Shashidhar T B, Bajwa Dilpreet, Tyagi Shubhi, Chandra Indresh
Department of ENT and HNS, Artemis Hospitals, Gurugram, Room No. 1014, Sector 51, Gurugram, Haryana 122001 India.
Indian J Otolaryngol Head Neck Surg. 2023 Sep;75(3):2621-2625. doi: 10.1007/s12070-023-03849-4. Epub 2023 May 10.
Navigating Surgical Complexities associated with a case of Adenotonsillectomy in Arnold Chiari Malformation type 2. Arnold-Chiari or Chiari malformations (ACM) describe a group of deformities of the posterior fossa and hindbrain, which includes the cerebellum, pons, and medulla oblongata. Sleep-disordered breathing is a known but poorly evaluated comorbidity in patients with ACM. Obstructive sleep apnoea (OSA) in children is mainly caused by tonsillar and adenoid hypertrophy, and surgical resection of the palatine tonsils and adenoids is indicated depending on OSA severity. A 4-year-old male child suffering from Arnold Chiari type 2 malformation presented to us in OPD with Severe OSA. Clinical and endoscopic examination revealed presence of Grade 4 adenoids tissue and Grade 4 tonsillar hypertrophy. Patient was planned to undergo Coblation adenoidectomy and Tonsillectomy with Uvulopalatoplasty for the management of OSA. Patient tolerated the procedure well and extubating was un-eventful. Patient was kept in PICU for overnight observation and was discharged on next day without any major complications. Patient of Arnold Chiari malformation type 2 presenting with severe OSA due to peripheral cause like Chronic adenoid and tonsillar hypertrophy present an operative challenge due to nil neck extension and minimal oral cavity space. The key is that ACM 2 along with its complications, such as difficult airway, increased intracranial pressure, and autonomic dysfunction, makes it very challenging and requires well-structured and disciplined management by combined anaesthesiology, neurology, and operative team which emphasize on preoperative, intraoperative, and postoperative complications and its timely management.
应对与2型阿诺德-奇阿里畸形患者扁桃体腺样体切除术相关的手术复杂性。阿诺德-奇阿里畸形（ACM）是指一组后颅窝和后脑的畸形，包括小脑、脑桥和延髓。睡眠呼吸障碍是ACM患者已知但评估不足的合并症。儿童阻塞性睡眠呼吸暂停（OSA）主要由扁桃体和腺样体肥大引起，根据OSA的严重程度，需进行腭扁桃体和腺样体的手术切除。一名患有2型阿诺德-奇阿里畸形的4岁男童因严重OSA前来我院门诊就诊。临床和内镜检查发现存在4级腺样体组织和4级扁桃体肥大。计划对该患者进行低温等离子腺样体切除术、扁桃体切除术及悬雍垂腭咽成形术以治疗OSA。患者手术耐受良好，拔管过程顺利。患者在重症监护病房观察过夜，次日出院，无任何重大并发症。由于颈部无法伸展且口腔空间极小，2型阿诺德-奇阿里畸形患者因慢性腺样体和扁桃体肥大等外周原因导致严重OSA时，手术具有挑战性。关键在于ACM 2及其并发症，如气道困难、颅内压升高和自主神经功能障碍，使其极具挑战性，需要麻醉科、神经科和手术团队进行精心组织和严格管理，强调术前、术中和术后并发症及其及时处理。
