【摘要】：研究背景：阻塞性睡眠呼吸暫停綜合征(obstructive sleep apnea-hypopnea syndrome, OSAHS)是指睡眠過程中上氣道反復(fù)發(fā)生部分或全部阻塞,導(dǎo)致通氣不足甚至呼吸暫停,是一種兒童常見的睡眠相關(guān)呼吸障礙性疾病,主要表現(xiàn)為：睡眠時(shí)張口呼吸,伴有憋氣甚至呼吸困難；白天多動(dòng)、學(xué)習(xí)困難、伴攻擊性行為等認(rèn)知異常表現(xiàn),甚至并發(fā)肺源性心臟病等呼吸、循環(huán)系統(tǒng)病變。其在流行病學(xué)和病理生理學(xué)特點(diǎn)上,與成人相比具有較大不同,治療方面,扁桃體和腺樣體手術(shù)能顯著改善OSAHS病情,是兒童OSAHS的首選治療方法,而作為成人一線治療方法的持續(xù)正壓通氣僅用于圍手術(shù)期以及患有21-三體綜合征、嚴(yán)重畸形等無法采用手術(shù)治療的重度OSAHS患兒。但腺樣體和扁桃體參與咽淋巴環(huán)的組成,發(fā)揮重要作用,尤其是對(duì)兒童的體液及細(xì)胞免疫防御有重要意義,此外,其濾泡上皮也有一定的屏障作用。近年來,等離子扁桃體部分切除術(shù)以其疼痛反應(yīng)輕、術(shù)后恢復(fù)快而被逐漸應(yīng)用,該術(shù)式可否既解決呼吸道梗阻問題、又將隱窩上皮的屏障功能盡可能地保留,受到了廣泛關(guān)注,同時(shí)目前各種形式的扁桃體腺樣體相關(guān)手術(shù)的研究中,對(duì)于OSAHS患兒手術(shù)前后免疫功能變化的觀點(diǎn)尚不一致,有關(guān)不同術(shù)式對(duì)兒童OSAHS的治療效果的研究并不多。目的：研究單純腺樣體切除、腺樣體切除伴扁桃體部分切除、腺樣體切除伴扁桃體全部切除三種術(shù)式對(duì)OSAHS患兒體液及細(xì)胞免疫功能的影響,探討不同術(shù)式的適用情況,為個(gè)體化的臨床治療提供理論依據(jù)。方法：本研究為前瞻性臨床試驗(yàn)。1.選取2014年06月至2014年12月因睡眠時(shí)打鼾或張口呼吸于山東大學(xué)齊魯醫(yī)院就診、并經(jīng)多導(dǎo)睡眠監(jiān)測(cè)確診的符合納入標(biāo)準(zhǔn)的150例兒童OSAHS患者,根據(jù)扁桃體分級(jí)分為單純腺樣體切除組(A組)、腺樣體切除伴扁桃體部分切除組(B組)、腺樣體切除伴扁桃體全部切除組(C組)三組,每組各50例。2.于PSG檢查后次日和術(shù)后6個(gè)月時(shí)進(jìn)行血液標(biāo)本的采集,采集時(shí)間均為7：00-8：OOam,送化驗(yàn)室檢測(cè)Ig水平及T細(xì)胞亞群百分比,并做好記錄。3.隨訪期間隨時(shí)記錄并發(fā)癥發(fā)生情況,術(shù)后前三天對(duì)所有患兒采用Wong-Baker FACES疼痛評(píng)分表評(píng)估疼痛程度,術(shù)后6個(gè)月時(shí),采用多導(dǎo)睡眠監(jiān)測(cè)與臨床癥狀相結(jié)合的方法判定手術(shù)療效,術(shù)后未做睡眠監(jiān)測(cè)者以臨床癥狀改善程度作為評(píng)定依據(jù),同時(shí)統(tǒng)計(jì)各種術(shù)式的有效率。結(jié)果：1.與術(shù)前相比,三組患兒術(shù)后6個(gè)月時(shí)的免疫指標(biāo)水平變化無統(tǒng)計(jì)學(xué)意義(P0.05)。2.術(shù)后第1天、第2天,A、B、C三組的疼痛評(píng)分依次升高,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)；術(shù)后第3天時(shí),A、B兩組的疼痛評(píng)分無明顯差異(P0.05),但均明顯低于C組(P0.05)。3.A組有3例患兒的扁桃體較術(shù)前明顯增大(Ⅲ級(jí)),B組有2例扁桃體較術(shù)前增大(Ⅱ級(jí)),C組無扁桃體再增生。術(shù)后6個(gè)月時(shí)對(duì)三種術(shù)式有效的概率進(jìn)行評(píng)估,根據(jù)臨床癥狀和PSG結(jié)果,A、B、C三組分別為93.94%、96.67%、97.30%,無明顯差異(P0.05)。結(jié)論：?jiǎn)渭兿贅芋w切除術(shù)、腺樣體切除伴扁桃體部分切除、腺樣體切除伴扁桃體全部切除術(shù)對(duì)患兒的體液及細(xì)胞免疫功能均無明顯影響,且均可達(dá)到治療兒童OSAHS的效果。單純腺樣體切除術(shù)、腺樣體切除伴扁桃體部分切除患兒術(shù)后疼痛性低�？梢钥紤]根據(jù)扁桃體肥大程度來決定扁桃體的保留與否或者是否行部分切除術(shù)。
[Abstract]:Background: obstructive sleep apnea-hypopnea syndrome (OSAHS) refers to the repeated partial or full obstruction of the upper airway in the process of sleep, resulting in insufficient ventilation and even apnea. It is a common sleep related respiratory disorder in children, which is mainly manifested in mouth breathing during sleep. It is accompanied by suffocation or even breathing difficulties, cognitive abnormalities such as daytime hyperactivity, learning difficulties, and aggressive behavior, and even pulmonary heart disease, such as respiratory and circulatory diseases, which are significantly different from adults in epidemiological and pathophysiological characteristics. Tonsillar and adenoid surgery can significantly improve OSAHS The disease is the preferred treatment for OSAHS in children, and continuous positive pressure ventilation, as a first-line treatment for adults, is only used in the perioperative period and in severe OSAHS children with 21- trisomy syndrome and severe malformation, but adenoids and tonsils are involved in the composition of the pharyngeal ring, especially for children. In recent years, the plasma tonsillectomy has been used in recent years for its mild response to pain and