RU119999U1 - DACRIOSTOMA DILATOR FOR MICROENDOSCOPIC ENDONASAL DACRYOCISTORINOSTOMY - Google Patents

Abstract

A device for microendoscopic endonasal dacryocystorhinostomy, characterized in that it is a structure of two hollow cylinders made of silicone rubber and hermetically connected to each other at an angle of 115-140 °, with a wall thickness of 1-1.5 mm, inner diameters of 1.5 and 3 mm and a length of 3-5 and 6-8 mm, respectively, while on the front and rear walls of a cylinder larger in diameter and length, there are holes 1 mm in diameter at a distance of 4 mm from each other.

Description

The proposed utility model relates to ophthalmology and is intended for the prevention of dacryostomy overgrowth in the postoperative period.

Dacryostomy is an artificial fistula between the lacrimal sac and the nasal cavity, created (during the operation of the dacryocystorhinostomy) to normalize the evacuation of the lacrimal fluid from the conjunctival cavity in the event of obstruction of the natural outflow path through the nasolacrimal duct. Features of the healing of the mucous membrane of the nasal cavity are such that often lead to stenosis and contraction of the dacryostomy in the postoperative period, and, consequently, to relapse of the disease. The formation of (due to the close anatomical location) synechia between the lateral wall of the nasal cavity in the dacryostomy region and the anterior end of the middle nasal concha leads to the same undesirable result.

Various methods have historically been proposed to prevent overgrowth of the anastomosis of the lacrimal sac with the nasal cavity: silk threads or horse hair were passed through the lacrimal tubules and anastomosis, it was suggested to leave the silver probe in the anastomosis until it is fully formed. Other authors proposed to leave stainless steel wire in the anastomosis after dacryocystorhinostomy for 21 days. A number of authors used the method of dacryocystorhinostomy with the introduction of an endotracheal tube into the anastomosis, which is formed after a hole is made in the lacrimal bone with a boron or chisel. The tube is removed after a few days. It is believed that in this way a greater percentage of favorable outcomes can be achieved than with conventional dacryocystorhinostomy. For the same purpose, B.F. Cherkunov (1962) developed a special method for tamponade of the anastomosis with a rubber cap made of a baby's nipple. Drainage, abutting the tip against the outer wall of the lacrimal sac, is tightly fixed in the dacryostomy and prevents the adhesion of its edges (Cherkunov BF Diagnostic and surgical treatment of persistent lacrimation: Dis .... Candidate of medical sciences. - Moscow, 1962). It should be noted that the above drainage was widely used during the operation of external dacryocystorhinostomy (DCR). The use of insufficiently biologically inert material (glove rubber), as well as the need for independent production of drainage immediately before each operation are the disadvantages of the device. In addition, the negative aspects of external dacryocystorhinostomy are major trauma, bleeding, the need to stitch, poor cosmetic effect (the presence of a scar on the skin of the face).

Carrying out endoscopy by endonasal access avoids the above disadvantages. VG Beloglazov et al. Developed an endotracheal tube model for endonasal surgery. It is made of PVC pipe with an outer diameter of 6 mm and an inner diameter of 4 mm. A small visor is cut out from above for introducing a lacrimal sac into the dome, and the cut-off part of the endotracheal tube inserted into the lacrimal sac is directed to the mouth of the lacrimal tubules. The body of the tube itself is made as short as possible to prevent clogging. At the bottom of the tube there is a “tail” for fixation. The surgeon makes an endotracheal tube during surgery from a sterilized boiling polyvinyl chloride tube. The length of the tube and its sections depends on the anatomical dimensions of the lacrimal sac, nasal cavity, etc. The shape and dimensions of the endotracheal tube allow it to be introduced into the remaining part of the lacrimal sac cavity so that the edges of the bag do not reach the edges of the tube cut by 2-3 mm and fix by immersing the “tail” of the tube into the opened lacrimal duct. (Beloglazov V.G. Endonasal intubation of the lacrimal sac in dacryocystitis: Dis .... Candidate of medical sciences. - Moscow, 1963). A method using such a tube is effective, however, the large size of the tube does not allow it to be considered gentle. In addition, polyvinyl chloride is not currently the modern preferred material for implantation.

