The airway management and treatment of newborns with micrognathia and laryngomalacia
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摘要: 目的 探讨小下颌畸形伴喉软化新生儿的围手术期气道管理及治疗。方法 2022年1—12月共纳入6例小下颌畸形伴喉软化新生儿。术前喉镜检查发现合并喉软化。小下颌畸形确诊为皮罗综合征。术前患儿均存在Ⅱ度以上的喉梗阻表现，需予以吸氧或无创呼吸机辅助通气治疗。所有患儿均同期行喉软化手术和双侧下颌骨牵引成骨术，术中用低温等离子射频刀消融短缩的杓会厌皱襞，术后气管插管3~5 d。术前、术后3个月行多导睡眠呼吸监测评估(PSG)及气道CT检查。结果 6例患儿中4例术前需要吸氧，2例需无创呼吸机辅助通气治疗。手术平均年龄为40 d，术中均未损伤下牙槽神经血管束，术后均未出现口角歪斜等下颌缘支损伤表现。喉软化表现为混合型：Ⅱ型+Ⅲ型；最大下颌骨牵引延长距离20 mm，最小12 mm，平均16 mm；后气道间隙由术前平均3.5 mm增加到术后9.5 mm；AHI由平均5.65降至0.85，最低血氧饱和度由平均78%增加至95%。术后患儿均成功拔除气管插管，缺氧、喂养困难等喉梗阻症状均消失。结论 小下颌畸形伴喉软化新生儿存在多平面的气道梗阻，早期同时行喉软化术和下颌骨牵引成骨术安全可行，能有效解决患儿缺氧、喂养困难等喉梗阻症状，同时显著改善小下颌的外观。Abstract: Objective To explore the perioperative airway management and treatment of newborns with micrognathia and laryngomalacia.Methods From January to December 2022, a total of 6 newborns with micrognathia and laryngomalacia were included. Preoperative laryngoscopy revealed concomitant laryngomalacia. These micrognathia were diagnosed as Pierre Robin sequences. All patients had grade Ⅱ or higher symptoms of laryngeal obstruction and required oxygen therapy or non-invasive ventilatory support. All patients underwent simultaneous laryngomalacia surgery and mandibular distraction osteogenesis. The shortened aryepiglottic folds were ablated using a low-temperature plasma radiofrequency during the operation. Tracheal intubation was maintained for 3-5 days postoperatively. Polysomnography(PSG) and airway CT examination were performed before and 3 months after the surgery.Results Among the 6 patients, 4 required oxygen therapy preoperatively and 2 required non-invasiveventilatory support. The mean age of patients was 40 days at surgery. The inferior alveolar nerve bundle was not damaged during the operation, and there were no signs of mandibular branch injury such as facial asymmetry after the surgery. Laryngomalacia presented as mixed type: type Ⅱ+ type Ⅲ. The maximum mandibular distraction distance was 20 mm, the minimum was 12 mm, and the mean was 16 mm. The posterior airway space increased from a preoperative average of 3.5 mm to a postoperative average of 9.5 mm. The AHI decreased from a mean of 5.65 to 0.85, and the lowest oxygen saturation increased from a mean of 78% to 95%. All patients were successfully extubated after the surgery, and symptoms of laryngeal obstruction such as hypoxia and feeding difficulties disappeared.Conclusion Newborns with micrognathia and laryngomalacia have multi-planar airway obstruction. Simultaneous laryngomalacia surgery and mandibular distraction osteogenesis are safe and feasible, and can effectively alleviate symptoms of laryngeal obstruction such as hypoxia and feeding difficulties, while significantly improving the appearance of micrognathia.
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表 1 病例资料特征
项目 例1 例2 例3 例4 例5 例6 均值 手术时年龄/d 35 45 42 40 41 37 40 性别 男 男 女 女 男 女 / 下颌牵引距离/mm 16 14 12 16 18 20 16 喉软化分型 Ⅱ Ⅱ Ⅱ Ⅱ+Ⅲ Ⅱ+Ⅲ Ⅱ / 
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表 2 治疗效果
序号 后气道间隙/mm 最低血氧饱和度/% AHI 术前 术后 术前 术后 术前 术后 1 3.5 9.6 79 95 5.6 0.6 2 4.2 11.0 83 98 4.5 0.6 3 4.3 10.6 86 98 3.8 0.4 4 3.5 9.0 74 95 6.8 0.8 5 3.0 8.8 77 92 7.5 1.2 6 2.5 8.0 69 92 - 1.5 均值 3.5 9.5 78 95 5.65 0.85 P < 0.01 < 0.01 < 0.01 “—”为无法完成检测。
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