6周[2]。伊曲康唑(itraconazole)对曲霉菌敏感,副作用小。Gumaa等[4]对22例曲霉菌性肉芽肿型CIFRS给予伊曲康唑100 mg,1天2次,疗程6周,获良好疗效。二性霉素B(amphotericin B)为广谱杀真菌药物,对隐球菌属、组织胞浆菌属、芽生菌属、副球孢子菌属、球孢子菌属、曲霉菌属、毛霉菌属和一些念珠菌属等均敏感,对急性暴发型者尤能获得良好的控制,但副作用较大。本组最终病理证实为CIFRS的18例采用口服伊曲康唑0.1 g,1天2次,持续半个月~1个月,同时取二性霉素B术腔灌洗(50 mg二性霉素B加生理盐水100ml),每周1次。CIFRS由于真菌菌丝或孢子已经侵入黏膜、腺体、血管或骨质中,残留的病变黏膜术后复发率高,因此我们同意行鼻腔鼻窦清创术、彻底地清除病变鼻窦黏膜,以及术后给予长期全身抗真菌药物治疗[1,2,5-7]。
再论CIFRS的概念--我们的意见:
Stringer等[2]认为CIFRS多发生在长期全身应用皮质类固醇激素、糖尿病或白血病的个体,且临床少见。本研究CIFRS病例除2例合并Ⅱ型糖尿病外,均无长期全身应用皮质类固醇激素史和白血病史。且48例FRS中约1/3是CIFRS,且多数从出现症状至接受治疗的时间是5周~3个月,和NIFRS无差异。因此我们认为,多数CIFRS可不合并有糖尿病或白血病或有长期全身应用皮质类固醇激素史。我们推测,“CIFRS临床少见”可能是其早期病例被误诊为NIFRS所致。
de shazo等[1]和Stringer等[2] 认为CIFRS易复发、预后不好。本研究CIFRS采取鼻窦清创术联合抗真菌药物治疗一次手术治愈率为81.8%,表明早期及时和合理的治疗多数可获得治愈。
因此,我们提出对CIFRS的概念是:缓慢进行性组织侵犯的FRS,其早期的病程、临床症状和鼻窦CT特征与NIFRS相似,但窦内病变多为泥石样物并伴多量稠脓,窦黏膜多表现为剧度肿胀、暗红色、质脆易出血和表面颗粒样改变或黏膜呈黑色、坏死样改变。临床并非少见。可发生在没有长期全身应用皮质类固醇激素和合并糖尿病或白血病的个体。早期诊断和鼻窦清创术联合抗真菌药物治疗多数可获得治愈。


A21.侧颅底病变的外科治疗

解放军总医院耳鼻咽喉头颈外科
韩东一

侧颅底外科是颅底外科的一个分支和重要组成部分,它主要涉及与侧颅底骨面相邻或穿入其骨面生长的所有良性或恶性肿瘤的治疗。侧颅底解剖结构复杂,有很多供应大脑的重要血管和神经通过,故该区域病变的外科治疗危险大,过去曾一度认为是手术禁区。近年来随着影象诊断、介入放射学、手术进路和手术方法的改进以及电生理监测等领域的发展,侧颅底外科有了惊人的进展。本文介绍侧颅底外科的定义、治疗疾病的种类,几种主要手术进路。结合文献复习介绍解放军总医院近10年来开展侧颅底病变如巨大颅底、岩尖先天性胆脂瘤切除,巨大桥小脑角脑膜瘤切除,颞下窝良、恶性肿瘤的切除以及经颈、颞、枕进路颞骨切除治疗颞骨恶性肿瘤以及听神经瘤切除中面神经和听力保护等方面的经验。


A22.鼻内镜下经鼻-蝶窦进路垂体瘤切除术

华中科技大学同济医学院耳鼻咽喉科学研究所
附属协和医院耳鼻咽喉科(武汉,430022)
孔维佳

随着CT/MRI扫描技术的发展以及内镜制造工艺的完善, 功能性内镜鼻窦外科已成为治疗鼻窦炎和鼻息肉疾病的主要手术方法。 近年来,鼻内镜外科在鼻外科的应用日趋广泛,经鼻内镜手术范围逐渐扩大,经鼻内镜手术处理鼻-眼及鼻-颅相关性疾病已逐渐显示出经鼻内镜外科的优势。
数年来, 我们应用经鼻内镜下经鼻-蝶窦进路垂体瘤手术切除垂体瘤十余例,无一例手术并发症。 术后随访六个月至三年, 无一例复发。 与传统的经翼点进路以及经鼻中隔蝶窦进路相比,经鼻内镜下经鼻-蝶窦进路垂体瘤切除术具有如下特点: ①手术进路对正常结构损伤极微;②术中定位方便准确;③手术简捷省时;④术中出血少;⑤手后并发症极少。 本报道对经上鼻甲进路蝶窦手术优点和局限性作一简要介绍,并结合蝶鞍区的神经血管解剖特点、蝶窦的发育类型、垂体瘤的病理分类,对鼻内镜下经鼻-蝶窦进路垂体瘤切除术的手术步骤以及该手术的优点和局限性进行讨论。


A23.下咽癌的手术治疗

上海市武进路85号上海市第一人民医院耳鼻咽喉-头颈外科
上海交通大学附属第一人民医院
董  频1    於子卫   金斌  祝江才

目的:以各种方法手术切除肿瘤治疗下咽癌患者并取得良好的功能恢复与改善。 方法:采用简便易行、损伤小的下咽修补成形方法,对下咽癌肿瘤切除术后的缺损采用局部缝合、舌骨下肌群皮瓣、胸大肌皮瓣、胃代食道修补咽、食管、舌根缺损。结果:2000年5月至02年10月共行手术治疗10例,其中梨状窝癌,T1N1M01例,T1N3M01例,T2N1M03例,T3N0M03例,T3N1M02例,T3N2M02例,T4N1M03例,T4N2M01例;环后区癌T1N1aM02例,后壁区T3N1M01例,上壁区T3N1M01例。肿瘤切除后采用胸舌骨肌筋膜修补患侧室带、声带缺损1例,咽舌跟1例,胃代食道3例,喉气管代食道2例,局部缝合1例,颈部皮片修补1例 。术后无误咽,吞咽功能正常,7例拔除套管,呼吸、发音功能正常;2例带套管呼吸。结论:对于不同部位不同分期的肿瘤分别采用不同方法修补咽、食道缺损,可取得良好的功能恢复及预后。


A24. Reconstruction of major Defects
in the Head and Neck After Tumor Ablation—
Features of the Defects and Options of Reconstruction

Department of Otolaryngology Head & Neck Surgery,
Bethune International Peace Hospital, China
Xiaoming Li,

Reconstruction of major defects in the head and neck is a major challenge for the head and neck surgeons, especially when the defect is large and complex. Moreover, defects in the region often possess different problems depending on the location, tissue types and quantity. A wide variety of reconstructive modalities are thus necessary for optimal reconstruction.
Cranial facial defects: This kind of defect is often associated with a skull base incompetence. It is located beyond the common donor site of pedicled reconstructive flaps used. When there is a cranial-facial defect, a big volume, well vascularized flap is needed to fill the defect and to seal off any CSF fistula. Other requirements include the need to separate the contaminated sinonasal compartment from the brain and the meninges, to provide an adequate supporting of the brain and to fill a cave-like defect. Under this circumstance, free flaps such as rectus abdominas or latissimus dorsi could be used. The reconstructive option is no longer restrained by the length of the pedicle and arc of rotation of the pedicle flap. Pedicled myocutaneous flaps such as PMF are sometimes used for these purposes, but in many patients, the pedicled myocutaneous flap provides suboptimal reconstruction. Introduction of free flaps “frees” the surgeons from these constraints.
Oral cavity, oropharynx defects: Defects resulting from resection of extensive tumors in the oral cavity and oropharynx pose different problems. They are sometimes small and simple, but frequently large and complex. The latter situation include msculo-mucosal whole layer defect after glossectomy, complete loss of floor of mouth, buccal defect, and the composite complicated defect created after resection of the mandible. Flaps used in the reconstruction of these defects should meet following requirements:
a)Appropriate tissue volume
b)Good intra-oral lining
c)Satisfactory reshaping of the mandible
d)Desirable lubricating function for deglutition
e)Regaining the local sensation if possible
In view of the above points, a pliable and thin micro-vascular free fascio-cutaneous flap or a patch-on visceral free graft is applicable to re-surface the mucosal defects after tongue resection. A pedicled PMF can be used to reconstruct the floor of mouth and the whole tongue. The through to through buccal defects can be repaired with a deltopectoral flap in combination with a visceral free graft. The pedicled costomyocutanous PMF or an osteocutaneous flap such as radius and fibula could be reshaped to reconstruct the arc of the mandible and provide intra-oral lining simultaneously. The need for epithelial-covered, watertight closure of oral and oropharygeal defects is obvious. Although the myocutaneous flaps provide these functions adequately, in obese patients, too much bulk might be delivered to the oral cavity or pharynx and thus compromise the flap blood supply and mobile pharyngeal structures. Free flaps again offer the closest match presently available and give sufficient watertight suturing.
Hypopharynx and cervical esophagus defects: Defects produced after partial laryngopharyngectomy can either be closed primarily or restored with a patch-on PMF. Following total laryngopharyngectomy, the patient requires reconstruction of an epithelial-lined conduit between the oropharynx and esophagus. Local cervical skin flaps has high complication rates and staged deltopectoral flap reconstruction requires multiple operations with long hospitalizations. Tubed myocutaneous flap allow for single stage reconstruction,  but it is also associated with significant complications such as fistula formation and anastomotic stenosis, especially after radiotherapy. The patched PMF is good for repairing the subtotal defects following the partial pharyngectomy. For the segmental circumferential defects of the pharyngoesophagus, free jejunal transfer is one of the most reliable reconstructive options. If an epithelial-lined conduit is required, a tubed free cutaneous flap such as radial forearm flap and lateral thigh flaps could be used. When the esophagus along with the larynopharynx is removed for tumor resection, stomach pull-up reconstruction is the appropriate procedure.
Anterior and lower neck defects: Ablation of a recurrent or very advanced tumor often produces a huge musculo-cutaneous defect in the anterior neck. If the tumor extends down to the thoracic inlet such as in stomal recurrence, extensive resection down to the superior mediastinum is then warranted. After tumor ablation, major vessels in the lateral and lower neck, and in superior mediastinum are exposed. A big volume, well vasscularized myocutaenous flap is required to cover the major vessels, to obliterate the dead space and to resurface the overlying skin. PMF with some modifications is suitable for reconstruction of such defects.
Major vessel defects: Great vessels in the neck, including jugular vein and carotid artery, are sometimes invaded by metastatic cancers or direct infiltration of advanced cancers from adjacent structures. It is safe to remove tumor-anchored jugular vein on either side of the neck just as in the radical neck dissection. However, after en block resection of the neck malignancy along with the involved carotid artery, the latter has to be reconstructed to prevent neurological complications. Auto-, allo-vessel grafts or artifitial vessel substitutions can be used to reconstruct the great vessel defect with satisfactory results.


