鼻内镜下难治性鼻出血出血点寻找及止血策略

难治性鼻出血是指出血部位隐蔽,经前鼻镜无法窥及出血部位的凶猛的鼻出血.曾经有文献报道此类出血,并命名为"隐蔽性鼻出血"、"顽固性鼻出血"等.但是由于操作医师技术水平的差异,对于"难治性"的定义难以规范我们的理解为难治性鼻出血往往因为出血部位无法明确,盲目进行前鼻孔鼻腔填塞,或后鼻孔Flash尿管压迫,导致填塞后仍反复出血,既往采用蝶腭动脉结扎、电凝,筛前动脉结扎及电凝等方法[1].随着鼻内镜外科的发展,鼻内镜解剖及鼻腔血运的研究,鼻出血的治疗已经不再是难题[2-5].但是文献中多为针对蝶腭动脉主干的电凝处理[4-5],而且对于鼻出血的出血部位寻找及止血水平仍参差不齐,我们近几年来每年治疗难治性鼻出血800多例,门诊治疗成功率在98％以上.现将难治性鼻出血主要责任血管位置、出血点寻找策略等进行总结如下     

颈外动脉结扎后能否再通的临床观察(附2例报告)

目的探讨已经结扎的颈外动脉能否通过结扎处或通过结扎处上下血管间形成的侧支循环吻合再通.方法1988年9月至1995年4月对9例严重顽固性老年鼻出血患者施行了颈外动脉结扎术,其中2例分别于颈外动脉结扎后5年和7年在结扎侧鼻腔再次出血,为明确患者已经结扎的颈外动脉和复发鼻出血之间的关系,对患者已经结扎的颈外动脉进行血管数字减影造影.结果已经结扎的颈外动脉不会通过双重血管结扎处,也不会通过结扎处上下血管形成的侧支循环吻合再通,而且在结扎处周围也不可能形成侧支循环的吻合支,已经结扎的颈外动脉和复发鼻出血之间没有任何关系.结论已经结扎的颈外动脉不会随着时间的推移而重新再通.     

射频治疗在鼻出血中的应用

鼻出血是耳鼻咽喉头颈外科的常见急诊之一,60%的人一生中至少发生过一次鼻出血[1].鼻出血可发生于任何年龄,男性多于女性,发病率约为10%～13%[2].许多全身和局部疾病均可引起鼻出血,长期间断的鼻出血可引起贫血,严重者甚至可导致休克.     

治愈1例顽固性鼻出血的体会

鼻出血为耳鼻咽喉科的常见急诊,大多经鼻腔填塞、冷冻、烧灼、微波、激光等治疗可愈.现报道1例顽固性鼻出血,经过前后鼻孔填塞、选择性颈外动脉栓塞、鼻内镜下双极电凝止血、膨胀海绵填塞,均无效,最后行筛前动脉结扎,加结缔组织片和生物胶粘贴于渗血处,才彻底止血.     

鼻出血的治疗(附79例病例分析)

目的：总结鼻出血的治疗经验，分析治疗中可能存在的问题，探讨各种治疗措施在处理鼻出血中的意义。方法：对近6年来住院治疗的鼻出血病人79例进行回顾分析。结果：79例均治愈，治疗手段包括前后鼻孔填塞、内镜下激光烧灼、颈外动脉和/或筛前动脉结扎、经上颌窦颌内动脉结扎或数字减影血管造影颌内动脉栓塞等。结论：治疗鼻出血的关键是找淮出血部位及明确出血原因，并根据病人实际情况采取有效止血措施。     

高频电凝在筛前筛后动脉结扎术中的应用

筛前筛后动脉结扎通常用于上述动脉所供区域的顽固性鼻出血.是一种有效的治疗方法,常常达到立竿见影的效果。自1937年首次开展,一直运用至今。但就其筛前筛后动脉切断的问题,一般都不主张[1,2]。在近些年的临床工作中,我们尝试了6例高频单极电凝灼断(或切断)筛前筛后动脉治疗顽固性鼻出血,疗效满意,无任何并发症,介绍如下。     

