RU2284773C1 - Method for treating laryngeal stenosis cases of paralytic origin - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making frontal access to thyroid cartilage plate and forming chondroperichondral flap. The greater portion of internal cricothyroid and thyroarytenoid muscles is excised and vocal process of arytenoid cartilage is excised. Nasal septum autocartilage is brought under the frontal one-third of the vocal fold, the flexible cone with the vocal fold are taken apart. Then, autograft is placed onto external thyroid cartilage plate and sutures are fixed thereon.

EFFECT: retained vocal ligament and larynx protection function; early cannula removal; reduced risk of suture eruption through thyroid cartilage plate.

5 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in the treatment of stenosis of the larynx of paralytic etiology.

Currently, treatment of laryngeal stenosis is carried out by endolaryngeal, extralaryngeal and endoscopic methods. Of the extra-laryngeal methods, the King methods are most widely used (King, V.T. New and Functiion Restoring Operation for Bilateral abductor Cord Paralisis, Preliminary Report / BTKing // JAMA. - 1939. - V.112. - No. 4. - P. 814-823), Woodman (Woodman, DG Arch. Otolaryng. - 1946. - V.43. - P.63-65). Their advantage is that the larynx is not opened and the mucous membrane is not damaged, and the released vocal fold can be assigned to the cartilage base of the larynx. King, with a short duration of laryngeal paralysis, proposed an extra-laryngeal approach to the posterior edge of the thyroid cartilage plate, the vocal fold and the arytenoid cartilage, mobilization of the arytenoid cartilage and its attachment by the vocal process to the posterior part of the thyroid cartilage and distal m. omohyoideus. Sato and Ogura (Sato F., Ogura JH - Laryngoscope (St. Louis). - 1978, V.88. - P.689-696) showed that the method of muscle transposition proposed by King, does not provide improved mobility of the vocal folds due to replacement transposed muscles with scar tissue or fixation with adhesions to surrounding tissues.

The Woodman method was modified by Karpova O.Yu. (A.S. 992036 USSR). The author proposed a partial excision of the posterior parts of the vocal and thyroid muscles, which facilitated the displacement of the vocal process with a partially retained suture with a partially retained vocal fold into the vacated area and reduced the likelihood of suture eruption. The main difficulty of the operation was to conduct a thread of chrome catgut around the vocal process in such a way as to avoid injury to the mucosa, and subsequently the likelihood of scarring in the lumen of the glottis. The method allows you to increase the lumen of the glottis and to de-cannulate the patient, however, as the author notes (Karpova O.Yu. -39.), The disadvantage is the high probability of suture eruption with excessive thread tension, and it is almost impossible to re-stitch around the vocal process. With insufficient tension of the thread, the expansion of the lumen will be small. Thus, the method does not exclude the possibility of recurrence of stenosis.

Prof. I.A. Kurilin and coauthors (A.s. 520100 and 709074 USSR) proposed a method for extra-laryngeal lateral fixation of the vocal fold (I. Kurilin. Plastic surgery of the larynx and trachea. Message II. / I.A. Kurilin, F.A. Tyshko / / Journal of ear, nasal and throat diseases. - 1983. - No. 1. P.1-8). The expansion of the glottis was achieved by extra-laryngeal mobilization, lateral movement and fixation of the elastic cone and the quadrangular membrane of the larynx to the plate of the thyroid cartilage. Unlike the previously developed method for treating patients with median stenosis of the larynx according to copyright certificate No. 520100, the vocal process is not excised, and the elastic cone is stitched with one suture. The vestibular fold is also stitched at the site of attachment to the arytenoid cartilage and with it is fixed to the base of the upper horn of the shield plate.

The method allows to expand all sections of the larynx, the voice-forming function is preserved, and the patient can be de-canned in the early stages (4-5 days). The disadvantage of this method is, in a larger percentage of cases, a violation of the protective function of the larynx when the arytenoid cartilage deviates back during flashing of the vestibular fold, trauma due to the need for rotation of the larynx.

A known method for the treatment of median stenosis, proposed Tsurikov V.G., Uskov A.E. (Pat. 2082335 of the Russian Federation, class MKI A 61 B 17/24), in which the lateral-vertical movement of the arytenoid cartilage and its fixation between the signet of the ring-shaped cartilage and the posterior lower part of the thyroid cartilaginous posterior cervical posterior plate are followed by the extra-laryngeal route after cervical joint disarticulation. cricoid muscles and the removal of the vocal fold to the plate of the thyroid cartilage. This method allows you to expand the middle floor of the larynx, but it is not always technically possible and is quite traumatic due to the approach to the posterior edge of the plate of the thyroid cartilage, and also does not exclude the scoop's return to its original position.