A25. Auditory Brainstem Implant in NF2

Department of OtorhinolaryngologyHopital Beaujon Paris, France
Olivier Sterkers

Summary:Auditory brainstem implants have shown their efficiency, and safety in the auditory rehabilitation of NF2 patients. Their indications have now been extended to other bilateral profound hearing loss when cochlear implantation is impossible. This study describes the functional outcome of 14 patients implanted in our center since 1996. Eleven patients currently used their implants. Eight had very good (speech understanding without lip-reading) or good (speech understanding with lip-reading) performances in daily life activity. Auditory results may vary depending on the local conditions of the cerebellopontine angle at the time of implantation, and on the preoperative communication abilities of each patient, but the majority of the patients has an important functional benefit from the auditory brainstem implant.

Objectives: The aim of this study is to evaluate the Auditory Brainstem Implant (ABI) performance in 11 patients with Neurofibromatosis type Ⅱ (NF2), and other indications such as ossified cochlear (2 cases) or Mondini’s malformation (1 case).
Study design: Between1996 and 2002, 14 patients (16 to 47 years) have been implanted with a 21 electrode NucleusR (Cochlear, Australia) device. A pre-operative work-up including clinical, radiogical, lip-reading, and psychological assessment was performed. A translabyrinthine approach was chosen in all cases. The auditory perception with the ABI was evaluated by testing: i) vowels and consonants; ii) mono- and bisyllabic words in open-set lists; iii) speech with usual sentences in open-set lists.
Results: Three patients had very good results with the ability to understand without lip-reading. Five patients reached good results with improvement of speech understanding with lip-reading. Two patients had fair results because of prelingual deafness in one case, and poor lip-reading in the other one. One patient, with only 4 electrodes functional because of side effects without auditory responses on other electrodes, had a poor benefit: only noise detection. One case was a non-user because of the absence of auditory responses after activation. In this case, the CT showed a post-operative haematoma with secondary displacement of the implant. Two NF2 patients died (one disease progression, and one postoperative pulmonary embolism).
Conclusion: These results show the benefit of ABI in several clinical situations: NF2 with or without previous tumour removal, post-meningitis ossified cochlea and inner ear malformation.



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A26. NOTRE EXPERIENCE DES TUMEFACTIONS PAROTIDIENNNES FROIDES UNILATERALES SUR 5 ANS.(OUR EXPERIENCE OF COLD UNILATERALTUMEFACTIONS OF THE PAROTID.)

H&Ocirc;PITAL DE LA CROIX ROUSSE - SERVICE ORL – 69004 – LYON
M. POUPART, Fl. PEROTTINO, A. COSMIDIS, JC. PIGNAT

MOTS CLEFS :
Tuméfaction parotidienne unilatérale froide.
Parotidectomie totale.
RESUME :
Objectifs : Evaluer les différents types de tumeur froide parotidienne unilatérale.
Regrouper les signes cliniques révélateurs.
Définir la place des examens complémentaires.
Etudier les séquelles de la parotidectomie totale.
Sujet et méthode : 114 parotidectomies ont été étudiées sur un délai de 5 ans. Il s’agissait dans tous les cas de figure de tuméfaction froide unilatérale.
Une parotidectomie totale a été réalisée chez tous les patients sauf un cas d’énucléation.
Résultats : L’existence d’une atteinte du nerf facial, d’une adénopathie, d’une douleur est presque toujours corrélée à la nature maligne de la tuméfaction. L’examen complémentaire le plus utile appara&icirc;t être l’échographie; le plus performant l’IRM. Les  résultats anatomopathologiques confirment la prédominance de l’adénome pléiomorphe avec cependant un grand polymorphisme à ce niveau.
Les complications post-opératoires immédiates sont rares et globalement bénignes.
Les complications à long terme sont marquées essentiellement par les récidives en cas de chirurgie non-maximaliste.
Dans le cadre des tumeurs malignes, la place du curage ganglionnaire et de la radiothérapie dépendent du type anatomopathologique.
Conclusion : Cette étude confirme la corrélation entre signes cliniques et nature anatomopathologique ; les examens complémentaires doivent rester rares et économes. Sur le plan anatomopathologique, on observe un grand polymorphisme des réponses avec cependant une prédominance de l’adénome pléiomorphe.
Enfin, confirmation de la nécessité de réaliser des parotidectomies totales qui ne doivent pas engendrer de complication majeure.


A27. Clinical application of digitalized
hearing aids for presbycusis

Department of Otolaryngology ,Sendai Hospital of Posts and
Telecommunications Sendai, Japan
Tomonori Takasaka


A28. Treatment of tongue cancer

Department of Surgery, The University of Hong Kong, Hong Kong , China
Po Wing Yuen

Tongue cancer is best treated by surgical resection for early cancer and combined surgery with radiotherapy for advanced cancer. Surgical resection should aim at a minimum of 1.5 cm surgical margin1. Large size tumor should be resected with 2 cm margin. Partial glossectomy of up to half of oral tongue can be closed primarily. Larger size defect should be reconstructed with regional or free flap.
There is high incidence of 30-40% subclinical nodal metastasis of oral tongue carcinoma even in the early stage. Among all the tumor parameters and predictive models being evaluated, tumor thickness has been shown to be the most significant factor which can be used to predict risk of subclinical nodal metastasis.  Tumor thickness can also be used to predict local recurrence and survival. The management of N0 neck should be planned according to tumor thickness2. With the use of 3 mm and 9 mm division, tumor thickness of up to 3 mm has 8% subclinical nodal metastasis, 0% local recurrence and 100% 5-year actuarial disease free survival. Since the risk subclinical nodal metastasis is low, the N0 neck should be observed. Tumor thickness of  4 - 9 mm has 44% subclinical nodal metastasis, 7% local recurrence and 76% 5-year actuarial disease free survival; the N0 neck may be considered for elective neck dissection. Tumor of 10 mm or more has 53% subclinical nodal metastasis, 24% local recurrence and 66% 5-year actuarial disease free survival; the patient should have post-operative radiotherapy to reduce both local and regional recurrence, and therefore elective neck dissection is not necessary when the patient has been planned to undergo radiotherapy.


A29. Supraglottitis in Hong Kong

Division of Otorhinolaryngology, Department of Surgery
Prince of Wales Hospital, The Chinese University of Hong Kong
John K. S. Woo

“spiglottitis” is perhaps more popular amongst clinicians, nevertheless, supraglottitis” is a more accurate description of the condition. In the Prince of Wales Hospital, the ENT Unit has managed 95 cases of supraglottitis” between August 1986 and June 2002. Adult cases dominated the picture with only 4 paediatric cases. There was a marked variation in annual and seasonal incidence. There were slightly more male than female cases. The age incidence plateaued between the 4th and 6th decades. All the peadiatric patients presented with stridor while the clinical picture of the adult patients was much more variable including sorethroat (100%), fever (47%), dysphagia (47%) dyspnoea (39%). In contrast to the experience in the West where Haemophilus influenzae type b is the most important cause, there were no predominant micro-organisms identified from the patients in our series. Streptococcus milleri was the commonest pathogens identified. Adequate control of the airway remained the most important aspect of management. All paediatric patients required endotracheal intubation and were managed in the Intensive Care Unit (ICU). Adult patients with respiratory distress, however mild, were observed in ICU. Those with more severe respiratory obstruction had their airways secured by either endotracheal intubation or tracheostomy. Overall, 70% patients required ICU admission. The average ICU and hospital stay were 3.2 and 12.3 days. Septicemia and deep neck space abscesses were more likely to occur in the older patients. There were two airway related and one non-airway related deaths in the present series. In conclusion, supraglottitis is still associated with significant mortality and morbidity. A standardize protocol for management is necessary for a satisfactory coutcome.