rapid recovery after operation. The operation can not only solve the problem of respiratory obstruction, but also retain the barrier function of the recess epithelium as far as possible. In the study of all forms of tonsillar adenoid related surgery, there is no agreement on the changes of immune function in children with OSAHS before and after operation. There are few studies on the therapeutic effect of different surgical methods on children's OSAHS. Objective: To study the simple adenoidectomy, adenoidectomy with tonsillectomy, The effects of adenoidectomy with all three kinds of tonsillectomy on the humoral and cellular immune function of children with OSAHS were used to explore the application of different surgical procedures and to provide a theoretical basis for the individualized clinical treatment. Methods: This study was a prospective clinical trial of.1. from 2014 to December 2014 for snoring or mouth breathing during sleep. 150 cases of children OSAHS diagnosed in Qilu Hospital of East University were diagnosed by polysomnography and were divided into simple adenoidectomy group (group A), adenoidectomy with tonsillectomy group (group B), adenoidectomy with all three groups of almond excision group (group C), 50 cases in each group of.2. were examined by PSG. After the next day and 6 months after the operation, the blood samples were collected and collected for 7:00-8:OOam. The Ig level and the percentage of T cell subgroups were detected in the laboratory. The complications were recorded at any time during the follow-up period of the record.3.. The pain degree was assessed by the Wong-Baker FACES pain score table in all the children after the operation, and 6 after the operation. At the end of the month, polysomnography was combined with clinical symptoms to determine the effect of the operation. The patients who did not do sleep monitoring were based on the improvement of clinical symptoms. At the same time, the effective rate of various kinds of surgical procedures was measured. Results: 1. compared with the preoperative, the level of immune indexes at 6 months after operation in the three groups was not statistically significant (P0 .05) first days after.2., second days, A, B, C three groups of pain scores increased in turn, the difference was statistically significant (P0.05), third days after the operation, A, B two no significant difference in pain score (P0.05), but obviously lower than C group (P0.05).3.A group 3 cases of flat peach body significantly increased (grade III), 2 cases of tonsils increased before surgery (II). C group had no tonsillar hyperplasia. Three kinds of effective probability were evaluated at 6 months after operation. According to clinical symptoms and PSG results, A, B, C three groups were 93.94%, 96.67%, 97.30%, respectively. Conclusion: adenoidectomy, adenoidectomy with tonsillectomy, adenoidectomy with all tonsillectomy There is no obvious effect on the humoral and cellular immune function of the children, and it can be achieved in the treatment of children's OSAHS. Simple adenoidectomy, adenoidectomy with partial tonsillectomy in children with low pain after surgery can consider the tonsil hypertrophy to determine the tonsils or not.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R766.9

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