超选择性颈外动脉分支栓塞术在难治性鼻出血中的应用

目的:探讨经微导管超选择性颈外动脉分支栓塞术在治疗难治性鼻出血中的应用价值。方法:46例难治性鼻出血患者,首选超选择性颈外动脉分支栓塞术者36例,首选颈外动脉结扎者10例。结果:36例首选颈外动脉分支栓塞术者1次性治愈32例(88.9%),10例首选颈外动脉结扎者1次性治愈4例(40.0%)。前者平均住院4.8d,后者平均住院10d。复发患者均经综合方法有效止血,并发症少。结论:经微导管超选择性颈外动脉分支栓塞术治疗难治性鼻出血简便、安全、有效,疗效明显优于颈外动脉结扎,综合运用多种方法能有效治疗难治性鼻出血。     

顽固性鼻出血的治疗

目的 探讨不同治疗方法对顽固性鼻出血的意义。方法 224例顽固性鼻出血病例中,50例行颈外动脉结扎,35例行筛动脉结扎,鼻内镜下治疗139例,鼻咽填塞3例。结果 224例中,随访3个月,颈外动脉结扎者复发率22.00%,筛动脉结扎者复发率17.14%,鼻内镜下治疗者复发率4.32%。结论 应用鼻内镜辅助检查明确出血灶后局部止血效果明显,且复发率低。     

鼻内镜下蝶腭动脉结扎术在难治性后鼻出血患者中的应用

最近,鼻内镜下蝶腭动脉结扎术(ESPAL)治疗难治性后鼻出血受到国内外广泛关注[1].本文通过复习国外有关文献,将ESPAL介绍如下.     

颈外动脉结扎治疗老年人严重鼻出血

作者采用颈外动脉结扎治疗老年人严重鼻出血，讨论了手术时机的选择，结扎血管的选择与方法及结扎时应注意的事宜     

One‐stop neck lump clinic: phase 2 of audit. How are we doing?

One‐stop neck lump clinic: phase 2 of audit. How are we doing? Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one‐stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.     

A Decrease in Maxillary Sinus Pressure,as Seen in Upper Airway Allergy or Infection,Results in an Increase in Upper Airway Nitric Oxide Levels

The paranasal sinuses are connected to the nasal cavity via small osties. Ostial occlusion, caused by mucosal swelling, will result in a slowly increasing negative pressure inside the sinus cavity. In parallel, the oxygen content in the sinus will decrease, resulting in the development of relative hypoxia. Hypoxia is a powerful inducer of nitric oxide (NO) synthase, and inducible NO synthase has been shown to be present in considerable amounts in the upper airways, including the sinuses. The present study was designed to investigate whether a reduction in sinus pressure would affect upper airway NO production. Thirteen healthy volunteers were investigated. A pressure chamber was used to lower the ambient pressure to-4.9 kPa. NO was sampled from one nostril or via a drainage tube inserted into the maxillary sinus before, during and after the hypobaric exposure. When the pressure was decreased, NO levels increased from 256 &#45 15 to 316 &#45 19 ppb ( n =13, p <0.001). The NO levels remained elevated (282 &#45 21 ppb; p <0.05) when measurements were repeated 20 min after leaving the chamber. The nasal airway resistance (V2 tot ) also increased as a result of the chamber session (from 16 &#45 2° before to 21 &#45 3° after; p <0.05). An increase in NO levels was also found when the experiments were repeated with NO sampled directly from the maxillary sinus (225 &#45 6 before and 265 &#45 9 ppb after; n =6, p <0.001). For control purposes the nasal analyses were repeated again, this time under hyperbaric conditions (+4.9 kPa). This resulted in a slight decrease in the NO levels (from 273 &#45 22 to 241 &#45 17 ppb; n =10, p <0.001), but there was no change in the nasal airway resistance. We conclude that a reduction in sinus pressure, as seen in upper airway allergy or infection, may result in an increase in upper airway NO production.     