A30. Osseointegrated Implant Retained Facial Prostheses

Department of Otolaryngology,Sahlgrens University Hospital
SE 413 45 Gothenburg ,Sweden
Kerstin Bergstrom CDT.

Osseointegrated extraoral implants have been used for retention of facial prostheses since 1979 in adult patients and since 1983 in children. The concept has been developed considerably during these 25 years.
Inmplant retained prostheses have been used for rehabilitation after tumor surgery, malformations and trauma of external ear, orbit, nose and midface.
The goal is to provide the patient with a facial prosthesis with realistic, natural appearance and good function. To achieve a lifelike effect and good function of a facial prosthesis great effort must be put into replicating the missing anatomical part.
Attention to harmony, texture, colour matching and blending of tissue interface is very important to get a good aestethic result.
The choice of retention system is important to get a safe and secure retention of the facial prosthesis. Preoperative planning for fixture position is crucial to the final outcome of the restoration. A close cooperation and feedback between the surgeon and anaplastologist is imperative. Team work is of great importance in the preoperative evaluation, during the surgical procedure as well as when the prosthesis is made and during follow up.


A31. Cochlear Implants:
The Singapore General Hospital Experience

Department of Otolaryngology,Cochlear Implant Programme Singapore General Hospital
Low Wong-Kein

Two adults received cochlear implants at the Singapore General Hospital (SGH) in 1989. The Programme at that time faced difficulties and remained inactive for the next several years until 1997. A new multi-disciplinary team was set up and the first child in Singapore was implanted in that year. In 2001, the government started a national pilot scheme, which subsidises up to 80% of the cost of the device. About the same time, universal newborn hearing screening was also started in Singapore on a national scale. To support the screening programme, a hospital-based auditory-verbal therapy (AVT) programme was set up in SGH. Renowned international AVT Consultant, Ms Judith Simser was engaged for one year to train a core group of local AV therapists in SGH. This group of therapists is able to communicate to patients in various languages and dialects, such as English, Chinese, Malay, Tamil and sign language.
SGH has now managed more than 200 cochlear implantees, which includes both children and adults. About half of these are patients from overseas, with different native languages. The results had generally been excellent. Over the years, important lessons have been learnt, including cochlear implant issues relating to setting up of a programme, assessment, surgery, rehabilitation as well as universal newborn hearing screening.


A32. Epigenetic aberrations of nasopharyngeal carcinoma

Department of Surgery, The University of Hong Kong, Hong Kong, China
Po Wing Yuen

Serologic EBV antibody screening of NPC has been practiced for many years. It however has problem of either low specificity or low sensitivity. The sensitivities are found to be 93% for VCA, 84% for EBNA1, 74% for Zta, 73% for EA. Gene-specific methylation is common in primary undifferentiated nasopharyngeal carcinoma (NPC). DNA released from apoptotic or necrotic cell death including those aberrantly methylated promoter DNA of cancer cells is absorbed into the circulation as cell-free plasma DNA of the patient.  Methylated DNA was detectable in plasma of NPC patients before treatment including 46% for CDH1, 42% for p16, 20% for DAP-kinase, 20% for p15, and 5% for RASSF1A. The panel of 5 methylation markers have sensitivity of 71% and specificity of 91%.

Serologic EBV IgA and methylation marker in NPC and normal controls
EBV IgA +Methylation +EBV IgA +Methylation -EBV IgA –Methylation +EBV IgA –Methylation -Total
NPC25 (89%)12 (52%)4 (80%)0 (0%)41
Normal3 (11%)11 (48%)1 (20%)28 (100%)43
Total282352884

Combination of EBV IgA and methylation is recommended for screening NPC. A recommended algorithm of clinical management after serologic screening of both EBV antibody and methylation markers would be: (a) high risk group for nasoendoscopy and nasopharyngeal biopsy - to have nasoendoscopy and nasopharyngeal biopies for all patients with positive methylation irrespective to EBV antibody positive or negative status; (b) low risk group for reassurance without nasoendoscopy - individuals having both EBV antibody and methylation marker negative can be confidently reassured of exclusion of NPC, and nasoendoscopy is not necessary; (c) moderate risk group for nasoendoscopy alone without routine nasopharyngeal biopsy - individuals with discordant results of positive EBV antibody and negative methylation marker should be investigated with nasoendoscopy, random nasopharyngeal biopsy is not necessary unless suspected area in the nasopharynx is visualized during nasoendoscopy, the blood tests and nasoendoscopy should be repeated regularly till both EBV antibody titre and methylation marker become negative.
In comparison with the serologic EBV antibody or EBV DNA alone, the use of combination of serologic EBV antibody and the panel of methylation markers has markedly increased the overall diagnostic accuracy in both detection and exclusion of NPC.


A33. 15 years experience
in Bone-anchored Hearing Aids (BAHA)

Division of Otorhinolaryngology, Department of Surgery,
the Chinese University of Hong Kong, Shatin, Hong Kong SAR, PRC.
Michael CF Tong, Gordon Soo, Willis S S Tsang, C Andrew van Hasselt

There has been a revived interest in the use of percutaneous BAHA system in the treatment of deafness in adults and children for the past two years.  BAHA works by transmitting sound directly through the skull to the inner ear with an implantable titanium component, bypassing the middle ear conducting mechanisms.  The Chinese University of Hong Kong has gathered experience in both the transcutaneous and the percutaneous device since 1987.  This presentation summarizes the principles of the BAHA system and illustrates operative techniques of the percutaneous BAHA system (Entific Medical Systems AB) we have been employing since 1995.  Indications including bilateral congenital atresia of the external ear canal, bilateral chronic middle ear infections, bilateral and unilateral conductive hearing loss, single-sided deafness and rehabilitation of patients with nasopharyngeal carcinoma are outlined.  For a successful implantation of the device, meticulous intra-operative and post-operative care should not be underrated.  Future development of the BAHA system will also be discussed.


A34. Laryngeal and Pharyngeal cancer, Partial Surgeries, and conservation Procedures with chemotherapy

Department of Otolaryngology – Head and Neck Surgery Hopital Tenon,Paris,  Fance
J. Lacau St Guily


A35. Current Estimates of Deafness and Hearing Impairment, Prevention Strategies
and Activities in China

ORL Dept. Jiangsu Province Hospital Nanjing Medical University Jiangsu
Ear and Hearing Centre Affiliated to HI-IFOS-ISA
Xingkuan Bu

ESTIMATES OF DEAFNESS AND HEARING IMPAIRMENT
According to the national statistics (1.57 million sample survey) in 1987, there were 17.7 million hearing and speech disabled people in China at that time (2.04% of the population, hearing loss of more than 40 dB HL on average at 0.5k, 1k and 2k Hz, at the better ear). Hearing disabilities were the most common of all kinds of disabilities (vision disability: 0.79% of population, intelligence disability: 0.65%, limb disability: 0.53%, mental disability: 0.11% and complex disabilities: 0.63%).
Seventeen years have passed since the last survey. What is the present situation in the world’s most populous country? The answer is important not only for China’s development but also for the global campaign of prevention of deafness and hearing impairment.
We conducted the pilot study on WHO Ear and Hearing Disorders Survey Protocol in July /August 2002 in Jiangsu Province China (figure 1, 2). Using multi-stage PPS method, three clusters, 195 households (616 subjects), were selected as the pilot study subjects. All items of the WHO protocol were implemented. The investigating rate was 97.7 %, the absent rate and refuse rate were 2 % and 0.3 % respectively. The pilot study had the main result of 6.4 % disabling hearing impairment and 13.9 % all levels of hearing impairment. This figure was three times than previous data (2.04 %, 1987)!
Because of the small sample size, the result of the pilot study may not be the real picture in China.
We are carrying on Four or Six-Province survey in order to gather more information. But comparing with WHO data of disabling hearing impairment from 1985 to 2001 (six times increased!), we could image as the largest part of world population, how big and how heavy burden of this disability in China! This burden leads to a massive social and economic cost and severely hinders China’s development.

PREVENTION STRATEGIES AND ACTIVITIES

1. Raising public awareness
The National Ear Care Day (March 3) has been set up since 2000.
Large consultation activities on streets were held in almost all cities throughout whole China on that day (figure 3). This annual public campaign played great role in raising awareness and spreading scientific knowledge about hearing. Especially, it made more people know the risk of ototoxic damage from the abuse and/or improper use. It also made more people conscious of the importance of early detection and early intervention for hearing impairment.
Awareness also has been raised in the media by TV show, radio broadcast and publishing stories, which showed hearing aids successfully rehabilitating from a deaf-child to an excellent university student.
These awareness activities encouraged more and more hearing impaired people and their families to accept scientific treatment for their hearing problems.