There is a method with a combined gentle external endolaryngeal approach, proposed in 1984 by Ejnell et al., Lateral fixation of the vocal fold and supplemented by V. Ulosa and K. Balsyavichus (Ulosa V. Surgical treatment of bilateral laryngeal paralysis with lateral fixation of the vocal fold / V. Ulosa, K. Balsevichus / / Bulletin of Otolaryngology. - 1998. - No. 6. P.24-27.). The method consists in the simultaneous intervention of two surgeons. One stupidly distinguishes the central part of the shield plate and ligatures are applied to the vocal fold through two hollow injection needles, while the other, under an operating microscope, controls the position of the needle in the lumen of the larynx and the filament. The disadvantage is the ability to erupt ligatures and return the vocal fold to its original position.

The closest is the method of myoarythenoidectomy proposed by prof. Lapchenko S.I. and cand. honey. Sciences Gadzhievym R.Sh. (Lapchenko S.N. Submucosal myoarytodenectomy for stenosis of the larynx of paralytic etiology / S.N. Lapchenko, R.Sh. Gadzhiev // Bulletin of otolaryngology. - 1987. - No. 4. P.44-48), taken by us as a prototype. Extralaringeal approach to the plate of the thyroid cartilage in front, the latter is dissected paramedially throughout; plates of the thyroid cartilage are bred to the sides, the late cricoid muscle is exfoliated from the inner perichondrium to the lateral edge of the arytenoid cartilage. The latter is captured and fixed, isolated from the cricillary joint and removed to the surgical wound. Lateral and posterior cricoid muscles, oblique and transverse arytenoid muscles are dissected. Further, from front to back to the arytenoid cartilage, the external thyroid muscle is separated from the internal. The arytenoid cartilage is removed with a block of muscles, with the exception of the separated vocal process. Then, with the U-shaped sutures, the vocal muscle is fixed on the surface of the thyroid cartilage, the latter is sutured along the external perichondrium, an obturator roller above the tracheostomy is inserted. With a favorable course of healing of the postoperative wound for 8-9 days, the obturator roller is replaced with a T-shaped silicone endoprosthesis, with which the patient is subsequently discharged from the hospital. The method allows to expand the inter-folding space and improve the breathing function, however, it does not allow maintaining the vocal function, it is rather traumatic due to the complete dissection of the shield plate and the risk of developing chondroperichondritis. Removal of the arytenoid cartilage with a muscle block in most cases violates the protective function of the larynx. The method requires long-term use by a patient of a T-shaped silicone tube, which is a psychologically negative point for the patient. Silicone endoprostheses are used by patients for 3-4 months, they have to independently change the latter, to produce sanitary-hygienic treatment. The method cannot exclude the recurrence of stenosis with the development of purulent-necrotic complications around the obturator roller or endoprosthesis in the postoperative period.

We first proposed a method for the treatment of median stenosis of the larynx of paralytic etiology by lateral fixation of the vocal fold, including an extra-laryngeal approach to the anterior thyroid cartilage plate, an infra-peritoneal resection of the vocal process of the arytenoid cartilage with excision of the internal cricothyroid and most part of the thyroid and medulla; laying a part of the auto-cartilage under the anterior third of the vocal fold; abduction of the elastic cone with the vocal fold by applying ligatures and tightening them on an autograft placed on a plate of the thyroid cartilage. The resection of the vocal process scooped with excision of the thyroid and corpuscular and internal cricothyroid muscles leads to an expansion of the interfold space and improved respiratory function, and bringing a part of the cartilaginous autograft under the anterior third of the vocal fold helps to maintain vocal function. Since trophic changes in the thyroid cartilage often occur due to hormonal status, an imbalance of thyroid hormones, and concomitant pathology, in order to prevent cartilage fragility and eruption of lateral-fixing sutures, we proposed to lay a simulated autograft from a quadrangular cartilage of the nasal septum in such a way that the nasal septum is fixed so that on this graft.

There is no need to rotate the larynx and injure surrounding formations; the conditions are created for a good overview of the operative action. The probability of developing chondroperichondritis after surgery is reduced due to minimal trauma to the thyroid and arytenoid cartilage.

Detailed description of the method.

The stages of operations are shown in figure 1, figure 2, figure 3, figure 4, figure 5, where 1 is a chondroperichondral flap; 2 - thyroid cartilage; 3 - thyroid membrane; 4 - scaly cartilage; 5 - the vocal process of the arytenoid cartilage; 6 - thyroid and inner cricoid muscles; 7 - autograft brought under the front third of the vocal fold; 8 - autograft superimposed on a plate of the thyroid cartilage; 9 - ligatures superimposed on an elastic cone; 10 - ligatures carried out through a chondroperichondral flap.