Physiologische Grundlagen einer Hörprothese

Zusammenfassung Im Bemühen, eine Hörprothese zu entwickeln, die ein Sprachverständnis erlaubt, erscheint es zumindest fürs erste am zweckmäßigsten, durch künstliche elektrische Reizung des Hörnerven die natürlichen Verhältnissen so gut als möglich zu imitieren. Der normale Hörnerv enthält etwa 30000 Nervenfasern, die sich qualitativ gleich, quantitativ jedoch unterschiedlich verhalten, wobei über die Eigenschaften der von den ÄHZ kommenden Spiralfasern im Augenblick sichere Aussagen nicht möglich sind (siehe 2.3). Die quantitativen Unterschiede zwischen den einzelnen Hörnervenfasern beziehen sich auf deren Frequenzabstimmung, Frequenzselektivität, Schwellen, Intensitätsfunktionen und — wichtig insbesondere für das Vorhaben einer künstlichen elektrischen Reizung — in Zeitunterschieden in den Aktivitätsmustern, die durch Laufzeitunterschiede auf der Basilarmembran bedingt sind (2.3). Diese Zeitunterschiede in der Aktivität einzelner Fasern liegen im Bereich mehrerer ms (2.3.6; 2.3.7). Die durch Schallreize im normalen Hörnerven ausgelösten Aktionspotentiale haben überdies einen probabilistischen Charakter, d. h. ihr Auftreten ist keineswegs streng determiniert. Es versteht sich von selbst, daß man bei künstlicher, elektrischer Reizung nicht alle verbliebenen Nervenfasern selektiv reizen kann. Somit wird eine Reizelektrode immer eine Gruppe von Nervenfasern erregen müssen. Bei jeder denkbaren elektrischen Reizung wären alle Fasern im Reizbereich einer Elektrode synchron und streng deterministisch aktiviert, was einen außerordentlich ernstzunehmenden Unterschied zu natürlichen Verhältnissen darstellt (3.2).Um die Zahl der zum Sprachverständnis mindestens notwendigen Reizkanäle abzuschätzen, wird man, in Ermangelung anderer experimenteller Daten, von psychoakustischen Untersuchungen an Normalhörenden auszugehen haben. Diese haben gezeigt, daß das Gehör neben einer außerordentlichen Fähigkeit verschiedene Tonhöhen zu unterscheiden, andererseits die Fähigkeit besitzt, bestimmte Frequenzgebiete zu sogenannten Frequenzgruppen zu integrieren. Die in eine solche Frequenzgruppe fallende Schallenergie wird zu einem einheitlichen Höreindruck verarbeitet. Es scheint also sinnvoll, die für einen Prothesenbau notwendige Zusammenfassung von Gruppen von Fasern des Hörnerven in verschiedene Reizkanäle entsprechend diesen Frequenzgruppen vorzunehmen (3.1). Demnach müßte der Sprachbereich in 15 Reizkanäle aufgeteilt werden, was wiederum, wenn man in der Cochlea reizen will, 1,2 mm Abstand von Kanal zu Kanal erlauben würde. Dabei müßte der Reizerfolg sauber auf die einzelnen Kanäle beschränkt bleiben, d.h. eine optimale Kanaltrennung erreicht werden. In Anbetracht der groben Abweichungen der neuronalen Aktivität vom normalen Verhalten, die bei künstlicher, elektrischer Reizung unvermeidlich sind, ist freilich unsicher, ob die angegebene Zahl ausreichen würde. Andererseits ist es in Anbetracht der zu erwartenden Stromverteilung im Sprachbereich kaum vorstellbar, mehr als die angegebene Zahl von Kanälen realisieren zu können.Was die Kodierung der Schallparameter innerhalb eines Elektrodenkanals betrifft, wird vorgeschlagen, die Frequenzkodierung nach dem Ortsprinzip optimal auszunutzen, und im Hinblick auf die Periodizitätsanalyse und die Lautheitskodierung sich soweit als möglich den natürlichen Verhältnissen anzunähern (3.3). Dabei wären Laufzeitunterschiede zwischen den Kanälen und der probabilistische Charakter der neuronalen Entladungen soweit als möglich einzuführen, um die Dominanz eines periodicity pitch zu vermeiden.Eine für Sprachverständnis ausreichende Prothese ist auch nur denkbar, wenn eine Prothese die zur Sprachübertragung notwendige Übertragungskapazität besitzt. Ergebnisse der Kanal-Vocoder-Technik zeigen, daß Sprache noch mit 1500 bit/s befriedigend übertragen werden kann. Eine Abschätzung der möglichen Leistungsfähigkeit einer 15-kanaligen Prothese (3.4), basierend auf der Zahl der möglichen unterscheidbaren Unterschiedsstufen der Hörempfindung, ergibt, daß diese Übertragungskapazität knapp erreicht werden könnte. Allerdings ist damit noch nicht gesagt, daß das Zentralnervensystem die angebotene Information auch im Sinne einer Phonemanalyse auswertet und damit für ein Sprachverständnis maximal ausschöpft. Nur für diesen Fall wäre ein Sprachverständnis zu erwarten.Als Reizort erscheint in erster Linie die Cochlea (5.1) geeignet. Für den Fall einer Degeneration der primären afferenten Fasern des Hörnerven ist aufgrund physiologischer Überlegungen auch der Nucleus cochlearis ventralis (5.5) interessant, allerdings würde so nur der ventrale Anteil der Hörbahn stimuliert. Doch besitzen auch andere Reizorte spezifische Vorteile (5.2–5.4).Theoretische Überlegungen (6.1) und experimentelle Messungen an implantierten Elektrodensätzen (6.3) zeigen, daß die Forderung der Kanaltrennung nur schwer zu erreichen sein wird. Deswegen wird der dynamische Bereich (im Hinblick auf Veränderung des Reizstromes) eines nach den obigen Kriterien konstruierten Reizkanals auf maximal 3 dB zu beschränken sein, so daß Erregungsausbreitung auf weitere Bereiche der Cochlea durch Ansteuerung von mehreren Reizkanälen zu imitieren wäre.Die Chancen, eine Prothese zu verwirklichen, die befriedigendes Sprachverständnis auf der Basis einer quasinatürlichen Reizung des Hörnerven erlaubt, wird von uns in Anbetracht der geschilderten mannigfaltigen Schwierigkeiten als sehr niedrig angesehen. In Anbetracht des großen Nutzens, der andererseits eventuell resultieren könnte, halten wir die Erforschung des Problems jedoch für angebracht.Es wird von uns vorgeschlagen, auch zu untersuchen, ob sich für eine prothetische Versorgung vorverarbeitete Sprache besser eignet (7.). Für Prothesen, die ein Sprachverständnis nicht anstreben, halten wir eine Implantation in die Cochlea für überflüssig. Hier erscheint uns die Implantation von Reizelektroden am runden Fenster (Douek et al., 1977; Fourcin et al., 1978; s. a. 1. und 7.) wegen des geringeren Risikos der überlegenere Weg.Die zitierten eigenen Arbeiten der Autoren wurden mit Unterstützung der DFG durchgeführt (DFG-K1 219).     