2. The Guidelines for Clinical Use of Ototoxic Drugs was issued in 1999.
Ototoxic drugs were considered the fourth main cause of hearing loss, subsequent to presbyacusia, otitis media and high fever in China (National survey, 1987).
In order to control and reduce this kind of avoidable hearing loss, The National Ministry of Health issued guidelines and required all clinicians, especially primary health care workers, to pay more attention to use of ototoxic drugs, they should be vigilance of the risk and ensure medical safety.  It was good official intervention; we feel that the incidence of drugs-induced hearing loss has been decreasing in recent years, although there is still lack of accurate data.

3. Universal Newborn Hearing Screening Program has been recommended.
At the present, approximately 20 million babies were born every year in China. About 60 000 hearing impaired newborns will be added per year. A large sum of those newborns is a serious public health and social problem. Universal Newborn Hearing Screening Program (UNHSP) was strongly recommended in documents from central and local governments since 1999. Up to now, at least 15 provinces and/or municipalities (near half of all provinces in China) start to conduct the program with OAE and/or AABR procedures. The National Conferences on UNHSP were held in 2000 and 2002. We have not accurate prevalence data of hearing impairment of newborns yet. Results varied from 2.87 ‰ to 5.90 ‰ in different reports.
UNHSP provides the earliest opportunity to identify and deal with hearing impairment in one’s life. The value is clearly precious. It is absolutely worth recommending if there are trained staff, rehabilitation services and facilities already available.

4. Initiating the national campaign of “Helping hearing disabled people 2001-2005”.
Purchasing ability is a big problem to limit the use of hearing aids in China. For reducing hearing disabled people’s heavy burden, China’s government is initiating the national campaign to provide appropriate and affordable hearing aids and rehabilitation services for poor deaf and hearing-impaired children from 2001 to 2005.
NEXT STEPS
China is the biggest developing country. There are 1723 rehabilitation centres for deaf children. 200 000 deaf children were trained with hearing aids in the last ten years. Most of them developed speech well and entered schools without language barriers. About 1500 profound deaf-children accepted cochlear implant since 1997.  We have got significant achievements, but compared with huge hearing disabled people in China, much work remains to be done.
At present, following items should be particularly considered and conducted.
1.To update definitions of disabling hearing impairment and grades of hearing impairment.
Disabling hearing impairment in China is defined as a permanent unaided hearing threshold level for the better ear of 41 dB or greater on average at 0.5, 1.and 2 KHz both in adults and children.
Comparing with WHO recommendation (1991 and 1997), two points should be updated.
1). To add 4 KHz to the average hearing threshold lever.
2). Disabling hearing impairment in children should be defined separately. That should be as a permanent unaided hearing threshold level for the better ear of 31 dB or greater on average at 0.5, 1, 2, and 4 KHz.
The classification of grades of hearing impairment also should be updated in two points:
1). To add 4 KHz to the corresponding audiometric ISO value (Average of 0.5, 1, and 2 KHz) at the better ear.
2). To change grades from six grades (25 dB or better, 26 – 40 dB, 41 – 55 dB, 56 –70 dB, 71 – 90 dB and 91 dB or greater) to five grades (25 dB or better, 26 – 40 dB, 41 –60 dB, 61 – 80 dB and 81 dB or greater).
It would be obviously that if we use new criteria, the figure of hearing disabled people in China would be much more increased.

2.To conduct new epidemiological study on deafness and hearing impairment.
All the prevalence data of hearing impairment in China were from the national survey in 1987. The previous data cannot reflect the current situation. In addition, present definitions are different from before. So a new epidemiological study to obtain accurate data is basic, important and urgent.

3. To promote services for older people with hearing impairment.
As life expectancy increases, attention to older people with hearing impairment becomes more and more important. Presbyacusia was the number one cause of hearing disability in China (44.88 %, national survey 1987).  It leads to loneliness and neglect. We should provide aural rehabilitation and hearing aids services not only for children as priority but also for older people in order to improve their quality of life.



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  发帖心情 Post By:2004/4/17 18:50:00 [只看该作者]

耳鼻咽喉头颈颅底的组织成分复杂,其缺损及畸形的修复目前仍存在很大困难,现有的修复方法存在很多缺点。耳鼻咽喉头颈颅底的修复重建对组织器官的外形、功能要求较高,而用于修复的自体组织来源十分有限,组织工程学的提出,为这些临床问题的解决提供了新的途径,因此,耳鼻咽喉头颈颅底外科组织工程学将具有广泛的研究和应用前景。
耳鼻咽喉头颈颅底外科组织工程研究热点:
一、软骨组织工程:耳鼻咽喉头头颈颅底软骨组织分布广泛,软骨的自身修复能力极其有限,其缺损修复是临床难点。软骨组织工程将是解决上述难点的一个有效途径。美国Genzyme公司研制的人工软骨CarticelTM已获得FDA批准用于临床,Reprogenesis公司人工软骨已进入III期临床实验。目前已可制备出人颞下颌关节、耳、鼻窦形状的软骨。
软骨种子细胞的选择:
理想的软骨种子细胞应具备以下特点:1、取材方便,对机体损伤小。2、易于体外培养,有良好的生物学活性。3、植入体内有良好的增殖修复能力。4、有良好的远期疗效。
常用的软骨组织工程种子细胞:1、自体软骨细胞:优点为分离培养简单,可直接合成软骨基质。缺点为来源及传代能力有限。2、间充质干细胞:优点为来源广泛,分化能力强,取材方便。缺点为:分化方向具有不确定性,需加以诱导。3、异体细胞:优点为来源不受限制。缺点为存在免疫反应,取材时可能涉及伦理学问题。4、转基因细胞:优点为通过基因工程解决所有种子细胞存在的缺点。缺点为近期应用前景及远期安全性尚不明确。
二、骨组织工程:耳鼻咽喉头颈骨组织构成颅面支架,形态复杂,作用广泛,由于涉及保护脑等重要组织并构成颅面美容的基础,因此对精确塑形要求高。听小骨是人体最小的骨骼,起传音的重要功能,利用组织工程的方法可在形态和功能上达到完美修复。国外在修复四肢长骨及脊柱等松质骨研究上进展很快,部分产品已应用于临床。
骨组织工程种子细胞的选择:理想的骨组织工程种子细胞应具有以下特点:1、具有成骨潜能。2、易于分离培养,体外扩增快。3、稳定性好,连续传代仍能保持成骨潜能。4、取材方便,对机体损伤小。
目前种子细胞的主要来源有:间充质干细胞、骨膜及软骨膜成骨细胞。其中来源于骨髓的间充质干细胞因取材方便、创伤小、培养周期短、细胞增殖快而成为常用的种子细胞。
三、神经组织工程:耳鼻咽喉头颈颅底周围神经分布十分广泛,各种损伤均有可能波及神经,如面神经、三*神经、迷走神经等。神经损伤后所发生的一系列病理生理改变,使神经修复效果很差。周围神经的主要功能细胞是雪旺氏细胞,能参与髓鞘形成,对神经再生及功能恢复起着重要作用。目前实验研究中已可以修复2-10cm以上周围神经缺损。
神经组织工程应用于临床的可能性:组织工程神经可被制成不同口径及长度,来源不受限制,手术过程简单。目前已可使用无血清培养基体外培养雪旺氏细胞,避免血清中可能携带的病毒及其它有害物质,有望应用于人体。临床电生理检查,使神经再生过程得到有效监控。对雪旺氏细胞的进一步研究及生物材料的研究进展,使神经组织工程应用于临床的可能性大大增加。
耳鼻咽喉头颈颅底的其它组织工程研究:软骨、骨组织工程的研究是耳鼻咽喉头颈颅底组织工程学研究的重点及热点,而其它的组织工程研究如肌肉、血管、肌腱等,以及各种复合组织工程的研究,对耳鼻咽喉头颈颅底的修复也具有重要意义。
四、肌肉组织工程:
五、肌腱组织工程:
六、血管组织工程:
组织工程支架材料:
天然材料:胶原、纤维蛋白、甲壳素及其衍生物、天然珊瑚等。
合成材料:聚乳酸、聚乙醇酸、聚酸酐、聚原酸酯、聚膦腈、聚酯尿烷、聚丁酸等。
两类材料各有优缺点,目前组织工程工程学研究更倾向于使用人工合成的可降解生物材料,并通过对这些材料的改性,使其各方面的特点适合于不同的组织工程要求。
组织工程对支架材料的要求:1、组织相容性好,无排斥反应。2、生物可降解性,降解可调性及降解无毒性。3、易于塑形,易于消毒,易于保存。4、材料的表面修饰性能好。5、材料的物理结构性能好。6、诱导性能好。
组织工程在耳鼻咽喉科的主要应用领域:
一、耳再造术:耳廓完全或部分缺损的病因有先天性及后天性两种。先天性常见的是指耳廓发育不全,并常伴有外耳道、中耳及颌面部的畸形,称之为Treacher-Chollins综合征,其发生率为1:7000。后天性耳廓完全或部分缺损多为外伤所致,大部分也需行耳再造术。另外,耳廓软骨膜的化脓性炎症可引起软骨的大片坏死,耳廓失去软骨的支架作用,结缔组织增生及瘢痕挛缩所造成的菜花耳畸形,也需进行耳再造术。
二、鼓膜修补-听骨链重建术:各种原因导致的鼓膜穿孔、听骨链断裂或缺损需行鼓膜修补及听骨链重建手术,慢性化脓性中耳炎是主要病因。海军总医院全军耳鼻咽喉科中心每年的中耳炎手术约在400人次以上。利用骨组织工程及皮肤组织工程技术,再造出人工鼓膜及听小骨,目前在技术上是完全可行的。目前应用较多的高密度羟基磷灰石假体,就是一种骨组织工程材料。组织工程鼓膜及听小骨将具有随意塑形、来源方便、不易吸收、简化操作等优点,在临床上有很好的应用前景。
三、鼻成形术:
1、萎缩性鼻炎手术:萎缩性鼻炎的发生率约占耳鼻咽喉门诊病人的3%左右。常用的手术方法有1)、鼻腔粘骨膜下埋藏术。2)、鼻腔外侧壁内移加固术。30、前鼻孔缩小术。利用骨组织工程方法,可以在鼻腔粘骨膜下形成与周围骨组织完好结合为一体的新生骨组织,并很好地解决以上缺点,取得满意的疗效并会大大提高病人的接受程度。
2、鼻成形术:各种原因引起的如鞍鼻、歪鼻、鼻中隔穿孔、鼻翼软化等鼻骨支架、软骨支架、软组织的畸形或缺损,需行鼻成形术。
四、喉气管狭窄成形术:
喉、气管狭窄分为先天性和后天性,先天性很少见,后天性主要由于各种外伤、医源性或感染性等后遗瘢痕狭窄,总的发病率并不高,但治疗很棘手,是耳鼻喉科难题之一。组织工程为喉气管狭窄的治疗提供了一个很好的方法,目前已经可以再造出管形的组织工程软骨,这种方法将使喉气管重建术得到进一步发展。
五、颌面整形术及喉再造术:
各种先天性或后天性的颌面畸形或组织缺损,需要进行整形。先天性的如小颌畸形发生率为1:2000-1:30000。虽发生率不高,但患者总人数并不少,成年或接近成年的患者多需进行颏成形术进行整形。后天性的如外伤、肿瘤术后等往往造成组织缺损,需要用大量的组织来填充缺损。
喉肿瘤手术或喉外伤导致的喉缺损,可以考虑用组织工程骨或软骨组织进行喉支架重建。
结语:
组织工程是在组织水平上操作的生物工程,主要致力于组织和器官的再生和形成,它是对外科领域中组织、器官缺损和功能障碍传统治疗方法和模式的一次革命。同时,组织工程是一门多学科交*的边缘学科,将是二十一世纪具有潜力的高技术产业,必将产生巨大的社会和经济效益。耳鼻咽喉头颈颅底组织工程学的提出,将为耳鼻咽喉头颈颅底外科的修复重建开辟新的前景。