In connection with the development in recent years of endoscopic techniques for operations in the nasal cavity, microendoscopic endonasal dacryocystorhinostomy (DCR) is becoming more common. The operation under the control of optics can minimize tissue trauma (reducing the size of the removed flap of the mucous membrane of the nasal cavity, the diameter of the “window” in the lacrimal bone), provides a more precise formation of the dacryostomy. Nevertheless, the relevance of prevention of relapse of lacrimation after microsurgery remains relevant. For this purpose, a method of bicanalicular intubation is used, including the use of a thin (0.8-1.2 mm in diameter) silicone tube, which is sequentially passed through the lacrimal openings, lacrimal canaliculi, lacrimal sac and removed through the dacryostoma into the nasal cavity, where the ends of the tube are fixed coupling (Beloglazov VG, Dzharullazade Ch.D. Reconstructive surgery of the lacrimal ducts using silicone tubes: Guidelines. - M.: All-Russian Research Institute of Eye Diseases, Ministry of Health of the USSR, 1988). Intubation of the tear ducts prevents the development of relapse due to the persistent and long-term preservation of their lumen, which contributes to the complete epithelization of the newly created paths and is one of the most important reasons for a successful outcome. However, the use of a silicone tube with a sleeve is ineffective for maintaining the lumen of the dacryostomy during the formation of cicatricial adhesions between the lateral wall of the nasal cavity and the anterior end of the middle nasal concha.

The objective of the invention is the development of an improved dilator dacryostomy.

The technical result of the proposed device is the reliable prevention of postoperative fusion of the dacryostomy after microendoscopic endonasal dacryocystorhinostomy.

The technical result is achieved through the use of a dacryostomy dilator made of silicone rubber, as well as its shape in the form of a structure of two hollow cylinders, hermetically connected to each other at an angle of 115-140 °, with internal diameters of 1.5 and 3 mm, respectively , 3-5 mm and 6-8 mm, wall thickness 1-1.5 mm, as well as holes with a diameter of 1 mm at a distance of 4 mm from each other.

The device is schematically represented in figure 1, where 1 and 2 are hollow cylinders, 3 is the wall thickness, 4 and 5 are holes for fixing. The dilator of the dacryostomy is a design of two hollow cylinders (1, 2), hermetically connected to each other at an angle of 115-140 °, with internal diameters of 1.5 and 3 mm and a wall thickness of 1-1.5 mm (3). The length of the smaller diameter of the hollow cylinder (2) is 3-5 mm, the length of the larger diameter of the cylinder (1) is 6-8 mm. On the front and rear walls of the larger cylinder there are holes (4, 5) for fastening the structure with a diameter of 1 mm each, located at a distance of 4 mm from each other.

The dilator part located in the lacrimal sac prevents adhesion of the edges of the dacryostomy. The intranasal part is placed in the middle nasal passage, which prevents the formation of synechia between the anterior end of the middle nasal concha and the dacryostomy region. Thus, the patency of the artificial path of the outflow of tear fluid in the postoperative period is maintained. Depending on the individual structural features of the lateral wall of the nasal cavity, in each case, one should choose a dilator with the most convenient angle between the cylinders that make it up. A dacryostomy dilator made of silicone, a biologically inert material, can be installed for the long term necessary to subside the postoperative reactive inflammatory process and complete the reparative process.

The device is used as follows. At the final stage of the operation of microendoscopic endonasal DSB, when the fistula between the lacrimal sac and the nasal cavity is formed, through it the ends of the silicone stent (0.8 mm in diameter, 20 mm long) are passed through the lacrimal openings and the lacrimal tubules into the lacrimal sac. Next, the ends of the bicanalicular silicone stent are passed through the mounting holes in the wall of the dacryostomy dilator. The assistant holds the ends of the stent in a taut state and makes sure that the inter-palpebral part remains of sufficient length for free opening of the eyelids. The surgeon, grasping the dilator with forceps, leads him along the stent to the dacryostomy area, where the design is installed in such a way that the smaller cylinder is located in the lacrimal sac cavity, and the larger cylinder remains in the region of the anterior end of the middle turbinate, displacing the latter medially. The ends of the bicanalicular stent are fixed to each other using a sleeve (a piece of a larger diameter silicone tube) and cut with scissors.