The expression of vascular endothelial growth factor (VEGF) and VEGF‐C in early laryngeal cancer: relationship with radioresistance

The expression of vascular endothelial growth factor (VEGF) and VEGF‐C in early laryngeal cancer: relationship with radioresistance Angiogenesis is essential for tumour growth and invasion. Vascular endothelial growth factor (VEGF) is a prime mediator of tumour angiogenesis. VEGF‐C is a closely related protein that effects lymphatic endothelial cells and may be important in the process of lymphatic metastasis. The purpose of this study was to evaluate the expression of these cytokines in patients with T1 and T2a glottic, squamous cell carcinoma, in comparison with normal epithelial control tissue, to ascertain any association with radioresistance. Twenty‐two tumours treated by radiotherapy (13 radiosensitive, nine radioresistant) and seven normal control tissues were studied. The minimum follow‐up was 2 years after radiotherapy. Expression of VEGF and VEGF‐C was evaluated by immunohistochemistry of formalin‐fixed, paraffin‐embedded biopsy specimens. Analysis was carried out using a quantitative computer image analyser. Both VEGF and VEGF‐C were detectable in tumour and normal control specimens. There was increased expression in tumour specimens of both VEGF (P = 0.03) and VEGF‐C (P < 0.001). In addition, the expression of VEGF‐C was associated with tumours of higher histological grade (P = 0.021). There was, however, no difference in VEGF and VEGF‐C expression between radioresistant and radiosensitive tumours. The expression of VEGF and VEGF‐C is increased in early laryngeal squamous cell carcinoma (SCC). However, measuring the expression of these proteins cannot predict radioresistance in this tumour group.     