A38.P物质-----听觉传入通路的神经递质

第四军医大西京医院全军耳鼻咽喉专科中心
邱  建  华

P物质(Substance P, SP),是最早发现的神经肽之一。是众多感觉神经的递质或调质。在听觉神经通路中是否含有以SP作为神经递质传入通路未见报道。我们应用免疫细胞化学、束路追踪、免疫电镜、免疫双标结合电生理技术对这一课题进行了系统研究。发现从耳蜗Corti器到听觉各级中枢,广泛分布SP阳性的神经元、神经纤维、终末及其受体。免疫电镜表明,螺旋神经节细胞的胞浆内有直径为50~70nm的SP阳性的清亮小囊泡。在线粒体的外膜、内膜及核膜上有电子密度增大的SP阳性产物,耳蜗核内存在较多的SP阳性的轴突与阳性的树突形成的轴-树突触,一般均含有两个或两个以上的活性接触点,突触后膜明显增厚,属典型的I型兴奋型突触。也可见SP阳性的轴突末梢与树突棘及胞体形成的突触结构。阳性轴突终末内,SP贮存在50~70nm的清亮小囊泡内,突触部位可见囊泡释放。在下丘及内侧膝状体也以SP阳性的轴突终末与阳性树突形成的I型兴奋性突触为主,突触后膜下常可见明显的突触小体,SP在终末中的贮存方式与耳蜗核相同。
将HRP注入耳蜗核递行追踪至同侧的螺旋神经节,发现螺旋神经节中的神经元广泛标记HRP,其中46%的HRP标记神经元为SP阳性,表明螺旋神经节至耳蜗核的传入通路中有SP传入通路。HRP注入一侧下丘中央核后,可见HRP标记细胞位于对侧CN的耳蜗前腹核及背侧核,其中对侧耳蜗前腹核内HRP-SP双标神经元约占HRP标记神经元的50%,证明CN至下丘的神经传入通路中有SP的传入通路。
尽管目前对SP在听觉生理中的意义尚不清楚,但其在听觉系统的广泛分布及相关的生理研究,表明其在声信号的传导及调控中起有重要的作用。


A39.创伤性视神经病的治疗进展

复旦大学 眼耳鼻喉科医院
王德辉 钱江

创伤性视神经病(Traumatic optic Neuropathy, TON)是一种相对少见的疾病,轻者可有视力减退,重者可完全失明。TON的治疗存在着很大争议,治疗方法有单纯观察经过,药物治疗,手术视神经减压,药物治疗加手术视神经减压等。传统的手术视神经减压包括经颅进路、鼻外经筛进路、经眼眶进路、鼻内进路等,1991年鼻内镜首次用于视神经减压术。
自2002年起我院共完成创伤性视神经病视神经减压术28例,随访3~18个月的有24例共26侧;其中男22例、女2例;3例为双眼损伤,2例接受双眼手术。受伤到手术间隔时间为3天~4周不等。所有病人都经大剂量激素治疗(甲基强地松龙400mg/天,至少3天),视力无明显改善后手术。手术前视力,无光感22侧,有光感3侧,眼前手动1侧。所有病人都经鼻内镜下常规神经减压术,手术先切除钩突,再去除筛泡,经基底板进入后筛,经蝶筛间隔开放蝶窦。定位出患侧视神经管,去除骨壁,切开鞘膜,以中甲或钩突粘膜覆盖鞘膜切开出。
术前无光感者22例中术后有感光者10例(10/22)、2例有手动(2/22);3例术前有光感者术后2例有眼前手动(2/3),1例眼前1米可见手指(1/3);术前眼前手动者,术后视力0.3。手术后视力有改进者为61.5%(16/26)。手术中明确见到视神经管骨折线19例(19/26), 其中有明显骨折移位的7例(7/26)。术前CT检查报告视神经管骨折3例(3/26)。无手术后视力下降及其他并发症出现。
内镜下鼻内镜进路视神经减压术似乎有效,有明显骨折和骨折移位者似乎效果更好。因为缺少严格的对照及病例数尚少,因而难以得出确切的结论。但与传统方法相比,内镜下鼻内镜进路视神经减压术具有创伤小、术中定位视神经管准确和术后恢复快等优点。还须进行大样本、随机、对照分组研究,以确定鼻内进路内镜下视神经减压的有效性。


A40. Craniofacial Surgery: Our experience at the
Singapore General Hospital

Department of Otolaryngology Singapore General Hospital
C. Goh

Craniofacial surgery is a well established surgical procedure which is suited for the extirpation of tumours of the anterior skull base. It is a surgical technique which combines a transcranial and transfacial approach and usually requires the expertise of a multidisciplinary team.
About 80% of tumours arising from the anterior skull base are malignant, although the figures can vary significantly from the various medical institutions. Squamous cell carcinomas of the nose and paranasal sinuses have been reported as the most common malignant neoplasm requiring craniofacial surgery. Other lesions include adenocarcinomas, undifferentiated carcinomas, olfactory neuroblastomas, salivary gland tumours, neuroendocrine carcinomas, cutaneous malignancies, sarcomas, malignant neurilemmomas and chordomas. Olfactory neuroblastoma was the most common condition which we dealt with in our series
Benign neoplasms like angiofibromas, fibro-osseous lesions, neurovascular tumours, inverted papillomas and meningiomas which lie intimately with or invade the skull base may also require craniofacial resection to remove them completely.
Not all tumours of the skull base can be removed by craniofacial surgery. Absolute contraindications to surgery would include unilateral internal carotid artery involvement with poor or absent collateral circulation, bilateral carotid artery invasion, bilateral cavernous sinus invasion, massive brain invasion, bilateral optic nerve or optic chiasma involvement and tumours which are metastatic to the skull base. The presence of distant metastases is also an absolute contraindication except for adenoid cystic carcinomas as these patients can have a relatively long life expectancy in spite of the presence of metastases.
Relative contraindications include dural invasion, minimal brain invasion, sphenoid sinus invasion, clival invasion, unilateral cavernous sinus invasion and carotid artery invasion with good collateral circulation.
There are a number of expected sequelae of craniofacial surgery and this includes anosmia, paraesthesia and crusting of the sino-nasal cavity. The potential complications of this procedure can be grouped into intracranial and orbital complications. Most of the complications are minor although some may have grave consequences and even death. Fortunately, the incidence of peri-operative mortality is low and is below 5% in almost all reported series.
Craniofacial surgery is a safe and effective technique for the extirpation of anterior skull base tumours and is best done by a multidisciplinary team.