The dacristoma dilator is removed 3 months after surgery. To do this, cut the inter-palpebral part of the bicanalicular stent with scissors, then the dilator is removed from the side of the nasal cavity under the control of endoscopic optics.

As part of a clinical study using the above method, 12 patients (14 eyes) with a pathology of the lacrimal apparatus were operated on. The following results were achieved: recovery (absence of tear and suppuration) - in 7 patients (9 cases) (64%); improvement (periodic lacrimation with patency of the dacryostomy and absence of symptoms of inflammation) - in 5 patients (5 cases) (36%). Relapse of dacryocystitis was not noted. The follow-up period was 1 year.

Clinical example:

Patient K., born in 1935, medical history No. 193, was in the clinic of the Research Institute of Eye Diseases RAMS from 01/17/2011 to 01/24/2011 with a diagnosis of Chronic suppurative left-sided recurrent dacryocystitis. Complaints of lacrimation and purulent discharge from the left eye. History: Tearing from the left eye for 6 years; 07/06/2010 microendoscopic endonasal dacryocystorhinostomy with bicanalicular intubation on the left was performed; 4 months after the operation, lacrimation resumed and purulent discharge from the left eye appeared; the installation of antiseptic drugs (okomistin) in the left eye - without a significant positive effect; 12/20/2011 - the removal of the lacrimal stent was performed. An objective examination noted: OS - lacrimation, with pressure on the projection area of the lacrimal sac from the lacrimal openings, a thick mucopurulent discharge appears. When washing the lacrimal passages to the left through the lower lacrimal opening, a solution of furatsilina 1: 5000 - the liquid flows out through the upper lacrimal opening, but does not pass into the nasal cavity. Color tests with a 3% solution of collargol: tubular positive up to 5 minutes, nasal - negative. X-ray of the lacrimal passages on the left: contrast medium (30% iodolipol), introduced through the lower lacrimal opening of the OS, is determined in the dilated lacrimal sac, measuring 0.5 × 0.7 × 1.0 cm, then it does not enter. During endoscopic examination of the nasal cavity using direct vision optics, cicatricial fusion of the anterior end of the left middle nasal concha with the lateral wall of the nasal cavity is noted, the dacryostomy is not visualized.

01/19/2011, the operation was performed: Restoring patency of the artificial anastomosis on the left with the installation of the proposed dilator dacryostomy. In the postoperative period, an anemization of the mucous membrane of the left middle nasal passage and a toilet of the left half of the nasal cavity were performed.

The dacryostomy dilator was removed on 04/22/2011. The patient does not complain of lacrimation. An endoscopic examination visualizes the formed dacryostomy on the lateral wall of the nasal cavity on the left; color samples with 3% collargol solution: tubular - positive up to 2 minutes, nasal - positive up to 3 minutes. When washing the lacrimal passages on the left with a solution of furatsilina 1: 5000 - the fluid passes freely into the nasal cavity. Achieved recovery.

Thus, the use of the proposed dilator dacryostomy after microendoscopic endonasal DCR allows you to achieve positive long-term results of surgical intervention and to avoid the onset of relapse.

Claims (1)

Device for microendoscopic endonasal dacryocystorhinostomy, characterized in that it is a structure of two hollow cylinders made of silicone rubber and hermetically connected to each other at an angle of 115-140 °, with a wall thickness of 1-1.5 mm, internal diameters of 1.5 and 3 mm and a length, respectively, 3-5 and 6-8 mm, while on the front and rear walls of the larger diameter and length of the cylinder there are holes with a diameter of 1 mm at a distance of 4 mm from each other.