Limited Surgery for Cancer of the Larynx and Hypopharynx: Options and Consequences

We reviewed surgical options for laryngeal preservation (limited surgery) in laryngeal and hypopharyngeal cancers and the consequences of the options. Of 44 patients with laryngeal cancer, 11 (25%) received limited surgery and 33 (75%) received total laryngectomy. The survival rates were 91% for the limited surgery group and 73% for the total (radical) surgery group. Of 31 patients with hypopharyngeal cancer, 7 (23%) received limited surgery and 24 (77%) received total laryngopharyngectomy. The survival rates were 53% for the limited surgery group and 40% for the total (radical) surgery group. The survival rates associated with limited surgery were thus better than those for total (radical) surgery for cancers of both the larynx and hypopharynx. This was attributed to the limited surgery group comprising well-selected patients with confined lesions. Organ preservation surgery should be technically simple, reliable in terms of its functional impact and, above all, should not jeopardize the patient's survival. Supracricoid subtotal laryngectomy with cricohyoidoepiglottopexy or cricohyoido-pexy has great potential for laryngeal preservation and will become the major limited surgery modality for treating cancer of the larynx. Limited surgery, however, needs to be performed with great care and is indicated only for very well-selected patients with cancer of the hypopharynx.     

Treatment of Maxillary Sinus Carcinoma: Clinical Results Using the Kitasato Modality

The conventional therapeutic regimen for maxillary sinus carcinoma consists of dissection of the maxilla, full-dose irradiation and extensive chemotherapy. However, the results obtained with this treatment are often poor. Even when patients recover, their quality of life is significantly reduced as a result of deformity of facial structures and swallowing and articulation dysfunctions. A retrospective analysis of 68 patients with maxillary sinus carcinoma treated with the Kitasato modality between 1975 and 1999 was conducted. All patients underwent pergingival maxillary sinus surgery combined with pre- and postoperative irradiation therapy with standardized total doses of 16 Gy; the postoperative irradiation was given in combination with regional intra-arterial infusion chemotherapy administered via the superficial temporal artery. All visible tumor lesions were removed where possible in order to preserve or facilitate cellular immunity after surgery. The cumulative 5-year survival rates were 85.7% for Stage II patients, 88.1% for Stage III, 76.6% for Stage IVA and 75.0% for Stage IVB.     

Cervical Reflex Induced by Click Stimuli in Cats

We studied click-evoked potentials in the anterior horn of the spinal cord in 17 cats. A concentric needle electrode was inserted into the anterior horn of the spinal cord at levels C3-C6. Potentials evoked with 105 dB SPL clicks were recorded with a peak latency of 4.89-5.10 ms only at the C3 level. These responses were observed 45-60 dB SPL above the auditory brainstem response (ABR) threshold, and no potentials were evoked by stimulation of the contralateral ear. Average was performed 100 times with changes in stimulation frequency of 1-20 Hz. The amplitude of the potentials decreased with increasing stimulus frequency, but there were no changes in ABRs. The responses disappeared after destruction of the medial vestibulospinal tract at the obex level, but ABRs were still recorded. The spinal nucleus of the accessory nerves was located in the anterior horn of the spinal cord at levels C1-C6, and the sternocleidomastoid muscle motoneurons were found at levels C1-C3. The click-evoked potentials recorded in this study reflect responses of the spinal nucleus of accessory nerves through the vestibulospinal tract to click stimulation. The responses have the same characteristics as vestibular-evoked myogenic potentials that can be recorded using surface electrodes over the sternocleidomastoid muscles of humans.     