A41. New therapy for hypopharyngeal carcinoma

Department of Otolaryngology,Tan Tock Seng Hospital,Singapore
Paul Mok


A42. Vestibular Schwannomas:  growth characteristics based on imaging and immunohistochemical markers

Department of Otolaryngology,Sunnybrook & Women’s College
Health Sciences CentreUniversity of Toronto,Canada
Joe Chen

The management of vestibular schwannoma(VS) is no longer limited to surgery.   The increasing roles of conservative/expectant management and of Stereotactic Radiotherapy have directed our focus on tumor behavior.  A better understanding of tumor behavior will allow Otolaryngologists to select treatment modalities most appropriate for their patients.  The attendees will learn about the natural history of VS when left untreated,  compared with tumors treated with radiotherapy.  A review of the literature and personal experience with serial and metabolic imaging(MRI/PET/SPECT),  and the use of immunohistochemical markers to determine tumor characteristics will be emphasized.


A43. Nitric Oxide in Human Upper Airways:
History, Development and Challenge.

Institute of Cardiac-pulmonary Sleeping Disorder,
Toronto General Hospital Toronto University
Wei Qian

About a quarter century ago, scientists noticed there was a substance served as a blood vessel dilator, which was a nonadrenergic noncholinergic (NANC) transmitter. It was defined as an endothelium derived relaxant factor (EDRF). In July 1986, Furchgott and Ignarro reported that EDRF is nitric oxide (NO). It elicited an avalanche of research activities in many different laboratories around the world and also led its pioneer discoverers to the stage of the Nobel Prize in Physiology or Medicine in 1998. It has been found that NO is generated by many kinds of tissue/organs and plays significant roles in different biologic processes.  
Development of Nasal NO measurements:
At the beginning of 1990’s, it was revealed that NO is detectable from the exhaled air and nasal NO concentration measured is folds higher than that from lower airway. Different techniques for nasal NO measurement have been developing by research groups. It is widely accepted that the aspiration flow rate plays a key role in nasal NO measurement. To achieve the maximum nasal NO output, the aspiration flow needs to be high enough to generate the turbinate flow in the nasal airways during the measurement. In normal adult subject, the flow rate ranges from 3 to 6 litters per minute. The features of aspiration flow during the nasal NO measurement will be discussed in the presentation.
Possible roles of nasal NO:
1.Nasal NO and nasal cycle: The cyclical congestion of nasal airways, nasal cycle, has been documented for over thousand years, but the purpose of it still remains mystery. One study revealed that NO accumulation during the cyclical nasal congestion might help in modulating the epithelia clearance rate.
2.Nasal NO and pulmonary function: Studies had demonstrated that inhaled NO may help in modulating the pulmonary ventilation/perfusion ratio. Adding NO into oxygen inhalation has been proved helpful to increase the oxygen saturation in pulmonary hypertension or COPD patients. NO might serve as a link in the interaction of upper and lower airways.
3.Nasal NO and nasal obstruction: Since high concentration NO has antiviral and antimicrobial features, high NO concentration might be helpful in keeping the hygiene in the poor ventilated and drained sinuses and obstructive nasal airways. However, the concerns of the damage of NO to the nasal mucosa remain further investigation.
Potential in nasal NO studies:
1.Although there are great efforts in establishing the techniques of nasal NO measurement, there is no so-called standardized technique yet. The reference values of nasal NO in different populations need to be determined as well.
2.Exhaled NO (ENO) measurement has been a useful probe in screening and monitoring the lower airways inflammation such as asthma. However, more information are required in nasal NO clinical significances and applications.
3.Some specific research projects can be carried on in the near future.
Summary:  Since it was first reported that nitric oxide (NO) is a gaseous signaling molecule derived by endothelium in human blood vessels about a score years ago, it has been documented that NO is generated by many kinds of tissue/organs and plays significant roles in different biologic processes. It has been found that nasal and sinus mucosa deliver large amount of NO during respiration. However, the clinical importance and application of the nasal NO need further investigation. This presentation reviews the history of NO studies, development in the nasal NO measurements, discusses the physiological and pathophysiological roles of nasal NO and the potential of this specific gas in future studies.


A44. Image Guidance in Endoscopic Sinus Surger

Department of Otolaryngology,Tan Tock Seng Hospital
Singapore Jin keat siow

This lecture will review the Role of IGS in ESS and the Current IGS Systems available worldwide. The author will demonstrate how Pre-Operative IGS Planning can be interpreted effectively with the additional modality of the saggital section. The Principles and Different Modalities of IGS Registration will be discussed. The Process of IGS during surgery will be illustrated via video clips. The Benefits, Limitations and Future Directions of IGS will conclude the lecture.


A45. IRON-DEFICIENT HEARING LOSS

Ai-Hua Sun, Shun-Zhang Lin, Shu-Chang Tian.
Department of Otolaryngology, Changzheng Hospital
Jin-Ying Li. Department of Hematology, Changhai Hospital
Second Military Medical University,  Shanghai 200003, CHINA

Iron deficiency(ID) or iron deficiency anemia(IDA),producing physiological and biochemical alterations, has long been regarged as the most prevalent nutritional disorders encountered in surveys of diverse populations both in developing and developed countries. Fifteen percent of the world's population suffers from iron-deficient anemia(IDA). The link between ID and sensorineural hearing loss, however, remains the big unknown until recently when we first documented the electrophysiologic, histopathologic, histochemical and biochemical changes in the cochleas of ID rats and the characterrizations of red cell basic ferritin(RCBF), serum ferritin(SF), haemoglobin(Hb), serum iron(SI) and circadian variation in serum iron(CVSI)values in the patients with different kinds of sensorineural hearing loss. Rationally, we propose the term iron-deficient hearing loss(IDHL) on the basis of its laboratory test characteristics and specifics of its response to iron therapy. From 1984 through 2000, 153patients were enrolled in this study. Of the 153 patients, 105 experienced gradual sensorineural hearing  loss and 48 experienced sudden hearing loss. One ear was affected in 54  patients, while 99 had bilateral hearing loss.Eighty-three were males, and 70 were famales. Prediagnosis medical evaluations included a history and physical examination, tuning fork test,pure-toneand impedance audiometry, auditory brain-stem response(ABR) and/or distortion product otoacoustic emission(DPOAE), calorictesting, electronystagmogram, radiographs, CT scan or magnetic resonance imaging(MRI) of skull, neckandinternalauditorycanal. Laboratory evaluations included   Hb, SI with serum magnesium(SM), copper(SC),zinc(SZ)and  calcium(SCa), CVSI, SF and RCBF. The statistical method employed for the analysis of these data was performed by using a  Instat2 program.
The  characterizations of laboratory tests for the diagnosis of IDHL found  in this study are summarized in table 1.
Table 1. Laboratory testing data in the patients with IDHL
_________________________________________________________________
Measurements    Patients with IDHL   Healthy subjects with normal
(mean±SD;n=153)      hearing (mean±SD;n=116)
_________________________________________________________________
Hb,g/l          105.03±13.49*            133.90± 8.21
SF,ug/l          28.85±13.56*             95.88±32.13
RCBF,ag/cell     11.55± 5.78*             28.05± 4.82
CVSI,umol/l      -1.12± 0.21*              6.55± 0.17
SI, umol/l       19.96± 2.58*             26.55± 3.13
SC, umol/l       14.37± 2.73              14.28± 3.49
SZ, umol/l       14.26± 2.39              14.70± 4.58
SM, mmol/l        1.11± 0.12               1.10± 0.19
SCa,mmol/l        2.40± 0.37               2.44± 0.52
________________________________________________________________
* Significantly different(p<0.01) compared to healthy subjects
with normal hearing
The CVSI, the peak being in the morning and the trough in the  early evening, was over ±3.582umol(normal range of circadian variation  in our laboratory) in 11(7.19%) of the 153 cases of IDHL and in 134 (87.58%) of 116 healthy subjects with normal hearing. Statistically,  the difference was significant(P<0.001).
All patients were treated for a period of 3-24 months with iron  therapy. The intramuscular iron injection was used in the patients  whose Hb concentration was less than 100g/l in children, 120g/l in men  and 110g/l in women. The dosage of the iron treatment was individualized depending on such factors asthebodyweight,Hb  concentration and duration of hearing loss. Details of administration  of the iron therapy have been previously published .
The criterion for improvement was a minimum of a 30 dB hearing gain  at the majority of frequencies by the end of treatment. The total  hearing improvement was 64.71%(99/153), those patients who had a  shorter time from the onset of hearing loss to the beginning of therapy  showed a better response to iron therapy. In 78 of 99 patients who  responded to iron therapy, the mean Hb, SI and SFconcentrations  significantly increased from 98.92±21.18 g/l, 19.54±2.52 umol/l and  29.21±13.16 ug/l to 134.44±15.07 g/l, 27.79±3.65 umol/l and 94.45±30.01 ug/l respectively. And CVSI reached normal limits.Whereas of36 caseswho had no improvement in their hearing,the mean Hb and SFconcentrations rose from 97.76±14.50 g/l and 26.59±12.82 ug/l to 131.35±12.66 g/l and 96.48±13.57 ug/l, respectively. The SI and CVSI,however, no significant changes were observed.
The term IDHL is first introduced to refer to treatable sensorineural hearing loss caused by iron deficiency.IDHL may be divided into two main types: acute and chronic, which make up 10% to 15% of total sensorineural hearing loss. One of the most important laboratory characteristics is the patients with IDHL have low concentration of haemoglobin, serum ferritin,red cell basic ferritin and serum iron as well as abnormal circadian variations in the serum iron level.
We feel that the final diagnosis of IDHL maybe made by any of the three or more of the following clinial and laboratory examinations: 1. A definite history of ID or ID anemia. 2. Hb concentration less than 130g/l in men, 120g/l in women and 105g/l in children. 3. SF <30ug/l. 4. RCBF <11.38ag/red cell. 5. CVSI <3.58umol/l. 6. SI <19.36umol/l.It is believed that iron therapy should be  the principal treatment for IDHL.