The operation is performed on the less mobile and closer to the midline side. Extralaringeally, a skin incision is made along the inner edge of m.sternoclaidomastoideus from the lower edge of the projection of the hyoid bone down by 6-7 cm. Then, the outer soft tissues layer by layer are separated from the plate of the thyroid cartilage 2 (Fig. 1), departing 0.5 cm from the midline towards the alleged resection of the internal structures of the larynx. Then, on the same side, at the lower edge of the thyroid cartilage, a thyroid-membranous membrane 3 (Fig. 1) is dissected by 1.5-2 cm, the internal perichondrium is peeled off at the site of attachment of the external and internal thyroid muscles. Then an oblique incision of the cartilage is made without reaching the upper edge of 1.5 cm so that a chondroperichondral flap 1 is formed (Fig. 1). The thyroid cartilage 2 (figure 2) breaks down, is taken on a holder and retracted, which reduces injuries and the likelihood of developing chondroperichondritis compared to the prototype. Next, the external thyroid-muscle is separated from the voice to the arytenoid cartilage 4 (figure 2). The pear-shaped sinus exfoliates posteriorly, along the upper edge of the cricothyroid joint, the lateral cricoid muscle intersects. A large part of the thyroid-cervical and internal cricothyroid muscles 6 is excised (Fig. 2). The process 5 is separated by a perichondrium with a voice and resected (Fig. 2), which allows preserving the protective function of the larynx. Under the anterior third of the vocal fold, an auto-cartilage of the nasal septum 7 is applied (Fig. 3) to maintain the vocal function. An elastic cone is identified, two sutures 9 (FIG. 3) are applied atraumatically to the elastic cone without damaging the mucous membrane, then the plate of chondroperichondral flap 1 is pierced with the same needle 10 (FIG. 4), the latter is put into place. A pre-modeled autograft from a quadrangular cartilage of the nasal septum is laid on the outer plate of the shield in such a way that lateral-fixing sutures are attached to this graft 8 (Fig. 5). This reduces the likelihood of teething lateral-fixing sutures and provides a strong fixation.

The degree of abduction of the vocal fold is determined by direct laryngoscopy. Drainages are introduced into the wound, and it is sutured in layers. Two weeks later, the patient is decanulated.

Example: Patient P., 54 years old, was admitted to the clinic of ENT diseases of the SSMU with complaints of shortness of breath, difficulty breathing during physical exertion. From the anamnesis it is known that in 1999 the patient was operated on for adenoma of the right lobe of the thyroid gland, in 2002 - a similar operation on the left. In the postoperative period, due to an increase in the signs of laryngeal stenosis, a lower tracheostomy was performed. After 6 months, she was hospitalized in the ENT clinic with complaints of the presence of a tracheostomy tube for decanulation. Upon receipt with indirect laryngoscopy, the laryngeal mucosa is pink, the vocal folds are white, motionless, are located in the paramedial position, the glottis in the posterior sections is 1-2 mm, the voice is hoarse. Diagnosis: bilateral paralytic stenosis of the larynx, condition after tracheostomy. On October 14, 2003, the lateral fixation of the right vocal fold was proposed by us and in the manner described above in detail. The postoperative period was uneventful. On the 15th day, the patient was decanulated, discharged on the 24th day. After discharge, the laryngeal mucosa is pink, clear, inter-folding space in the back section up to 7-8 mm. The protective function of the larynx is not impaired. At the follow-up examination, after a year, breathing was satisfactory, a violation of the protective function of the larynx was not observed, the width of the inter-folding space in the rear sections was 8 mm. The slight hoarseness of the voice remained.

The proposed method has currently operated on 6 patients with good results. None of them showed a violation of the protective function of the larynx. All patients were decanulated after 2-3 weeks and discharged 24-27 days after surgery. In the distant postoperative period (after 1-1.5 years), the inter-fold lumen did not decrease and amounted to 6-8 mm in the posterior third. A moderate improvement in voice function was noted.

As can be seen from the description of our proposed method for the treatment of median stenosis of the larynx of paralytic etiology, compared with the prototype, it has a number of significant advantages, the main of which are:

- saving voice function;

- less traumatic due to the formation of a chondroperichondral flap;

- preservation of the protective function of the larynx due to resection of only the vocal process of the arytenoid cartilage;

- the ability to get rid of cannula carriage in a fairly early postoperative period (2-3 weeks);

- reducing the likelihood of eruption of lateral-fixing sutures through the plate of the thyroid cartilage and strong fixation on the autograft.

The method was developed in the ENT clinic of SSMU; it was tested in 6 patients with stenosis of the larynx of paralytic etiology with good results.

Claims (1)

A method for treating median stenosis of the larynx of paralytic etiology with the extra-laryngeal route, including front access to the plate of the thyroid cartilage, abduction of the elastic cone with the vocal fold and fixing it on the surface of the plate of the thyroid cartilage, characterized in that a chondroperichondral flap is formed from the thyroid cartilage, the most part is dissected thyroid muscles, resect the vocal process of the arytenoid cartilage, bring the autocartilage of the nasal septum under the anterior third of the voice new folds, as well as impose an autograft on the outer plate of the thyroid cartilage and fix the sutures on it.

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