Tongue Base Reduction with Temperature-controlled Radiofrequency Volumetric Tissue Reduction for Treatment of Obstructive Sleep Apnea Syndrome

In recent years a considerable effort has been made to establish the use of different surgical techniques for the treatment of obstructive sleep apnea syndrome (OSAS). Nevertheless, treatment of hypopharyngeal obstruction due to tongue base hypertrophy remains in many ways an unsolved problem. The aim of this study was to evaluate the safety and efficacy of tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction in the treatment of OSAS. Twenty patients with OSAS and tongue base hypertrophy were treated with radiofrequency tissue ablation. An intensified treatment protocol was used, delivering 2,800 J per treatment session under local anesthesia. Two nights of polysomnography testing were performed before and after treatment. Daytime sleepiness, snoring and postoperative morbidity were assessed using questionnaires. Mean respiratory disturbance index (RDI) was reduced from 32.1 to 24.9/h after a mean of 3.4 treatment sessions. Six patients (33%) were cured after the procedure (reduction in RDI of &#83 50% and a postoperative RDI of <15/h) and ten (55%) showed an improvement of >20% in their RDI. Daytime sleepiness and snoring improved significantly. Peri- and postoperative morbidity was low; one severe complication occurred (tongue base abscess). We were able to achieve similar cure and responder rates to those reported in a recently published pilot study but with a reduced number of treatment sessions. We believe that this technique may improve patient acceptance and have beneficial cost implications.     

Cochlear Function in Ears with Immunomediated Inner Ear Disorder

The aim of the present study was to evaluate the performance of ears with inner ear disorder, responsive to immunosuppressive drugs, in advanced tests designed to assess primary cochlear functions (temporal integration, frequency selectivity, cochlear mechanics). The results of this study suggest that immunomediated inner ear disease results, in the acute clinical stage, in the development of endolymphatic hydrops, which increases the stiffness of the vibrating structures within the inner ear and causes dysfunctions of the outer hair cells. Our patients presented with upsloping or flat sensorineural hearing loss, absence of evoked otoacoustic emissions and distortion-product otoacoustic evoked emissions and abnormal temporal integration, frequency selectivity and cochlear mechanics. Following immunosuppressive treatment, hydrops recovered, hearing subsequently returned to normal, the audiometric curve became flat at low-to-middle frequencies and primary cochlear function tended to normalize. This study seems to support the usefulness of testing primary cochlear functions in order to monitor the clinical course of immunomediated inner ear disorders.     

Bacterial Interference Between Pathogens in Otitis Media and Alpha-Haemolytic Streptococci Analysed in an In Vitro Model

Bacterial interference studied by means of agar methods has shown a decreased number of inhibitory alpha-haemolytic Streptococci among otitis-prone children. Additional information was gained regarding the interplay between alphahaemolytic Streptococci (AHS) and otitis media (OM) pathogens by comparing the bacterial interference in broth with the interference activity studied using agar overlay methods. We found that non-typeable Haemophilus influenzae (NTHI) and Moraxella catarrhalis are readily inhibited by AHS in broth. Streptococcus pneumoniae was more bacteriostatically inhibited. If two OM pathogens were inoculated simultaneously, an isolate of AHS with poor inhibitory activity was not able to inhibit the growth, in contrast to an isolate of AHS with good inhibitory activity. The initial amount of AHS inoculated with M. catarrhalis seemed to play a decisive role with respect to the inhibitory activity. M. catarrhalis developed reduced susceptibility against AHS both in vivo and in vitro . In vivo studies showed that children with secretory otitis media had fewer isolates of AHS in their nasopharynx with the ability to inhibit all the test pathogens than healthy children ( p < 0.001). Although the factor(s) responsible for the inhibitory activity have thus far not been defined, we could exclude low pH and nutrition depletion as the inhibitory mechanism of AHS with good inhibitory activity.