A46.食物抑制法耳鸣动物模型的建立

上海中医药大学附属岳阳医院 耳鼻咽喉科
李明

目的:建立食物抑制耳鸣动物模型,为耳鸣研究提供一种客观手段。方法:雄性健康wistar大鼠30只,随机平均分成6组。第1、2组为水杨酸组,皮下注射水杨酸钠(salicylic acid 缩写为SA),每日350mg/kg体重;第3、4组为生理盐水组;第5、6组为尼莫地平组,注射水杨酸后再皮下注射尼莫地平每日1mg/kg体重。在一周的适应期内,只在夜间给动物投放食物,然后禁食。将禁食后非常饥饿的动物置于隔声室内进行条件反射训练,训练只在夜晚进行。持续给予背景白噪声,强度为55 dB(SPL)。第1、3、5组从条件反射建立前开始给药。训练时给动物供食并记录摄食次数。背景噪声停止为条件刺激,电击为非条件刺激。经强化训练后形成“背景噪声停止-摄食减少或停止”的条件反射。第2、4、6组在条件反射建立后开始给药。最后,所有动物不再给予电击,观察条件反射的消退时间,以判断动物是否产生耳鸣。每组实验结束后从中随机选取5只大鼠,取耳蜗进行硝酸银染色,铺片观察。结果:各组动物的消退时间经方差分析显示具有显著意义。大鼠注射水杨酸钠后有耳鸣产生,尼莫地平能够消除水杨酸钠诱发的耳鸣。耳蜗铺片未见明显改变。动物夜间训练兴奋性良好,造模成功率达到96.7%。 结论:  食物抑制耳鸣动物模型能证实水杨酸钠造成的动物耳鸣的存在。本实验方法切实可行,可重复性良好。


A47.喉二重原发癌及其发生机制

浙江大学医学院附属第二医院耳鼻咽喉科
杨蓓蓓

大多数头颈部癌的发生与烟酒的过量摄入相关,组织学上多数为鳞状细胞癌。喉癌是最常见的头颈部恶性肿瘤,约占后者的40%。在过去的几十年,喉癌的局部和区域控制方面取得了令人鼓舞的进步,病人的生活质量也明显改善,但是总的生存率并非同样乐观。两个主要的原因是,与远处转移相关第一个原发肿瘤的复发,以及较高的二重原发癌发生率,有时甚至发生在喉癌治疗后的许多年以后。本文综合报告喉二重原发癌的临床及其发生机制的研究。
头颈部二重原发癌的发生率,各家报道有明显的差异,主要由于研究的样本量,病人的地区分布和随访时间不同的缘故。根据希腊Nikolaou AC et al 统计514例喉癌56月的随访资料,喉二重原发癌的发生率为8.17%,其中同步二重原发癌的发生率为1.55%,异步二重癌的发生率为6.61%。头颈部二重原发癌在第一个原发肿瘤诊断后的最初3年以内发生的机会最大,特别是喉癌,在初次诊断后的3年以内,预期10%-14%患者发生二重原发癌,其中约10%(占总数的1%)为同步的二重原发癌。支气管癌是喉癌患者最常见的二重原发肿瘤形式,可占40-60%,其次是食道。此外已有学者注意到,喉癌病人中,泌尿道二重原发癌的发生率在增加。呼吸道以外的喉二重原发癌几乎一半以上为膀胱癌。60-70岁年龄阶段,发生第二个原发癌的机率较其他年龄组为高(P<0.01)。声门上型癌病人二重原发癌的发生率似乎较声门型癌高。喉二重原发癌患者的生存时间与二重癌的发生部位相关。30例出现呼吸道或上消化道二重癌的病人中,17例死亡(57%);而12例其他部位的二重癌患者中,仅2例死于该疾病(17%)。两组间的死亡率,经Kaplan-Meier检验,有统计学上的显著差异(log-rang test = 6.14, P = 0.0132)。
到目前为止,能解释二重原发肿瘤发生机制的仍然是区域性癌变理论和多步癌变学说。我们曾对21例喉癌和癌旁组织中的转化生长因子-α(TGF-α)及其受体mRNA进行定量分析,结果显示,喉癌和癌旁组织学正常的喉粘膜组织中的TGF-α及其受体mRNA均明显高于声带息肉组织(P<0.05)。说明癌基因的表达上调,不但可发生于喉癌组织,也可发生于喉癌旁组织学正常的区域。符合区域性癌变理论。推测该区域在致癌因素的继续刺激下,首先发生粘膜上皮细胞内的DNA的改变,包括癌基因激活和/或抑癌基因的灭活,在此基础上可能发生一个或多个癌前期病变,继而发生恶性转化而成为癌。我们还研究了喉癌、癌旁、喉乳头状瘤和声带息肉组织端粒酶的活化率,发现喉癌和喉乳头状瘤组织端粒酶阳性率均高于声带息肉组织,而癌旁组织的端粒酶阳性率甚至高于喉癌组织(P<0.05)。结合病理学观察, 25例癌旁组织中, 7例上皮完全正常,15例上皮呈现不同程度增生,3例上皮呈轻度不典型增生。组织学上从正常到上皮增生和轻度不典型增生,端粒酶活化率有逐渐增高趋势。说明端粒酶的激活,与原癌基因表达等其他的分子生物学改变一样,发生于癌表型完全产生之前。根据区域性癌变理论,癌旁喉粘膜,由于长期暴露于致癌因素的刺激下,有较大的潜在的癌变危险,甚至喉癌患者的整个上呼吸消化道都是如此。
喉二重原发癌,特别是在呼吸道和上消化道,治疗上极为困难,即使能很早期诊断也是如此。一旦诊断为二重原发肿瘤,病人的生存率就急剧下降。显然,早期诊断不如预防更能改善病人的生存率。1976年Sporn提出预防性化疗的概念,试图预防和终止细胞从癌前期状态转化为浸润癌。特别是近十年,头颈部癌已成为预防性化疗的模型。具有讽刺意义的是,随着头颈部癌首次诊断和治疗技术的提高,病人的生存期延长,而发生二重原发癌的危险性也在提高。因此,头颈部癌患者成功治疗后,预防二重癌的发生已成为世界范围内临床和实验室迫切需要研究的课题。


A48.新型铒-YAG激光在镫骨手术应用及效果观察

上海市第一人民医院分院  
陈文文 邓亚新 童军 乔艺 钟笑 张裕华

国内自王正敏1997年首先报告CO2激光镫骨手术以后[1],激光应用逐渐引起国内同道的重视。但国内激光镫骨手术的报道仍不多见。激光由于其非接触、脉冲能量微小、容易控制、对内耳热辐射、扰动极微等优点,手术的安全性大大提高。设备费用也较前大大降低,为国内推广提供了现实可能。我们在2001年引入新型的Er: YAG(Er: yttrium aluminum garnet 铒-钇铝柘榴石)激光,在耳硬化症镫骨手术,取得良好结果,现报告如下:
对象和方法 手术对象共21例(25耳)。男7例,女14例,4例为双侧,是我院2001年1月至2002年12月间收治的耳硬化症患者。平均年龄47.42岁(范围20-74岁)。4耳系外院手术未成功而再手术者,其中2耳是伴有锤前韧带骨化的镫骨耳硬化症再手术病例,另1耳伴有面神经嵴与镫骨之间骨质桥接。术前平均气骨差(取500,1000,2000Hz三频率均数,下同)为45.28dB(范围18-70 dB),平均气导71.92dB(范围43-123 dB)。手术设备为卡尔-蔡司(Carl Zeiss)公司提供的与手术显微镜相配套的铒-YAG激光系统。25耳全部采用王正敏论述的小开窗技术,并应用自制的具有防滑脱功能的挂钩式镫骨活塞。激光使用参数一般用70毫焦尔,连续脉冲,耳硬化症镫骨手术平均每例手术40-50次脉冲(其中镫骨头、肌10-35次,断足弓10-20次,底板窗2-3次)。疗效评价术后气骨差缩小15dB以上为有效。
结果:术后听力:经平均7.69月(范围3-16月)随访,无失访,气骨差全部缩小20dB以上。术后平均气骨差15.56dB,平均缩小29.72dB。配对t检验: P<0.01,差异有极显著性意义。2耳(8%)缩小50dB以上, 4耳(16%)缩小40dB以上,6耳(24%)缩小30dB以上,3耳(12%)缩小20dB以上。13耳(52%)小于10dB(闭合)。22耳(88%)比术前气骨差缩小一半以上。随访期内无一例骨导下降。术前4000和8000Hz骨导平均水平45.2dB,术后为43.6dB,配对t检验:P>0.05,差异无显著性意义。16例术后没有眩晕,5例有轻微眩晕。
讨论和结论:1980年代起,大多数是采用CO2或氩激光,铒激光只是近年才在少数耳硬化症病人中使用,这是一种非接触型、可见的激光,与CO2等其他激光不同,后者需要另有氦氖激光做导引光斑。与接触型半导体激光也不同。铒-YAG激光发射2940nm波长的光能,可以被细胞间隙或细胞外的水分子直接完全吸收,决无可能发生内耳穿透、破坏膜性迷路的情况,因而特别适合镫骨手术中应用。而这种穿透性内耳损伤在使用其他类型激光(如:CO2,钬激光,氩激光)是可能或非常容易发生的。其原理是铒-YAG对组织的消融不是由于热效应,而是一种机械效应,是由于细胞间的水分子直接吸收了铒激光后,水的蒸发,引起组织组合状态在几微秒时间内瞬间改变。Jamali 分别用钬激光和铒激光在豚鼠耳蜗基底转打出0.5-0.6mm孔,分别90分钟, 1天, 2周,和 4周后取出耳蜗做扫描电镜,发现钬激光的外毛细胞有损伤融合,铒激光没有任何损伤。认为铒激光是能替代热能性CO2激光的最佳选择,而钬激光有损伤内耳可能,不宜使用。1997年王正敏报告43例CO2激光手术,术前气骨差平均29.2±5.7dB,术后减少为11.2±6.6dB。本文术前平均气骨差45.28dB(范围18-70 dB),术后平均气骨差15.56dB,缩小29.72dB,13耳(52%)气骨差闭合。但铒-YAG激光声波强度达到100-120dB,高于CO2 激光,必须有所警惕。另外,Shah[8]等人动物和尸体实验表明,在使用铒-YAG激光足板钻孔,同时在圆窗测量温度,可以有2℃升温。虽然比钬激光升温25℃低得多,但并不是完全没有升温改变,减少足板穿孔时过长连续脉冲而改用间断脉冲,预防升温及升温带来的负效应是必须注意的。


A49.新生儿听力筛查-诊断-干预上海经验

上海儿童医学中心
许政敏

一、目的和意义
国外研究表明,听力障碍在正常新生儿中的发病率约为0.1%-0.3%。而
重症监护病房抢救的新生儿,其听力障碍的发病率可高达2%-4%。(1)国内在上海地区研究发现,正常新生儿中听力障碍的发病率为0.279%,而在重症监护病房中的新生儿发病率为1.34%。
听力正常的儿童一般在4-6个月时开始出现牙牙学语的现象,这是语言启蒙的重要阶段。如有听力障碍的儿童,由于缺乏有效的声音刺激,使语言发育障碍,势必会影响其情感和智力的正常发育。(2)由此可见,早期发现有听力障碍的患儿早期干预,对减少聋哑残病发病率起着重要作用。因此,1994年美国联合委员会(4)发表声明,倡导进行听力普查,要求所有出生3个月以内的新生儿和婴幼儿必须进行听力检查。近期在美国已有近40个州相继开展新生儿听力筛查。
国内对新生儿听力筛查工作相继开展。包括在北京,上海,南京,山东,浙江,但还未建立一个有效的运转网络及系统工程(筛查-诊断-干预)。本讲课课题为新生儿听力筛查-诊断-干预,探讨在上海地区开展这一工作以及运转机制。这对今后在全国范围内有效的开展这一工作起着积极的推进作用。
二、新生儿听力筛查
1.第一阶段:科研(1999年8月-2001年12月)
在1999年8月-2001年12月,获得上海市科委的重大项目。新生儿听力筛查和干预方法研究。研究的对象主要分二组:第一组为正常出生的新生儿为5315人。第二组为重症监护病房的新生儿598人。研究结果为在上海地区新生儿听力障碍的发病率为0.279%,重症监护病房的新生儿发病率为1.34%。研究筛查模式,采用DPOAE的二次筛查法(初筛和复筛),提出了筛查技术的注意事项及各种影响筛查的结果。提出了二次确诊法,大大减少了筛查的假阳性及假阴性,提高筛查的敏感性和特异性。同时,对新生儿听力筛查阳性被确诊为听力障碍的患儿进行干预方法的研究。研究结果显示:干预时间选择在出生6个月为佳,这对患儿的语言发育非常重要。选择2组试验组及对照组,评估方法采用自由声场测试,言语,识别,语言表达率,动态观察了3个月,6个月,12个月。轻度-重度感觉神经聋(40-90dB)可进行声放大听力矫正,双侧极重度感觉神经性聋(>=90db)行人工电子耳蜗植入。听力矫正之后,听功能-言语-语言康复,最好安排在康复中心进行系统训练。上述数据提供给上海市卫生局,行政部门作为制定在全市范围内开展新生儿听力筛查,作为参数数据。
2. 第二阶段:培训(2002年1月-2002年3月)
在2002.1-2002.3,上海市卫生行政部门,根据我们提供大量数据,一起制定在全市开展新生儿听力筛查计划。而前期的准备工作,最重要的是培训筛查人员。这一工作在上海市卫生局,行政部门的协调下,上海儿童医学中心,上海新华医院,培训,145个市区级以上综合性医院及妇幼保健院筛查点,共计300多名医务工作者,培训二周,理论授课为新生儿听力筛查意义,新生儿听觉传导解剖和生理。新生儿听力筛查新技术,以及听力筛查操作注意事项。操作授课为DPOAE(畸变产物耳声发射)一起使用,做到每个学员能够操作筛查1-2个新生儿,经过理论和实践考试,通过者发放上岗证书。
3.第三阶段:实施(2002年3月3日起)
在上海市卫生局行政部门的协调下,在2002.3.3爱耳日,在上海儿童医学中心内成立了一个上海市儿童听力障碍诊治中心,负责对全市听力筛查未通过的婴儿进行复查和确诊以及治疗。负责对新生儿听力筛查的质量控制,以及负责将有关数据上报到行政部门。上述工作都在行政部门的协调下进行。并在3.3日宣布在全市范围内开展新生儿听力筛查工作。具体筛查-诊断-干预模式见图I
三、诊断
在上海市新生儿听力筛查点,经过两次筛查,初筛和复筛,不管是一侧还是二侧耳未通过,都要转诊到上海市儿童听力障碍诊治中心,即在上海儿童医学中心内,转诊前填写好三联单(病人-筛查中心-诊治)。一般进行二次确诊。第一次3个月,第二次6个月,确诊采用诊断性中心听性脑干诱发电位,诊断性耳声发射,声导抗,自由声场行为测听。诊治中心不但要确诊患儿听力损失情况,包括听力损失程度以及听力损失的部位,传导性耳聋,感音性耳聋,以及神经性耳聋,而且还要到筛查点质量控制。质量控制标准值根据国外报导以及我们深研得到数据,具体数值如下:
正常新生儿:初筛控制在15-20%,复筛控制在3%,第一次确诊1.4%。第二次确诊为  0.1%-0.3%。
NICU高危听力障碍新生儿:初筛:20%-25%,复筛6%,第一次确诊3-8%
第二次确诊2%。
从2002.3.3开始全市开展新生儿听力筛查8万多人,初筛阳性600多人,已在上海儿童医学中心确诊的病人数57人。
四、干预
初确诊的婴儿患有听力障碍,需及时进行干预,干预的时间根据国外报导以及我们显示,最佳干预时间定在出生6个月,这对听功能-言语-语言发育最佳时期。得到我们科研数据也证实了这一点。如何评估,我们采用自由声场行为测听。言语识别率,语言表达率,对实验组,对照组动态观察3个月,6个月,12个月。
干预的内容包括,听力矫正,可为声放大,手术以及人工耳蜗植入。矫正之后听功能训练,言语-语言康复,这一工程是由上海儿童医学中心与康复中心一起完成。听功能训练听力矫正之后出生6个月-18个月,这是语言的启蒙的重要间断。训练包括;听觉察觉,听觉注意,听觉定位,听觉识别,听觉记忆和听觉选择。在这时期指导家长如何进行训练,定期2-3个月进行随访。1周岁以后进行言语-语言康复。包括单独发音,音节水平,单词水平,水平训练,这需要和康复中心结合,系统的进行训练,促进听力障碍患儿的言语-语言功能的正常发育。



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gudongsh
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  发帖心情 Post By:2004/4/17 18:54:00 [只看该作者]

前几天在上海参加会议,现将专题报告的内容让同道共享。
就是不知有没有侵犯知识产权。


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加好友 发短信 耳鼻喉科医生 资深版主
等级:注册用户 帖子:3402 积分:1183 威望:12 精华:3 注册:2002/4/29 22:08:00
  发帖心情 Post By:2004/8/3 20:34:00 [只看该作者]

上海耳鼻咽喉的学术气氛很脓,每2m都要组织各专业专家对该专业进行理论讲座,共同提高,有空的时候,我也乘车去上海分享一下。课后讨论也激烈,各种细节问题都会交流,提高很大。

不知其他地区如何,我知道浙江没做到。



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  发帖心情 Post By:2013/6/25 15:26:00 [只看该作者]

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